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Wisdom Teeth:
What are wisdom teeth?
Wisdom teeth are also called third molars. They usually erupt in your late teens to early twenties.
They are known for the problems they can cause. Removing wisdom teeth can solve the
symptoms you are experiencing now, and prevent future problems.
What is an impacted tooth?
An impacted tooth is when there is inadequate space for the tooth to erupt. Many people's jaws
are too small for the wisdom teeth to grow in. They can't take their normal position for chewing
and cleaning. This can lead to future problems. There are several types of impactions:
Soft Tissue: Not enough room for the gum tissue to retract for adequate cleaning.
Partial Bony: The tooth only partially erupts. It cannot function properly and creates
Complete Bony: There is no space for the tooth to erupt. It can remain embedded in the
jaw and can cause future problems.
Problems Wisdom Teeth Cause
When there is not enough room for your wisdom teeth, problems may arise. These may develop
immediately or years after they erupt, or even if they are impacted. They frequently arise when
the teeth are hard to reach and clean. These include:
Infection: The most common problem we see is pericoronitis, which is a localized gum
infection. Without enough room, the gum tissue gets infected, causing pain, swelling,
bleeding and difficulty chewing.
Tooth Decay: Wisdom teeth can be hard to clean because they're at the back of the
mouth. This can lead to decay of both the wisdom tooth and the tooth next to it.
Gum Disease: This is due to problems flossing in the back of the mouth, or as a result of
bacteria and food debris collecting under and around the gum tissue of the wisdom tooth.
Gum disease can lead to the loss of the adjacent molar.
Cysts and Tumors: A tooth that has not erupted is encased in a sac. When this sac
enlarges and fills with fluid, it forms a cyst. The cyst can expand and destroy surrounding
bone. In some cases, it can change into a tumor.
Crowding: Retained and impacted wisdom teeth may be a factor in crowding. An
impacted tooth can push nearby teeth forcing them out of alignment. This can interfere
with your bite, as well as orthodontic treatment. Crowding can also damage adjacent
When should they be removed?
Early removal is often recommended. This prevents many of the problems that you can
encounter. Problems tend to occur with greater frequency after age 30. As we get older the risk
of complications increase and people heal slower.
Risks and Complications
Any surgery has risks. The risks vary depending on age and the position of your teeth. These
Sore Joints and Muscles: Soreness, bruising, swelling and jaw stiffness is normal after
removal. These problems often resolve in a week or so.
Infection: Signs of infection usually are a sudden increase in pain and swelling. This is
often treated with antibiotics, rinsing the socket, or both.
Dry Socket: This is when the blood clot dissolves or dislodges too soon after surgery. It
causes pain and a slow recovery. It is treated by placing a special dressing in the socket to
relieve the pain.
Sinus Problems: Upper wisdom teeth sometimes lie just below the sinus. Removal can
lead to a communication between the mouth and sinus. These usually close
spontaneously. You may be given special instructions and an antibiotic to prevent a sinus
Nerve injury: There is a nerve in your lower jaw that gives you feeling to your teeth,
tongue, gums, lip and chin. In some people, the nerve is close to the roots of the wisdom
teeth. If the nerve is injured, you can experience numbness or tingling of these areas. It
usually resolves gradually over weeks to months. In rare cases, it can be permanent. In
teenagers the roots are usually not completely formed, so the roots are farther away from
the nerve.
After Surgery
Proper postoperative care is very important. Follow your postoperative instructions closely.
Control bleeding. Firmly bite down on gauze for 1 - 2 hours. Use constant pressure. It
should stop in 2 - 3 hours. Some oozing is normal for a few days.
Take your medication as directed. Use the pain medication and antibiotics if prescribed.
You may also use ibuprofen if advised.
Reduce swelling. Keep your head elevated and use ice packs.
Get adequate nutrition. Once the gauze is removed, drink liquids. Stay on a soft diet until
you feel comfortable chewing.
Protect the extraction site. Avoid dislodging the blood clot. Do not brush your teeth,
rinse, smoke, spit, or drink through a straw for the first day.
When to Call the Doctor
If the pain becomes more severe or is not controlled with pain medication.
Bleeding becomes hard to control.
Swelling becomes worse instead of better.
Persistent nausea or vomiting.
Itching, rash, or other symptoms that may be an allergic reaction.
Dental Implants:
About 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. The person who has lost teeth
regains the ability to eat virtually anything, knowing that their teeth appear natural and that facial
contours will be preserved and they can smile and chew with confidence.
Replacing a missing Tooth
Usually, when you lose a tooth, it is best for your oral health to have it replaced. Missing teeth
can affect your "bite" as well as your ability to speak and chew. Their loss can increase the
burden on your remaining teeth and can cause muscle pain in your jaws and headaches. And of
course, losing a tooth can affect your appearance.
What are Dental Implants?
A natural tooth consists of a root and a crown. The part of the tooth that you see and eat with is
called the crown. Beneath the crown is the root, which anchors the tooth through the gum tissue
to the jawbone. When you lose a tooth, you lose both the root and the crown. To replace a tooth,
we first have to replace the root. A dental implant acts as a new root.
Implants are titanium posts, which are inserted into the jawbone where teeth are missing. These
metal anchors act as tooth-root substitutes. The bone bonds with the titanium, creating a strong
foundation for replacement teeth. Small posts are then attached to the implant, which protrude
through the gums. These posts provide stable anchors for replacement teeth. Implants also help
preserve facial structure, preventing the bone deterioration that occurs when teeth are lost.
Are Dental Implants an Option for me?
Do your dentures cause discomfort when you eat?
Does your denture slip or fit poorly?
Are the teeth holding your bridge loosening or moving?
Are you embarrassed about missing teeth or dentures when you smile?
Are missing teeth preventing you from chewing, eating and enjoying food?
Have you lost teeth because of an accident or disease?
Anyone missing teeth, and who can benefit from increased chewing efficiency, improved
appearance, and speech is a candidate for dental implants. Portions of the jaw that are missing
due to an accident, disease or birth defect can often be reconstructed using implants.
If you are considering dental implants, your mouth will be examined thoroughly and your dental
and medical history will be reviewed to ensure that dental implants are appropriate for you. Xrays of your jaws will be taken to evaluate your jawbone and to determine if it will accommodate
implants. Occasionally, more detailed information is required and can be provided by special xrays. They will help determine if additional tests or procedures are needed to place your implants
The Surgical Procedure
Most implants are placed in the office. The procedure lasts from 1-3 hours depending on the
surgery. For most patients, the placement of dental implants involves two surgical procedures.
First, implants are placed within your jawbone. For 3 - 6 months following placement, the
implants beneath the surface of the gums gradually bond with the jawbone. You should be able
to wear a temporary denture during this time.
After the implant has bonded to the jawbone, the second phase begins. The implants are exposed
and small posts (called abutments) are attached which will act as anchors for the replacement
teeth. These posts protrude through the gums. When the artificial teeth are placed, these posts
will not be seen. Often, these abutments can be placed initially at the time of implant placement.
Most patients experience minimal disruption of their daily life. We will review the time required
for treatment at the time of your consultation.
Your replacement teeth will be constructed by your dentist. Depending on the situation, the
replacement may be a single tooth (crown), multiple teeth (crowns or bridge). If all of your teeth
are missing, a denture is made that can be either removable or screwed in place. It can only be
removed by your doctors for cleaning and maintenance.
Bone Graft:
Dental implants need bone to hold them in place. It is necessary to have enough width and height
of bone to support a strong, healthy and long lasting implant. Bone may have been lost as a result
of infection, disease, atrophy, and pressure from dentures. This often leaves a condition in which
there is poor quality and quantity of bone suitable for placement of dental implants. Sometimes a
patient may not have enough bone in the jaw to support an implant. In these situations, most
patients are not candidates for placement of dental implants. In such cases, a bone graft may be
necessary before an implant can be placed.
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.
Bone grafting is a routine and predictable procedure. Most bone grafting procedures are minor
and can be performed in the office surgical suite under IV sedation or general anesthesia. Down
time after surgery is minimal and can vary between 2 to 4 days depending on the size of the graft
and the donor site.
Bone grafting can be done using your own bone or substitutes such as synthetic bone, banked
bone, or calcium based materials from natural sources that your body can convert into new bone.
Bone grafts can be taken from inside the mouth, in the area of the chin, or wisdom tooth region.
We will discuss and advise the best option for your case.
Types of Bone Grafting
Socket Preservation
Socket preservation grafting is done to conserve the bone in the area of the jaw that a dental
implant will be placed. When teeth are extracted, the surrounding bone and gums will shrink and
recede. In order to preserve the bone after an extraction, the socket is filled with bone or bone
substitute. It is then covered with gum, or an artificial membrane. The socket heals, eliminating
shrinkage and collapse of surrounding bone and gum tissue. The newly formed bone provides the
foundation for an implant to replace the tooth.
Sinus Lift Procedure
The maxillary sinuses are above the upper teeth. Sinuses are empty spaces lined by a membrane.
The floor of the sinus is the roof of the upper jaw. Some of the roots of the teeth extend into the
maxillary sinuses. When the upper teeth are removed, there is often just a thin wall of bone
separating the maxillary sinus and the mouth. When the sinus wall is thin, it is impossible to
place dental implants in this bone. The solution is called a sinus graft or sinus lift graft. The
surgeon enters the sinus, and the sinus membrane is lifted upward so the bone can be placed
where it is needed on the floor of the sinus. 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, sinus grafting and implant placement can sometimes be performed as a single
procedure. If not enough bone is available, the sinus graft 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 Augmentation
This is a technique used to restore lost bone when the jaw ridge is too thin to place implants. A
bone graft is placed to increase jaw width and/or height. These dimensions are increased by
expanding the jaw, placing bone graft material, or both. The site is allowed to heal for a few
months before placing the implant.
Major Bone Grafting
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.
Facial Trauma:
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
and Maxillofacial Surgeons are trained, skilled in these areas, and are uniquely qualified to
manage and treat facial injuries. Dr. Florio is well trained and proficient at diagnosing and
treating traumatic injuries of the face. These include:
Fractures of the facial skeleton
Facial lacerations and soft tissue injuries
Intra oral lacerations
Avulsed (knocked out) teeth
Injuries to the face, impart a high degree of emotional and physical trauma to patients. The art
and art of treating these injuries requires special training involving experience and an
understanding of how the injury and treatment will influence the patient's function and
appearance. Types of facial injuries can range from injuries of teeth to severe injuries of the skin
and bones of the face. Facial injuries are classified as either bony injuries (fractures), soft tissue
injuries (skin, gums, nerves, salivary glands), or injuries to the teeth and surrounding structures.
Bony Injuries of the Maxillofacial Region
Fractures of the bones of the face are treated in a manner similar to fractures in other parts of the
body. Treatment is determined by various factors, which include the location and severity of the
fracture, as well as 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 option involves wiring the jaws together for fractures of the upper and/or lower jaw. Other
types of fractures are best treated and stabilized by surgical placement of small plates and screws
at the involved site. This technique of treatment can often avoid the necessity of having the jaws
wired together. This technique is called "rigid fixation". The use of rigid fixation can improved
the recovery period for many patients, allowing them to return to normal function more quickly.
The treatment of facial fractures is 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. The incisions
that are necessary are designed to be small and when possible, are placed so that the resultant
scar is hidden.
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, and salivary
Injuries to the Teeth and Surrounding Dental Structures
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 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 (ideally within 1
hour), the better chance it will survive. Never attempt to wipe the tooth off, since remnants of the
ligament, which holds the tooth in the jaw, are attached and are vital to the success of replanting
the tooth.
Other dental specialists may be called upon. Endodontists may need to perform root canal
therapy. Restorative dentists 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.
Dental Surgery:
Most types of dental surgery are straightforward, and can be performed in the office under local
anesthesia and nitrous oxide (laughing gas) if desired. You can expect mild to moderate
discomfort for a few days following the extraction. There may be some swelling, stretching of
your lip, or bruising. In general, you should start to feel better after 2-3 days. Some patients
prefer not to return to work on the day of surgery, usually because of minor post-extraction
bleeding and discomfort. We will provide you with post-operative instructions, extra gauze and a
prescription for pain medication or antibiotics (if needed) after your treatment. Dr. Florio will see
you 7-10 days after surgery to evaluate the healing process.
If you prefer to be sedated or "go to sleep", a preoperative appointment to evaluate you and
discuss anesthesia options is mandatory. This allows us the opportunity to review your medical
history, determine what procedures are needed and otherwise prepare you for your procedure.
If your medical history is complex and you are taking a number of prescribed medications,
we may need to discuss your dental treatment with your physician before we can treat you.
Please bring a list of all medications you are currently taking with you to your first
Extractions (Tooth Removal)
Teeth may need to be removed for a number of reasons, usually due to decay, infection, gum
disease, or trauma. This results in painful, abscessed and/or loose teeth. In some non-emergency
situations involving one or several teeth, we can evaluate and treat you at the same visit. If your
dentist has recently taken x-rays that show the teeth, please bring them with you. If not, we will
take them.
Occasionally, a tooth that has had a root canal will develop an infection and surgery is
recommended. An apicoectomy (apico for short) is a surgery used to save damaged teeth. An
apicoectomy procedure can be used to locate fractures that do not appear on x-rays. Damaged
root surfaces, small cysts or infections that involve the surrounding bone may also be treated
with this procedure.
During an apico, an incision is made in the gum tissue to expose the bone and surrounding
inflamed tissue. The damaged tissue and root tip is usually removed, and a special filling is
placed in the end of the root to prevent re-infection. The gum tissue is sutured back in place. The
bone naturally heals around the root over time restoring full function.
Pre-prosthetic Surgery
Some patients require minor oral surgical procedures before receiving a denture. The preparation
of your mouth before the placement of a prosthesis is referred to as pre-prosthetic surgery. This
ensures the maximum level of comfort. A denture sits on the bone, so it is very important that the
bone is smooth, and the proper shape and size. If a tooth needs to be extracted, the underlying
bone might be left sharp and uneven. For the best fit of a denture, the bone might need to be
smoothed or reshaped. Occasionally, excess bone would need to be removed prior to denture
One or more of the following procedures might need to be performed in order to prepare your
mouth for a denture. We will review your particular needs with you during your appointment.
bone smoothing and reshaping
removal of excess bone, or bone ridge reduction
removal of excess gum tissue
Exposure and Bracketing of an Impacted Tooth
An impacted tooth simply means that it is below the gums and cannot enter the mouth and
function. This can happen to any tooth. Patients frequently develop problems with impacted third
molar (wisdom) teeth. The maxillary canine (upper eye tooth) is the second most common tooth
to become impacted. The canine is a critical tooth in the dental arch and plays an important role
in your bite. They help guide the rest of the teeth into the proper bite.
The techniques involved to aid eruption can be applied to any impacted tooth, but most
commonly, they are applied to the maxillary canine. In cases when a tooth will not erupt
spontaneously, the orthodontist and Dr. Florio work together to get these unerupted teeth to
erupt. First, a space will be opened to provide room for the impacted tooth to be moved into its
proper position in the dental arch.
The gum on top of the impacted tooth will be lifted up to uncover or expose the tooth
underneath. Once the tooth is exposed, an orthodontic bracket with a small chain is bonded to the
exposed tooth. The chain is then attached to the orthodontic wire. The gum will be returned to its
original location and only the chain remains visible.
Shortly after surgery, the patient will return to the orthodontist. A rubber band or spring will be
attached to the chain to slowly pull the tooth into its proper place. This is a controlled, slow
process and usually takes months to complete.
Corrective Jaw Surgery:
What Is Orthognathic Surgery?
Orthognathic surgery is a combined orthodontic and surgical approach to place the teeth, jaws,
and other associated hard and soft tissue structures into their optimal anatomical positions. This
may be necessary because of congenital abnormalities, growth disturbances or trauma.
Correction of these abnormalities generally results in improvement in function such as chewing,
speaking and breathing and often enhances facial aesthetics. Surgery may also be helpful as an
adjunct to orthodontic treatment to enhance the long-term results of orthodontic treatment, and to
shorten the overall time necessary to complete treatment.
Orthognathic surgery is needed when the jaws are misaligned and/or teeth don't seem to fit with
jaws. First, the orthodontist moves the teeth into their best position in relation to the jaws.
Surgery is then performed to correct the position of either the upper jaw, lower jaw or both. After
the jaws are repositioned, the orthodontist is then able to properly finish the bite into the best
possible relationship. This not only improves facial appearance, but also ensures that teeth meet
correctly and function properly.
Who Needs Orthognathic Surgery?
People who can benefit from orthognathic surgery include those with an improper bite or jaws
that are positioned incorrectly. In some people, the upper and lower jaws may grow at different
rates. This can affect chewing function, speech, long-term oral health and appearance. Injury to
the jaws and birth defects can also affect jaw alignment. There are several reasons why
correction of a jaw abnormality through orthodontics and surgery may be beneficial. Some of
these reasons are listed here:
When orthodontic treatment alone cannot correct a problem. There are times when
congenital abnormalities, growth disturbances, or previous trauma has resulted in jaw
positions that prevent conventional orthodontics from achieving a satisfactory functional
and esthetic result.
To improve jaw function. Correcting this bite frequently helps many people chew food
normally and eat things that they have been previously unable to eat.
To enhance the long-term orthodontic result (stability). When an underlying jaw
abnormality is responsible for a bite problem, orthodontic movement must sometimes be
done in such a way that it will be difficult to maintain the position of the teeth long term.
Surgery can often improve the stability of the teeth in these cases.
Reduction in overall treatment time. In some cases, options for treatment include
orthodontics alone or a combination of orthodontics and surgery. Often, a combined
orthodontic and surgical approach can be completed in a shorter period of time.
Movement of the jaws into a normal anatomical position may decrease the amount of
orthodontic treatment that is necessary.
Change in facial appearance. Placement of jaws in the proper position gives a similar
result to the underlying soft tissues and adjacent structures of the face. This results in a
more pleasing facial appearance.
Improved breathing. When surgery is performed on the jaws, the ability to breathe is
frequently improved through opening of the airway. This type of surgery often greatly
improves problems associated with sleep apnea.
Improved speech. Correction of poorly positioned jaws or teeth may have a positive
effect on abnormal speech. Jaw surgery may need to be combined with speech therapy to
correct speech abnormalities.
Improvement in jaw pain. Patients who have jaw joint pain or pain in their jaw muscles
may experience some improvement after correction of jaw position. While this pain
reduction occurs for many patients, there is no absolute guarantee that correction of jaw
positioning will be able to totally eliminate or reduce pain.
If you are a candidate for Corrective Jaw Surgery, we 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.