WISDOM TEETH

  • Wisdom Tooth Removal – By the age of eighteen, most adults have developed 32 teeth; 16 teeth on the top and 16 teeth on the bottom. Each tooth in the mouth has a specific name and function. The teeth in the front of the mouth (incisors and canines) are ideal for grasping and biting food into smaller pieces. The back teeth or premolars and molars are used to grind food up into a consistency suitable for swallowing.
  • The average mouth is made to hold only 28 teeth. It can be painful when 32 teeth try to fit in a mouth that holds only 28 teeth. These last four teeth in the back of your mouth are known as Third Molars, or “wisdom teeth.”
  • Why Should I Remove My Wisdom Teeth? Wisdom teeth are the last teeth to erupt within the mouth. When they align properly and gum tissue is healthy, wisdom teeth do not have to be removed. Unfortunately, this does not generally happen. The extraction of wisdom teeth is necessary when they are prevented from properly erupting within the mouth. They may grow sideways, partially emerge through the gum and even remain trapped beneath the gum and bone. Impacted teeth can take many positions in the bone as they attempt to find a pathway that will allow them to erupt successfully.
  • These poorly positioned impacted teeth can cause many problems. When they are partially erupted, the opening around the tooth allows bacteria to enter and will eventually cause an infection. The result: swelling, stiffness, pain and illness. The pressure from the erupting wisdom tooth may move other teeth and disrupt the orthodontic or natural alignment of teeth. The most serious problem occurs when tumors or cysts form around the impacted wisdom tooth, resulting in the destruction of the jawbone and healthy teeth. Removal of the offending impacted tooth or teeth usually resolves these problems. Early removal is recommended to avoid such future problems and to decrease the surgical risk involved with the procedure.
  • Oral Examination – With an oral examination and x-rays of the mouth, Dr. Shuren can evaluate the position of the wisdom teeth and predict if there may be present or future problems. Studies have shown that early evaluation and treatment result in a superior outcome for the patient. Patients are generally first evaluated in the mid- teenage years by their dentist, orthodontist or by an oral and maxillofacial surgeon. All outpatient surgery is performed under appropriate anesthesia to maximize patient comfort. Dr. Shuren has the training, license and experience to provide various types of anesthesia for patients to select the best alternative. These include local anesthesia, or an I.V. anesthetic. Ocassionally, special circumstances dictate that the procedure be performed with general anesthesia as an out-patient in the hospital.
  • Removal – Anesthetic options as well as the surgical risks (i.e. sensory nerve damage, sinus complications, possible damage to adjacent teeth and possible TMJ disorders) will be discussed with you before the procedure is performed. Once the teeth are removed, the gum is sutured. To help control bleeding, bite down on the gauze placed in your mouth. You will rest under our supervision in the office until you are ready to be taken home. Upon discharge, your post-operative kit will include postoperative instructions, a prescription for pain medication, anti-inflammatories, and a follow-up appointment in one week to ensure proper healing. If you have any questions, please do not hesitate to call us at 519-979-7227. Alternatively, many post-op questions may be be answered by going to the “Surgical Instructions” section of this website and clicking on “post-op instructions.” Our services are provided in an environment of optimum safety that utilizes modern monitoring equipment and staff that are experienced in anesthesia techniques.

EXTRACTION OF ROUTINE TEETH

  • Extraction of Routine Teeth – You, your Dentist and Dr. Shuren may determine that you need a tooth extraction for any number of reasons. Some teeth are extracted because they are severely decayed; others may have advanced periodontal disease, or have broken in a way that cannot be repaired. Other teeth may need removal because they are poorly positioned in the mouth (such as impacted teeth), or in preparation for orthodontic treatment. The removal of a single tooth can lead to problems related to your chewing ability, problems with your jaw joint, and shifting teeth, which can have a major impact on your dental health. To avoid these complications, in most cases, Dr. Shuren will discuss alternatives to extractions as well as replacement of the extracted tooth.
  • The Extraction Process – At the time of extraction Dr. Shuren will need to numb your tooth, jawbone and gums that surround the area with a local anesthetic. Additional forms of anesthesia are available, if needed, although they may require another appointment. During the extraction process you will feel a lot of pressure. This is from the process of firmly rocking the tooth in order to widen the socket for removal. You may feel pressure during your extractions, but should not feel pain. If you do feel pain at any time during the extraction please let us know right away. We will stop what we are doing in order to make you more comfortable before completing your extraction.
  • Sectioning a Tooth – Some teeth require sectioning. This is a very common procedure done when a tooth is so firmly anchored in its socket or the root is curved and the socket can’t expand enough to remove it. The doctor simply cuts the tooth into sections then removes each section one at a time.

DENTAL IMPLANTS

  • Dental implants are changing the way people live. They are designed to provide a foundation for replacement teeth which look, feel and function like natural teeth. A person who has lost teeth regains the ability to eat virtually anything, knowing that teeth appear natural and that facial contours will be preserved. Patients with dental implants can smile with confidence.
  • What are Dental Implants? The implants themselves are tiny titanium posts, which are inserted into the jawbone where teeth are missing. These metal anchors act as tooth root substitutes. They are surgically placed into the jawbone. The bone bonds with the titanium, creating a strong foundation for artificial teeth. Small posts (abutments) are then attached to the implant, which protrude through the gums. These posts provide stable anchors for artificial replacement teeth. Implants also help preserve facial structure, preventing bone deterioration that occurs when teeth are missing.
  • The Surgical Procedure – In the past, the placement of dental implants involved two surgical procedures. As technology has improved with time, the implant healing periods have shortened and most cases are completed with only one surgery. Posts protrude through the gums. When the artificial teeth are placed, these posts will not be seen. The entire procedure can take as little as 3 months, but sometimes requires more than a year if bone grafting is necessary. Most patients experience minimal disruption in their daily life.
  • Surgical Advances – Using the most recent advances in dental implant technology, Dr. Shuren is able to place single stage implants. There are even situations where the implants can be placed at the same time as a tooth extraction – further minimizing the number of surgical procedures. Advances in dental implant technology have made it possible, in select cases, to extract teeth and place implants with crowns at one visit. This procedure, called “immediate loading,” greatly simplifies the surgical process.
  • Who actually performs the implant placement? Implants are a team effort between an Oral and Maxillofacial Surgeon and a Restorative Dentist. While Dr. Shuren performs the actual implant surgery, and initial tooth extractions and bone grafting if necessary, the restorative dentist (your dentist) fits and makes the permanent prosthesis. Your dentist will also make any temporary prosthesis needed during the implant process.
  • What types of prostheses are available? A single prosthesis (crown) is used to replace one missing tooth – each prosthetic tooth attaches to its own implant. A partial prosthesis (fixed bridge) can replace two or more teeth and may require only two or three implants. A complete dental prosthesis (fixed bridge) replaces all the teeth in your upper or lower jaw. The number of implants varies depending upon which type of complete prosthesis (removable or fixed) is recommended. A removable prosthesis (over denture) attaches to a bar or ball in socket attachments, whereas a fixed prosthesis is permanent and removable only by the dentist. Dr. Shuren performs in-office implant surgery in a hospital-style operating suite. Inpatient hospital implant surgery is for patients who have special medical or anesthetic needs or for those who need extensive bone grafting from the jaw, hip or tibia.
  • Why dental implants? Once you learn about dental implants, you finally realize there is a way to improve you life. When you lose several teeth – whether it’s a new situation or something you have lived with for years – chances are you have never become fully accustomed to losing such a vital part of yourself.
  • Dental implants can be your doorway to renewed self-confidence and peace of mind – A Swedish scientist and orthopedic surgeon, Dr. Per-Ingvar Branemark, developed this concept for oral rehabilitation more than fourty years ago. With his pioneering research, Dr. Branemark opened the door to a lifetime of renewed comfort and self-confidence for millions of individuals facing the frustration and embarrassment of tooth loss.
  • Why would you select dental implants over more traditional types of restorations? There are several reasons: Why sacrifice the structure of surrounding good teeth to bridge a space? In addition, removing a denture or a “partial” at night may be inconvenient, not to mention that dentures that slip can be uncomfortable and rather embarrassing.
  • Are you a candidate for implants? If you are considering implants, first your mouth must be clinically examined thoroughly and your medical and dental history reviewed. Then, a radiographic evaluation must be performed and correlated with clinical findings. If you mouth is not ideal for implants, ways of improving outcome, such as bone grafting, may be recommended.
  • What type of anesthesia is used? The majority of dental implants and bone graft can be performed in the office under local anesthesia, with or without an I.V. anesthetic.
  • Do Implants need special care? Once the implants are in place, they will serve you well for many years if you take care of them and keep your mouth healthy. This means taking the time for good oral hygiene (brushing and flossing) and keeping regular appointments with your dental specialists.

BONE GRAFTING

  • Major and Minor Bone Grafting – Over a period of time, the jawbone associated with missing teeth atrophies or resorbs away. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants. Today, we have the ability to grow bone where needed. This not only gives us the opportunity to place implants of proper length and width, it also gives us a chance to restore functionality and esthetic appearance.
  • Major Bone Grafting – Bone grafting can repair potential implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone is either obtained from a tissue bank or your own bone is taken from the jaw, hip or tibia (below the knee.) Sinus bone grafts are also performed to replace bone in the back of the upper jaw. In addition, special membranes may be utilized that dissolve under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration. Major bone grafts are typically performed to repair defects of the jaws. These defects may arise as a result of traumatic injuries, tumor surgery, or congenital defects. Large defects are repaired using the patient’s own bone. This bone is harvested from a number of different sites depending on the size of the defect. The skull (cranium), hip (iliac crest), and lateral knee (tibia), are common donor sites. These procedures are routinely performed in an operating room and require a hospital stay.
  • Sinus Lift Procedure – The maxillary sinuses are air-filled spaces behind your cheeks and on top of the upper teeth. Some of the roots of the natural upper teeth extend up into the maxillary sinuses. When these upper teeth are removed, there is often just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place. When the sinus wall is very thin, it is impossible to place dental implants in this bone. There is a solution and it’s called a sinus graft or sinus lift graft. The dental implant surgeon enters the sinus from where the upper teeth used to be. The sinus membrane is then lifted upward and donor bone is inserted into the floor of the sinus. Keep in mind that the floor of the sinus is the roof of the upper jaw. After several months of healing, the bone becomes part of the patient’s jaw and dental implants can be inserted and stabilized in this new sinus bone. The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option other than wearing loose dentures. If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the sinus augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.
  • Ridge Expansion – In severe cases, the bony ridge has been resorbed and a bone graft is placed to increase ridge height and/or width. This is a technique used to restore the lost bone dimension when the jaw ridge gets too thin to place conventional implants. In this procedure, the bony ridge of the jaw is literally expanded by mechanical means. Bone graft material can be placed and matured for a few months before placing the implant. As stated earlier, there are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patient’s own bone for repairs, we generally get the best results. In many cases, we can use allograft material to implement bone grafting for dental implants. This bone is prepared from cadavers and used to promote the patients own bone to grow into the repair site. It is quite effective and very safe. Synthetic materials can also be used to stimulate bone formation. We even use factors from your own blood to accelerate and promote bone formation in graft areas. After discharge, bed rest is recommended for one day and limited physical activity for one week.

SURGERY FOR ORTHODONTICS

  • Oral Surgery for Orthodontics – Many patients are referred to our practice by area orthodontists. Their orthodontists will request we perform a surgical procedure that will then permit the orthodontists to properly align the patients teeth. Sometimes, this is as simple as removing some retained primary (“baby”) teeth, removing some permanent premolars to create space if there is too much crowding, or removing wisdom teeth after the other teeth are orthodontically aligned so that the developing wisdom teeth don’t adversely affect the teeth in front of them. In more involved cases, some permanent teeth may fail to erupt at the expected time. If this occurs, the orthodontist will request surgical exposure of an impacted tooth. This consists of removing the bone and gum tissue covering a tooth embedded in the bone so that an orthodontic bracket may be placed. This will provide the orthodontist access to that embedded tooth so that they can apply a force to it and bring it to it’s proper position. In some situations there is a missing tooth in a very important area of the mouth. Certain cases may dictate removing an unerupted tooth in a less important area and placing it surgically into this very important area for it to develop. This is called procedure is called autotransplantation. In other instances, certain situations will dictate the use of skeletal anchorage. This consists of surgically inserting small titanium screws into either the upper or lower jaw bones. These anchorage screws will protrude somewhat through the gum tissue. Your orthodontists will then apply a force to a tooth by stretching an elastic or applying a spring between the bracket on the tooth and the top part of the anchorage screw. Once the desired tooth movement is achieved, the anchorage screws are simply removed. Finally, simple soft tissue procedures like frenectomies are sometimes advised by the orthodontists. This entails removing the frenum, or muscle attachment and the thin layer of gum tissue covering the frenum, from under the under lip. This prevents relapse of a diastema (space between the two front teeth) once it has been orthodontically closed.

FACIAL TRAUMA

  • Facial Trauma – Injuries to the face, by their very nature, impart a high degree of emotional, as well as physical trauma to patients. The science and art of treating these injuries requires special training involving a “hands on” experience and an understanding of how the treatment provided will influence the patient’s long term function and appearance. Oral & Maxillofacial Surgeons meet and exceed these modern standards. They are trained, skilled and uniquely qualified to manage and treat facial trauma. Dr. Shuren is on staff at Windsor Regional and Hotel Dieu Hospital and delivers emergency room coverage for facial injuries, which include the following conditions: • Facial lacerations • Intra oral lacerations • Avulsed (knocked out) teeth • Fractured facial bones (cheek, nose or portions of the eye socket) • Fractured jaws (upper and lower jaw) *Fractured Frontal bones
  • The Nature of Maxillofacial Trauma – There are a number of possible causes of facial trauma such as motor vehicle accidents, accidental falls, sports injuries, interpersonal violence and work related injuries. Types of facial injuries can range from injuries of teeth to extremely severe injuries of the skin and bones of the face. Typically, facial injuries are classified as either soft tissue injuries (skin and gums), bone injuries (fractures), or injuries to special regions (such as the eyes, facial nerves or the salivary glands).
  • Soft Tissue Injuries of the Maxillofacial Region – When soft tissue injuries such as lacerations occur on the face, they are repaired by suturing. In addition to the obvious concern of providing a repair that yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands and salivary ducts (or outflow channels). Dr. Shuren has trained to be proficient at diagnosing and treating all types of facial lacerations.
  • Bone Injuries of the Maxillofacial Region – Fractures to the bones of the face are treated in a manner similar to the fractures in other parts of the body. The specific form of treatment is determined by various factors, which include the location of the fracture, the severity of the fracture, the age and general health of the patient. When an arm or a leg is fractured, a cast is often applied to stabilize the bone to allow for proper healing. Since a cast cannot be placed on the face, other means have been developed to stabilize facial fractures. One of these options involves wiring the jaws together for certain fractures of the upper and/or lower jaw. Certain other types of fractures of the jaw are best treated and stabilized by the surgical placement of small plates and screws at the involved site. This technique of treatment can often allow for healing and elimininates the necessity of having the jaws wired together. This technique is called “rigid fixation” of a fracture. The relatively recent development and use of rigid fixation has profoundly improved the recovery period for many patients, allowing them to return to normal function more quickly. The treatment of facial fractures should be accomplished in a thorough and predictable manner. More importantly, the patient’s facial appearance should be minimally affected. An attempt at accessing the facial bones through the fewest incisions necessary is always made. At the same time, the incisions that become necessary, are designed to be small and, whenever possible, are placed so that the resultant scar is hidden.
  • Injuries to the Teeth and Surrounding Dental Structures – Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Oral surgeons usually are involved in treating fractures in the supporting bone or in replanting teeth that have been displaced or knocked out. These types of injuries are treated by one of a number of forms of splinting (stabilizing by wiring or bonding teeth together). If a tooth is knocked out, it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better chance it will survive. Therefore, the patient should see a dentist or oral surgeon as soon as possible. Never attempt to wipe the tooth off, since remnants of the ligament that hold the tooth in the jaw are attached and are vital to the success of replanting the tooth. Other dental specialists may be called upon such as endodontists, who may be asked to perform root canal therapy, and/or restorative dentists who may need to repair or rebuild fractured teeth. In the event that injured teeth cannot be saved or repaired, dental implants are often now utilized as replacements for missing teeth. The proper treatment of facial injuries is now the realm of specialists who are well versed in emergency care, acute treatment, long term reconstruction and rehabilitation of the patient.

ORAL PATHOLOGY

  • Oral Pathology – The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in color. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or cancerous growth: *Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth *A sore that fails to heal and bleeds easily *A lump or thickening on the skin lining the inside of the mouth *Chronic sore throat or hoarseness *Difficulty in chewing or swallowing These changes can be detected on the lips, cheeks, palate and gum tissue around the teeth, tongue, face and/or neck. Pain does not always occur with pathology. However, any patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer. We would recommend performing an oral cancer self-examination monthly and remember that your mouth is one of your body’s most important warning systems. Do not ignore suspicious lumps or sores. Please contact us so we may help. Larger or more suspicious lesions require investigation by obtaining a piece of the tissue in question. This is traditionally known as a biopsy. The tissue abnormality will need to be anesthetized either locally, or in conjunction with some type of sedative technique. It is then placed in a jar of tissue preservation and sent to a lab where a pathologist will identify it under a microscope.

TMJ DISORDER

  • Temporomandibular Joint Disorders – TMJ (temporomandibular joint) disorders are a family of problems related to your complex jaw joint. If you have had symptoms like pain or a “clicking” sound, you’ll be glad to know that these problems are more easily diagnosed and treated than they were in the past. These symptoms occur when the joints of the jaw and the chewing muscles (muscles of mastication) do not work together correctly. TMJ stands for Temporomandibular Joint, which is the name for each joint (right and left) that connects your jaw to your skull. Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important. No one treatment can resolve TMJ disorders completely and treatment takes time to become effective. Dr. Shuren can help you have a healthier and more comfortable jaw.
  • Trouble with Your Jaw? TMJ disorders develop for many reasons. You might clench or grind your teeth, tightening your jaw muscles and stressing your TM joint. You may have a damaged jaw joint due to injury or disease. Injuries and arthritis can damage the joint directly or stretch or tear the muscle or ligaments. As a result, the disk, which is made of cartilage and functions as the “cushion” of the jaw joint, can slip out of position. Whatever the cause, the results may include a misaligned bite, pain, clicking or grating noise when you open your mouth or trouble opening or closing your mouth wide.
  • Do You Have a TMJ Disorder? • Are you aware of grinding or clenching your teeth? • Do you wake up with sore, stiff muscles around your jaws? • Do you have frequent headaches or neck aches? • Does the pain get worse when you clench your teeth? • Does stress make your clenching and pain worse? • Does your jaw click, pop, grate, catch, or lock when you open your mouth? • Is it difficult or painful to open your mouth, eat or yawn? • Have you ever injured your neck, head or jaws? • Have you had problems (such as arthritis) with other joints? • Do you have teeth that no longer touch when you bite? • Do your teeth meet differently from time to time? • Is it hard to use your front teeth to bite or tear food? • Are your teeth sensitive, loose, broken or worn? The more times you answered “yes,” the more likely it is that you have a TMJ disorder. Understanding TMJ disorders will also help you understand how they are treated.
  • Treatment – There are various treatment options that Dr. Shuren can utilize to improve the harmony and function of your jaw. Once an evaluation confirms a diagnosis of TMJ disorder, Dr. Shuren will determine the proper course of treatment. It is important to note that treatment always works best with a team approach of self-care joined with professional care. The initial goals are to relieve the muscle spasm and joint pain. This is usually accomplished with a pain reliever, anti-inflammatory or muscle relaxant. Steroids can be injected directly into the joints to reduce pain and inflammation. Self-care treatments can often be effective as well and include: • Resting your jaw • Keeping your teeth apart when you are not swallowing or eating • Eating soft foods • Applying ice and heat • Exercising your jaw • Practicing good posture Stress management techniques such as biofeedback or physical therapy may also be recommended, as well as a temporary, clear plastic appliance known as a splint. A splint or nightgaurd fits over your top or bottom teeth and helps keep your teeth apart, thereby relaxing the muscles and reducing pain. Appliances also help to protect from tooth wear. This appliance would be made by your dentist.
  • What about bite correction or surgery? If your TMJ disorder has caused problems with how your teeth fit together, you may need treatment such as bite adjustment (equilibration), orthodontics with or without jaw reconstruction, or restorative dental work. This would be treated by your dentist. Surgical options such as arthroscopy and open joint repair restructuring are sometimes needed but are reserved for severe cases. Dr. Shuren does not consider TMJ surgery unless the jaw can’t open, is dislocated and nonreducible, has severe degeneration, or the patient has undergone appliance treatment unsuccessfully.

CORRECTIVE JAW SURGERY

  • Orthognathic Jaw Surgery (Corrective Jaw Surgery) Orthognathic surgery is needed when the jaws, and the teeth within them don’t seem to fit together correctly. Teeth are straightened with orthodontics and corrective jaw surgery repositions misaligned jaws. This not only improves facial appearance, but more importantly ensures that teeth meet correctly and function properly against each other.
  • Who Needs Orthognathic Surgery? People who can benefit from orthognathic surgery include those with an improper bite or jaws that are positioned incorrectly. Jaw growth is a gradual process and in some instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that can affect chewing function, speech, long-term oral health and appearance. Injury to the jaw and birth defects can also affect jaw alignment. Orthodontics alone can correct bite problems when only the teeth are involved. Orthognathic surgery may be required for the jaws when repositioning is necessary.
  • Difficulty in the following areas should be evaluated: • difficulty in chewing, biting or swallowing • speech problems • chronic jaw or TMJ pain • open bite (teeth not in contact while biting together) • protruding jaw • breathing problems • facial deformity and/or deformity Any of these symptoms can exist at birth, be acquired after birth as a result of hereditary or environmental influences or as a result of trauma to the face. Before any treatment begins, a consultation will be held to perform a complete examination with x-rays. During the pre-treatment consultation process, feel free to ask any questions that you have regarding your treatment. When you are fully informed about the aspects of your care, you and your dental team will make the decision to proceed with treatment together. If you are a candidate for Corrective Jaw Surgery, Dr. Shuren will work closely with your dentist and orthodontist during your treatment. The actual surgery can move your teeth and jaws into a new position that results in a more attractive, functional and healthy dental-facial relationship.