Surgery

RISKS

Any surgical procedure whether very small or extremely complex and challenging has the same inherent risks. It is important for the patient to always be well informed of any procedure to be carried out by their dentist so that informed consent is established. After a surgical procedure there can be swelling, pain or discomfort, infection or continued numbness. The anatomy of the oral cavity brings many sensitive structures into the surgical field. In the lower jaw when working around the lower second bicuspids we find the Mental nerve. Also in the posterior of the mandible under the molars and especially close by when removing wisdom teeth or placing implants is the Trigeminal nerve. The Infraorbital nerve is high above the maxillary first bicuspid and in play with large cysts or infections. Besides nerves the other main structure which becomes involved in different oral surgeries are the maxillary sinuses found above and in between the upper molars and or bicuspids. The nasal cavity is nearby high above the roots of the upper front teeth and is a limiting factor in implant placement. By utilizing an exacting and gentle minimal invasion surgical technique Dr. Kirshen minimizes post operative complications. Thorough diagnosis and treatment planning isolates the position of the nerves so they can be avoided thus minimizing the possibility of numbness or parasthesia post surgery. Transient parasthesia can be experienced even after a simple injection if the nerve is touched during delivery of the anaesthetic solution. The odds are 1 in 250,000 or larger  but must be expressed. The use of medications either pre or post operatively help contain many of the symptoms so that pain relievers and antibiotics are in our armementarium to best help you. Dr Kirshen believes that a patient must be well educated in their treatment options so they can make an intelligent decision and partner in attaining the best outcomes. Dr. Kirshen distributes educational material regarding all the procedures which are carried out in the office so you can review your options at home.

Extractions

There certain cases that necessitate the need for tooth extraction. These include: teeth with advanced bone loss that are loose due to periodontal disease, teeth with advanced dental decay that has extended into the roots, impacted wisdom teeth that may cause damage to the adjacent teeth and may become infected or those teeth with large abscesses that have caused extensive bone loss and cannot be restored. When we decide to extract a tooth we will provide you with treatment options to restore the site to optimal aesthetics and function.


 

Wisdom Teeth Extractions

Wisdom teeth are often trapped at the back of the jaw without the necessary space to fit into the arch. This is especially true when you have had orthodontic treatment to straighten the teeth as there wasn't enough room for the first 28 teeth, now try adding 4 more. All teeth require a good band of keratinized epithelium or attached gingiva around the neck of the tooth to protect it from the ingress of bacteria. At the back of the mouth we all run out of this protective tissue and with a lot of wisdom teeth trapped unable to come all the way in, we see a lot of gum infections and swelling. This can be quite painful and may need a regimen of antibiotics to quiet it down before the wisdom teeth can be extracted. In our office Dr Kirshen offers a wide variety of sedative options to help you through the procedure and insure your comfort in a safe environment. If the wisdom teeth are trapped far below the gum line and have no possibility of erupting into the mouth there may be the possibility that you can "let sleeping teeth lie there". Each case must be interperted on the individuals needs and presentation. The risks and complications of wisdom teeth extraction are the same as any surgical procedure and can be found at the top of this information page.



http://www.utoronto.ca/dentistry/newsresources/evidence_based/EBR2010/W1_EBLREPORT2010.pdf


Connective Tissue Grafting

A quick lesson in anatomy. There are two types of oral mucosa around your teeth. Attached and unattached gingiva. Attached gingiva is firm, stippled texture, pink tissue which protects the gum line from shifting. It is directly adjacent ot the necks of the teeth. Unattached gingiva is directly below the attached and is redder and can be distinguished due to the small blood vesels which are readily visible and the fact that it moves when we eat and talk. When a patient has recession of the gum line, the underlying root surface becomes exposed and over time this can lead to tooth sensitivity. In the recession process you are losing attached gingiva and its underlying bone. If the recession continues and enough bone is lost you can also experience looseness of teeth as they become mobile. Dr. Kirshen will best advise you when it is time to reverse the process by recommending whether a connective tissue graft or free gingival graft is necessary. The concept is to borrow tissue from the roof of the mouth (palate) or use an allograft from a cadaver or porcine, and to graft it into place around the exposing root. There are two goals in achieving success with this technique. First, Dr. Kirshen wishes to bolster the amount of attached gingiva so no further recession can occur and second, to attempt to cover the exposing root surface and lessen the amount of root exposure. The best success and most root coverage is achieved using a patient's own donor tissue, but this is not always possible or warranted especially in treating a large number of teeth in the same session or to lessen the morbidity after surgery by not having to enter a second site. For these circumstances Dr. Kirshen has available in his armamentarium the use of cadaver tissue (Alloderm) or porcine tissue (specially treated connective tissue from pigs). As the trend of orthodontics is to try to treat the patient without extracting any teeth we are seeing more recession at an earlier age because the teeth have been moved into narrower parts of the arch unable to accomodate the width of the teeth and thus leading to recession. By not extracting teeth we are seeing less problems later with joint soreness (TMJ Syndrome) but more recession. Please remember that the orthodontist has done the best with the genetic makeup of the patient and recession is a risk of treatment well worth taking.


Free Gingival Graft

A free gingival graft differs from a connective tissue by the type of tissue that is donated to the recession site. A free gingival graft involves taking the outer layer of the roof of the mouth and grafting it to the root surface. The thicknesses are in the 10th's of millimetres that are used. For a connective tissue graft the outer layer of the palate is opened like a trap door and the connective tissue below and over the bone is harvested and then moved to the recession site. The trap door is replaced and sutured or glued closed. There is less sensation on the palate utilizing a connective tissue graft over a free gingival graft, and Dr. kirshen will best advise what is most best beneficial to each individual depending on the parameters at presentation.


Crown Lengthening

This common surgery involves lifting back the gums and removing the tartar. The gums are then sutured back in place so that the tissue fits snugly around the tooth again. A pocket reduction procedure is recommended if daily at-home oral hygiene and a professional care routine cannot effectively reach these deep pockets. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide. This allows the gum tissue to better reattach to healthy bone. The teeth will appear longer as we are forcing recession to reduce the pocket depth.


Bone Graft - Allograft

When a tooth is lost, a hole is left in the bone where the tooth existed and the bone that surrounded the tooth may collapse. If an implant is desired to replace the tooth, the collapse of the bone may prevent implant placement. An allograft is freeze-dried bovine bone that can be placed into the tooth socket at the time of extraction for socket preservation. The grafting material is left within the jaw bone for several months as it integrates with surrounding bone. After osteointegration an implant can be placed into the bone so a crown can be fabricated to replace the missing tooth.


Sinus Elevation

The nasal sinuses exist within the upper jaw bone and are close to the roots of the posterior teeth. When the back teeth are lost, the jaw bone shrinks and the sinuses may expand down into the area where the roots of the teeth once existed. This is called pneumitization. If implants are to be utilized to replace the missing back teeth then a sinus elevation procedure with a bone graft may be required prior to implant placement. The sinus membrane can be elevated and grafting materials placed under the Schneiderian membrane to re-grow the bone that was lost. Approximately 9 months of healing is required prior to implant placement when the lost bone is extensive. There are situations where the implants can be placed at the same time as sinus augmentation thus cutting down the overall length of treatment time.


Implant Surgery

Implant Procedure The introduction of dental implants has transformed dentistry the most over the last quarter century. When we first began working after graduating from the University of Toronto Dental Facyulty in 1980 the field of dental implantology was in its infancy and considered experimental. Dr Kirshen was definitely a visionary as he embraced the new technology early and has placed and restored thousands of implants. Today the field of implantology allows us to treat many conditions and improve the lives of our patients.
Dr. Kirshen has used implants in fixed and removeable solutions used to replace the roots of missing teeth for over 30 years. After an implant is placed into the jaw bone, it may either be restored immediately or it is allowed to heal for several months to become integrated within the bone. Upon full healing, a coping is attached to the implant using a screw and an impression of the mouth is taken so the dental technician can fabricate a post that will screw into the implant with an ideal angulation. A new impression is taken with the post cemented in place so the dental technician can fabricate a crown to attach to the post. The crown will be made to closely replicate the shape, contour and colour of the natural tooth.




Flap Surgery

Your bone and gum tissue should fit snugly around your teeth like a turtleneck. When you have periodontal disease, this supporting tissue and bone is destroyed, forming "pockets" around the teeth. Over time, these pockets become deeper, providing a larger space for bacteria to thrive and wreak havoc. As bacteria accumulate and advance under the gum tissue in these deep pockets, additional bone and tissue loss follow. Eventually, if too much bone is lost, the teeth will need to be extracted.

Flap surgery is sometimes performed to remove tartar deposits in deep pockets or to reduce the periodontal pocket and make it easier for you or your dental professional to keep the area clean. This common surgery involves lifting back the gums and removing the tartar. The gums are then sutured back in place so that the tissue fits snugly around the tooth again. A pocket reduction procedure is recommended if daily at-home oral hygiene and a professional care routine cannot effectively reach these deep pockets. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide. This allows the gum tissue to better reattach to healthy bone. The teeth will appear longer as we are forcing recession to reduce the pocket depth. This may also cause tooth sensitivity as more root structure is exposed to the oral environment.Time will usually be the ultimate desensitized but if it persists then Dr.Kirshen can recommend various options to minimize the sensitivity beginning with special toothpastes such as Prevident Boost by Colgate, to treating the roots with desensitizing agents in office. Only in extreme cases may there be a need for root canal therapy or fully covering all the root surfaces using a crown procedure.


Endodontic Surgery

There are cases where an abscess develops at the root tip even after root canal treatment. This occurs when all the infected bacteria could not be removed within the root or when the initial infection was severe. Surgery is an alternative option to root canal retreatment to remove the bacteria from the root tip without disturbing the crown of the tooth. An incision is made in the gum tissue and the apical portion of the root is located in the  bone where the infection can then be cleaned out. The tip of the root is cut off in a procedure called an apioectomy and the root canal system is re-sealed with a small retrograde filling to help the bone reform. This procedure can be utilized as an alternative to conventional root canal therapy when the tooth has a good crown or cap on it due to previous dental work and re-treatment would cause an undue expense. Each case must be decided on its own merits.There are some cases where the procedure may be unsuccessful and the tooth may still require extraction. Where root canal therapy is approximately 90% successful, root canal surgery is only successsful in about 80% of cases.