Wisdom teeth surgeries and removals are a common procedure. The wisdom teeth are also called the third molars and are the last to grow in your lifetime. They are located at the far corners of the mouth two at the top and two at the bottom.
Reasons for surgery Through a person’s teens, 28 teeth are already grown and in place. This means that there might be just about no room left for the wisdom tooth to grow appropriately. With deficiency of space, the teeth either emerge at an angle or just get stuck. The impacted wisdom teeth that haven’t broken through the surface of the gum fully can cause severe dental difficulties. There are resulting pain, infection and cyst formations that lead to ultimately extracting the teeth.
Untreated wisdom teeth may lead to:
- Damage to adjacent teeth
- A fluid-filled sac or a cyst
- Surrounding bone damage
Preparations and tests
A dental x-ray of the wisdom teeth and the adjacent teeth is taken
A thorough physical examination of the mouth and teeth are conducted
All medical and family history is collected
If you are a smoker, cessation of smoking is advised
The procedure for extraction of wisdom tooth lasts for about 30 to 60 minutes.
Local anesthesia is administered – injections near the area of the surgery at the gums will numb it
An incision in the gum exposes the tooth and the bone
Any bone blocking the access to the tooth is also removed
The area is cleaned of any debris after tooth is removed
The wound is stitched close and gauze is placed on the area to control bleeding
Slight bleeding might be experienced the first day and jaw may seem sore and swollen. A soft food diet is recommended for almost 3 days after the surgery. Normal activities can be resumed within 24 to 48 hours after the procedure. Oral antibiotics may be prescribed to aid the healing process.
Anatomy The treatment of maxillofacial trauma is quite complex and is best explained through the anatomy of the maxillofacial region. The region is divided into 3 parts: the upper face constituting of the frontal bone and the frontal sinus, the mid-face which constitutes of the nasal, ethmoid, zygomatic and maxillary bones and the lower face containing the mandible.The trigeminal nerve is responsible to deliver sensations to the skin on the face, besides motor functions such as chewing and biting.
Types of trauma
Frontal bone fractures happen when there is a blow to the forehead involving the frontal sinus also.
Orbital floor fracture is an isolated fracture involving the medial wall.
Nasal fractures occur when there is direct trauma to the nasal area.
NOE or nasoethmoidal fractures travel from the ethmoid bone to the nose with resultant damage to the lacrimal apparatus, the nasofrontal duct or the medial canthus.
ZMC or zygomaticomaxillary complex fractures are also as a result of direct trauma and affect the orbital floor and the infraorbital foramen and extending into the zygomaticomaxillary, zygomaticofrontal and zygomaticotemporal sutures.
Zygomatic arch fractures occur when there is a direct trauma induced to the zygomatic arch and can involve the zygomaticotemporal suture.
Maxillary fractures are of three types Le Fort I, II or III which is the horizontal maxillary fracture, a pyramidal fracture and craniofacial dysfunction respectively.
Alveolar fractures involve the alveolar area of the mandible or maxilla which usually occurs due to direct but low-energy impacts.
Mandibular fractures are secondary to the U-shape of the jaw, occurring in multiple locations.
Panfacial fractures involve the upper face, mid face and lower face combining 3 to 4 facial units.
Diagnosis and investigation
A physical examination is conducted to reveal if there is bleeding from the nose, nasal blockage or skin lacerations. There could be bruising surrounding the eyes and the distance between the eyes could be widened, with changes in vision and movement of the eyes.
Fractures are investigated with appropriate x-rays and CT scan of the head, upper face, mid face and lower face are conducted depending on the nature of the trauma.
A CBC is done to check for haemoglobin and haematocrit if excessive bleeding is noted. SMA-20 and bhCG studies are also conducted.
TreatmentUsually a surgical intervention is the treatment option if any of the injuries prevent normal functioning of the organs. The aim of the treatment is to clear the airway, control the bleeding, fix the bone segments by treating the fracture and even try and prevent scarring.
Sinus lift procedures
What is a sinus lift procedure?A sinus lift surgery or a maxillary floor sinus augmentation surgery is a bone grafting procedure performed to add bone to the upper jaw near the molars and the premolars. It raises the floor of the maxillary sinuses by moving the sinus membrane upward correcting bone height that might have been lost due to periodontal (gum) disease. Implants in the upper jaw are difficult to place especially due to poor bone quantity. The quality of the bone is also insufficient due its proximity to the sinus.Sinus lift procedures are essentially done by Sparks Dental’s specialists who are oral and maxillofacial surgeons.
Osteotome sinus lift The osteotome technique is a traditional or conservative method of sinus elevation and considered least-invasive. Also called the Summers Technique, the elevation is instantaneously followed by a dental implant. Bone grafting substance is fitted in the space between the bone and sinus floor by making a minute hole in the jaw bone. The holeis made for the dental implant and with the help of a surgical instrument, the sinus floor pushed upward through this hole.
Window sinus liftAlso known as LWT or lateral window technique, the sinus elevation procedure is necessarily followed by a healing period that can last at least up to 6 months. The technique believes that a sinus augmentation is a prerequisite to raise the maxillary posterior area which might have minimal residual bone quantity.
Crestal Window elevationCrestal Core Elevation or Crestal Window Elevation is a technique considered as a less invasive alternative to the Lateral Window Technique. The Lateral Window technique has its own limitations such as lack of visibility when the surgeon operates on the Schneiderian Membrane and accessing the sinus floor. The Crestal Window Elevation technique is predictable with low patient morbidities.
Advantages and uses of sinus lift procedure
The primary use or advantage of the sinus lift procedure is its ability to correct bone height in the upper jaw. When back teeth or molars are lost, there is very little bone left for an implant. The anatomy of the skull does not permit enough bone in the upper jaw as compared to the lower jaw.
The size and shape of the sinus varies from individual to individual and it can sometimes happen that the upper jaw and the maxillary sinus are naturally too close to each other for any implants to be affixed.
Bone resorption can occur due to tooth loss. When teeth in the area are missing for too long, bone loss can be noticed with very little space for implants to be placed.
Anatomy of the TMJThe TMJ or temporomandibular joint is a bi-arthoidal hinged jaw joint that allows complex movements such as chewing, swallowing, yawning and talking.It is made up of three bony surfaces the mandibular fossa, the head of the mandible and the articular tubercle. The articular disc separates the surfaces of the bone to reveal two synovial joints. It also consists of three extracapsular ligaments which are the sphenomandibular ligament, the lateral ligament and the stylomandibular ligament.
TMJ disordersA dysfunctional TMJ can be extremely painful and cause severe limitations to lifestyle. Some of the TMJ disorders are
Myofascial pain – pain and discomfort in muscles influencing jaw movements
Arthritis – inflammatory and degenerative category of joint disorder which can even affect the TMJ
Internal disorder such as derangement and displacement of the disc, trauma and injury to the condyle and dislocation of the jaw
Management of TMJ
ArthroscopyArthroscopy is usually done under general anaesthesia. A small incision is made in front of the ear. A slender lighted arthroscope is inserted through the slit into the temporomandibular joint for visualization along with other surgical instruments. The surgery attempts to reposition the disc, remove thickened cartilage and scar tissue, lavage the joint and tighten the joint.
Open joint surgery or arthroplastyA TMJ arthroplasty or open joint surgery is done when there are indications of bony aberrations, damaged and dislocated discs and severe adhesions. The patients present with intractable TMJ pain. Usually a choice of surgery for patients with intracapsularankylosis, the procedure aims at meniscoplasty or discoplasty, discectomy or meniscectomy, condylotomy, condylectomy and joint replacement (total or partial). An incision is made at the sideburn extending into the ear and the skin flap is reflected exposing the fascial layer. Then the TMJ capsule is exposed revealing the meniscus which is examined for abnormalities and subsequently repaired.
Arthrocentesis Arthrocentesis is done for patients presenting with displaced discs. Under local anaesthesia, the needle insertion sites are marked on the skin. There are usually two points one 10mm which corresponds to the glenoid fossa and the other 2mm point beneath the canthotragal line. A 19-guage needle is inserted in the first point and the joint space is filled with NaCl 0.9% saline solution. The needle is then introduced into the second point to fill the space with the solution. A total of about 400 ml NaCl 0.9% saline is used to conduct the lavage.
Indications Unusual and persistent oral mucosal abnormality despite removal of surrounding irritants and treatment, is indicative of a biopsy. These persistent lesions could bleed and grow rapidly imply suspected malignancy. The lesions are indurated and ulcerated, fixed deep into the tissues and are red or white in colour.
ApproachThere are several methods of sample tissue collections for histopathologic examination, from the oral mucosa. A standard scalpel biopsy can give a satisfactory specimen to perform a biopsy. Other means adopted are needle biopsy, punch biopsy, laser, biopsy punch and electrocautery devices. Comprehensive oral examinations routinely involve several diagnostic tests which provide ancillary information for a definitive diagnosis and treatment procedure.
Fine needle aspiration cytologyA fine needle aspiration cytology would be invited when a neck mass cannot be explained by mere physical examination. A prudent examination of the upper aerodigestive tract consisting of the larynx, nasopharynx and hypopharynx is warranted if the lesion believed to be metastatic. Topical or infiltrative anaesthesia is administered on the overlying skin. Larger needles or the common 21-guage needle attached to a custom 10 mL disposable syringe holders are used. As a simple clinical procedure, FNA is accurate when sufficient cells for examination are obtained
Incisional biopsyAn incisional biopsy aims to define a lesion on the basis of its histopathological aspect and establish prognosis of suspicious malignant and premalignant lesions. A most representative sample of the lesion is attained along with some peripheral normal tissues and intact mucosa is taken to make a definitive diagnosis. Incisional biopsies are performed on large ulcerated lesions with a long axis greater than 1cm. Diagnostic abilities are enhanced by staining the mucosa with toluidine blue or tolonium chloride dye which stains only the affected mucosa leaving the other areas intact.
Excisional biopsyA lesion may be removed in its entirety provided the differential diagnosis is a benign entity. Excisional biopsy includes the usage of a suction device which has to be used with caution to prevent inadvertent loss of lesion. The decision to perform an excisional biopsy is driven by the size of the lesion, its location, nature of attachment to underlying tissue, the regional anatomy and its accessibility. Local anaesthetics applied are regional or field blocks through infiltration of peripheral area of the lesion. After stabilizing the oral mucosa, the two ellipsical incisions are made all around the lesion. A wedge-shaped specimen is collected and the wound left behind is easy to close.
Tumors of the jaw
Soft tissue tumours: Soft tissues are connective tissues, adipose tissues, skeletal muscles and supportive tissues of the peripheral nervous system. Histologic classifications of the soft tissue tumours are based on its morphological demonstrations. Overall soft tissue tumours are heterogenous and composite mesenchymal lesions with extensive differentiations. Developing in the connective tissue, the soft tissue sarcoma is an uncommon incidence of cancer. They possess a wide spectrum of biological behaviour with about 50 histologic subtypes. They are broadly distributed in terms of occurrence as:
Other sites, head and neck 12%
Jaw bone tumours: Osteosarcomas are malignant tumours of the bone rising histologically known to produce malignant osteoids. They predominantly emerge mesenchymal cells responsible for the formation of bones. Odontogenic mandibular cysts or tumours of the jaw bone are structures lined with odontogenic epithelium and are defined by their location rather than their histologic attributes. There are several types of odontogenic cysts:
Periapical cyst: Periapical cysts are one of the most common of odontogenic cysts with etiological presentations related to tooth infection which in turn leads to the necrosis of the pulp.
Dentigerous cyst: Also one of the common odontogenic cysts, develops in the confines of the dental follicle that encompasses an unformed tooth. It is not neoplastic and frequently found in the mandibular and maxillary third molars and maxillary canines.
Lateral periodontal cyst: These are non-inflammatory cysts, small, radiolucent and well demarcated. They are found in the mandibular premolar space and sometimes in the maxillary anterior.
Primordial cyst: Cystic degeneration of a formative dental follicle which does not complete odontogenesis is called a primordial cyst. It is rare and diagnosis is subject to complete dental history of a patient.
Odontogenic Kertocyst: Kertocystic odontogenic tumours are of extreme importance with histologic diagnosis. They are aggressive lesions, grow rather rapidly, difficult to remove and recurrent.
ORAL CANCER SCREENING
The death rates due to oral cancer have been steadily increasing over the past decade. Incidences of oral cancer are heavily dependent on habits such as smoking and tobacco abuse. One of the most common oral cancer is the squamous cell carcinoma among the lesser known ones which are melanoma, Kaposi sarcoma and adenocarcinoma all occurring intraorally.
The oval shaped oral cavity is divided into two parts the oral vestibule and the oral cavity proper. The binding factors are lips – anterior, cheeks – lateral, mouth – inferior, oropharynx – posterior and palate – superior. The bony case of the oral cavity is made up of the maxillary bones and the mandibular bones. The lips, tongue, gingiva, teeth, hard palate, retromolar trigone, cheek mucosa and the floor of the mouth, together form the oral cavity.
Physical Exam: Oral cancer can occur anywhere – the tongue, gingival, floor of the mouth, tonsils, oropharynx, salivary glands and the hypopharynx. The popular squamous cell carcinoma is perceived on the lateral perimeter of the tongue. The retromolar trigone, the floor of the mouth and the hard and soft mucosa may also be affected. Though the most difficult portion to examine is the posterior-inferior tongue due to its location, a thorough physical examination will reveal red and white coloured formations on the surface textures. Observations are erythroplakia or patchy erythema or leukoplakia. The surface mucosa appears eroded and ulcerated, flat yet moderately raised as a plaque.
Radiological Tests : Imaging is extremely useful especially CT scan and Cone CT for assessing cancer in the bone. For lesions in the tongue and intraoral soft tissues MRI is recommended. For more about radiological screenings, please view: <22SPARKS_GENERALDENTISTRY_ ORALMEDANDRADIO>.
Diagnostic Tests: Sparks Cosmetic and Dental Centre adopt some of the latest oral cancer screeing and diagnostic techniques.
Cytomorphometry – Also known as the oral CDx brush test, a brush biopsy is obtained along with a DNA cytometry for screening oral cancer. Preneoplastic lesions such as lichen ruber, lichen planus, verrous leukoplakia etc. are screened through exfoliative biopsy. The mucosa is scraped off in a rotation from about 5 to 15 times under firm pressure.
Tissue molecular markers – Combined with brush biopsy, biomarkers and peptide profile patterns are assessed with the help of MALDI-TOF-MS or matrix assisted laser desorption or ionization – time of flight – mass spectrometry.
DNA image cytometry – This technique is done in combination with brush biopsy to assess oral leukoplakia to predit the onset of oral dysplasia. It efficiently differentiates between keratocanthomas and squamous cell carcinoma of the dermous.
LSCEM – LSCEM stands for laser scanning confocal endomicroscope which is a non-invasive imaging technique which scans the mucosa at a microscopic level. It captures volumetric datasets through progressive depth slices.
Oral cancer screening by standardized criterion requires a tissue biopsy. It is especially effective for large and dysplastic lesions.
Visualizations – adjuncts used in visualization
Toluidine blue (TB) adjunctive applies the use of 1% TB, prerinse of 1% acetic acid solution and a mouth rinse or topical swab of TB continued by a postapplication rinse using 1% acetic acid.
Fluoroscence visualization – A prerinse of 1% acetic acid which is followed by direct visual inspection with a blue light source to illuminate abnormal tissues is conducted.