ORAL SURGERY
EXTRACTIVE SURGERY
There are cases in which, despite the best attention and technology available, some teeth may no longer be salvable. This usually occurs in the following cases:
Severe forms of periodontal disease that have led to a total or almost total resorption of the supporting bone and consequent very high mobility of the tooth itself.
Caries so deep that it has also compromised the roots in an irreparable way
Vertical fractures of the tooth root.
Unfavorable tooth position (e.g. including wisdom teeth), especially if it causes gum problems.
a) SIMPLE EXTRACTION
The tooth is dislocated (i.e. detached from its original seat) with the help of forceps and levers, depending on the opportunity. Teeth with more than one root are often cut with a bur to extract the roots separately. All extractions are performed with rather cautious maneuvers that aim to preserve as much bone as possible: this in order not to jeopardize the possibility of making an implant in place of the lost tooth. Too hasty extractions can sometimes demolish a certain amount of bone and then prevent rehabilitation. The extraction may be followed by the application of surgical stitches or not, depending on the situation. Alternatively, a sterile gauze compress can be used to aid clot formation
The patient is asked not to carry out excessive rinsing: the presence of blood in the mouth can be removed with a short rinse, bearing in mind that however the excess will tend to hinder the clot. It will obviously be advisable to avoid chewing food on the injured side, again to avoid disturbing healing or infecting the extraction site. Situations of bleeding will be buffered by compressing the part with gauze or a clean fabric (never with cotton or paper!). Depending on the need, the patient will be able to deal with a possible post-operative pain with anti-pain relievers according to the dentist's indication, preferring those without acetyl salicylic acid (aspirin), because they have anticoagulant characteristics. In cardiac patients on chronic aspirin therapy, the intake will have been discontinued prior to the extraction with the consent of the treating physician.
A possible (infrequent) complication of the extraction is the infection of the wound, which manifests itself with increasing pain in the following days, swelling and bad smell: this eventuality is obviously the responsibility of an antibiotic.
b) COMPLEX OR SURGICAL EXTRACTION
Some teeth require much more complex maneuvers than conventional ones to be extracted. Usually these complications arise from the position that these teeth have in the mouth. A typical example of this is the extraction of the included or semi-embedded wisdom tooth. The third molar (especially the lower one) often has a nasty habit of not erupting (coming out into the open) on a regular basis, or not at all. In this case, the extraction turns into a real surgery in which it will be necessary to incise the gum and reach the tooth through the bone. Even in certain cases of semi-inclusion, the dentist will have to create access through the gum and sacrifice a certain amount of bone in order to extract the tooth.
The postoperative consequences are very similar to those already described in simple extractions.
BONE INCREASE
In this type of surgery it is proposed to increase the amount of bone present in a given area of the mouth, in order to obtain enough of it to be able to perform an implant where it was not possible before. The interventions are different in the case of the maxilla and mandible.
a) BONE FILLERS
The substances that are used to form new bone are of various types and vary from freeze-dried bone of animal origin to synthetic substances based on calcium. It is difficult to establish precisely which of these gives the greatest guarantee of attachment, however recent studies seem to indicate that deproteinated bovine bone performs better than the patient's own bone.
b) SMALL AND LARGE SINUS ELEVATION
It is applied in the maxilla, in particular in the posterior sectors (molars). In essence, it is a question of compensating for the lack of bone, partially filling a natural cavity that is located above the roots of the upper teeth, roughly below the cheekbone, and which is called the Maxillary Sinus: it is a lateral cavity of the nose and is one of the so-called "paranasal sinuses".
The small sinus lift, consists in pushing some regenerative material into the sinus, through an extraction cavity or a hole made to insert an implant: in fact, this technique is applied in the same surgical session in which the implant is performed and can lead to a bone height gain of up to 4 mm.
The large sinus lift is a more delicate operation and consists in the opening of a lateral door that gives access to the cavity, and which is made on the external wall of the jaw, towards the cheek. This technique allows for much greater bone gains, and even to completely fill the maxillary sinus. Depending on the technique used, the implants can also be placed in the same session.
c) CRESTAL BONE INCREASE
It is applied to both the mandible and the maxilla, however its main use is in the lower arch, where there are no natural cavities to fill. In this case, in fact, the substance is placed on the exposed bone of the Mandible. A very frequent and safe intervention in this case is the removal from the iliac crest (hip bone) under general anesthesia and immediate positioning on the recipient bone. Of course this is too complex a surgery to be performed in a normal dental office, and often requires general anesthesia: it therefore remains the responsibility of a good maxillofacial surgery hospital ward.
