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Surgical Dentistry

  • Implants

  • Dental Implants

    • Why Dental Implants?

    • Surgical Procedure

    • Types of Prostheses

    • Overview of Steps

  • Bone Grafting

    • Sinus Bone Graft

    • Socket Preservation Bone Graft

  • Wisdom Teeth

  • Impacted Teeth

  • Oral Pathology

  • Pre-Prosthetic Surgery

  • Cone Beam CT

  • IV Conscious Sedation

     

     

     

     

     

     

     

     

     

What is an Oral and Maxillofacial Surgeon?

An oral and maxillofacial surgeon is unique within the dental and medical fields due to the training and scope of practice. A rigorous 4 to 6 years of hospital-based surgical and anesthesia training is required after graduation from dental school to become an oral and maxillofacial surgeon. Many oral and maxillofacial surgeons, including doctor, obtain a medical degree during their training. During their residency training, oral surgery residents work in various medical specialties, such as internal medicine, general surgery, anesthesia, plastic surgery, otolaryngology, neurosurgery, and emergency medicine.

Oral and maxillofacial surgeons diagnose and treat the functional and esthetic conditions in areas related to the teeth, mouth and facial regions.

Scope of Training

  • Oral surgery:

    • Dental extractions

    • Dental implants

    • Bone and soft tissue grafts

    • Gingival surgery

  • Facial trauma treatment

  • Jaw and facial reconstruction

  • Surgical correction of jaw and facial deformities

  • Temporomandibular joint surgery

  • Facial esthetic procedures

  • Pathology of the mouth, face and neck

  • Outpatient anesthesia

What is a Certified Specialist in Oral and Maxillofacial Surgery?

A certified specialist in oral and maxillofacial surgery indicates that the surgeon has obtained high standards of training and knowledge in the specialty, and has been rigorously tested to ensure that this achievement has been reached.

A certified specialist has completed the following:

  • Graduation from a residency program in oral and maxillofacial surgery

  • Completion of the fellowship exam of the Royal College of Dentists of Canada

  • Obtained a dental specialty license from the appropriate provincial regulatory body

 

In (IRAQ-USA-U.K) there are nine recognized dental specialties:

  • Dental Public Health

  • Endodontics

  • Oral and Maxillofacial Surgery

  • Oral Medicine and Pathology

  • Oral and Maxillofacial Radiology

  • Orthodontics and Dentofacial Orthopedics

  • Pediatric Dentistry

  • Periodontics

  • Prosthodontics

Why choose a Certified Specialist in Oral and Maxillofacial Surgery for your care?

The intensive and rigorous training and examination requirements to become a certified specialist help ensure that the doctor has attained a high level of proficiency and expertise in diagnosis and management of conditions of the oral and facial region, including performing surgical procedures.

First Visit

Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, surgery can be performed on the same day as the consultation. However, a complex medical history or treatment plan will require an evaluation first and a second appointment to provide treatment on another day.

Please assist us by providing the following information at the time of your consultation:

 

  • Your referral slip and any x-rays if your dentist has asked you to bring them.

  • A list of your medical conditions and current medications.

  • If you have dental insurance, please bring your insurance information. This will save time and allow us to help you process any claims.

IMPORTANT: All patients under the age of 19 years of age must be accompanied by a parent or guardian at the consultation visit.

Dental Implants

 

Dental implants are changing the way people live. They are designed to provide a foundation for replacement teeth that look, feel, and function like natural teeth. Patients with dental implants can smile, speak, and eat with confidence. A full set of teeth also preserves the contours of the face, keeping you from looking old before your time.

 

 

What Are Dental Implants?

Dental implants are small titanium screws that are surgically placed into the jaw bone where teeth are missing. These metal anchors act as tooth root substitutes. The bone bonds with the titanium, creating a strong foundation for artificial teeth. Small posts, also known as abutments, are then attached to the implant. These posts protrude through the gums to provide stable attachments for artificial replacement teeth, which include crowns, bridges or dentures.

Implants also help preserve facial structure, preventing bone deterioration that occurs when teeth are missing. When all the teeth are missing and this bone recedes significantly, changes in facial appearance may occur, such as loss of lip support. This results in a collapsed appearance of the lips and skin wrinkling.

Why Select Dental Implants Over Traditional Treatment Options?

Generally, there are three prosthetic options to replace missing teeth:

1. Fixed bridge (bridge cemented over adjacent teeth)

2. Dentures (removable partial or full denture)

 

3. Dental implant-supported prosthesis (crown, fixed bridge, removable denture)

Fixed Bridge : Previously, a bridge was the only fixed (non-removable) solution for replacing missing teeth. However, there are several disadvantages of bridges:

 

  • When a bridge is placed, the adjacent teeth must be cut to hold the bridge

  • A bridge is usually more difficult to clean because one cannot floss in the normal way. Special floss must be used to keep the underside of the bridge clean; otherwise cavities will form on the support teeth, resulting in the bridge losing support and breaking off the support teeth.

  • The bone under a bridge will continue to recede (also called bone resorption) over time, which may result in noticeable spaces under the bridge. Dental implants placed in bone will help prevent this bone loss.

  • If there are multiple adjacent teeth missing, the span of the bridge will be longer, resulting in a higher risk of failure due to bite force overload. Dental implants can prevent this risk by either replacing each missing tooth with a single implant and crown, or by replacing the missing teeth with a bridge supported by multiple implants. In this way, the bite forces are dissipated over multiple implants.                                                                                                                                              

Dentures: The removable option for replacing one or more missing teeth. There are several disadvantages of dentures (full denture or partial denture):

 

  • The possibility of a loose fit and inability to chew hard food or speak properly.

  • A denture can feel bulky in the mouth and affect the sensation of taste.

  • Jaw bone recession over time, resulting in a loose denture since it does not fit to the underlying tissue anymore. Dental implants help retain bone and minimize this bone loss.

  • If a partial denture is made, some of the natural teeth may need to be cut/prepared to support and retain the denture.          

Because dental implants have a longer success rate than bridges or dentures, dental implants over a lifetime can be the cost-effective as well as esthetic treatment of choice. However, each person is unique and has different circumstances. We recommend that you discuss all treatment options with your dentist and oral surgeon prior to making a decision.

 

The advantages of dental implants include the following:

 

  • Improved function for eating and speaking

  • Enhanced appearance and smile

  • Greatly reduced bone loss compared to dentures and bridges, thereby the possibility of esthetic compromise or loose dentures is prevented

  • Other teeth do not need to be cut/prepared as with the case in placing a dental bridge or with a partial denture

  • Greater success rate (lifespan) of implants compared to dentures or bridges. The prosthesis (crown, denture or bridge) on the implants will undergo normal wear and tear and may need repair or replacement in the future

  • Ease of cleaning for individual implant crowns- similar to brushing and flossing a natural tooth                                               

The disadvantages include the following:

  • Usually longer duration of treatment from implant placement to final prosthesis placement

  • Usually higher initial cost

  • May require bone grafts to support the implant if there is insufficient bone                                                                                                                            

Are You A Candidate For Implants?

If you are considering implants, your mouth must be examined thoroughly and your medical and dental history reviewed. If you mouth is not ideal for implants, ways of improving outcome, such as soft tissue grafting or bone grafting, may be recommended.

What Type Of Anesthesia Is Used?

The majority of dental implants and bone grafts can be performed in the office under local anesthesia, with or without conscious sedation.

Do Implants Need Special Care?

Once the implants are in place, they will serve you well for many years if you take care of them and keep your mouth healthy. This means taking the time for good oral hygiene (brushing and flossing) and keeping regular appointments with your dentist. Poor oral hygiene and lack of follow up with your dentist for cleanings and check ups may result in failure of the dental implants and the attached prosthesis.

The Surgical Procedure

 

Dental implant placement is a team effort between the surgeon and dentist (or prosthodontist). While doctor performs the actual implant surgery, initial tooth extractions, and bone grafting if necessary, the restorative dentist (your dentist) fits and makes the permanent prosthesis. Your dentist will also make any temporary prosthesis needed during the implant process.

For most patients, the placement of dental implants involves two surgical procedures. First, implants are placed within your jaw bone. For the first three to four months following surgery, the implants are beneath the surface of the gums gradually bonding with the jaw bone. You should be able to wear temporary dentures and eat a soft diet during this time. For a missing front tooth, a temporary partial denture (“flipper”) or sometimes a temporary crown can be used so that you do not have a missing tooth when you smile or speak. If the dental implant is replacing a tooth in the back of the mouth, you have the option of just leaving the space open while the implant heals under the gums.

After the implants have bonded to the jaw bone, the second stage begins. doctor will uncover the implants and attach small posts (also called healing abutments) that protrude through the gums. After 2-3 weeks of gum healing, your general dentist or prosthodontist will make the final crown(s) or prosthesis. Most patients experience minimal disruption in their daily life.

Surgical Advances

Single Stage Implants:

Using the most recent advances in dental implant technology, doctor  may be able to place single stage implants. With single stage implants, the healing abutments are placed at the same time as the implants are placed so as to avoid a second stage surgery to place them. A minimum of 3 months of healing time is required before the crown or prosthesis can be made.

Immediate Implant after Tooth Extraction:

There are even situations where the implants can be placed at the same time as a tooth extraction – further minimizing the number of surgical procedures. Traditionally, after a tooth was extracted, a waiting period of three months was required for adequate bone healing before implant placement. In certain circumstances, doctor can place the implant during the same appointment as the tooth extraction, thereby eliminating the traditional 3 month waiting period. This is called immediate implant placement.

Dental Implants: Types of Prostheses

 

What Types Of Implant Prostheses Are Available to Replace Teeth?

A crown is used to replace one missing tooth – each crown attaches to its own implant.

A partial prosthesis (fixed bridge) can replace two or more teeth and may require only two or three implants.

 

A complete dental prosthesis (fixed bridge or removable overdenture) replaces all the teeth in your upper or lower jaw. The number of implants varies depending upon which type of complete prosthesis is planned. A removable overdenture attaches to a bar or ball on the implants, whereas a fixed prosthesis is permanent and removable only by the dentist.

 

Surgeon will work with your dentist to plan the prosthetic stage of replacing your tooth/teeth. If you do not have a dentist or prosthodontist, Surgeon can refer you to one that is experienced in the prosthetic replacement of teeth on dental implants.

Overview of Steps in Replacing Missing Teeth with Dental Implants:

  • Examination and preliminary X-rays and/or C.T. scan

  • Extraction of tooth/teeth as needed

  • Soft tissue grafts and/or bone grafts as needed

  • Placement of the dental implants

  • Delivery and installation of the prosthesis: crown, fixed bridge, or removable prosthesis

Bone Grafting  

Over a period of time, the jaw bone associated with missing teeth recedes away. This often leaves a condition in which there is poor quality and quantity of bone. In these situations, most patients are not candidates for placement of dental implants because implants require adequate bone for a stable foundation.

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. Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease or injuries.

When a bone graft is required, it may be placed at the same time as implant placement. However, if there is a lot of missing bone, the bone graft will have to be placed first and allowed to heal for at least 3-6 months prior to implant placement. Surgeon will provide his recommendation after completing the exam and reviewing the x-rays.

There are five main sources of bone for grafting:

  • Your own bone- usually obtained from a location within your jaw

  • Human donor bone

  • Animal bone- usually bovine (cow) bone

  • Synthetic- usually a calcium phosphate material

  • Human growth factors- e.g.: bone morphogenic protein

Sinus Bone Graft (Sinus Lift)

The maxillary sinuses are air-filled cavities that are behind your cheeks and above the upper back teeth (molars and premolar teeth). After upper back teeth are removed, there may be inadequate height of bone to support a dental implant. In this situation, a sinus bone graft may be advised.

A sinus bone graft increases the quantity of bone in the upper jaw so that there is enough bone support for implants. The surgeon enters the sinus and a bone graft is inserted into the floor of the sinus. Sometimes there is sufficient existing bone to stabilize the implant so that the sinus bone graft and implant placement can be performed at the same appointment. If not enough bone is available, the sinus graft will have to be performed first and allowed to heal for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.

There is inadequate height of bone for implant placement. A sinus bone graft is placed and allowed to heal. Later, the implants are placed.

Socket Preservation Bone Graft

 

After a tooth is extracted, the surrounding bone will start to recede. Within one year of extracting a tooth, the bone may lose as much as 50% of its width. This may very well prevent placement of an implant.

If you are planning to have an implant placed, Surgeon may recommend a socket preservation bone graft at the time of tooth removal. The purpose of this procedure is to preserve the bone height and width, thereby minimizing the amount of bone deterioration prior to implant placement. In this procedure, a bone graft material is placed into the tooth extraction socket immediately after a tooth is removed. The graft is then covered with a dissolvable collagen material to protect and hold the bone graft within the socket. The gum tissue will heal over the bone graft over 3-4 weeks. After 3-4 months of bone graft healing, the site is then ready for an implant to be placed.

Each person’s situation is unique. At your consultation appointment Surgeon will advise you whether a socket preservation bone graft is recommended.

 

Socket Preservation Bone Graft at the Time of Tooth Removal

 

Wisdom Teeth

Wisdom Tooth Presentation

To provide you with a better understanding of wisdom tooth extraction, we have provided the following multimedia presentation. Many common questions pertaining to wisdom tooth extraction are discussed.

 

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 premolar teeth) are ideal for grasping and biting food into smaller pieces. The back teeth (molar teeth) are used to grind food into a consistency suitable for swallowing.

The average mouth usually has enough room 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 Have My Wisdom Teeth Removed?

Wisdom teeth are the last teeth to erupt within the mouth. When they align properly and the gum tissue is healthy, wisdom teeth do not have to be removed. Unfortunately, this does not usually happen. The extraction of wisdom teeth is recommended when they do not properly erupt within the mouth. They may grow sideways, partially emerge from the gum, and even remain trapped beneath the gum and bone. In these situations, the wisdom teeth are described as “impacted”. Impacted wisdom 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 partially erupt through the gums, it is difficult to keep the area clean. This results in food getting stuck, and plaque and tartar to build up on the tooth surface. The result is discomfort in the gums, but can progress to pain, swelling, and jaw stiffness if a gum infection develops. Cavities may also form on either the wisdom tooth or the second molar in front due to the difficulty in cleaning. Again, this can cause pain and infection if left untreated. Oftentimes, the cavity on a second molar can be too deep for a dentist to place a filling. In that situation, the second molar must be removed. Although rare, the most serious problem occurs when tumors or cysts form around the impacted wisdom teeth, resulting in the destruction of the jaw bone and healthy teeth. Early removal is recommended to prevent the above problems and to decrease the surgical risk involved with the procedure. People who have wisdom teeth removed when they are younger tend to have a quicker recovery (less pain and swelling) and fewer complications.

X-ray demonstrating a cavity in the impacted wisdom tooth and signs of infection in the bone due to difficulty in keeping the tooth clean.

 

X-ray demonstrating a cyst around an impacted wisdom tooth

The Consultation

With an oral examination and x-rays of the mouth, Doctor can evaluate the position of the wisdom teeth to determine if there are current or possibly future problems. Patients are generally first evaluated in their mid-late teenage years by their dentist, orthodontist or by an oral and maxillofacial surgeon. At the consultation appointment Doctor will discuss with you if removal of the wisdom teeth is advised, the benefits and risks of treatment or no treatment, and the alternative treatments if available.

Anesthesia

In most cases, the removal of wisdom teeth is performed under either local anesthesia or sedation. Doctor has the training, qualifications, and experience to provide various types of anesthesia. He generally recommends IV conscious sedation for patient comfort during removal of wisdom teeth.

After Removal

Once the teeth are removed, the gum is usually sutured. To help control bleeding, bite down on the gauze placed in your mouth. You will rest under our supervision in the office until you are ready to go home. Upon discharge, you will receivepostoperative instructions, and a prescription for a pain medication, antimicrobial mouth rinse and possibly an antibiotic and corticosteroid (for swelling reduction) depending on your medical history and the complexity of the surgery.

 

Impacted Canines

An impacted tooth means that it is “stuck” and cannot erupt into function. The most commonly impacted teeth are wisdom teeth. However, any tooth in the mouth can become impacted and steps may be taken to try to bring the tooth into function. Management of an impacted canine tooth is explained below.

Impacted Canine Tooth

The maxillary canine (also called an upper cuspid or eye tooth) is the second most common tooth to become impacted. The canine 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 that they guide the rest of the teeth into the proper bite.

Normally, the maxillary canine teeth erupt into place around age 13 and cause any space left between the upper front teeth to close tighter together. If a canine tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch.

Early Recognition Of An Impacted Canine Is Important

The American Association of Orthodontists recommends that a panorex screening x-ray, along with a dental examination, be performed on all dental patients around the age of seven years to count the teeth and determine if there are problems with eruption of the adult teeth. This exam is usually performed by your general dentist who will refer you to an orthodontist if a problem is identified.

If the canine tooth is impacted, an orthodontist may place braces to open spaces between the teeth to allow for proper eruption of the canine. Treatment may also require referral to an oral surgeon for extraction of retained baby teeth, extra teeth (supernumerary teeth) and/or adult teeth that are blocking the eruption of the canine.

The older the patient, the more likely an impacted canine will not erupt by itself even if the space is available. If the eruption path is cleared and the space is opened up by age 11-12, there is a good chance the impacted canine will erupt by itself. By age 13-14, it is less likely that the impacted canine will erupt by itself even with the space cleared for its eruption. The treatment for this problem is explained in the next section. If the patient is over 40, there is a much higher chance the tooth will be fused in position. Unfortunately, the only option in this case is to extract the impacted tooth and replace it with a dental implant, or leave the impacted tooth and replace it with a fixed bridge or removable partial denture.

What Happens If The Canine Will Not Erupt When Proper Space Is Available?

In cases where the canine will not erupt spontaneously, the orthodontist and oral surgeon will work together to treat this problem. Each case must be evaluated on an individual basis but treatment will usually involve the orthodontist placing braces on the teeth (at least the upper arch). The braces will be used to open a space between the teeth to provide room for the canine to be moved into its proper position. If the baby canine has not fallen out already, it is usually left in place until the space for the adult canine is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon.

The surgeon will lift the gum on top of the impacted tooth to expose the hidden tooth underneath. If there is a baby tooth present, it will be removed at the same time. The oral surgeon will bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature chain attached to it. The chain will then be temporarily attached to the orthodontic arch wire. Sometimes the surgeon will leave the exposed impacted tooth uncovered. 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 the patient will return to the orthodontist. A rubber band will be attached to the chain to pull 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. Once the tooth is moved into the arch in its final position, the gum around it will be evaluated. In some circumstances, minor “gum surgery” may be required to add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function.

Other Impacted Teeth

The basic principles described above for the management of an impacted canine tooth can be applied to other impacted teeth in the mouth (except wisdom teeth, which are generally removed). Consultation with your orthodontist and oral surgeon will provide you an individualized treatment plan based on your circumstances.

Oral Pathology

The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and pink in color. Any alteration in this appearance (a “lesion”) could be a warning sign for a pathological process. The most serious of these is oral cancer.

The following can be signs of a lesion:

  • Red or white patches in the mouth.

  • A sore that fails to heal and bleeds easily

  • A lump or thickening on the mucosa lining inside of the mouth

  • Chronic sore throat or hoarseness

  • Difficulty in chewing or swallowing

  • Unexplained swelling

  • Numbness of the lips and chin not attributable to another cause

These changes may be detected on the lips, tongue, gums, and mucosa lining in your mouth. Pain does not always occur with pathology.

 

Pre-prosthetic Surgery

 

The preparation of your mouth before the placement of a prosthesis (e.g.: denture) is referred to as pre-prosthetic surgery.

Some patients require minor oral surgical procedures before receiving a partial or complete denture in order to ensure the maximum level of comfort. A denture sits on the gums and the underlying bone ridge, so it is very important that they are the proper shape and size. After a tooth is extracted, the underlying bone might be sharp and uneven. The bone would then need to be smoothed out or reshaped to ensure a comfortable fit of the denture. The gums may also be loose and mobile, or very large and bulky. In either case, gum surgery would be required to correct this situation to ensure a stable and comfortable denture fit. One or more of the following procedures might need to be performed in order to prepare your mouth for a denture:

  • Bone smoothing and reshaping (alveoloplasty)

  • Removal of excess bone (tori removal)

  • Bone ridge reduction (alveolectomy)

  • Removal of excess gum tissue (gingivoplasty or gingivectomy)

  • Exposure and/or removal of impacted teeth                                                                                                                                                                        

We will review your particular needs during your consultation appointment.

Cone Beam CT

In addition to two dimensional digital radiography, Richmond Oral and Facial Surgery offers an advanced imaging modality known as cone beam computed tomography (CBCT). CBCT is a three dimensional scan of the jaw and teeth which provides a level of anatomical accuracy not possible with 2-D technologies.

Dr. Chau may recommend a CBCT under certain circumstances if he believes the scan would provide information that would improve your care. A typical example is in implant and bone graft treatment planning. Another example is evaluating the location of the nerve in relation to the roots of a wisdom tooth. Taking a CBCT scan is similar to getting another well-known x-ray known as a panorex. It takes less than 30 seconds to obtain a CBCT scan, and within minutes you can review the findings with Dr. Chau on a monitor.

Examples of Cone Beam C.T.

The above panoramic x-ray shows an impacted canine tooth in the upper jaw. However, the root of the tooth is not very clear.

 

 

A cone beam C.T. scan clearly and accurately shows the very curved root of this impacted canine tooth.

A cone beam C.T. scan was taken to evaluate this subtle jaw fracture in a patient.

IV Conscious Sedation

IV (intravenous) conscious sedation is a safe form of anesthesia for patients who are nervous and/or want to be asleep for the surgery. During your consultation appointment, Surgeon will evaluate your medical history to determine if you are a candidate for IV sedation in the office.

A patient who undergoes IV sedation first has an IV started in a vein in the arm. The medication is then administered through the IV line, and within one to two minutes, the patient will fall asleep (sedation). Once a person is sedated, the surgical procedure will commence.

During this period of sedation, the patient is continually monitored by Surgeon and his staff. Specialized monitoring equipment that is used includes a heart rhythm monitor, blood pressure cuff, and pulse oximetry.

After the surgery is complete, it usually takes about 20-30 minutes for a patient to wake up and be ready to go home. A responsible adult is required to escort the patient back home either by car or taxi. The patient will also have some numbness in the mouth for a few hours since local anesthetic (freezing) is administered while asleep.

 

How is IV Conscious Sedation Different From Other Forms of Sedation?

IV conscious sedation is different from oral sedation and general anesthesia. In oral conscious sedation, a person takes an oral pill and must commonly wait about 30 - 60 minutes for a feeling of relaxation to take affect. Although a patient can be given larger doses to become unaware of what is going on (sedation), it is difficult to dose to this level and there is a risk of over-sedation. In general anesthesia, the patient has a deep anesthetic which requires supervision by an anesthetist, and the patient has a breathing tube inserted to maintain proper breathing.

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