Procedures

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."

Why Should I Remove My Wisdom Teeth?

Wisdom teeth are the last teeth to erupt within the mouth. When they align properly and gum tissue is healthy, wisdom teeth do not have to be removed. Unfortunately, this does not generally happen. The extraction of wisdom teeth is necessary when they are prevented from properly erupting within the mouth. They may grow sideways, partially emerge from the gum and even remain trapped beneath the gum and bone. Impacted teeth can take many positions in the bone as they attempt to find a pathway that will allow them to erupt successfully.

These poorly positioned impacted teeth can cause many problems. When they are partially erupted, the opening around the tooth allows bacteria to grow and will eventually cause an infection. The result: swelling, stiffness, pain and illness. The pressure from the erupting wisdom tooth may move other teeth and disrupt the orthodontic or natural alignment of teeth. The most serious problem occurs when tumors or cysts form around the impacted wisdom tooth, resulting in the destruction of the jawbone and healthy teeth. Removal of the offending impacted tooth or teeth usually resolves these problems. Early removal (14 - 17 years of age) is recommended to avoid such future problems and to decrease the surgical risk involved with the procedure.

Oral Examination

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

Removal

In most cases, the removal of wisdom teeth is performed under general anesthesia. Options as well as the surgical risks (i.e. sensory nerve damager, sinus complications) will be discussed with you before the procedure is performed. Once the teeth are removed, the gum is sutured and gauze is placed in your mouth to bit on to control bleeding. You will rest under our supervision in the office until you are ready to be taken home. Upon discharge, your post-operative kit will include postoperative instructions, a prescription for pain medication, antibiotics and a follow-up appointment in one week. if you have any questions, please do not hesitate to call us at 661.945.4040.

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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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.

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

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 temporary, 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 anterior positioning appliance moves your jaw forward, relives pressure on parts of your jaw and aids in disk repositioning. It may be worn 24 hours/day to help your jaw heal. An orthotic stabilization appliance is worn 24 or just at night to move your jaw into proper position. Appliances also help to protect from tooth wear.

What about bite correction or surgery?

If your TMJ disorder has caused problems with how your teeth fit together, you may need treatment such as bite adjustment (equilibration), orthodontics with or without jaw reconstruction, or restorative dental work. Surgical options such as arthroscopy and open joint repair restructuring are sometimes needed but are reserved for severe cases. Dr. Malone does not consider TMJ surgery unless the jaw can’t open, is dislocated and nonreducible, has severe degeneration.

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Orthognathic Surgery

Orthognathic surgery is needed when jaws don't meet correctly and/or teeth don't seem to fit with 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.

Who Needs Orthognathic Surgery?

People who can benefit from orthognathic surgery include those with an improper bite or jaws that are positioned incorrectly. Jaw growth is a gradual process and in some instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that can affect chewing function, speech, long-term oral health and appearance. Injury to the jaw and birth defects can also affect jaw alignment. Orthodontics alone can correct bite problems when only the teeth are involved. Orthognathic surgery may be required for the jaws when needing repositioning.

Difficulty in the following areas should be evaluated:

• difficulty in chewing, biting or swallowing
• speech problems
• chronic jaw or TMJ pain
• open bite
• protruding jaw
• breathing problems

Any of these can exist at birth or may be acquired after birth as a result of hereditary or environmental influences or the result of trauma to the face. Before any treatment begins, a consultation will be held to perform a complete examination with x-rays. During the pre-treatment consultation process, feel free to ask any questions that you have regarding your treatment. When you are fully informed about the aspects of your care, you and your dental team will make the decision to proceed with treatment together.

Technology and Orthognathic Surgery

Dr. Malone uses modern computer techniques and three-dimensional models to show you exactly how your surgery will be approached. Using comprehensive facial X-rays and computer video imaging, we can show you how your bite will be improved and even give you an idea of how you'll look after surgery. This helps you understand the surgical process and the extent of the treatment prescribed and to see the benefits of orthognathic surgery.

If you are a candidate for Corrective Jaw Surgery, Dr. Malone 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.

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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 sever 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. These are procedure usually performed under light intravenous sedation in the office.

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 overnight stay in the hospital.

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

Distraction Osteogenesis

Distraction osteogenesis (DO) is a relatively new method of treatment for selected deformities and defects of the oral and facial skeleton. It was first used in 1903. Then, in the 1950’s the Russian orthopedic surgeon, Dr. Gabriel Ilizarov slowly perfected the surgical and postoperative management of distraction osteogenesis treatment to correct deformities and repair defects of the arms and legs. His work went mostly unnoticed until he presented to the Western Medical Society in the mid-1960’s.

Distraction osteogenesis was initially used to treat defects of the oral and facial region in 1990. Since then, the surgical and technological advances made in the field of distraction osteogenesis have provided the oral and maxillofacial surgeons with a safe and predictable method to treat selected deformities of the oral and facial skeleton.

Frequently Asked Questions About Distraction Osteogenesis

What does the term distraction osteogenesis mean? Simply stated, distraction osteogenesis means the slow movement apart (distraction) of two bony segments in a manner such that new bone is allowed to fill in the gap created by the separating bony segments.

Is the surgery for distraction osteogenesis more involved than "traditional surgery" for a similar procedure? No. Distraction osteogenesis surgery is usually done on an outpatient basis with most of the patients going home the same day of surgery. The surgical procedure itself is less invasive so there is usually less pain and swelling.

Will my insurance company cover the cost of osteogenesis surgical procedure? Most insurance companies will cover the cost of the osteogenesis surgical procedure provided that there is adequate and accurate documentation of the patient’s condition. Of course, individual benefits within the insurance company policy vary. After you are seen for your consultation at our office, we will assist you in determining whether or not your insurance company will cover a particular surgical procedure.

Is distraction osteogenesis painful? Since all distraction osteogenesis surgical procedures are done while the patient is under general anesthesia, pain during the surgical procedure is not an issue. Postoperatively, you will be supplied with appropriate analgesics (pain killers) to keep you comfortable, and antibiotics to fight off infection. Activation of the distraction device to slowly separate the bones may cause some patients mild discomfort. In general, the slow movement of bony segments produces discomfort roughly analogous to having braces tightened.

What are the benefits of distraction osteogenesis versus traditional surgery for a similar condition? Distraction osteogenesis surgical procedures typically produce less pain and swelling than the traditional surgical procedure for a similar condition. Distraction osteogenesis eliminates the need for bone grafts, and therefore, another surgical site. Lastly, distraction osteogenesis is associated with greater stability when used in major cases where significant movement of bony segments are involved.

What are the disadvantages of distraction osteogenesis? Distraction osteogenesis requires the patient to return to the surgeon's office frequently during the initial two weeks after surgery. This is necessary because in this time frame the surgeon will need to closely monitor the patient for any infection and teach the patient how to activate the appliance.

In some cases, a second minor office surgical procedure is necessary to remove the distraction appliance.

Can distraction osteogenesis be used instead of bone grafts to add bone to my jaws? Yes. Recent advances in technology have provided the oral and maxillofacial surgeon with an easy to place and use distraction device that can be used to slowly grow bone in selected areas of bone loss that has occurred in the upper and lower jaws. The newly formed bone can then serve as an excellent foundation for dental implants.

Does distraction osteogenesis leave scars on the face? No. The entire surgery is done within the mouth and the distraction devices used by Dr. Malone remain inside the mouth. There are no facial surgical incisions are made so no unsightly facial scars result.

Are there any age limitations for patients who can receive osteogenesis? No. distraction osteogenesis works well on patients of all ages. In general, the younger the patient the shorter the distraction time and the faster the consolidation phase. Adults require slightly longer period of distraction and consolidation because the bone regenerative capabilities are slightly slower than those of adolescence or infants.

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 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 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 lip, palate or both. Cleft defects occur in about one out of every 800 babies.

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

Cleft Lip Treatment

Cleft lip surgery is usually performed on young children. 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:

• Close the gap or hole between the roof of the mouth and the nose.
• Reconnect the muscles that make the palate work.
• 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.