Cutting Remarks

Oral surgery armamentariums vary by procedure. We look at some of the latest instruments and devices used in treatments ranging from extractions and implant placement to cosmetic surgery. In any case it’s vital for GPs, specialists and sales reps to keep lines of communication open.

Any time cutting — of either hard or soft tissue — is involved in dentistry, it may be considered oral surgery. Therefore, you could say that all dentists perform oral surgery every day. Indeed, the term “oral surgery,” often combined with the term, “maxillofacial,” covers a lot of ground.

But despite the fact that oral and maxillofacial surgery is a specialty in its own right, general dentists increasingly perform many of the types of treatments, from implant placement to cosmetic surgery, which would fall under its purview. “We are seeing more surgical procedures being done by the general practitioner that had in the past been referred to the oral surgeon,” says Gregori Kurtzman, DDS, who operates a general dental practice based in Silver Spring, Maryland, that specializes in implant and cosmetic dentistry.

An internationally recognized lecturer, Kurtzman notes that general practitioners are adding myriad surgeries to their repertoires. Many are perfectly capable of tackling straightforward procedures, he says, though referral to a specialist is always a smart move if complexities are foreseen.

Whether a general practitioner should tackle a procedure comes down to personal decision. Abtin Shahriari, DMD, who operates an oral-facial surgical practice in Atlanta says that because oral surgery procedures are variable and no true standard exists, a general practitioner’s decision of whether to perform a procedure in-house or refer the patient to a specialist is not an easy one. “Each case depends on the general dentist’s comfort zone,” he says. “The doctor has to be extremely in tune and knowledgeable of the patient’s general health and medical history in order to give the best advice. Nevertheless, it is crucial to realize there is a whole body association to the oral cavity. A specialist’s extensive training is beneficial when tackling patient procedures, especially when complications arise.”

Regardless of which type of practitioner performs a surgical procedure, each option will require a particular armamentarium to facilitate the best outcome. Many of these armamentariums have remained the same over the years, but the field is not without innovations.


POINT OF SALE: TOOLING UP

  • Because general dentists are undertaking more kinds of procedures, from implant placement to cosmetic dentistry, they especially can benefit by having a wide range of armamentariums on hand.
  • Having the right tool for the job is paramount and especially important when you consider that atraumatic extractions are credited with a reduction in dry socket incidences.
  • While a range of hand instruments and handpieces are still necessary in many surgical procedures, ultrasonics and lasers are gaining momentum.
  • Ultrasonic units and hard- and soft-tissue lasers are reportedly less traumatic than other cutting options, and result in less bleeding and faster healing.

Indeed, as Shahriari notes, “There is a movement in oral surgery going from static treatment planning to dynamic treatment. The ability to treatment plan complex surgical cases using 3D imaging allows us to plan more effectively and produce the best possible result. In the past, impressions were obtained, poured, and guides were fabricated. Now, the incorporation of 3D imaging, intraoral scanning, and computer assisted modeling decreases error and improves results.”

As more customers expand their patient services to include oral surgery procedures, there is no time like the present to get up to speed on the latest and most trusted devices clinicians turn to when performing these treatments.

GET OUT

Sometimes, there is just no way around an extraction. But properly pulling a tooth often requires a bit more finesse than tying a string to a door. Some teeth may come out easily, but others may be complicated. For instance, third molars, otherwise known as wisdom teeth, can be challenging because of their posterior location and the fact that they are often impacted, which means they haven’t erupted through the gum tissue fully, if at all.

“Impacted third molars can be managed by GPs if they have experience in flap surgery and complications,” Kurtzman explains. “But those teeth in close proximity to the inferior alveolar nerve (IAN), would be best referred because of potential nerve damage issues and from a liability standpoint. When an IAN repositioning is needed for posterior mandible implant placement, this should be performed by an oral surgeon with experience.”

An extraction involves removing the tooth, inflicting the least trauma possible to the surrounding tissues. Atraumatic extractions are particularly important given the evidence that the development of alveolar osteitis, or dry socket, is associated with traumatic extractions.

What is known as “closed-tooth extraction” may be performed on teeth that are fully erupted. Such cases may simply require the use of a scalpel to loosen a tooth from its soft tissue attachments; a periosteal instrument to retract tissue surrounding a tooth; an elevator hand instrument to expand the bony tooth socket to loosen the tooth or portions of a segmented tooth; and forceps, available in a variety of tooth-specific designs, to extract the tooth.

But for impacted teeth, a surgical extraction, or “open extraction,” will be required. Scalpels are used to incise soft tissue, which is reflected back to gain access to the tooth. If bone must be cut, or if a tooth must be fragmented, a high-speed dental drill and appropriate bur, or a chisel and mallet have been traditional go-to instruments, in addition to tools such as elevators. More recently, other technologies have gained ground. “Piezoelectric surgical units have been a major leap forward in cutting and manipulation of bone,” Kurtzman says. “The vibrations are less traumatic to the bone, allow thinner cuts than burs and are safer when soft tissue is contacted.”

Kurtzman also notes that lasers have gained traction. “The Er:YAG is being utilized for hard-tissue applications, allowing cutting of bone and tooth with less trauma than achieved with a bur, while having the added benefit of improved healing and stimulation of angiogenesis, while sterilizing the site without negative effect to the patient’s cells or structures. The diode laser has excellent soft-tissue applications and is increasingly being used to replace the scalpel to cut soft tissue with coagulation abilities with added benefits in patients with bleeding issues related to anticoagulation medications.”

PROSTHETIC PREPARATIONS

Once a tooth has been extracted, it must be replaced with something to avoid alignment and occlusal problems. Preprosthetic treatments prepare the alveolar ridge to accommodate a prosthetic such as a denture or implant.

Because the bony ridge on which dentures rest must be the proper shape and size, in some cases, bone tissue must be removed, reduced, smoothed or recontoured. Clinicians might employ ultrasonics or lasers, or reach for traditional bone-cutting hand instruments. These might include chisels and mallets to cut bone; osteotomes for bone splitting; ronguers to remove sharp edges on the alveolar ridge and other areas; and files to smooth edges.

In other cases, bone tissue must be added through tissue grafting. The aim with removable prosthetics such as dentures is to enhance retention and fit. But placement of a fixed prosthetic, such as a dental implant, can be challenging in patients for whom bone loss is an issue. Since implants are supported by bone structure, such cases also may require bone grafting.


WHAT IS THE ORAL AND MAXILLOFACIAL SPECIALTY?

PHOTOGRAPHER/ISTOCK/THINKSTOCK

PHOTOGRAPHER/ISTOCK/THINKSTOCK

The American Dental Association defines “oral and maxillofacial surgery” as “the specialty of dentistry which includes diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.”

These specialists typically complete four years of surgical residency in a hospital setting along with their counterparts in medicine. Their training, however, zeroes in on the hard and soft tissues of the face, including the mouth and jaws. Unlike other residents, oral and maxillofacial surgical interns are trained in anesthesiology.

This rigorous training prepares them to not only treat issues in the oral cavity, including teeth, but also to address head, neck, jaw and facial injuries, diagnose and treat oral cancer and sleep apnea, and perform corrective and cosmetic facial, gum and jaw procedures. This includes some traditionally endodontic procedures, such as apical surgery.

Other procedures performed by these specialists include:

  • Dentoalveolar surgeries such as tooth extractions, orthodontic treatments, and preprosthetic preparation.
  • Dental implant surgery, which may include bone grafting and sinus lifts.
  • Reconstructive surgery, which can include bone and skin grafts to replace lost or deformed structures.
  • Treatment of orofacial pain stemming from issues such as infection, malocclusion, tempormandibular joint problems, tumors or nerve pathology.

Implants are increasingly preferred to dentures among today’s patients. These osseointegrated prosthetics offer a hassle-free natural look, and over the past 25 years, there has been a tremendous increase in implants being placed — many by general dentists. “The simple cases can be placed predictably,” Kurtzman says. “Yet, complex cases are best managed with a team approach, and involving a surgical specialist should be considered.”

Placement of dental implants necessitates drilling into bone, which is referred to as an “osteotomy.” In essence, the implant takes the place of the root and provides stability for the implant as a whole, which includes the abutment and crown. Traditionally, burs and saws on rotary straight and contra-angle handpieces have been used to prepare bone for implants, but, again, more recently, ultrasonic units and lasers have become star players.

GOING UP

Sometimes, due to spatial constraints in the upper jaw, implant placement requires a sinus lift. This essentially lifts the sinus membrane to make room for more bone. Kurtzman explains, “A sinus lift, also called a sinus augmentation, is a procedure performed in the posterior maxilla when implants are planned but insufficient bone height is available to contain the implants.”

To increase bone volume, bone material must be grafted onto the upper jaw, below the sinus. Bone chips derived from the osteotomy during the preparation phase can be used as grafting material in the space between the sinus membrane and the palatal floor.

A range of innovative instruments and devices, used with hand instruments, can help in such procedures, including surgical suction units that contain bone and tissue fragments so lines don’t clog. Also, in the case of both ultrasonic and rotary instruments, surgical handpieces with integrated LED lights illuminate the surgical field. And hands-free operation of such instruments via sophisticated drive units allows good speed and torque control. Some even are designed to measure implant stability.

But sometimes it’s not bone, but soft tissue that must be manipulated.

COSMETIC SURGERY

Cosmetic procedures in dentistry don’t just pertain to hard-tissue restoration or whitening. Many are performed to improve gumline esthetics through surgical recontouring or excising excess gingival tissue in what is called a gingivectomy. In the case of esthetic crown-lengthening procedures, we’re often talking about removing and reshaping gum tissue to get rid of the dreaded gummy smile. In other cases, diseased tissue, past the point of help by other means, must be removed.

Gingival reshaping is somewhat of an art. The clinician is, after all, crafting a smile. Again, traditional instruments include a scalpel to remove gum tissue, and diamond burs may be used to bevel tissue. But soft-tissue lasers such as diode or carbon dioxide (CO2) are making inroads, and for good reason. Compared to the blade, lasers, which cauterize as they go, offer practically bloodless surgery and promote faster healing.


LEXICON

  • Alveolar osteitis: A painful post-extraction condition that occurs when the blood clot is lost or fails to form, leaving bone and nerve endings exposed.
  • Angiogenesis: The creation of new blood vessels.
  • Inferior alveolar nerve: The nerve that supplies sensation to the lower teeth.
  • Osseointegration: Refers to bone and another type of material, such as an implant, becoming one.
  • Pedicle: A strip of tissue, that, when used as a graft, remains attached to its original site.
  • Subepithelial tissue: The tissue under the epithelial, or outer tissue that lines the oral cavity.

The flip side of the cosmetic coin is gingival recession, when there is not enough gingival tissue to cover roots. This may be due to aging, and may result from periodontal disease. This is not only an esthetic problem. It also can result in hypersensitivity and increase the risk for root caries. In such cases, the addition of tissue through a gum graft is typically indicated. “Gum grafting is used to generate or build keratinized tissue around the teeth or implants for improved long-term predictability and success,” Shahriari explains, noting that this supports gingival function and esthetics.

CHALLENGES AHEAD

When asked what he sees as a primary challenge in the practice of oral surgery, Shahriari doesn’t hesitate. “Not being able to grow new teeth using stem cell research,” he says. But he adds, “Luckily, this innovative technology looks promising for the future.”

With all of the technologies at their disposal, clinicians — whether generalists or specialists — are able to offer more streamlined, high-quality care than ever. And your familiarity with the latest innovations will help practitioners select the appropriate instruments to do just that.

In Kurtzman’s view, the primary challenge in performing surgeries such as implant treatment lies in the coordination of the team approach. Says Kurtzman, “As implant treatment is a restorative treatment with a surgical component, the oral surgeon needs to let the restoring dentist dictate where the implants are needed, and then, if necessary, create the bone in those areas to allow the restorative-driven implants to be placed. This, however, does not mean the surgeon cannot suggest changes to treatment.”

Perhaps the best recipe for success is delivered by clinicians who recognize their own limitations and solicit help on cases when necessary. It is here that teamwork and communication are critical, for when it comes to cutting remarks, it’s helpful if everyone speaks the same language.

 

Featured photo by PHOTOGRAPHER/ISTOCK/THINKSTOCK

From MENTOR. March 2017;8(3):20-22,24.

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