Normally we are born with 32 teeth in an adult dentition. This means 16 in the top and 16 in the bottom. The last teeth to erupt at around 18 years of age are the wisdom teeth right at the back of the mouth. Actually wisdom teeth are normal teeth that just arrive a bit late. Because the whole jaw is usually occupied with other teeth, wisdom teeth have to fit into whatever space is left. Often there is no room and that's where the problems start.
In some cases wisdom teeth may fit in fine and do not cause immediate problems. These patients are lucky and can treat them just like ordinary teeth. If problems are seen they normally fall into three categories.
If there is limited space, a corner of the wisdom tooth may erupt through the gum and then stay that way. Once or twice a year the patient may feel a bit of discomfort and swelling. Normally they think that "the tooth is coming through". In real terms, the area around the crown is always infected because food and bacteria get under the gum causing a chronic infection around the crown called pericoronitis. Once or twice a year this turns into an acute episode which causes pain an swelling.
The second area of concern is that if wisdom teeth have no place to erupt they start "pushing" forward against the remaining teeth. These then may start crowding together in the front, causing shifting and malocclusions. If a patient has had orthodontic treatment this may be very distressing because it can ruin results from such treatment.
The last problem that occurs repeatedly is a wisdom tooth that is angled forward and pushes against the root of the tooth before him. Initially no symptoms may be present and the patient may feel that everything is fine. "They don't worry me at all". The result over time is often that the tooth in front of the wisdom tooth develops root decay at the point of contact. In the end, the patient looses the tooth before the wisdom tooth and has to go to great length to have it replaced.
It makes sense to evaluate the situation and to take appropriate measures before these issues occur. Normally we will evaluate a young person at about 18 years of age. An x-ray will be taken to determine the presence and position of any wisdom teeth as well as the potential for future complications. If the teeth look as if they may cause trouble in future it will be recommended to have them removed at that time.
Removal of wisdom teeth can normally be done in the dental chair with local anaesthetic's. Because of the amount of anaesthetic that has to be used, we recommend that teeth are removed in sessions of two at a time.
If patients are reluctant to have the procedure done in the chair or want all four teeth removed at once we will refer them to a maxillofacial surgeon who will perform the procedure under general anaesthetic in a hospital.
Bone build-up of an area in the mouth is also called bone augmentation. It normally goes together with placing dental implants.
Bone is lost through various means. The following are the most common reasons:
- Bone loss from gum infections. This is found around the tooth while a tooth has a periodontal infection.
- Bone loss from root infections and abscesses. If a patient gets an abscess bone is lost at the tip of the root.
- Teeth with root fractures. If a root is split or has a longitudinal crack, it may result in a chronic infection with bone loss in the area of concern.
- Bone loss from an traumatic extraction. If teeth are extracted and a section of the surrounding bone is lost it will not re-grow. Today special techniques are used called "autraumatic extraction" to preserve the bone for later.
- Natural bone loss called "bone resorbtion" in areas with missing teeth. This is a normal process and happens after teeth have been extracted. This process is accelerated if a person wears an ill-fitting denture that pushes on the gum.
When bone has been lost it never grows back on its accord. Today lack of bone is a major challenge when dental implants are planned. Implants rely on adequate bone as a foundation and cannot be placed if insufficient or extremely soft bone is present.
If a bone ridge needs to be augmented the area is anaesthetized and the bony area exposed. The recipient site is prepared by removing all infected tissue, cleaning away soft tissue remnants and placing small holes in the underlying bone. This allows new blood vessels to grow upwards and to supply the new bone that will be placed.
Bone is obtained by harvesting in an area away from the recipient site. The patients own bone is mixed with artificial bone granules and placed into the recipient site. A whitish membrane is placed over the bone mixture and the gum is then sutured back into place. The membrane will have to be removed at a later stage or it may dissolve after a few months. Membranes prevent the overlaying soft tissue to grow into the new bone. This would prevent the slow growing bone to attain adequate strength and the results would be compromised. In addition membranes prevent shrinking of the new bone before implants are placed.
Ridges can be augmented in height and width. In extreme cases two procedures may be required to obtain enough bone.
In the upper jaw the situation is slightly different. In the back areas the maxillary sinus is situated above the tips of the molars. If a molar is lost, the sinus may grow down thus leaving a hollow area which is not suited for implants. To solve this problem sinus lift procedures can be performed.
Again the area is anaesthetized, and the side of the sinus is exposed. A small opening is prepared and artificial bone is placed to "thicken" the layer of bone that will be available to place the implant. The area is then closed up and left to heal for 4 to 6 months.
Bone is slow growing tissue. Artificial bone and the patients own bony tissue form new bone over a few months. During this process the area has to be protected. Gum tissues grow a lot faster and will invade areas of bone if not protected by membranes. After augmentation bone should be left for 4 to 6 months to heal and mature. In certain cases implants are placed at the same time as the bone buildup. This saves time and eliminates a second procedure.
Dental implants are "artificial roots" that are placed into a bony site. Implants will integrate into the jaw over 3 months and can be restored to anchor new crowns, fixed bridges or even dentures.
Periodontal surgery involves the gum and the bone around your teeth. It is performed to stop infection and gum disease, to improve the health of your soft tissues and to modify and improve areas of the visible gum that look displeasing.
Common issues that require periodontal surgery are the following:
Open Flap Surgery
Advanced periodontal (gum) infections with bone loss around one or more teeth. Here the patient and the clinician cannot reach into the deep pockets that have formed over time. Cleaning these areas to initiate healing requires the gum to be lifted, the roots and surrounding bone cleaned and treated with special antibiotics.
Infections at the tip of the root that could not be solved by conventional root canal therapy will sometimes be approached by this technique. Here the area is anaesthetized, the tip of the root is removed and the area cleaned from all infected tissue. The resulting hollow in the jawbone is filled up with artificial bone granules. This procedure is called an apicectomy. Healing leaves the tooth a bit shorter but if successful with no infection. This procedure is especially valuable if the tooth is part of a larger bridge that would need to be replaced if the tooth cannot be saved.
Guided Bone Regeneration (GBR)
Bony defects near the root of one or more teeth that resulted from gum disease can sometimes be filled with artificial bone. In a case like that the area is anaesthetized, the gum is opened and the roots, bone and surrounding tissues is cleaned meticulously. The the root of the tooth is etched with a mild acid to remove all bacterial toxins. Artificial bone is packed against the root and around the tooth. This is covered by a special teflon membrane to keep gum tissue away from the area. In this way the bone can regrow and mature without being hampered by soft tissues. It is "guided to regenerate".
GBR can be successful in special cases. It requires good surgical skills and patients who are dedicated to excellent home care and committed to regular follow up and professional cleanings.
Aesthetic Gingival Surgery
In cases where the gums are asymmetrical, show grey crown margins or have receeded, various surgical techniques are available to improve the aesthetic situation. Please feel free to ask us about various possibilities.
What to do!
After wisdom teeth removal, bone augmentation, implant placement or periodontal surgery patients should do the following:
- Strictly use the medication as prescribed.
- Keep ice packs over the area as long as possible. Even if it is for 3-5 hours.
- Rest for the rest of the day. Don't be a hero.
- Never rinse your mouth more than twice a day. Rinsing too much can remove the natural blood clot and leave the wound open to bacterial infection.
- Never smoke after surgery! This should be at least 10 days. (Better is forever) Smoking is a killer for any healing process and can initiate severe infections.
- Avoid coarse foods like whole wheat bread with seeds, muesli or grainy cereals. Seeds easily get stuck in a wound and may interfere with healing. Normal smooth food is fine.
- Discuss any homeopathic remedies with us first. Some homeopathic substances have dramatic side effects that can influence post-operative healing.
What to expect!
For the week after surgery patients can expect the following:
- A certain amount of swelling up to about 4 days.
- Pain and discomfort for about 3-5 days.
- Difficulty in opening their mouth wide.
- After 5-7 days the patient should be fine and functions should be back to normal.
When something is wrong!
How does it feel if something is going wrong? The following will indicate that a patient should contact us and have things checked:
- Excessive bleeding after an hour or even later. A bit of bloody saliva is normal and will stop after 2 hours.
- Increasing pain and swelling after 3-5 days.
- Foul smell and taste coming from the wound.
- Redness and swelling over the outside areas.
- Warm or heated skin over the removal area.
- Any itching or redness on the rest of the body. The patient may be allergic to the medication.
The above areas indicate that some infection is interfering with the healing process. In this case the wound will be cleaned out gently and specific medication applied to the area.
If anything seems out of place, please give us a call! We'll help you to be comfortable and on the road to recovery soon.