Oral Surgery Procedures


Wisdom Tooth Removal (3rd Molars)


Wisdom Tooth Removal (3rd Molars)

Wisdom teeth, also known as third molars, are the molars that the furthest back in the upper and lower  jaws. The last to develop, if they grow in at all,  wisdom teeth usually erupt when you are “older and wiser,” between 16 and 20 years of age. Many times these teeth become “impacted” or trapped in the jaw and will not fully erupt, potentially causing more serious problems.

What problems can wisdom teeth cause?

  • Damage to Adjacent Teeth
  • Periodontal Bone Loss and Pockets
  • Infection
  • Cysts and Tumors
  • Jaw Joint (TMJ) Problems
  • Trauma
  • Crowding or Shifting of Teeth

Not all wisdom teeth have to be removed. Wisdom teeth that have grown fully into the mouth, are surrounding by normal health gum tissues and can be easily cleaned and maintained may not require removal. However, any wisdom teeth, including fully erupted ones, that cannot be maintained should be removed.

At your first appointment, Dr. Johnson will complete a thorough oral examination and review of your current panoramic x-rays (less than one year old) which will allow us to determine if the wisdom teeth should be removed and the timing of their removal. In most cases, In most cases, if wisdom teeth are ready for removal, all should be done at one surgical appointment. If it is determined that surgery is indicated, the procedure will be discussed with you, along with anesthesia choices that are available. After meeting with Dr. Johnson, you will be able to discuss appointments and insurance benefits with a trained staff member.

For more information on wisdom teeth, please visit our page on Wisdom Teeth.


Dental Implants


Dental Implants

It is estimated by the American Association of Oral and Maxillofacial Surgeons that more than 40 Million American over the age of 55 have lost some or all of their teeth due to decay or periodontal disease. As Americans live longer, many will face years or decades of complete or partial toothlessness. Others, often younger, will lose teeth for the same reasons, or due to traumatic injuries where teeth are knocked out and the surrounding bone is damaged and lost.

Dental implants are metallic devices that replace the roots of missing teeth, so that dental implant crowns or bridges can be placed, or are placed as anchors to support and stabilize loose dentures.

Dental implants are usually manufactured from a medical grade space-age metal called titanium, which heals very well when placed in human tissues. In addition to being used in dental implants, titanium is used in the manufacture of such devices as hip, knee and other joint replacements, bone plates, and some artificial heart valves. There are many types and brands of dental implants available, so it is important to choose an implant that is manufactured by a reputable company, and that has a design and surface quality that encourages healing.

After being placed in the jaw bones in a very precise, implants heal by a process called OSSEOINTEGRATION. This means that the specially designed porous surface of the implant and the nature of titanium allow it to actually attract bone forming cells to shift from the jaw bone into the implant itself, forming bone that anchors the implant in place. In most cases, this requires several months of healing prior to placement of crowns, bridges or dentures.

For more information, please visit our Dental Implants page.


Impacted Tooth & Tooth Exposure


Impacted Tooth & Tooth Exposure

An impacted tooth is a tooth that is growing in the jaw in such a way that it is trapped and can not grow in and be a functional tooth. The most commonly impacted tooth is the wisdom tooth, but any other tooth in the mouth can develop as an impacted one, including eye teeth (cuspids), bicuspids and lower 12 year molars are the next most common.

To correct impacted teeth, there are a few treatment options. For impacted wisdom teeth, the most common procedure is extraction. For impacted canine teeth, several treatment modalities are available. Orthodontics (braces) can be used to open space for proper eruption. Primary (baby) teeth can either be extracted or surgically exposed to allow for the placement of an orthodontic bracket to help align the teeth.

  1. Impacted teeth are classified according to the position of the crown in the bone and into 4 main categories:
  2. Soft Tissue: A tooth covered by gum tissue, and positioned so that they can not grow in.
  3. Partial Bony: A portion of the crown is trapped in or covered by bone.
  4. Full Bony: Most or all of the crown is covered by bone.

Impacted teeth are further classified as to their angulation in the bone and positions relative to the roots of adjacent teeth. Each of these factors affects the potential difficulty and what must be done to remove the teeth.


Bone Grafting


Bone Grafting

In our office bone grafts are most commonly used to preserve or lost bone in preparation for placement of dental implants. After the extraction of teeth, the bone (called alveolar bone) forming the sockets has no further function, and immediately begins a shrinkage process call resorption.

The area will heal, the bone left behind may be too thin for dental implants in the future.Also, at the time of tooth removal, bone may have to be removed in order to remove the tooth. This can accelerate and worsen the shrinkage process. If left to heal without bone replacement or preservation procedures, the healing time after extractions before implant placement is much longer and there may not be adequate bone width for implants.

Generally, bone grafts are placed in one of 3 ways to prepare for future implant placement:

Socket Preservation or Bone Replacement Grafts: These grafts are placed into an extraction site at the time of tooth removal to preserve bone width and height. These grafts are also used to restore the bone that may have been removed during an extraction. After a healing period, implants may often be placed into these sites.

Augmentation Graft: These grafts are used to build up the width or height of shrunken extraction sites to recreate lost bone. Generally, a healing time of 6 months or more is required before implants.

Sinus Lift Graft: By creating a “window” into the sinus cavities, a bone graft can placed to increase the bone height to allow for a implants of proper length to be placed. Sometimes, implants can be placed simultaneously, but, if there is not sufficient for stabilization of implants, the grafts are allowed to heal for as much as 6 months before implants are subsequently placed.

There is a wide variety of bone grafting materials available but in our office we most commonly use grafts of human freeze-dried bone mixed with some of the patients own blood. Freeze-dried bone is human bone from healthy donors that has been laboratory processed, purified, and freeze-dried into a powder, made up of many particles. It is mixed with a component of your own blood., platelet-rich fibrin (PRF). The advantage of this combination is that PRF accelerates and improves the healing process, and over a period of time, the freeze-dried bone is replaced by the patient’s own bone.

In our office, we most commonly use grafts of human freeze-dried bone mixed with some of the patients own blood. Freeze-dried bone is human bone from healthy donors that has been laboratory processed, purified, and freeze-dried into a powder, made up of many particles. It is mixed with a component of your own blood, platelet-rich fibrin (PRF). The advantage of this combination is that PRF accelerates and improves the healing process, and over a period of time, the freeze-dried bone is replaced by the patient’s own bone.


Laser Assisted Surgery


Orthognathic Surgery

The use of lasers in dentistry and in oral surgery, specifically, is becoming more and more common. In general dentistry, these devices may be used in preparing teeth for fillings and in certain soft tissue procedures. There are multiple types and sizes of medical lasers depending on the area of the body being treated and the tissue type (bone, soft tissue, eyes, etc.) Research is ongoing to develop lasers that can be routinely used in procedures on the jaws themselves, such as removal of impacted wisdom teeth, but these devices are not yet available for general use.

Our office utilizes the diode laser for certain soft tissue procedures. It is particularly helpful in biopsies, the removal of lesions (growths) of the tongue, the roof of the mouth and the inside of the cheeks and lips. It is also helpful in performing frenectomies for the treatment of tongue-tie or persistent or recurrent spacing between upper front teeth, as well as soft-tissue procedures around implants.

Use of the laser for these procedures can reduce post-operative pain, speed healing, and reduce the need for sutures.


Additional Procedures


Guided bone regeneration (GBR), and guided tissue regeneration (GTR) are most commonly associated with bone grafting procedures and are most commonly performed in preparation for or at the time of placement of dental implants. With these techniques, Barrier Membranes are used along with grafting procedures to direct the growth of new bone and gingival tissues in locations that lack adequate bony dimensions to provide for proper function, esthetics or prosthetic restoration.

The goal of GBR is to replace portions of jaw bone lost during either natural shrinkage after tooth extraction or as a complication of previous surgery. It is also used at the time of implant placement surgery for greater stabilization of implants. While GBR focuses on hard tissues, GTR is used to replace deficient gum tissues. So, GBR is most commonly in the mouth to create, stimulate and support new hard tissue growth on the alveolar ridges (tooth-bearing portions of the jaws) to allow more stable and anatomically accurate placement of dental implants.

GBR uses Barrier Membranes to protect grafts and “guide” their healing and growth direction. Barrier membranes do just what their name implies: they act as a barrier to protect the graft material from the rapid ingrowth of gum and scar tissues into the more slowly healing bone graft materials that would naturally occur without their presence and prevent formation of mature bone tissues. They can also act as a “mold” to help control the position, volume and shape of the graft materials.

Barrier Membranes are can be naturally resorbing (dissolving membranes) made from collagen material or can be created from components taken from patients’ own blood called Platelet Rich Fibrin (PRF). In some cases where longer healing is required or more control of forming the shape of the graft site is needed, non-resorbable membranes may be used, which will require a simple procedure to remove the material prior to or at the time of implant surgery.

Oral cancer is one of the most common cancers in the U.S. About 37,000 people are diagnosed with oral cancer each year within the US. Out of those diagnosed with oral cancer, the fatality rate is just under 50%. The death rate associated with oral cancer is particularly high NOT because it is hard to discover or diagnose, but due to the cancer being routinely discovered LATE in its development. If detected early, the survival rate can be 80% or higher.

Oral Cancer Risk Factors

  • Alcohol Consumption
  • Tobacco Use
  • Persistent Viral Infections (HPV)
  • Greater Risk after Age 35
  • More Common among Men

Oral Cancer Symptoms

  • A sore/lesion in mouth that does not heal within two weeks
  • A lump or thickening in the cheek
  • A white/red patch on the gums/tongue/tonsil/lining of mouth
  • A sore throat/a feeling that something is caught in the throat
  • Difficulty chewing or swallowing
  • Difficulty moving the jaw or tongue
  • Numbness of the tongue or other area of the mouth
  • Swelling of the jaw that causes dentures to fit poorly

**Information provided by cancercenter.com

Identafi® 3000 Ultra

The Identafi® 3000 Ultra is an oral cancer screening which can enhance the early detection of oral cancer, while reducing any false positives in the testing. The Identafi® 3000 utilizes light of a white, violet, and amber wavelength to help distinguish lesion morphology and vasculature of oral lesions. Identafi® 3000 Ultra is a simple, painless and non-invasive device that improves our ability to visualize suspicious areas at their earliest stages, before they can progress to something far more serious, and potentially life-threatening. The Identafi® 3000 Ultra helps the doctor see what might be very hard to see with the naked eye alone. For more information on this valuable tool, please go here.

Careful screening to identify cancerous and non-cancerous conditions is very important. Surgical diagnosis of abnormal appearing growths or lesions of the mouth and face is indicated when clinical diagnosis cannot be adequately achieve and substantiated, and after ruling our temporary inflammatory or infectious causes. This requires biopsy of the site.

Biopsies are most commonly performed in our office using a local anesthetic. In some instances, intravenous anesthesia is indicated due to the location of the lesion or the nature of the surgery necessary to perform the biopsy.

Most lesions of the mouth are relatively small, so a suspicious lesion can often be removed in its entirety, an excisional biopsy. The totally removes all the visible lesion, and if the biopsy is benign, depending on the diagnosis, no other treatment may be required. Sutures are placed as needed.

If the area of concern is larger or wide spread, one or several small samples of abnormal tissue may be removed to give a better chance of accurate diagnosis. Sutures are placed, if needed. Once a diagnosis is attained, further treatment may be initiated and performed. In cases of malignancy, the patient would be referred to an oral cancer surgical specialist.

In some cases, a soft tissue laser is used to facilitate the procedure.

All specimens obtained at surgery are submitted to a certified pathology laboratory and reviewed by an Oral Pathologist who will provide as diagnostic report delineating the microscopic findings. These will be reviewed with the patient at the post-surgical appointment.

A small percentage of teeth having root canal procedures will redevelop symptoms including recurring pain and swelling. X-rays may exhibit changes indicating that infection has persisted or recurred. Apicoectomy or apical microsurgery can performed to attempt to treat the problem and avoid extraction of the tooth.

WHAT IS A ROOT CANAL?

Before discussing this surgical procedure, a review of non-surgical endodontic treatment or root canals can be helpful. In a normal tooth, there is a thread-like hollow space that runs from the tip of the root (apex) into the crown of the tooth. This space, or canal, contains the nerves and blood supply and is called the pulp.

Depending on the tooth, it may have up to three roots and each root may have one, two or more canals, and multiply accessory canals within several millimeters of the apex. When decay extends into the pulp of the tooth, or the tooth has been injured in some way, the pulp becomes irreversibly damaged and becomes infected (necrotic), often causing a toothache or abscess. To save the tooth, a root canal is required. When the root canal procedure is performed, the infected pulp is removed and replaced with a filling.

WHY IS SURGERY NECESSARY?

No medical procedures heal 100% of the time. Root canal procedures have as high as a 95% success rate. When NON-HEALING occurs, it may not mean that the root canal has failed, but may mean that the root canal is not enough to alleviate the problem.

Common reasons for this include:

  • A lesion at the end of the root of the tooth which has caused an infection.
  • Excessive bone loss around the root of the tooth
  • A microscopic fracture in the tooth root that was not visible on an Xray.
  • Anatomic irregularities in the root or the canal of the tooth which prevents filling material from forming a proper seal, allowing leakage. This may include hooked roots, accessory (extra) canals, abnormal calcifications within canals, and abnormally shaped canals.

A persistent condition can result in inflammation or infection of the tooth which may result in pain, swelling, drainage of pus from the gum, looseness of the tooth, changes in the x-ray suggestion bone loss around the roots, and failure of the x-ray to show healing after the root canal was completed.

This condition may occur soon after the root canal is completed, or years later. This may be treated with antibiotics and/or re-treatment of the root canal procedure. When this does not work, or is not indicated, the microscopic apical surgery is necessary to save the tooth.

HOW IS SURGERY PERFORMED?

Dr. Johnson performs this specialized surgery using a surgical microscope or magnifying surgical loupes. This allows the procedure to be performed at high magnification. With these devices, he is able to see defects, fractures and anatomic abnormalities that might not be seen otherwise, and, along with micro-instruments and advanced sealing materials, the procedure can be performed with greater precision and ease, resulting in faster healing and greater chance or success.

When an apicoectomy is performed, the root end of the affected tooth is exposed through a plastic surgical incision in the gum. The site is exposed, and a small opening is made into the area around the end of the root and inspected under the microscope. Infected or inflamed tissue is removed. The end of the root is shortened and prepared to receive a filling material to seal the root end.

If the infection has created a significant defect in the bone surrounding the root, a bone replacement graft may be necessary to enhance healing. Different types of grafts are used including human, animal, and artificial material called a barrier membrane, which helps prevent the re-growth of inflammatory tissue. Very small stitches are placed to aid healing.

After surgery, most patients experience some discomfort and swelling that is usually relieved by some medications. Most patients are usually seen 2-7 days after surgery for post-operative evaluation and removal of stitches. Success rates of greater than 90% have been achieved.

Other microscopic surgical techniques include root resection or hemisection (removal of part or all of the root of a multi-rooted tooth), intentional re-plantation (extraction of the tooth) in order to perform surgery on the root with replacement of the tooth into its socket), and other more uncommon procedures.

ARE THERE OTHER OPTIONS?

Some teeth that have previously had root canal procedures can be re-treated using conventional root canal methods. The presence of crowns, posts, other types of fillings, as well as extra canals or infections and cysts in the bone beyond the root ends may not allow this. Teeth with extensive fractures can not be treated with these conventional and surgical procedures and extraction is necessary. In some cases, patients prefer to have extractions performed and implants placed.

HOW DO I GET STARTED?

A pre-surgical consultation is necessary for the doctor to examine you, review your x-rays and medical history. A special 3D Digital Localized ConeBeam CT x-ray may be necessary. We will discuss your treatment options with you, and answer any questions you might have. It also allows the doctor to determine the need for pre-surgical medications, describe the planned surgery to you, discuss anesthesia options, and apprise you of expected costs.

An appointment for surgery may be made on the day of your consultation. Specific instructions to prepare you for the surgery, as well as any necessary prescriptions are given at that time.

Ridge Expansion
Adequate bone volume of the jawbone is necessary for the secure placement, stability, function, aesthetics and longevity of implants.  Because tooth loss can result in diminished bone volume in the jawbone, a bone expansion procedure may be necessary prior to implant placement.  This procedure can increase the height and/or width of the jaw ridge through the use of mechanical manipulation combined with a bone graft.  The Ridge Expansion takes several months to mature and be sufficiently strong for the placement of implants.  Ridge Expansion not only improves the function of implants, but is also a key contributor to the enhanced aesthetics, filling in the face around the gums and jaw and thus minimizing the appearance of aging.
“Extraction” is the general term used for the removal of a tooth. Teeth must be extracted for various reasons, including non-restorable decay, infection, fracture of the crowns or roots, abnormal position, shifting, and impaction. The process of removing a tooth varies with the condition and position of the tooth to be extracted, the number of roots the tooth has, the tooth or root’s position in the jaws, and the proximity of important structures, including nerves in the lower jaw and the sinus cavities.

Routine Extraction: utilizing instruments that, first, move or luxate the tooth, then grasp the tooth so that it can be moved and removed or “pulled” from its socket.

Surgical Extraction: a technique used to remove a tooth with multiple roots, so severely decayed so that it can not be grasped with routine instruments, or that is surrounded by such dense bone that it can not be moved easily. In these extractions, incisions may be made in the gum tissues adjacent to the tooth, bone may be removed from around the roots, and-or the tooth may be sectioned (cut in multiple pieces) to more easily facilitate it’s removal with other instruments. If necessary stitches may be placed, most often dissolving.

As we age, the maxillary sinuses, air cavities in the upper jaw, enlarge (called hyperaeration) and begin to surround the roots of the upper back teeth. This can result in openings between the sockets of extracted teeth and the sinuses, but also effectively reduces the hight of bone available for implants to replace missing upper teeth, particularly molars as it creates a naturally formed defect in the tooth bearing areas of the upper jaw.

Sinus Lift Grafting is a procedure that restores lost bone height to these areas. It allows implant placement in an area that could not otherwise be done, and is a great development of successful implant surgery in the upper jaw. Surgery is performed in our office, most commonly using intravenous and local anesthesia techniques. The procedure can be performed in two ways determined by the level of bone height already present.

In the Lateral Sinus Lift, an incision is made in the gum tissues, allowing exposure of the very thin bone of the cheek side of the upper jaw. A small window is made here that allows access to the sinus and placement of a bone graft onto the floor of the sinus to increase the height of the bone here to a level that will allow implant placement. A barrier membrane is placed over the graft and under the sinus membrane, as well as over the bony access window and under the overlying gum tissues to protect the graft. Sutures are placed. A healing time of about 6 months before implant placement.
In some cases, there is adequate bone present to stabilize an implant, but not sufficient for implants of adequate length to have a implant long and strong enough to support a replacement crown or to tolerate normal chewing forces. In these situations, a procedure called an Internal Sinus Lift Graft can be performed through the bone channel that is created to receive the implant. In this procedure, the implant recipient site is prepared, then special instruments are used to “lift” the very thin sinus floor and attached membrane up, allowing space for small barrier membranes and graft materials to be placed into the sinus. This will result in a localized area of bony regeneration and restoration of bone height around the implant. This procedure requires left grafting materials.

Graft materials most most commonly a combination freeze-dried bone and platelet rich fibrin (PRF) which is a component of the patients own blood which is drawn from the arm and prepared at the time of surgery.

Appropriate antibiotics, analgesics, antinflammatories and antibacterial mouth rinse as indicated will be prescribed for use prior to and after surgery.

Many oral surgery procedures can be performed using local anesthetics. These are given as injections in the areas of the surgery to be performed. Although commonly know as “Novocaine,” this is rarely used any longer in dentistry, as there are newer, safer and more effective options available. Some procedures are better performed with additional modalities.

Due to the nature of the surgery to be performed, their anxiety about the surgery and the desire to experience as little of the procedure as possible, many patients benefit from addition sedations options. These include:

Nitrous Oxide or Laughing Gas

Also known as conscious sedation or inhalation analgesia, laughing gas is administered to patients for relaxation and very light sedation during surgery. Local anesthetics are almost always still required. Nitrous oxide, can not induce a surgical level of anesthesia, so most patients are aware of the procedures being performed, but find the experience much less stressful. Combined with oxygen, it is administered through a small nasal mask or cannula, and patients can have some control of the level of the nitrous oxide they inhale by breathing either through their noses or mouths. After completion of their surgery, breathing pure oxygen for several minutes will allow for the gas to be totally removed from the system and patients may leave the office without assistance.

Intravenous Sedation / Anesthesia

For certain procedures, such as removal of impacted wisdom teeth, multiple extractions, some bone grafting procedures and for patients wanting a deeper level of sedation, and little or no memory of the procedures performed, the addition of intravenous medications is extremely helpful. Patients are asked to go without food or liquids for 6 hours prior to their procedures, and to bring an escort to take them home and be with them for the first 24 hours after surgery. At the time of surgery, Nitrous oxide is administered for relaxation, then an small injection in the arm or back of the hand is performed to establish an intravenous (IV) line. Gradual dosages of medications are given until a satisfactory level of sedation / anesthesia is attained. At that time, when the patient will not be aware of it, local anesthesia is administered and the surgery is performed. Monitoring of vital signs is performed as in hospital anesthetic procedures.

After a period of time in the recovery area, the patient is discharged into the care of their escort with discharge instructions and appropriate prescriptions. Plan to have not activities for at least the first 24 hours after IV anesthesia.

A pre-surgical consultation is necessary for those patients desiring to “be asleep” for their surgery.

Our goal is to make your oral surgery experience as pleasant and non-stressful as possible.