Dental Alveolar Surgery
There are many reasons it may become necessary for a patient to require some kind of dental alveolar surgery.

• Impaction of teeth
• Orthodontic necessity
• Infection
• Failure of endodontically treated teeth
• Non-restorable decay
• Oral Pathology

Dentoalveolar surgery is the surgical management of diseases of the teeth and their supporting hard and soft tissues. A tooth that fails to emerge or fully break through the gum tissue is, by definition,” impacted." While this is a common problem associated with third molars, or wisdom teeth, as they are the last teeth to develop and erupt into the mouth, other teeth can also become impacted.

Typical symptoms associated with impacted teeth are pain, swelling and signs of infection in the surrounding tissues. An impacted tooth has the potential to cause permanent damage to adjacent teeth, gum tissue and supporting bone structure. Impacted teeth are also associated with the development of cysts and tumors that can destroy large portions of the jaw.

On occasion during Orthodontic treatment, existing teeth may need to be extracted to allow the appropriate Orthodontic treatment plan to be pursued. In many instances, existing teeth may need to be extracted to allow for additional room. On occasion, a tooth may need to be exposed in order to allow the Orthodontists to manipulate it into the appropriate position.

Infections in the maxillofacial region can develop into life-threatening emergencies if not treated promptly and effectively. Pain and swelling in the face, jaws or neck may indicate an infection of dental or related origin. For less severe infections, evaluation and treatment may be done in the oral and maxillofacial surgery office. Depending on the diagnosis and severity of the case, oral and maxillofacial surgeons may work with other specialists to provide comprehensive patient care.

The failure of an endontically treated tooth may lead to the development of an oral infection that may result in localized pain and swelling in the area of the involved tooth. If left untreated, these symptoms can progress to an oral abscess that may also develop into life threatening situations.

Another possible reason for dental alveolar surgery would be the extraction of a tooth that has decayed to a point that does not lend itself to dental restoration. Again, failure to treat this situation can result in the development of a significant infection.

The diagnosis of pathology in the maxillofacial region is an important part of the oral and maxillofacial surgery practice. If indicated, biopsies and other tests can be performed to diagnose the problem and develop an appropriate treatment plan. Early detection and treatment of oral lesions greatly improve the patient's prognosis. Lesions may be managed medically and/or surgically.

Wisdom Teeth (3rd Molars) / Extractions
Wisdom teeth, or third molars, are your last teeth to develop in the mouth. Generally they appear in your late teens, or "age of wisdom". The normal position of these teeth is behind the upper and lower second molars. In most cases the average person does not have a large enough jaw to accommodate the four teeth comfortably.

This is why wisdom teeth are usually recommended for removal. Wisdom teeth often become impacted when their normal eruption pattern is interfered. A tooth may be only partially impacted. When this occurs, the tooth develops at an angle, partially breaking through the gum tissue. Some teeth fail to break through the gum tissue at all and thus remain totally impacted. Problems can develop from partially and fully impacted teeth. Partially impacted teeth may cause pain, infection, crowding and/ or damage to the adjacent teeth or bone. For fully impacted teeth, more concern is given if the sac that surrounds the tooth fills with fluid. It can enlarge and form a cyst. This cyst can create permanent damage to the adjacent teeth, jawbone, and nerves.

Concerns relating to wisdom teeth can occur with few or no symptoms. For these reasons, the removal of your wisdom teeth may be recommended before it causes obvious problems, particularly for young adults. A doctor who has specialized training in the removal of wisdom teeth is called an Oral and Maxillofacial Surgeon. Your surgeon will use special surgical and anesthetic techniques for the treatment of impacted wisdom teeth to create a more pleasant experience for you. If the wisdom teeth have fully erupted in a normal position, they may not be recommended for removal. They may only require observation by your general dentist to ensure proper cleaning and care is given. When the tooth is impacted, an incision is made in the gum tissue, revealing the tooth. In many cases there is a bony area covering the tooth. In many cases there is a bony area covering the tooth. This will be removed to well expose the tooth. The tooth may be removed in whole, or it may be sectioned and each fragment is removed individually. The removal of wisdom teeth can be safely performed in the surgeon's office with intravenous sedation. You will be required to bring an adult with you the day of your procedure, so he or she can drive you home.

In most cases, normal activity can be resumed within a couple of days, depending on the degree of impaction and the number of teeth removed. Before the surgeon determines if your wisdom teeth should be removed, a medical history and examination will be completed. Particular attention will be given to allergies, current medications, and health concerns that might affect the surgery and the administration of anesthesia. It is important that you provide us with complete information. An X-ray may be provided to our office by your dentist or other dental specialist or may also be taken by our office staff. The X-ray shows the presence of the teeth, and may reveal such important things as curved roots, proximity of the tooth roots to the nerves and sinuses, and other vital surgical information. Your surgeon will need to know this information to make accurate assessment of your health prior to providing treatment. Pre-sedation and post-surgical instructions as well as risks and complications, alternative treatment, and treatment benefits will be discussed with you at this time of the consultation. This information at the time of the consultation will be necessary for you and your surgeon to make an informed decision prior to providing care for you. You may experience some temporary changes in the mouth and cheek area following your surgery. Slight oozing of blood the first day and night may occur.

There may also be some discoloration in the area of surgery. This black and blue mark will normally turn yellow and fade within a few days. On the day of surgery, you may be asked to bite on a piece of gauze for a designated period of time.This controls excessive bleeding by helping a blood clot form at the extraction site. It is important not to disturb this area, allowing normal healing.  Discomfort - Discomfort can be the greatest 48 72 hours following your surgery. Pain medication can help alleviate this discomfort but if the pain becomes severe please contact your surgeon. Swelling - The application of ice packs on the day of surgery can decrease the inflammation that generally occurs. Swelling may increase slightly over the next 1 or 2 days, this is common. If the pain is persistent and pain medication is not minimizing, please contact our office. The surgical team will address any additional post-operative requirements with you at the time of surgery, if you have any questions and/or concerns please address them at the time of your consultation.

IV Sedation
To make your visit to our practice as pleasant as possible our doctors often recommend intravenous or IV sedation. A small catheter is placed in a vein in the arm allowing a combination of medications to be administered. These medications allow the patient to relax, and "sleep" throughout the procedure, awaking with no discomfort or memory of the surgery. The medications used are extremely safe, and our doctors have extensive training in their use. How to prepare for IV sedation will be explained to you at your evaluation appointment.

Dental Implants
Dental implants are titanium tooth root replacements which are inserted into the jaws to hold crowns, bridges, partial or full dentures. They are used when natural teeth are missing, or inadequate to support replacement crowns, bridges, or dentures. Implants have been developed over the past four decades, and are a reliable and cost-effective way of solving many problems related to the loss of the natural dentition.

The use of dental implants can be tooth-saving , in many cases avoiding the need for altering healthy neighboring teeth. Where a traditional bridge might be called for, a dental implant supporting a crown often allows the teeth adjacent to the space of the missing tooth to be left alone. Dental implants supporting crowns may actually cost less than traditional permanent bridgework .

Implants may also be used to provide support for dentures when patients have already lost most or all of their teeth. In these cases, multiple implants may be required to support denture frameworks which allow the patient to conveniently remove the denture for hygiene, while providing otherwise unattainable comfort and stability. Implants for denture support also help preserve the jaw by reducing bone loss often associated with conventional denture wear over a period of time.

Depending on your diagnosis and treatment plan, the surgical procedures, carried out comfortably under IV sedation, may involve a single surgery, or a staged series of procedures. In some cases, the implants may be placed in function immediately, while others may require prior bone or soft tissue grafting, or require a healing period of a few months in order to assure proper bonding of the implants to the jaw. In those instances, you should be able to wear a temporary prosthesis and eat a soft diet during the healing period. To provide you with a better understanding of the process, your implant surgeon will go over these details carefully with you at your consultation appointment.

Our goal is to help your restorative dentist enhance your smile , and restore confident chewing and speaking ability.

Corrective Jaw Surgery
Corrective jaw surgery, formally known as orthognathic surgery, is performed to properly align the upper and lower jaws. Some people develop and grow with one or both jaws either too large or too small, or simply out of proper alignment with one another. This imbalance may lead to difficulties with chewing, swallowing, speech, and facial disharmony. In addition, this jaw misalignment leads to a maloccusion (bad bite), which may result in premature loss of teeth and early jaw joint (TMJ) problems. Corrective jaw surgery results in proper alignment of the jaws and, in conjunction with orthodontics, provides a stable bite and often an improved facial balance and appearance.

The initial diagnosis of jaw deformities can be made by a variety of dentists and physicians. Often it is the general Dentist or Ortho-dontist who first notices the growth or developmental changes in the jaws. Frequently, it is then an Oral and Maxillofacial Surgeon who makes the diagnosis when evaluating a patient for a variety of problems, some of which may seem unrelated to mal-alignment of the jaws. Since the treatment of jaw imbalance usually requires careful coordination between an Orthodontist and Surgeon, your diagnosis is made by careful examination and review of dental models, photographs, computer assisted imaging, and X-rays. Once the proper diagnosis is made, each specialist uses their expertise and techniques to reach the goal of restoring facial balance, and a stable attractive bite. Jaw realignment involves both the facial skeleton and the teeth.

This is why treatment often requires more than one specialist: the Orthodontist to move teeth and the Surgeon to realign the jaws. Treatment is divided into three phases. Phase one encompasses presurgical orthodontics. Phase two involves the surgical procedure to correct the jaw relationship. Phase three includes post-surgical orthodontics. Phase One: The Orthodontist straightens the teeth in each jaw independently as if the jaws were in proper alignment. Therefore, during this phase of treatment, your bite will actually become "worse".
Your Orthodontist and Surgeon will coordinate treatment and mutually decide when to proceed to the surgical phase. Phase Two: The jaws are brought into proper alignment during surgery. The surgery is performed in the operating room under general anesthesia, and is carried out from within the mouth eliminating the need for noticeable facial incisions or scars. The jaws are held in correct position with small screws or plates. These reduce the need for jaws and teeth to be wired together either entirely or for only a few days. A very soft "non-chew" diet is then followed for 4-6 weeks. The screws or plates are considered permanent and are rarely removed. Phase Three: Is used for "fine tuning" of the bite by the Orthodon-tist. This phase usually lasts for several months, after which the braces are removed and retainers are worn to maintain the bite.

Just prior to surgery there will be several visits to our office. Final, detailed treatment planning for the surgical procedure is completed. A routine medical history and physical examination are performed and an extensive preoperative "teaching" session is completed in order to optimally prepare you for surgery.

Detailed information is given concerning what to expect in the hospital or out-patient facility, specific details about your operation, nutritional counseling, oral hygiene instruction, and details of post-surgical expectations and care. With modern advances, many procedures can be performed as outpatient surgery. Most patients return to school or work within seven to ten days. Discomfort is actually minimal. We expect numbness in the areas of surgery to last at least several weeks. During the healing phase, you can expect to lose approximately 5-10% of your body weight as a normal sequence of surgery.

However, following the nutritional guide-lines provided, the weight is usually regained without difficulty. Proper nutrition is very important to promote healing following an operation. A regular diet is resumed six to eight weeks after surgery. Exercise, with the exception of contact sports, can be safely resumed two to three weeks after surgery. Corrective jaw surgery may be a covered benefit of many major medical insurance policies. Medical benefits are preferred, as this is not "dental in nature".

We will contact your insurance carrier regarding your coverage prior to surgery. Our office staff is trained to provide information and assistance with pre-authorization and pre-certification for your surgical treatment. We care about your comfort. Most patients find the experience of orthognathic surgery (corrective jaw surgery) rewarding. Our surgeons and staff are always available to answer questions and assist you in preparing for treatment. Let us know if you would like to speak with patients who have already undergone corrective jaw surgery. Many of our patients are pleased to speak with you about their experience.

Q: When will I know exactly what operation will be required for me?

A : After full evaluation by both your orthodontist and surgeon, a plan for treatment is developed. As your teeth are moved, it is often necessary to modify the original plan. In the final stages before the operation, surgery is performed on models. This "model surgery" provides your surgeon with additional information about your operation before the final plan is made. This is why your specific surgical plan may change slightly just prior to surgery.

Q: WHat type of aneSthesia will I have?

A: All patients undergoing corrective jaw surgery will have general anesthesia. This means that you will be completely "asleep" before any part of the operation begins, and all of the operation is complete before you are awakened.

Q: Is CORRECTIVE JAW surgery painful?

A: It is very rare for patients to complain about much dis- comfort associated with this treatment, in fact, some of the mouth and face will be numb for a period of time.

TMJ
The temporomandibular joint (TMJ) is the jaw joint. There are two TMJ's, one on each side of the head just in front of the ears. The TMJ is unique among body joints for many reasons. First, it contains a different type of cartilage than other moving joints. Second, it has a hinge action, like the knee, a sliding action like the wrist, and a rotating action, like the hip. Third, the lower jaw connects both the right and left joints to each other.The TMJ is similar to a "ball and socket". The "ball" is the condyle at the top of your lower jaw. The "socket" is the fossa at the base of your skull. Between the condyle and fossa is a cushion of tissue, usually called the disk. There are various ligaments holding these structures together.

In order for the TMJ to function properly, the shape, integrity, and position of each component must be adequate and must interact properly with the associated muscle, teeth, and connective tissue. During your visit to our office you will be asked to complete a questionnaire that reviews not only your facial pain, but your medical and dental history as well. This helps us identify and focus on important issues related to your discomfort. You will undergo a variety of jaw measurements and, usually, a radiograph (X-ray) examination.

We will complete a thorough clinical examination of your jaws and jaw joints, as well as the head and neck. After reviewing all of the information gained from your history, examination, and radiographs, a variety of approaches may be used to arrive at a final diagnosis. Additional imaging studies, such as special X-rays, CT scans, or MRI may be ordered by your doctor. At other times medications or physical therapy are used to assist us in reaching a diagnosis. Because so many different types of problems can cause facial pain, we take this systematic approach. We understand and appreciate that it requires patience on your part as you pro-gress through your evaluation. Often, it is necessary to complete a somewhat lengthy evaluation just to arrive at a proper diagnosis, and determine what treatment will be most helpful.

The term "TMJ" has often been used as a "catch all" for many types of disorders. The TMJ is often blamed for a variety of symptoms when it may be functioning normally. TMJ pain may be from problems either outside the joint itself, or from derangement of its internal components. External sources, such as muscular headaches or sore jaw muscles, may cause referred pain to the joints. Internally, stressed ligaments, disruption or destruction of the disc, inflammation, and arthritis may cause pain. There are many theories on the cause of TMJ disorders, but in most cases there is more than one factor responsible. Contributing factors may be jaw trauma such as a sports injury, car accident, an improper bite, nervous habits such as clenching or grinding your teeth, and psychological factors including stress. Some medical problems including various types of arthritis, neuromuscular imbalances, inflammatory and connective tissue diseases can cause TMJ problems. Sometimes growth and development problems in the jaws may be involved. Regardless of how much pain is involved, effective treatment may vary from simple care to more extensive therapy. Self directed care can be effective, such as exercises, nutritional therapy, and the use of stress reduction techniques.

he most common dental treatment is the occlusal appliance, or splint, which is used to relax your occlusion (bite) and reduce the strain on the joints to allow them to rest and heal. Psychological counseling often helps patients whose TMJ condition may be related to anxiety and depression, or for those who have had long term, chronic pain. Antidepressant medication, or medication for severe headaches, may also be part of the treatment. If non-surgical therapies are successful after several months, arthrocentesis (joint irrigation), may be attempted to break up adhesions and flush inflammation from the joint. If this treatment fails, we may recommend surgery on the disk, or other components of the TMJ. Surgery involves opening the joint through a concealed incision just in front of the ear. Surgical treatment in patients who have pathology or derangement within the joint is highly successful, but not guaranteed. If surgical intervention is recommended for you, we will be discussing the specific procedure, benefits, risks, and potential complications with you in great detail.

It is our goal to identify, and correct the cause of your facial pain. Reaching that goal may require many visits for non-surgical and surgical care. These types of problems are often complicated. However, when approached patiently and metho-dically, the long-term result is usually satisfactory. Please feel free to consult one of our doctors for any specific concerns.

Q: Why does my TMJ evaluation require answering so many questions, taking measurements, x-rays, or additional diagnostic procedures?

A: The treatment of facial pain first requires the proper diagnosis. Identifying the source of your pain is important to determine whether or not the pain is from within the temporomandibular joint, from other structures, or even from a medical condition not related to the joints. Ideally, TMJ surgery would eliminate pain completely. More realistically, successful TMJ surgery results in decreased dysfunction and pain, facilitating normal activities. Following TMJ surgery, you may occasionally have "flare ups" of TMJ discomfort. These post-surgical symptoms are usually treated conservatively with soft diet, rest, medications, and splint therapy.

Q: Why does my TMJ evaluation require answering so many questions, taking measurements, x-rays, or additional diagnostic procedures?

A: The treatment of facial pain first requires the proper diagnosis. Identifying the source of your pain is important to determine whether or not the pain is from within the temporomandibular joint, from other structures, or even from a medical condition not related to the joints.

Q: Why do some doctors treat TMJ problems with orthodontics, others with splints or dental adjustments, and still others with surgery?

A: When pain is related to muscle or ligament strain, a combination of medicine and physical therapy is often helpful. Medications may reduce inflammation or muscle spasms. Splints and dental adjustments may help reduce stress placed on muscles or ligaments caused by an unbalanced bite, or habits such as grinding or clenching. Orthodontics may accomplish the same goal by improving the bite. Surgery is used for correction of problems from within the joint itself, such as pathology or derangements.

Q: Will I be able to chew immediately after my operation?

A: Yes, in most cases a soft diet is prescribed for four to six weeks after surgery. With physical therapy, our goal is to return you to a regular diet in eight to twelve weeks.

Q: What about arthrocentesis, is it an option for me?

A: Yes, in many cases this would be a preferable first surgical step.

Q: If I have a TMJ operation can I be guaranteed that I won't need any further surgery?

A: There are no treatments in medicine or surgery that are successful 100% of the time.Ideally, TMJ surgery would eliminate pain completely. More realistically, successful TMJ surgery results in decreased dysfunction and pain, facilitating normal activities. Following TMJ surgery, you may occasionally have "flare ups" of TMJ discomfort. These post-surgical symptoms are usually treated conservatively with soft diet, rest, medications, and splint therapy.

Cleft Palate Bone Grafting
Patients with congenital bone clefts or defects of the front upper jaw usually require closure of the defect and associated openings into the nasal cavity. This may require bone grafting to the defect. The surgery is commonly done in conjunction with orthodontic alignment of the upper jaw teeth in the area of the defect, and most commonly between 8 and 11 years of age.

The goal of treatment is to support teeth adjacent to the cleft and those unerupted teeth in the cleft area that require placement of additional bone to help bring them into their proper place in the jaw. By surgically providing a continuous upper gum and bone (alveolar) ridge, a more normal appearance and stability of the jaw is achieved. This also provides support for the lip and nose with improved symmetry of the facial appearance.

After the bone graft is placed and healed, the orthodontist is able to continue proper alignment of the teeth and the bite. This may require many years of orthodontic and further surgical care to achieve the best possible dental bite and appearance as growth and development are completed. After these procedures are finished, final cosmetic lip and nasal cosmetic surgical procedures may be indicated.