Oral Surgery Procedures

 

Dental Implants


Dental implants are actually a series of procedures used to recreate a missing tooth. The key part of a dental implant is the initial titanium implant which sits in the original tooth’s bone pocket, or alveolus. The titanium works well with the bone and actually forms a bond with it over time, much like the original bond between the tooth and the jaw bone. This is essential as it prevents bone loss that would normally occur with any other type of tooth replacement. Dental implants are capped with a crown, which replicates the enamel or visible portion of a tooth, and in many cases the replacement tooth will work just as well, if not better, than the original tooth.

What Is a Fixed Dental Bridge?

A fixed dental bridge is a non-removable prosthesis attached to remaining natural teeth

The false tooth or teeth literally bridge the gap between natural teeth. For a long time, fixed bridges were the best alternative for people who had lost teeth, as they were quite successful and esthetically pleasing. Unfortunately, bridges can also present some problems because the natural teeth that lie on either side of the bridge are filed to accept the appliance. This step in the bridge-making procedure may make these teeth prone to bacterial plaque accumulations, decay, periodontal disease, and the possible need for future root canals.

Cost Breakdown: Implant vs. Bridge

At first glance, it appears that a bridge is the more economical route, with total fees for a typical implant starting at the top end of the cost for a fixed bridge and ending a couple thousand dollars higher. But when comparing cost versus value, the dental implant is more cost-effective and the better treatment option – if the patient is a candidate for implants.

 

Extractions


Tooth extraction is the removal of a tooth from its socket in the bone. If a tooth has been broken or damaged by decay, your dentist will try to fix it with a filling, crown or other treatment. Sometimes, though, there's too much damage for the tooth to be repaired. In this case, the tooth needs to be extracted. A very loose tooth also will require extraction if it can't be saved, even with bone replacement surgery (bone graft).

Here are other reasons:

  • Some people have extra teeth that block other teeth from coming in.
  • Sometimes baby teeth don't fall out in time to allow the permanent teeth to come in.
  • People getting braces may need teeth extracted to create room for the teeth that are being moved into place.
  • People receiving radiation to the head and neck may need to have teeth in the field of radiation extracted.
  • People receiving cancer drugs may develop infected teeth because these drugs weaken the immune system. Infected teeth may need to be extracted.
  • Some teeth may need to be extracted if they could become a source of infection after an organ transplant. People with organ transplants have a high risk of infection because they must take drugs that decrease or suppress the immune system.
  • Wisdom teeth, also called third molars, are often extracted either before or after they come in. They commonly come in during the late teens or early 20s. They need to be removed if they are decayed, cause pain or have a cyst or infection. These teeth often get stuck in the jaw (impacted) and do not come in. This can irritate the gum, causing pain and swelling. In this case, the tooth must be removed. If you need all four wisdom teeth removed, they are usually taken out at the same time.

If you expect to have treatment with intravenous drugs called bisphosphonates for a medical condition, be sure to see your dentist first. If any teeth need to be extracted, this should be done before your drug treatment begins. Having a tooth extraction after bisphosphonate treatment increases the risk of osteonecrosis (death of bone) in the jaw.

Preparation

Your dentist or oral surgeon will take an X-ray of the area to help plan the best way to remove the tooth. Be sure to provide your full medical and dental history and a list of all medicines you take. This should include both prescription and over-the-counter drugs, vitamins and supplements.

If you are having wisdom teeth removed, you may have a panoramic X-ray. This X-ray takes a picture of all of your teeth at once. It can show several things that help to guide an extraction:

  • The relationship of your wisdom teeth to your other teeth
  • The upper teeth's relationship to your sinuses
  • The lower teeth's relationship to a nerve in the jawbone that gives feeling to your lower jaw, lower teeth, lower lip and chin. This nerve is called the inferior alveolar nerve.
  • Any infections, tumors or bone disease that may be present
  • Some doctors prescribe antibiotics to be taken before and after surgery.

This practice varies by the dentist or oral surgeon. Antibiotics are more likely to be given if:

  • You have infection at the time of surgery 
  • You have a weakened immune system 
  • You will have a long surgery 
  • You have specific medical conditions 

You may have intravenous (IV) anesthesia, which can range from conscious sedation to general anesthesia. If so, your doctor will have give you instructions to follow. You should wear clothing with short sleeves or sleeves that can be rolled up easily. This allows access for an IV line to be placed in a vein. Don't eat or drink anything for six or eight hours before the procedure. 

If you have a cough, stuffy nose or cold up to a week before the surgery, call your doctor. He or she may want to avoid anesthesia until you are over the cold. If you had nausea and vomiting the night before the procedure, call the doctor's office first thing in the morning. You may need a change in the planned anesthesia or the extraction may have to be rescheduled. 

Do not smoke on the day of surgery. This can increase the risk of a painful problem called dry socket. 

After the extraction, someone will need to drive you home and stay there with you. You will be given post-surgery instructions. It is very important that you follow them.

How It's Done 

There are two types of extractions: 

  • A simple extraction is performed on a tooth that can be seen in the mouth. General dentists commonly do simple extractions. In a simple extraction, the dentist loosens the tooth with an instrument called an elevator. Then the dentist uses an instrument called a forceps to remove the tooth.
  • A surgical extraction is a more complex procedure. It is used if a tooth may have broken off at the gum line or has not come into the mouth yet. Surgical extractions commonly are done by oral surgeons. However, they are also done by general dentists. The doctor makes a small incision (cut) into your gum. Sometimes it's necessary to remove some of the bone around the tooth or to cut the tooth in half in order to extract it. 

Most simple extractions can be done using just an injection (a local anesthetic). You may or may not receive drugs to help you relax. For a surgical extraction, you will receive a local anesthetic, and you may also have anesthesia through a vein (intravenous). Some people may need general anesthesia. They include patients with specific medical or behavioral conditions and young children.

If you are receiving conscious sedation, you may be given steroids as well as other medicines in your IV line. The steroids help to reduce swelling and keep you pain-free after the procedure.

During a tooth extraction, you can expect to feel pressure, but no pain. If you feel any pain or pinching, tell your doctor.

Follow-Up

Your doctor will give you detailed instructions on what to do and what to expect after your surgery. If you have any questions, make sure to ask them before you leave the office.

Having a tooth taken out is surgery. You can expect some discomfort after even simple extractions. Usually it is mild. Research has shown that taking nonsteroidal anti-inflammatory drugs (NSAIDs) can greatly decrease pain after a tooth extraction. These drugs include ibuprofen, such as Advil, Motrin and others. Take the dose your doctor recommends, 3 to 4 times a day. Take the first pills before the local anesthesia wears off. Continue taking them for 3 days. Ask your doctor for complete instructions.

Surgical extractions generally cause more pain after the procedure than simple extractions. The level of discomfort and how long it lasts will depend on how difficult it was to remove the tooth. Your dentist may prescribe pain medicine for a few days and then suggest an NSAID. Most pain disappears after a couple of days.

A cut in the mouth tends to bleed more than a cut on the skin because it cannot dry out and form a scab. After an extraction, you'll be asked to bite on a piece of gauze for 20 to 30 minutes. This pressure will allow the blood to clot. You will still have a small amount of bleeding for the next 24 hours or so. It should taper off after that. Don't disturb the clot that forms on the wound.

You can put ice packs on your face to reduce swelling. Typically, they are left on for 20 minutes at a time and removed for 20 minutes. If your jaw is sore and stiff after the swelling goes away, try warm compresses. 
Eat soft and cool foods for a few days. Then try other food as you feel comfortable.

A gentle rinse with warm salt water, started 24 hours after the surgery, can help to keep the area clean. Use one-half teaspoon of salt in a cup of water. Most swelling and bleeding end within a day or two after the surgery. Initial healing takes at least two weeks.

If you need stitches, your doctor may use the kind that dissolve on their own. This usually takes one to two weeks. Rinsing with warm salt water will help the stitches to dissolve. Some stitches need to be removed by the dentist or surgeon.

You should not smoke, use a straw or spit after surgery. These actions can pull the blood clot out of the hole where the tooth was. Do not smoke on the day of surgery. Do not smoke for 24 to 72 hours after having a tooth extracted.

Risks

A problem called a dry socket develops in about 3% to 4% of all extractions. This occurs when a blood clot doesn't form in the hole or the blood clot breaks off or breaks down too early.

In a dry socket, the underlying bone is exposed to air and food. This can be very painful and can cause a bad odor or taste. Typically dry sockets begin to cause pain the third day after surgery.

Dry socket occurs up to 30% of the time when impacted teeth are removed. It is also more likely after difficult extractions. Smokers and women who take birth control pills are more likely to have a dry socket. Smoking on the day of surgery further increases the risk. A dry socket needs to be treated with a medicated dressing to stop the pain and encourage the area to heal.

Infection can set in after an extraction. However, you probably won't get an infection if you have a healthy immune system.

Other potential problems include:

  • Accidental damage to nearby teeth, such as fracture of fillings or teeth
  • An incomplete extraction, in which a tooth root remains in the jaw — Your dentist usually removes the root to prevent infection, but occasionally it is less risky to leave a small root tip in place.
  • A fractured jaw caused by the pressure put on the jaw during extraction — This occurs more often in older people with osteoporosis (thinning) of the jaw bone.
  • A hole in the sinus during removal of an upper back tooth (molar) — A small hole usually will close up by itself in a few weeks. If not, more surgery may be required.
  • Soreness in the jaw muscles and/or jaw joint — It may be tough for you to open your mouth wide. This can happen because of the injections, keeping your mouth open and/or lots of pushing on your jaw.
  • Long-lasting numbness in the lower lip and chin — This is an uncommon problem. It is caused by injury to the inferior alveolar nerve in your lower jaw. Complete healing may take three to six months. In rare cases, the numbness may be permanent.
 

Bone and Gum Reconstructive Surgery


Periodontal plastic surgery is designed to restore form and function to the gum tissue, periodontal ligament, and the bone that supports your teeth or an individual tooth. The real long-term goal of any periodontal surgery is to increase the life expectancy of the teeth and their usefulness; it is not a cure for periodontal disease. Basically, periodontal surgery removes tissue that has been transformed by the disease and then reconstructs the gums and surrounding tissues to better support the teeth and to recreate a normal appearance.

Periodontal Disease

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Periodontal disease is diagnosed when gingival or gum tissue attachment to the teeth is abnormal and bone changes may be evident through x-rays. A dentist will determine the degree of periodontal disease by examining “pockets” between the gum and tooth to see how much detachment exists and then will thoroughly examine the x-rays. Your dentist and you can discuss treatment procedures once a periodontal disease diagnosis has been made, beginning with conservative behavioral changes and extending to periodontal plastic surgery.

Treating Periodontal Disease

Periodontal disease does not always respond to conservative measures taken before and after diagnosis. While surgery may be necessary in the end, knowing what steps you can take to prevent disease from forming, and from progressing, is very important.

Behavioral Change– When periodontal disease is detected, your dentist will first recommend a few behavioral changes including an enhanced oral hygiene program,quitting smoking, and possibly some additional lifestyle changes.

Tartar Removal– A regular and thorough professional tartar or calcified plaque removal program will become an essential part of your oral hygiene routine. Typically this is a painless procedure but, in some extreme cases, pain medication may be required for a few days.

Bite Therapy– Bite disorders can be treated after periodontal disease is diagnosed and treatment has begun. This may prevent future problems and will make your mouth an all-around more hospitable environment.

Surgical Therapy– In cases of severe periodontal disease, surgery will be necessary to repair and regenerate the soft and hard tissues and replace any missing teeth. The goal of surgery is to eliminate pockets between the gum and tooth and attempt to encourage reattachment and normal function and esthetics to the patient. There have been many advances in this field in both soft-tissue and hard-tissue replacement and regeneration, and a skilled periodontal plastic surgeon can restore an affected mouth to a pre-disease appearance.

Preventing Periodontal Disease

While steps can be taken to alleviate the ravages of periodontal disease, the best step is prevention. Remove plaque and bacteria through daily brushing, flossing, and regular oral hygiene. Routine visits to a dental professional for cleanings are also essential. Quitting smoking has proven to be very helpful in preventing the onset of periodontal disease. 

Dr. Rai and his staff were fantastic. I was feeling pain on both sides of my mouth. I called and they were able to get me in the following morning. They put me at ease and did a great job. I would highly recommend Dr. Rai.
Elizabeth W. - Santa Barbara, CA

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