ORAL SURGERY 

Impacted wisdom teeth

There are four types of impacted wisdom teeth; mesial, distal, horizontal and vertical. These need to be surgically removed usually by raising a flap adjacent to the impacted molar and after some bone removal the tooth is elevated out This is followed by some minor suturing. The risks involved with this procedure are some bleeding, potential swelling and/or bruising. The main risk which although is very minute is the potential risk of damage to the inferior alveolar nerve or one of its branches supplying the lower teeth on the same side of the molar as well as the lower lip.

This damage may leave the nerve bruised or lacerated causing temporary or permanent numbness to part or all of the side of the tongue and/or lower lip. This risk is very small but must be mentioned to the patient so as to gain consent. Nowadays with the help of onsite cone beam CT scans the nerve may easily be localised helping the clinician keep a distance preventing damage. Patients are placed on a regime of antibiotics. 

Duration of procedure approx: 30minutes.

Apicectomy

This is a procedure whereby the apical tip (approx 1/3 of the tip of the root) of the offending infected root-treated root is sectioned off. Teeth which have previously undergone root canal treatment and which seem correctly root-filled but still have a persisting infection at the tip may undergo this  procedure as a final resort avoiding extraction. This procedure involves a small semi-lunar incision adjacent to the offending root exposing the root and sectioning off. The flap is then sutured up. Patients are placed on a regime of antibiotics.

Duration of procedure approx: 45-60minutes. 

Cyst Removal 

The procedure for removal a cyst with or without an adjacent tooth is fairly straightforward.  In most cases it involves a normal routine extraction with surgical debridement of the underlying cyst. In some cases an incision must be done to visualize the cystic area , surgically debride the area with a hand-piece and thorougly irrigate it. 

Duration of procedure approx: 20-60 min.

Periodontal surgery

This procedure is performed on patients suffering from active periodontal disease having subgingival calculus and bone defects. The gingiva is incised along the crowns of the teeth exposing the roots. This allows the clinician to directly view the roots and bone levels. Deep thorough scaling and root debriding is performed with ultrasonic and hand instruments. The clean roots are then disinfecetd with saline and medic ated mouthwash containing chlorexidine di-gluconate. Once clean the bone defects may be filled with bone substitutes such as from Geistlich Biomaterials. Rigorous maintenance programs are must.

Periodontal regeneration may be performed so as to re-establish health and support the remaining teeth increasing the duration of life of the teeth. This treatment may be approached as a full mouth case or may be divided into quadrants. Patients are placed on a regime of antibiotics. 

Duration of procedure approx: 1hour per quadrant.

Dental Implant

Dental implants are fixtures inserted in the jaw with the intention of attaching a tooth or a prosthesis having teeth onto them. The majority of implants are manufactured out of titanium and are coated with a variety of coatings encouraging osseo-integration or bonding to bone.  Once the implants osseo-integrate with the patient's bone, a phenomenon normally requiring 3-6 months, permanent teeth may be fixed onto them. The teeth may be manufactured using conventional metal-ceramic material or all-ceramic metal-free alternatives. Implants may be used to support fixed teeth by screw or cement retention onto the implant or else used to support removable hybrid dentures. The implants utilized in this clinic are from the two worldwide leading brands Straumann www.straumann.com or Nobel Biocare www.nobelbiocare.com

Bone grafting

Bone grafting may be required during periodontal and implant therapy. Bone grafts may range in type from inlay particulate grafts to onlay block grafts. There are several types of bone grafting materials which may be used namely autograft, allograft and xenografts. An autograft is the gold-standard utilising the patients’ own bone from the surgical site or from another site in the mouth or body. Common grafting sites include the maxillary tuberosity, the chin, as well as the third molar area.

Allograft bone is human cadaver bone whilst xenograft bone substitute is bovine or porcine bone as well as mineral substitutes. These are inserted at the surgical site and supported by a membrane such as a collagen membrane. Larger grafts require a titanium mesh or titanium stabilising pins, which must later be removed following healing of the graft.

There are many bone grafting procedures ranging from simple additional grafts for minor bony defects to major bone jaw reconstructions.

Materials range from simple bovine bone ( Xenografts ) by Geistlich Biomaterials to large blocks by Puros ( Allograft-Human bone ). The patients own bone ( AutoGraft ) may also be used, but this means that a second surgical donor site will have to be introduced increasing the overall discomfort of the patient. As far as quality of bone goes, this is the gold standard,  however many studies show that new biomaterials may have grafting results as good as with the patients' own bone.

Methods of grafting may range from simple placement of loose bone granules stabilized by a biodegradable membrane to the placement of blocks stabilized by screws. These screws are either biodegradable or would have to be removed in a second surgical sitting. In most cases this would have to be done in two sittings whereby first bone is placed followed by implantation 4-6 months later. In this case scenario titanium meshes are used to stabilize the bone graft and prevent bone loss. For types of grafting associated with Implant dentistry please see Implant Dentistry under services.

Sinus Lift grafting/elevation

This is a procedure whereby a bone graft is done in the maxillary sinus partially filling it with grafting material so as to allow a solid bed for future implant placement.

There are 3 types of sinus lifts. The Summer’s technique involves bone placement through the osteotomy or implant site. Piezosurgery is used to create the opening in the sinus floor. Bone is then inserted in the future implant gently raising the lining of the Sinus floor filling it with bone. This technique is employed when a small bone graft is required increasing the height of the alveolar bone by 2-4mm. This technique is minimally traumatic and is usually performed with simultaneous implant placement.

The second technique involves a similar opening into the sinus through the future implant site. A balloon is inserted in the osteotomy site and slowly pumped raising the sinus membrane. This technique creates more space for a larger bone graft. This may or may not be performed with simultaneous implant placement.

The third technique involves opening a window in the side of the maxilla directly accessing and visualising the sinus. The piezosurgery unit is used to do the opening and raise the sinus floor. Bone may then be transferred and condensed in the sinus. This may be done to one or bone sides of the maxilla and is typically utilised when replacing missing upper posterior dentition (pre-molars and molars). Patients are placed on a regime of antibiotics and steroids. Depending on the remaining alveolar bone, implants may or may not be done simultaneously. If the patient presents with ~2-3mm of alveolar bone allowing implants to engage firmly in the patients natural bone then the graft and implants may be done together avoiding a second surgical intervention 4-6months later for implant placement. A healing time of 6months is required prior to tooth placement.

Nerve repositioning

This technique is used to surgically reposition the inferior alveolar nerve in the mandible so as to gain sufficient height for implant placement supporting future posterior mandibular dentition. Risks include nerve parasthesia to the tongue and/or lower lip. This technique is scarcely used nowadays as it is overcome by contemporary techniques through the All-on-4 procedure powered by Nobel Guide or utilising onlay grafting procedures avoiding the nerve altogether.