Procedures

Wisdom Tooth Removal

By the age of eighteen, the average adult has 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, canine and bicuspid teeth) are ideal for grasping and biting food into smaller pieces. The back teeth or molar teeth 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 four other teeth are your third molars, also known as "wisdom teeth."

Impacted Wisdom Teeth
Wisdom Tooth Pain/Swelling

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 do not erupt properly into the mouth. They may grow sideways, partially emerge from the gum and even remain trapped beneath the gum and bone. These poorly positioned impacted teeth can cause many problems. When they are partially erupted, the opening around the tooth allows bacteria to grow and will eventually cause an infection or promote decay of the adjacent teeth. 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.

Impacted Teeth Can Cause Decay
Wisdom Tooth Removal

 

Oral Examination

With an oral examination and x-rays of the mouth, Dr. Chuong 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. Chuong has the training, license and experience to provide various types of anesthesia for patients to select the best option.

Removal of Wisdom Teeth

In most cases, the removal of wisdom teeth is performed under local anesthesia, with or without intravenous sedation.  These options as well as the surgical risks (i.e. sensory nerve damage, sinus complications, infection, bleeding, etc.) 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.  You will be seen for a follow up evaluation approximately one week after surgery.  If you have any questions, please do not hesitate to call us at 727-894-1442. 

Our services are provided in an environment of optimum safety that utilizes modern monitoring equipment and staff that are experienced in anesthesia techniques.

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Corrective Jaw Surgery

Orthognathic surgery is needed when jaws don't meet correctly and/or teeth don't  fit together properly within the jaws. Teeth are straightened with orthodontics and corrective jaw surgery repositions misaligned jaws. This not only improves facial appearance, but also ensures that teeth meet correctly and function properly.

Improperly aligned Jaw
Corrective Jaw Surgery

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. Temporomandibular Joint (TMJ) problems, suhc as degenerative arthritis, may cause the jaw to shift out of position, which can adversely affect the bite.  Orthodontics alone can correct bite problems when only the teeth are involved. Orthognathic surgery is required  when repositioning of the jaws is necessary.

Difficulty in the following areas should be evaluated for possible orthognathic surgery:

  • difficulty in chewing, biting or swallowing 
  • speech problems 
  • chronic jaw or TMJ pain 
  • open bite 
  • protruding jaw
  • asymmetrical or crooked jaw
  • breathing problems, such as sleep apnea

Any of these problems can exist at birth, be acquired after birth as a result of hereditary or environmental influences, including 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 surgical team will make the decision to proceed with treatment together.

Corrective Jaw Surgery

If you are a candidate for Corrective Jaw Surgery, Dr. Chuong 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.  Please bring dental study models, facial and bite photographs, and x-rays to our office for your initial consultation, if they are available.

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Facial Trauma

Oral and maxillofacial surgeons are well versed in emergency care, acute treatment and long-term reconstruction and rehabilitation of facial injuries.  Oral and maxillofacial surgeons are trained, skilled and uniquely qualified to manage and treat facial trauma since knowledge of dentistry, bone healing, and the principles of surgery are critical to the proper reconstruction of facial injuries. 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 require 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. 

Dr. Chuong meets and exceeds these modern standards.  He is trained, skilled and highly qualified to manage and treat facial trauma.  Dr. Chuong is on staff at several local hospitals 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 eye socket)
  • Fractured jaws (upper and lower jaw)

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 damage to teeth to extremely severe injuries of the soft tissues and bones of the face. Typically, facial injuries are classified as either soft tissue injuries (skin, muscles, cartilage 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.  Dr. Chuong is a well-trained oral and maxillofacial surgeon and is proficient at diagnosing and treating all types of facial lacerations.

Bone Injuries of the Maxillofacial Region

Fractures of 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, its severity, and 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 jaws. Other types of fractures of the jaw are best treated and stabilized by the placement of small plates and screws at the involved site. This technique can often allow for more rapid healing and obviates 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.  These devices are made of titanium metal which is well tolerated by human tissues. Titanium does not trigger metal detectors at airports.

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 and maxillofacial surgeons are usually involved in treating fractures of 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 and maxillofacial 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.

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Dental Implants in St. Petersburg and Trinity / Palm Harbor

Tooth Extraction
Dental Implant

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 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 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

For most patients, the placement of dental implants involves two surgical procedures. First, implants are placed within the jawbone. For the first three to six months following surgery, the implants are usually beneath the surface of the gums, gradually bonding with the jawbone. You should be able to wear temporary dentures and eat a soft diet during this time.

After the implant has bonded to the jawbone, the second phase begins. Dr. Chuong will uncover the implants and attach small posts, which will act as anchors for the artificial teeth. These posts protrude through the gums. When the artificial teeth are placed, these posts will not be seen. The entire procedure usually takes six to eight months. Most patients experience minimal disruption in their daily life.

Dental Implant

 

Surgical Advances

Using the most recent advances in dental implant technology, implants can sometimes be done in a single surgical stage.  Such implants do not require a second procedure to uncover them, but do require a minimum of six weeks of healing time before artificial teeth are placed.  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. Chuong 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 whereby 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 denture) is recommended.  A removable prosthesis (overdenture) attaches to a bar or by ball in socket attachments, whereas a fixed prosthesis is permanent and removable only by the dentist.

Dr. Chuong performs in-office implant surgery in a hospital-style operating suite, thus optimizing the level of sterility.  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 leg.

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 avenue 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 thirty-five 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 and can be uncomfortable and rather embarrassing.

Are you a candidate for implants?

If you are considering implants, your mouth and jaws must be examined thoroughly and your medical and dental history reviewed.  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 intravenous anesthesia.

Do dental 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.

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Bone Grafting

Major and Minor bone grafting

Over a period of time, the jawbone associated with missing teeth atrophies or is resorbed. 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 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 posterior 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 large 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 behind your cheeks and on top of the upper teeth.  Sinuses are like empty rooms that have nothing in them.  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 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.  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 ridge of the upper jaw and the bottom of the sinus is available to stabilize the implant well, sinus grafting and implant placement can sometimes be performed as a single procedure.  If not enough bone is available, the sinus grafting will have to be performed first, and then the bone 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 ridge has been reabsorbed 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.

Nerve-Repositioning

The inferior alveolar nerve, which gives feeling to the lower lip and chin, may need to be moved in order to make room for placement of dental implants to the lower jaw.  This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molars and/or and 2nd premolar, with the above-mentioned secondary condition.  Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates only very slowly, if ever), usually other, less aggressive options are considered first (placement of blade implants, etc.)

Typically, we remove an outer section of the cheek side of the lower jawbone in order to expose the nerve canal.  Then we isolate the nerve and vascular bundle in that area, and slightly pull it out to the side.  At the same time, we will place the implants.  Then the bundle is released and placed back over the implants.  The surgical access is refilled with bone graft material choice and the area is closed.

These procedures may be performed separately or together, depending upon the individual's condition. 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 patient's 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. 

These operations are performed in the out-office surgical suite under IV sedation. After discharge, bed rest is recommended for one day and limited physical activity for one week.

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Pre-prosthetic Surgery

The preparation of your mouth before the placement of a prosthesis, such as a denture, is referred to as pre-prosthetic surgery.

Some patients require minor oral surgical procedures before receiving a partial or complete denture, in order to ensure the maximum level of comfort.  A denture sits on the bony ridge, so it is very important that the bone is of 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 needs to be removed prior to denture insertion.

One or more of the following procedures might need to be performed in order to prepare your mouth for a denture:

  • bone smoothing and reshaping
  • removal of excess bone
  • bone ridge reduction
  • removal of excess gum tissue
  • exposure of impacted teeth

We will review your particular needs with you during your appointment.

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Exposure and Bracketing of an Impacted tooth

An impacted tooth simply means that it is “stuck” and can not erupt into function.  Patients frequently develop problems with impacted third molar (wisdom) teeth.  These teeth get “stuck” in the back of the jaw and can develop painful infections among a host of other problems (see “Impacted wisdom teeth” under Procedures).  Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems.  The maxillary cuspid (upper eye tooth) is the second most common tooth to become impacted.  The cuspid tooth is a critical tooth in the dental arch and plays an important role in your “bite”.  The cuspid teeth are very strong biting teeth which have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together so they guide the rest of the teeth into the proper bite. 

Normally, the maxillary cuspid teeth are the last of the “front” teeth to erupt into place.  They usually come into place around age 13 and cause any space left between the upper front teeth to close tight together.  If a cuspid tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch.  The techniques involved to aid eruption can be applied to any impacted tooth in the upper or lower jaw, but most commonly they are applied to the maxillary cuspid (upper eye) teeth.  60% of these impacted eye teeth are located on the palatal (roof of the mouth) side of the dental arch.  The remaining impacted eye teeth are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.

Early recognition of impacted eye teeth is the key to successful treatment:

The older the patient, the more likely an impacted eye tooth will not erupt by nature’s forces alone even if the space is available for the tooth to fit in the dental arch.  The American Association of Orthodontists recommends that a panorex screening x-ray along with a dental examination be performed on all dental patients at around the age of 7 years to count the teeth and determine if there are problems with eruption of the adult teeth.  It is important to determine whether all the adult teeth are present or are some adult teeth missing.  Are there extra teeth present or unusual growths that are blocking the eruption of the eye tooth?  Is there extreme crowding or too little space available causing an eruption problem with the eye tooth?  This exam is usually performed by your general dentist or hygienist who will refer you to an orthodontist if a problem is identified.  Treating such a problem may involve an orthodontist placing braces to open spaces to allow for proper eruption of the adult teeth.  Treatment may also require a referral to an oral surgeon for extraction of over retained baby teeth and/or selected adult teeth that are blocking the eruption of the all important eye teeth.  The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any of the adult teeth.  If the eruption path is cleared and the space is opened up by age 11 or 12, there is a good chance the impacted eye tooth will erupt with nature’s help alone.  If the eye tooth is allowed to develop too much (age 13-14), the impacted eye tooth will not erupt by itself even with the space cleared for its eruption.  If the patient is too old (over 40), there is a much higher chance the tooth will be fused in position.  In these cases the tooth will not budge despite all the efforts of the orthodontist and oral surgeon to erupt it into place.  Sadly, the only option at this point is to extract the impacted tooth and consider an alternate treatment to replace it in the dental arch (crown on a dental implant or a fixed bridge).

What happens if the eye tooth will not erupt when proper space is available?

In cases where the eye teeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these unerupted eye teeth to erupt.  Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral surgeon.  The most common scenario will call for the orthodontist to place braces on the teeth (at least the upper arch).  A space will be opened to provide room for the impacted tooth to be moved into its proper position in the dental arch.  If the baby eye tooth has not fallen out already, it is usually left in place until the space for the adult eye tooth is ready.  Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eye tooth exposed and bracketed. 

In a surgical procedure performed in the surgeon’s office, the gum on top of the impacted tooth will be lifted up to expose the hidden tooth underneath.  If there is a baby tooth present, it will be removed at the same time.  Once the tooth is exposed, the oral surgeon will bond an orthodontic bracket to the exposed tooth.  The bracket will have a miniature gold chain attached to it.  The oral surgeon will guide the chain back to the orthodontic arch wire where it will be temporarily attached.  Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth (on selected cases located on the roof of the mouth).  Most of the time, the gum will be returned to its original location and sutured back with only the chain remaining visible as it exits a small hole in the gum. 

Shortly after surgery (1-14 days) the patient will return to the orthodontist.  A rubber band will be attached to the chain to put a light eruptive pulling force on the impacted tooth.  This will begin the process of moving the tooth into its proper place in the dental arch.  This is a carefully controlled, slow process that may take up to a full year to complete.  Remember, the goal is to erupt the impacted tooth and not to extract it!  Once the tooth is moved into the arch in its final position, the gum around it will be evaluated to make sure it is sufficiently strong and healthy to last for a lifetime of chewing and tooth brushing.  In some circumstances, especially those where the tooth had to be moved a long distance, there may be some minor “gum surgery” required to add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function.  Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.

These basic principals can be adapted to apply to any impacted tooth in the mouth.  It is not that uncommon for both of the maxillary cuspids to be impacted.  In these cases, the space in the dental arch form will be prepared on both sides at once.  When the orthodontist is ready, the surgeon will expose and bracket both teeth in the same visit so the patient only has to heal from surgery once.  Because the anterior teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, they are easier to erupt if they get impacted than the posterior molar teeth.  The molar teeth are much bigger teeth and have multiple roots making them more difficult to move.  The orthodontic maneuvers needed to manipulate an impacted molar tooth can be more complicated because of their location in the back of the dental arch.  

Recent studies have revealed that with early identification of impacted eye teeth (or any other impacted tooth other than wisdom teeth), treatment should be initiated at a younger age.  Once the general dentist or hygienist identifies a potential eruption problem, the patient should be referred to the orthodontist for early evaluation.  In some cases the patient will be sent to the oral surgeon before braces are even applied to the teeth.  As mentioned earlier, the surgeon will be asked to remove over retained baby teeth and/or selected adult teeth.  He will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth.  Finally, he may be asked to simply expose an impacted eye tooth without attaching a bracket and chain to it.  In reality, this is an easier surgical procedure to perform than having to expose and bracket the impacted tooth.  This will encourage some eruption to occur before the tooth becomes totally impacted (stuck).  By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the eye tooth will have erupted enough that the orthodontist can bond a bracket to it and move it into place without needing to force its eruption.  In the long run, this saves time for the patient and means less time in braces (always a plus for any patient!).

What to expect from surgery to expose and bracket an impacted tooth:

The surgery to expose and bracket an impacted tooth is a procedure that is usually performed in the oral surgeon’s office.  For most patients, it is performed with using laughing gas and local anesthesia.  The procedure is generally scheduled for 75 minutes if one tooth is being exposed and bracketed and 105 minutes if both sides require treatment.  If the procedure only requires exposing the tooth with no bracketing, the time required will be shortened by about one half.  These issues will be discussed in detail at your preoperative consultation with your doctor.  You can also refer to “Preoperative instructions” under Surgical Instructions on this web site for a review of any details.

You can expect a limited amount of bleeding from the surgical sites after surgery.  Although there will be some discomfort after surgery at the surgical sites, most patients find Tylenol or Advil to be more than adequate to manage any pain they may have.  Within 2-3 days after surgery there is usually little need for any medication at all.  There may be some swelling from holding the lip up to visualize the surgical site; it can be minimized by applying ice packs to the lip for the afternoon after surgery.  Bruising is not a common finding after these cases.  A soft, bland diet is recommended at first, but you may resume your normal diet as soon as you feel comfortable chewing.  It is advised that you avoid sharp food items like crackers and chips as they will irritate the surgical site if they jab the wound during initial healing.  Your doctor will see you 7-10 days after surgery to evaluate the healing process and make sure you are maintaining good oral hygiene.  You should plan to see your orthodontist within 7 days to activate the eruption process by applying the proper rubber band to the chain on your tooth.  As always your doctor is available at the office or can be paged after hours if any problems should arise.  Simply call Tampa Bay Maxillofacial Surgery (TMS) at 727-894-1442 if you have any questions.

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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, and curiously, is not often associated with oral cancer. 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.

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TMJ 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. Chuong 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 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 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. Chuong can utilize to improve the harmony and function of your jaw. Once an evaluation confirms a diagnosis of TMJ disorder, Dr. Chuong will determine the proper course of treatment.

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:

  1. Resting your jaw
  2. Keeping your teeth apart when you are not swallowing or eating
  3. Eating soft foods
  4. Applying ice and heat
  5. Exercising your jaw
  6. Practicing good posture.

Stress management techniques such as biofeedback or physical therapy may also be recommended, as well as a clear plastic appliance known as a splint.  A splint or nightguard fits over your top or bottom teeth and helps keep your teeth apart, thereby relaxing the muscles and reducing pain.  There are different types of appliances used for different purposes.  A nightguard helps you stop clenching or grinding your teeth and reduces muscle tension at night and helps to protect the cartilage and joint surfaces.  An orthotic stabilization appliance is worn 24 hours a day, or just at night to move your jaw into proper position.  Your doctor will advise you as to how and when to wear the splint.  Appliances also help to protect from tooth wear.

What about bite correction or TMJ 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 (orthognathic surgery), or restorative dental work.  Surgical options such as arthroscopy and open joint repair are sometimes needed but are reserved for severe cases. Dr. Chuong 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.

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Sleep Apnea

People with obstructive sleep apnea (OSA) have disrupted sleep and low blood oxygen levels. When obstructive sleep apnea occurs, the tongue is sucked against the back of the throat. This blocks the upper airway and air flow stops. When the oxygen level in the brain becomes low enough, the sleeper partially awakens, the obstruction in the throat clears and the flow of air starts again, usually with a loud gasp.

Repeated cycles of decreased oxygenation lead to very serious cardiovascular problems.  Additionally, these individuals suffer from excessive daytime sleepiness, depression, and loss of concentration.

Some patients have obstructions that are less severe called Upper Airway Resistance Syndrome (UARS). In either case, the individuals suffer many of the same symptoms.

The first step in treatment resides in recognition of the symptoms and seeking appropriate consultation.  Oral and Maxillofacial Surgeons offer consultation and treatment options.

In addition to a detailed history, the doctors will assess the anatomic relationships in the maxillofacial region.  With cephalometic (skull x-ray) analysis, the doctors can ascertain the level of obstruction.  Sometimes a naso-pharyngeal exam is done with a flexible fiber-optic camera.  To confirm the amount of cardiovascular compromise and decreased oxygenation levels, a sleep study may be recommended to monitor individuals overnight.

There are several treatment options available.  An initial treatment may consist of using a nasal CPAP machine that delivers pressurized oxygen through a nasal mask to limit obstruction at night.  One of the surgical options is a uvulo-palato-pharyngo-plasty (UPPP), which is performed in the back of the soft palate and throat.  A similar procedure is sometime done with the assistance of a laser and is called a Laser Assisted uvulo-palato-plasty (LAUP).  In other cases, a radio-frequency probe is utilized to tighten the soft palate.  Dr. Chuong can make a proper referral if he believes that you are a candidate for these procedures. 

In more complex cases, the bones of the upper and lower jaw may be repositioned to increase the size of the airway (orthognathic surgery).  This procedure is done in the hospital under general anesthesia and requires 1 to 2 days stay in the hospital.  This type of surgery is performed by Dr.Chuong after an appropriate sleep study and consultation.

OSA is a very serious condition that needs careful attention and treatment.  Most major medical plans offer coverage for diagnosis and treatment.

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Cleft Lip and Palate

During early pregnancy, separate areas of the face develop individually and then join together, including the left and right sides of the roof of the mouth and lips.  However, if some parts do not join properly, sections don’t meet and the result is a cleft.  If the separation occurs in the upper lip, the child is said to have a cleft lip.

A completely formed lip is important not only for a normal facial appearance but also for sucking and to form certain sounds made during speech.  A cleft lip is a condition that creates an opening in the upper lip between the mouth and nose.  It looks as though there is a split in the lip.  It can range from a slight notch in the colored portion of the lip to complete separation in one or both sides of the lip extending up and into the nose.  A cleft on one side is called a unilateral cleft.  If a cleft occurs on both sides, it is called a bilateral cleft.

A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum and upper jaw into separate parts.  A similar defect in the roof of the mouth is called a cleft palate.

Cleft Palate

The palate is the roof of your mouth. It is made of bone and muscle and is covered by a thin, wet skin that forms the red covering inside the mouth. You can feel your own palate by running your tongue over the top of your mouth. Its purpose is to separate your nose from your mouth. The palate has an extremely important role during speech because when you talk, it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating. It prevents food and liquids from going up into the nose.

As in cleft lip, a cleft palate occurs in early pregnancy when separate areas of the face have developed individually and do not join together properly. A cleft palate occurs when there is an opening in the roof of the mouth. The back of the palate is called the soft palate and the front is known as the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).

Sometimes a baby with a cleft palate may have a small chin and a few babies with this combination may have difficulties with breathing easily. This condition may be called Pierre Robin sequence.

Since the lip and palate develop separately, it is possible for a child to be born with a cleft of the lip, or palate or both.  Cleft defects occur in about one out of every 800 babies.

Children born with either or both of these conditions need the skills of several professionals to manage the problems associated with the defect such as nutrition, speech, hearing and psychological development.  In most cases, surgery is recommended. 

Cleft Lip Treatment

Cleft lip surgery is usually performed when the child is about 10 years old.  The goal of surgery is to close the separation, restore muscle function and provide a normal shape to the mouth.  The nostril deformity may be improved as a result of the procedure or may require a subsequent surgery.

Cleft Palate Treatment

A cleft palate is initially treated with surgery safely when the child is between 7 to 18 months old. This depends upon the individual child and his/her own situation. For example, if the child has other associated health problems, it is likely that the surgery will be delayed.

The major goals of surgery are to:

  1. Close the gap or hole between the roof of the mouth and the nose.
  2. Reconnect the muscles that make the palate work.
  3. Make the repaired palate long enough so that the palate can perform its function properly.

There are many different techniques that surgeons will use to accomplish these goals. The choice of techniques may vary between surgeons and should be discussed between the parents and the surgeon prior to the surgery.

The cleft hard palate is generally repaired between the ages of 8 and 12 when the cuspid teeth begin to develop.  The procedure involves placement of bone from the hip into the bony defect, and closure of the communication from the nose to the gum tissue in three layers.  It may also be performed in teenagers and adults as an individual procedure or combined with corrective jaw surgery.

What can be expected after the surgery?

After the palate has been fixed, children will immediately have an easier time in swallowing food and liquids. However, in about 1 out of every 5 children following cleft palate repair, a portion of the repair will split, causing a new hole to form between the nose and mouth. If small, this hole may result in only an occasional minor leakage of fluids into the nose. If large however, it can cause significant eating problems, and most importantly, can even affect how the child speaks. This hole is referred to as a "fistula," and may need further surgery to correct.

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