ORAL SURGEON TOOTH REMOVAL



ORAL SURGEON TOOTH REMOVAL: (Oral Surgeons, or Oral and Maxillofacial Surgeons, OMS for short)

In order to become an ORAL SURGEON , your dentist had to go 4 years of dental school, then 4-6 more years of an ORAL AND MAXILLOFACIAL SURGERY residency, then many have to do additional training beyond that!

In the process, SOME, but not all, program candidates are also awarded their MD.

ORAL SURGEONS do a variety of operations. Most notably, tooth extractions. They are often called upon to do the more complicated extractions, as well as many wisdom teeth.

Because of their advanced training, many oral surgeons are able to do:

  • higher levels of sedation in their offices, such as,
  • IV sedation
  • oral premedicated sedations, or in extreme cases,
  • general anesthesia

Aside from extracting teeth, OMS also perform:

  • biopsies
  • fix mandible fractures
  • deal with severe dental infections
  • and are often consulted with (or deal directly with) on any other issue a general dentist may need assistance with.

As with all specialties, you need to be referred by your general dentist first.




So why might you be referred to an OMS?

WISDOM TEETH:

WISOM TEETH are your third set of molars. Also known as the 18 year molars (in contrast to the 6 yr and 12 year molars, which are the first and second molars respectively). They erupt around 18 year of age (give or take), but are sometimes visible on pre-teenage patients. Because they begin to develop and are visible so early, they may be addressed before 18 or anytime later in life.

Often times patients do not have sufficient room in their mouth for the wisdom teeth, so they do not have enough room to erupt. Also, often times the wisdom teeth do not come in straight, and may be jetting up against the second molar.

Click here to see a diagram of tooth numbers

For example:

Picture courtesy of Stephen F. Gordon, 1993.



The bottom line is if the wisdom tooth does not erupt into proper position, it is not doing any good. Which leaves only two more possibilities, either it will not do anything, or it will cause harm.

What kind of harm?

  • It may make it more difficult to clean the second molars,
  • Causing loss of bone (periodontal disease)
  • It may get infected, which may lead to hospitalization, and surely
  • Pain

It is much easier to take out wisdom teeth when they are not causing problems. Once they becomes symptomatic, the patient is much more anxioius and often more difficult to deal with, and it is much more difficult to get adequate anesthesia when a tooth is infected or painful.

Also, the younger you are, the faster you heal.

It is MUCH better to have an asymptomatic wisdom tooth extracted when you are 20, RATHER THAN THE INFECTED, PAINFUL, ONE AT AGE 60!

On the other hand...

Some peoples’ come in straight

Some peoples’ NEVER come in.

Some peoples’ are close enough to vital structures to make the risks of extraction, outweigh the benefits of extraction.

These risks involve the aft mentioned:

  • INFECTION
  • NERVE DAMAGE
  • or other POST SURGICAL TRAUMA, that your provider can delve more deeply into.



DO GENERAL DENTIST EXTACT WISDOM TEETH? 

Yes. But, many general dentists are not comfortable taking out severely impacted wisdom teeth. When wisdom teeth are severely impacted, more invasive surgery needs to be done, there is a much higher chance of INFECTION, NERVE DAMAGE, or other POST SURGICAL complications.This is when you would be sent to an ORAL SURGEON. 

OTHER SURGICAL EXTRACTIONS:

ORAL SURGEONS also are called on to extract any teeth that a general dentist does not feel comfortable extracting. For any of the above reasons, the patient and dentist may be better served having an OMS perform the procedure.

TYPES OF EXTRACTIONS:

Full Boney Extractions: Teeth that are fully encased in bone.

Partial Boney Extractions: Teeth that are partially encased in bone.

Soft Tissue Extractions: Teeth that are covered by gum or other soft tissue.

Surgical Extractions: When tissue has to be moved, removed, or sectioned.

Simple Extractions: Teeth that come out whole, without extra surgery.


SEVERE DENTAL ANXIETY:

Even if your wisdom teeth are not difficult to take out, sometimes patients are referred to OMS if they are very anxious, and desire a higher level of sedation than NITROUS OXIDE.


BIOPSIES:

A BIOPSY is a surgical procedure done to either remove (entirely or partially) a lesion, in order to be able to use a microscope to definitively diagnose what it in fact is. If you have a suspicious growth in your mouth, it may need to be cut out in order to rule out any ORAL PATHOLOGY, such as CANCER, or to determine the best course of treatment.BIOPSIES can be done in ways, such as excisional (remove entire lesion) or incisional (remove part of the lesion). If there is a cyst in your bone, they may do an aspiration biopsy.


MANDIBLE FRACTURES:

In the event that you do have a MANDIBLE FRACTURE, you definitely will need to see an oral surgeon and your jaw will usually need to be fixed with arch bars at the least (which are wired to your teeth) to put your jaw back into proper position. Along with the arch bars on both upper and lower teeth, your jaws will often be WIRED SHUT (INTERMAXILLARY FIXATION).

This can be done under local anesthesia in a normal dental office, but most of the time is done under general anesthesia (you will be put to sleep in an operating room).

If the ARCH BARS are not sufficient, you may need to have METAL PLATES placed, which are SCREWED into your jaw. These also help to fix the MANDIBLE in the correct position. These are left in the bone indefinitely and do not need to be removed (unless they cause problems later, which is rare), so every dentist you see in the future will know that your jaw was once broken.

MANDIBLE FRACTURES can be treated by either plastic surgeons or oral surgeons. Either is capable, but ORAL SURGEONS have had much more extensive training in how the teeth should come together. Keep in mind, your jaw will heal however it is set, so if it is set incorrectly, your bite/occlusion will be off forever. This is why it is important that your surgeon has a good working knowledge of occlusion.

After the surgery, you will be wired shut for 6 WEEKS, and will need to sustain yourself on a liquid diet and blended food.

After the 6 weeks, the wires will most likely be removed (under local anesthetic in a dental office), and you should be able to once again function normally.



IMPLANTS:

If you have lost one or more teeth, implants may be used to help restore the spaces. Implants are an ever evolving field, but basically a screw is surgicallyl placed into your bone, the bone is allowed to heal around the screw, then a CROWN is attached to the screw. This is a very good single tooth replacement since the implant will function like a single tooth (as opposed to a BRIDGE, which has several teeth stuck together).

They also can be used to help retain BRIDGES, PARTIAL DENTURES, or FULL DENTURES .

IMPLANTS are not suitable for everyone however. Those with periodontal disease, inadequate thickness of gone, or sometimes smokers, all may not be good candidates for the procedure.

They are also fairly expensive, so be sure to get a comprehensive fee estimate before embarking down this road.


Click here for photos and further explanation of Tooth Implants


BONE GRAFTS:

bone graft is a surgical procedure where bone is added to an area to try and build up the ridge in order to help support the teeth or provide better esthetics when trying to restore an area. Also referred to asGuided Bone Regeneration, bone grafts replace missing bone and helps your body regrow lost bone. The new bone forms a matrix, much of which eventually gets replaced by your own bone.

In the case of implants, sometimes bone grafting is done at the same time as the implant placement, in order to help ensure success and proper incorporation of the bone and implant.

There are 4 different types of bone grafting material:

  • Autograft, which uses bone transplanted from one region to another in the same person
  • Allograft, which uses bone transplanted from one individual to another individual (of the same species, i.e, humans)
  • Xenograft, which uses bone transplanted from one species to another, i.e, animal to human
  • Alloplast, which is a synthetic bone graft material

The photos below illustrate the bone grafting process:

The photo on the left shows an extraction site that has had all infected tissue removed.

The photo on the right shows the bone grafting material being placed into the extraction site.

The photo on the left shows a membrane that is placed over the bone grafting material, which helps to hold the material in place while it heals. If a non resorbable membrane is used, it will need to be removed at a later date. If a resorbable membrane is used, it will not need to be removed.

The photo on the right shows the extraction site and bone graft sutured up.

Care After Bone Grafts:

  • Take Antibiotics as directed if prescribed
  • Rinse as directed to help keep it clean
  • Avoid the gum tissues around the graft for about 6 weeks when brushing and flossing



TOOTH REMOVAL PROCESS:

It is normally attempted to remove the tooth whole, in one piece. Depending on the condition of the tooth, where it is located, or the anatomy of the tooth; this may not be possible. When this is the case, the tooth is normally sectioned, or split into more than one piece, and the teeth are removed in pieces. This would be the case for example, when a wisdom tooth is impacted or not fully erupted into the mouth.

When a tooth is removed, the patient of course is anesthetized, but will still feel a great deal of pressure. Under local anesthetic (as opposed to a general anesthetic, when you are put to sleep), the pressure is still felt, but the patient should not feel any pain.

What is happening, is the dentist is exerting pressure via the tooth onto the bone, which expands the socket that the tooth is in. This makes the socket larger than the tooth roots, and allows the tooth to be removed.


POST OPERATIVE INSTRUCTIONS:

Normally after your extraction(s), the dentist will place gauze in your mouth and have you apply pressure to the areas where teeth were removed. This is to help stop the bleeding and allow a blood clot to form.

You need to keep pressure on the area for at least 20-30 minutes, but may need to apply pressure longer if the bleeding persists. Some people take longer to clot than others, and that's normal.

Regarding eating, you should keep the food as soft as possible, and away from the affected areas as well as you can.

After about 24 hours, you can start to rinse lightly with warm salt water. This should help the area feel better and help with healing.

You will feel the hole/socket for a week or more, but you do not need to worry about cleaning food and everything out of it. The extraction site will heal from the bottom up, so you won't get food trapped under the gum when it heals.

It is also recommended to refrain from smoking, spitting, drinking through a straw, diving, or doing anything that causes an increase in pressure to the area, as that can dislodge the clot and cause problems with healing.


SUTURES/STITCHES:

If a tooth comes out in one piece, most of the time sutures or stitches are not placed. If they are, your dentist will tell you if you need to come back to have them removed, or more commonly, they use GUTsutures, which resorb and will fall out on their own. These may stay in for a couple days to a couple of weeks.


ROOT TIPS:

During the extraction process, if the tooth breaks, the gum is normally reflected back and the dentist normally will need to remove bone in order to get access to the tooth or parts of tooth remaining in the socket.

Often times when a tooth breaks, it is at the end of the root, referred to as a root tip. There are occasions when a root tip can be left, but in most cases it is ideal to remove the root tip.

If the root has been in your mouth for several years and there is no sign of any pathology around it and it is asymptomatic, sometimes it is left in the jaws unless the situation changes.

Removing a root tip during an extraction can be a very difficult process, as sometimes the root tip is no bigger than the tip of a lead pencil.

Imagine a piece of tooth that sized, lodged at the bottom of the socket, which is essentially the same color as the bone it is lodged in. Throw in saliva, blood, and the fact that you are looking at it upside down and backwards (if the dentist is working on an upper tooth, they are often looking at a mirror image), and you get an idea of what is going on and why it sometimes takes awhile!




POST OPERATIVE COMPLICATIONS: After teeth are extracted, you normally will have some pain, swelling, and possibly bruising. These symptoms should dissipate over time, and get better. The actual extraction site can take up to 6 months to completely heal however, so you can expect to see some sort of hole there for several months.

Whenever teeth are extracted, complications can occur. The 2 most common are probably,

INFECTIONS and DRY SOCKETS.

INFECTIONS:

Infections are normally treated by oral antibiotics, and present as persisting swelling after the procedure. Some swelling is normal because of the trauma, but if it does not go away or gets worse, you may have an infection.

Antibiotics are normally taken for 7-10 days, and you need to take all of the pills regardless of whether the infection gets better or if the pain goes away beforehand. This is to ensure that all the bacteria is killed.

DRY SOCKET:

This is when the blood clot that normally forms in the extraction site comes out, and causes a great deal of pain. This is very common in smokers and more common in lower molars than other areas.

When this happens, the dentist usually packs the extraction site with a dressing which helps relieve pain and aid healing. This dressing needs to be changed every 1-2 days, and may need to be done for about a week.


SINUS EXPOSURES:

This is when the roots of upper molars extend near or into the sinus cavity, and when the tooth is removed, there is a communication with the sinus and the oral cavity. An easy test is to pinch the patient's nose and ask him/her to blow through their nose. If air comes out of the extraction site, you have an exposure.

This is a case when sutures are normally needed to try and close the extraction site as best as possible.

Often times this can be treated with antibiotics and a decongestant and the patient will be ok, as long as they the necessary precautions, such as not blowing their nose, swimming, or doing other things that cause undue pressure to the sinus area.

If the area does not heal, an oral surgeon may need to be consulted.



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