Why Should I Have My Wisdom Teeth Removed?

Wisdom teeth, the third molars, 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 successfully erupt.

What problems can wisdom teeth cause?

Wisdom teeth are at the back of the mouth and can be difficult to clean. This can lead to a number of problems; the most common problems are:
Infection of the gum around the wisdom tooth (pericoronitis). This occurs in 50-60% of patients that we see and is the most common reason why wisdom teeth are removed. This type of infection can be severe and cause pain & swelling, however sometimes symptoms are mild.

Tooth decay (dental caries) can occur in the wisdom tooth or the tooth in front. We see this in 25-30% patients. This may not cause immediate problems until the tooth decay affects the nerve of the tooth, then an abscess can form. Toothache pain will be a feature of this.

Wisdom teeth can be affected by gum disease (periodontal disease) or contribute to gum disease on the tooth in front (5-10% of patients that we see). Patients may get no symptoms at all from this, but it can still cause problems.

Cyst formation around the wisdom tooth. All teeth form within a sack and occasionally this sack can expand like a balloon. This is called a cyst. Over time this can become larger and cause problems. We see this in less than 1% patients.

How are wisdom teeth removed?

Each case is different, but generally speaking the wisdom tooth is not pulled out. It is elevated away from the gum using special instruments.

The gum around the tooth may need to be cut and lifted away from the tooth (we call this raising a flap). The tooth may also be cut into smaller pieces and in some cases a small amount of bone may be removed from around the tooth using a tiny surgical drill.

What kind of anaesthetic will I have?

I will offer you the safest type of anaesthetic that is right for you:

If the surgery is simple and you are happy with the thought of oral surgery, the tooth can be removed with just an injection to numb the area. This is a local anaesthetic and can be done in a clinic or in a hospital operating theatre.

If you feel the need for something to help with anxiety you can have local anaesthetic with some intra-venous sedation administered by a consultant anaesthetist.

Alternatively, if you are very anxious or the position of the wisdom tooth makes the surgery difficult, you can have a full general anaesthetic with a consultant anaesthetist. This can only be done in a hospital operating theatre.

What is the cost of wisdom tooth removal?

You can have the tooth removed under local anaesthetic for £500 – £600.

Intravenous sedation usually costs an additional £250.

If you wish to have the procedure carried out in a hospital operating theatre, including general anaesthetic, the cost will include the hospital charges and the total fee is usually in the region of £2300 to £2500.

How can I pay for surgical wisdom tooth extraction?

If you have private medical insurance you will almost certainly find they will cover you fully for impacted wisdom tooth removal.
Your policy should cover hospital costs, surgeon’s fees and, where applicable, anaesthetist’s fees. The insurance code for surgical removal of impacted tooth or teeth is F0910.

Extraction of impacted or misplaced teeth, particularly in young people who may be undergoing orthodontic treatment.

Occasionally when a dentist attempts to extract a tooth, weakened by a large filling it will fracture leaving the root or roots behind.  If the dentist is unable to remove the broken roots from the bone they can become infected causing severe pain.

Children often require the removal of impacted teeth or additional teeth known as supernumerary teeth to relieve crowding and before orthodontic treatment.  Abnormal or delayed eruption is a common problem. 

When the tooth cannot erupt into its normal position, the tooth can get physically obstructed and stuck in its position in the dental arch.  Not addressing this failure in normal eruption can lead to much larger developmental discrepancies.

Impacted teeth are usually found in the permanent dentition, but occasionally a primary tooth becomes impacted.  The most common primary tooth to be impacted is the primary second molar and requires removal to allow room for the permanent tooth to erupt

Sometimes, removal of an abnormal labial fraenum (the fold of tissue connecting the middle of the upper lip with the gums) is necessary to close the space between the upper front teeth.

Some children have a tongue tie which can interfere with eating and speech and has to be released surgically.

An impacted tooth simply means that it is “stuck” and cannot erupt into its normal position.  The upper canine tooth is the second most common tooth to become impacted after the wisdom teeth.  The upper canine teeth normally erupt around 11-12 years of age.  They play a vital role in lip support and act as the cornerstone of the mouth and play an important role in the “bite”.  Impacted upper canine teeth should not be ignored as they can cause damage to the roots of the upper incisor teeth which can become loose and be lost.

Why do I need treatment?

Because one or other of your canines are in the wrong place as part of your on-going orthodontic treatment it is necessary to help the tooth erupt into the mouth.  If left alone the tooth will not erupt normally and may either damage the roots of the front teeth or push them out of position.

What does the treatment involve?

Helping the tooth erupt into your mouth involves a relatively minor surgical procedure.  This usually takes place under a “day case” general anaesthetic, i.e. although you are put to sleep completely you will be able to go home on the same day as surgery.  While you are asleep the gum lying over the canine will be pushed back.  Occasionally some of the bone surrounding the crown of the tooth also needs to be removed.

How will the orthodontist pull the tooth into the correct position?

Once the canine tooth is exposed one of three things will happen under the same anaesthetic.  What is going to happen for you will already have been discussed.

A small bracket and chain.

A small bracket is glued to the tooth.  Attached to this is a chain which your orthodontist can then use to pull the tooth into the right position.  The chain is usually stitched out of the way but it is quite delicate and therefore it is important to be careful when eating for the first few weeks after surgery.

Cover plate.

Sometimes a small window will be cut in the gum over the tooth and a plastic “dressing” plate put in place to cover the area.  This plate is held in your mouth with clips that attach to some of your back teeth.  It is important that you wear the plate all the time except when you take it out to clean your teeth.  Without the plate the gum may grow back making it difficult for the orthodontist to move the tooth into position.

A pack.

Sometimes a pack made from gauze soaked in an antiseptic is placed over the tooth after it is exposed.  The pack is kept in position with stitches and removed after a few weeks.  You must be careful not to dislodge the pack.  If this happens you should contact the department for advice.

Sometimes it is necessary to hold the gum back in the right position with stitches at the end of the operation.  These are usually dissolvable and take about two weeks to disappear.

Is there much pain or swelling?

All of the above procedures are not particularly painful but you will obviously experience some soreness afterwards.  There is usually very little in the way of swelling.  If it is likely to be sore your surgeon will arrange painkillers for you.  It is not usually necessary to take antibiotics.

Jaw cysts are fluid-filled sacs within the bone of the jaws that can result in swelling, pain and infection. Some cysts become large and push against the roots of nearby teeth, making them loose. A cyst will not resolve by itself.  If a cyst becomes infected the whole cyst then becomes a type of abscess that is extremely painful. Therefore it is usually best to have the cyst treated before symptoms develop.

Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for the 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 it is 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 aesthetic appearance.

Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone can normally be harvested from other areas of either the upper or lower jaw.

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 in the lower jaw. This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molar teeth and/or and the second premolar tooth.  Since this procedure is considered a very aggressive, and there is almost always some postoperative numbness or altered sensation of the lower lip and chin, which recovers only very slowly, if ever, usually other, less aggressive options are considered first.

Typically, an outer section of the cheek side of the lower jawbone is removed in order to expose the nerve and vessel canal. The nerve and vessel bundle in that area are isolated and repositioned allowing implants to be placed without injuring the nerve. These procedures may be performed separately or together, depending upon the individual’s condition.

If an infection has occurred at the tip of the root of one of your teeth often it does not cause any symptoms but usually people are aware of discomfort and occasional episodes of swelling, gum boils or bad taste.  You may well already have been given a course of antibiotics in an attempt to treat the infection.

If left untreated the infection is likely to develop into an abscess or cyst.  As well as causing pain this can lead to the loss of bone surrounding the root.  As a result the tooth will become loose.

Your dentist will have already tried to get rid of the infection by removing the nerve of the tooth and placing a root filling.  The infection now needs to be removed surgically in a procedure called an “apicectomy”. 

This involves cleaning out the infection from the bone, removing a small portion of the tip of the root of the tooth and then sealing the root with a small filling.

It is necessary to make a small cut in the gum over the root of the tooth and then lift the gum off the bone.  The area of infection is uncovered by removing a small amount of bone with a drill. 

Any infected tissue is thoroughly cleaned away from the tip of the root before 2-3mm of the root tip is removed.  The root is sealed with a small filling.  The gum is then stitched back into place with dissolvable stitches that take around two weeks to disappear.  The whole procedure will take around 30 minutes from start to finish.

If you have any indication of Oral and Maxillofacial Disease being present in your mouth, then your doctor or dentist may consider referring you to see a specialist. 

If you have ulcers or lesions in the mouth, any lumps, cysts or tumours or your gums do not look healthy, these could all be signs of the early development of pathological processes.  Things like oral cancer need to be investigated early on so that treatment is not delayed.

Your doctor or dentist may consider referring if you have any of the following:

• Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth
• Sores in the mouth that bleed and do not heal
• A lump or thickening on the skin lining the inside of the mouth
• A chronic sore throat
• 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

During an oral cancer screening examination your surgeon will;

• Review of your medical and dental history
• Examine the tongue and insides of your mouth to check for red or white patches or sores
• Feel the tissues of the mouth to check for lumps or other abnormalities
• Order further testing on abnormalities that are found
• Discuss your treatment options including taking a biopsy or the complete removal of any lesions that are found

Soreness can occur anywhere in the mouth, including on the roof and floor of the mouth, in the cheek lining, on tongue, on the gums or on the lips.
Soreness can arise from different places and is due to different causes:

• White patches or rough patches
• Lumps or bumps
• Bleeding gums
• Loose teeth
• Persistent mouth ulcers

In most people, a sore mouth does not turn out to be mouth cancer, but there are cases when this is one of the first symptoms. A loose tooth that has occurred through tooth decay also exhibits the same symptoms as a loose tooth due to a mouth cancer on the jaw line.

Lichen planus

Lichen planus is an inflammatory condition that can affect the lining of the mouth as well as the skin. The cause is not fully understood. It is common and affects up to 2% of the population. Lichen planus is most frequent in middle age and women are affected slightly more frequently than men are. Although there is no known cure treatment can be given to make the symptoms better.

What does it look like?

In the mouth lichen planus is usually found on the inside of the cheeks and on the side of the tongue although it can also affect the gums and roof of the mouth. Usually lichen planus has a lace-like pattern of streaky white patches that occasionally can be thickened. Often the patches are symmetrical, i.e. affect the same site on different sides of the mouth. Sometimes lichen planus may be associated with red patches or sores.

What lichen planus is not!

It is not cancer.
It is not inherited, i.e. passed on from your parents.
It is not contagious, i.e. you cannot “catch it” from someone who has it or give it to somebody else.
It is not related to nutrition although some foods you eat can make the patches of lichen planus sore.

How is lichen planus diagnosed?

The appearance of lichen planus is usually typical and can be diagnosed by an experienced surgeon just looking inside your mouth. The diagnosis sometimes needs confirmation with a biopsy (i.e. removal of a small amount of tissue which can then be looked at closely under a microscope).

Burning mouth Syndrome

Burning mouth syndrome is a name given to discomfort or pain in the mouth. It often affects the tongue, lips and cheeks but other parts of the skin lining inside the mouth can also feel uncomfortable. Most people with the condition complain of a burning or scalded feeling, particularly of the tongue and palate.
Burning mouth syndrome is a common condition. It often affects women, particularly after the menopause, but men can sometimes get it too.
Up to one in three older women report noticing a burning sensation in their mouth.

What is the Cause?

The sensation of burning in the mouth can occasionally be the result of medical or dental problems. These include thrush infections and blood or vitamin deficiencies.
The hormonal changes around the menopause can be related to burning mouth syndrome.
It can also occur or get worse when somebody is stressed, anxious or depressed, or going through a difficult time of life.
Not knowing why your mouth is burning can also make you anxious.

Treatment

If you describe a burning sensation in your mouth you will be examined thoroughly to make sure another medical or dental cause is not responsible. Some blood tests may be arranged for you to look for such a possible cause.
Sometimes people get worried that they may have mouth cancer. This is quite a common anxiety of people with burning mouth syndrome.
Carrying out a thorough examination and any necessary tests will enable your doctor to reassure you that all is normal with no signs of cancer.
Symptoms often improve following reassurance that there is no serious disease present in the mouth.
The burning feelings can sometimes be worse at times of stress and go away when life is running more smoothly.
In the same way that low doses of antidepressants can help patients with neuralgia even if they are not depressed, sometimes low doses of antidepressants can relieve the symptoms of burning mouth syndrome.

Dry mouth

It is normal to occasionally have a dry mouth if you are dehydrated or feeling nervous, but a persistently dry mouth can be a sign of an underlying problem.
You should see your dentist or GP if you have an unusually dry mouth (known as xerostomia) so they can try to determine the cause.

What can cause a dry mouth?

A dry mouth can occur when the salivary glands in your mouth do not produce enough saliva.
This is often the result of dehydration, which means you do not have enough fluid in your body to produce the saliva you need. It is also common for your mouth to become dry if you are feeling anxious or nervous.
A dry mouth can sometimes be caused by an underlying problem or medical condition, such as:

• medication – many different medications can cause a dry mouth, including antidepressants, antihistamines and diuretics
• a blocked nose – breathing through your mouth while you sleep can cause it to dry out
• diabetes – a lifelong condition that causes a person's blood sugar level to become too high
• radiotherapy to the head and neck – this can cause the salivary glands to become inflamed (mucositis)
• Sjögren's syndrome – a condition where the immune system attacks and damages the salivary glands

If you see your dentist or GP, let them know about any other symptoms you are experiencing and any treatments you are having, as this will help them work out why your mouth is dry.

Recurrent Oral Ulceration

Recurrent oral ulceration is a term used to describe small mouth ulcers which typically last a few days but come back every few weeks or months.  Typically they affect the tongue, lips and cheeks, but any part of the mouth can get ulcers.  They are very common, often starting in childhood.  About two in every three people will have been affected with recurrent oral ulceration at some time in their lives

What causes them?

Although the cause of the most common type of recurrent oral ulceration is unknown there are lots of reasons why people can get other types of ulcers in their mouths.  Some ulcers can be related to low levels of iron or vitamins in the blood.  Rarely ulcers can be associated with skin or stomach problems.

How can I tell whether my mouth ulcers are related to another problem?

Your doctor will ask you about your general health and ask you questions about whether you have noticed any problems with your skin or stomach.  You will also be asked if you have noticed ulcers anywhere else on your body.

If you have mouth ulcers blood tests are usually taken to check if they are the result of another medical condition.  However the majority of people with mouth ulcers have completely normal blood tests.

Is there any treatment for the mouth ulcers?

Because mouth ulcers are so common their treatment has been studied by lots of scientists.  There are a wide variety of treatments available all of which probably make the ulcers go away more quickly and feel less painful but do not prevent the next crop of ulcers from occurring.  Mouthwashes (e.g. Corsodyl, Difflam) can be used.  Similarly weak steroids in the form of pastes, dissolving tablets or mouthwashes can sometimes help.

Trigeminal Neuralgia

is an extremely severe facial pain that tends to come and go unpredictably in sudden shock-like attacks.  The pain is normally triggered, for example by light touch, and is described as stabbing, shooting, excruciating or burning.  It usually lasts for a few seconds but there can be many bursts of pain in quick succession.

What is Trigeminal Neuralgia?

The trigeminal nerve is the fifth cranial nerve and its function is to send pain messages to the brain.  When the nerve malfunctions, pain messages are sent at inappropriate times and the pains can be of great severity.  In fact, TN is regarded as the most painful condition that is known in the medical world.

The pains are variously described as like a strong electric shock shooting through the face, or very intense sensations of stabbing and burning.  Trigeminal Neuralgia affects more women than men and pains are normally felt on one side of the face only, generally the right-hand side.  The majority of people affected are over 50 years old although young adults, and very rarely children, may also develop the condition.

What are the Causes of Trigeminal Neuralgia?

More research still needs to be undertaken into trigeminal Neuralgia but the transmission of abnormal messages of pain often appears to result from damage to the protective coating (myelin sheath) around the trigeminal nerve.  There are several possible causes of damage, including pressure from blood vessels or arteries, and, very rarely, tumours or multiple sclerosis.

Diagnosis

There is no diagnostic test for trigeminal Neuralgia, so the patient’s description of the pattern and nature of the pains is vitally important when it comes to getting an accurate diagnosis.  An MRI scan may show a compression of the trigeminal nerve by a blood vessel but even if no compression is visible, the cause of the pain may still be TN.

Treatments

Anti-convulsant medications are normally prescribed for people with TN and there are also a number of surgeries available which offer relief.  However, unless the diagnosis is classic trigeminal Neuralgia, surgical procedures may make the pain far worse.  For this reason, it is important to research the condition thoroughly with the help of an informed specialist before making any decisions on treatment.

What is a biopsy?

A biopsy is a procedure where a small piece of tissue is removed from an area so that it can be looked at closely under a microscope.  The biopsy may aim to remove an area completely (an excision biopsy).  This is usually only appropriate for small lumps or swellings.  Occasionally only a small piece of an abnormal area is removed to confirm a diagnosis (an incisional biopsy).

How is it done?

In most cases biopsies are carried out under local anaesthesia (an injection into the area to numb it).  The injection takes a couple of minutes to work and means that the biopsy will be painless.  The biopsy usually leaves a small hole that often requires stitching.  In the majority of cases the stitches used are dissolvable and take around two weeks to disappear.  The whole process (local anaesthetic injection, biopsy and stitching) usually takes around 15 minutes from start to finish.

Is there much soreness or swelling afterwards?

When the local anaesthetic wears off after a few hours there is relatively little in the way of pain or swelling.  Occasionally it is necessary to take simple painkillers (e.g. Paracetamol, Nurofen).  Usually any discomfort only lasts a few days.

Will there be much bleeding?

Although there may be a little bleeding at the time of biopsy this usually stops very quickly and is unlikely to be a problem if the wound is stitched.  Should the biopsy site bleed again when you get home this can usually be stopped by applying pressure over the area for at least 10 minutes with a rolled up handkerchief or swab.  If the bleeding does not stop please contact the department.

TMJ stands for temporomandibular joint, which is the name for each joint (right and left) that connects your jaw to your skull. These disorders occur when the joints of the jaw and the chewing muscles do not work together correctly.  Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important.

Like other joints, the jaw joint has a protective cartilage that cushions the bones as the jaw joint moves. The jaw has a small disc of cartilage that moves with the jaw; it slides backwards and forwards as the lower jaw moves. This disc can become displaced or folded and when it snaps back into place, the jaw ‘clicks’.  Problems with your disc may cause your jaw to lock open or closed making it difficult to open or close your mouth. 

The pain of a TMJ disorder radiates out from the jaw joint and is felt in the temple, cheeks, lower jaw or in the ear.

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.

Symptoms of TMJ disorder

• Clicking of the jaw when it is moved.

• Feeling as if the jaw has got stuck.

• Restricted jaw movement – not being able to open the mouth to yawn.

• Pain that feels like it is coming from the jaw joint, or that radiates around into the cheek, temple, and ear or down to the lower jaw or neck.

• Problems in the ear such as tinnitus (ringing in the ears), pain or feeling dizzy.

Mr Smith diagnoses and treats all types of TMJ disorder.  He recommends that if you are worried about your jaw joint or you are developing troublesome symptoms that you have your jaw joint checked by someone with his expertise.  TMJ disorders can often be treated easily without medical or surgical intervention but this becomes less likely if you ignore the problem and just hope it will go away.

Treatment

There are various treatment options that can improve the function of your jaw. Once an evaluation confirms a diagnosis of TMJ disorder, Mr Smith will determine the proper course of treatment. 

A splint (or night guard) fits over your top or bottom teeth and helps keep your teeth apart, thereby relaxing the muscles, repositioning your TMJ and reducing pain.  There are different types of appliances used for different purposes. A night guard helps you stop clenching or grinding your teeth and reduces muscle tension at night. It also helps to protect the cartilage and joint surfaces.

A soft diet is also an important step to begin with as you are experiencing symptoms with you joint. 

In addition certain patients respond well to over the counter anti-inflammatory medications such as Ibuprofen.

Stress reduction also helps with the recovery of TMJ issues.

The majority of patients with TMJ disorders respond well to these nonsurgical management strategies, but this takes time and effort on your behalf.

Arthrocentesis is a minimally invasive procedure that involves lysis and lavage within the temporomandibular joint, which is the washing and manipulation of the joint and if often useful for treating joints that are locking.  Steroids are placed directly into the joint space at the same time thus reducing inflammation of the TMJ.

The branches of the trigeminal nerve, including the lingual nerve and inferior alveolar nerves, are the sensory nerves that give sensation to the face and jaws and are often injured during dental and surgical procedures as well as in facial trauma.

The lingual nerve injury is often sustained during the removal of impacted mandibular third molars, wisdom teeth.  Many of these injuries are only temporary, with normal sensation returning to the tongue within a few days or weeks.

The reported incidence of lingual nerve injury ranges from 0.2% - 22%, the majority of these injuries being temporary with normal sensation returning within a few weeks or at worst 9-12 months.  The mean incidence of temporary nerve injury is approximately 7% with the incidence of permanent sensory disturbance being about 0.5%.

When the lingual nerve is injured patient experiences numbness, loss of sensation form the anterior two thirds of their tongue on that side, which may be profound if there is a significant nerve injury.  In the case of a crush injury, where the structure or the nerve remains grossly intact, the numbness can last up to three months before slowly returning towards normal, which can take up to a year. 

When the injury is more severe, such as a nerve section, the numbness can be permanent.  When there has been no recovery of sensation three months after the nerve injury, the probability that it  is a more severe injury should be considered, and the need for  surgical intervention, either microsurgical repair or neurolysis.

Patients with a severe nerve injury, where there is no recovery of sensation three months after the injury should be referred for specialist assessment and treatment.

The branches of the trigeminal nerve, including the lingual nerve and inferior alveolar nerves, are the sensory nerves that give sensation to the face and jaws and are often injured during dental and surgical procedures as well as in facial trauma.

The inferior alveolar nerve runs in a bony canal within the mandible and is vulnerable to damage from any dental or surgical procedure that may impinge on the mandibular canal.  The most common cause of injury is the removal of mandibular third molars, wisdom teeth, with a reported incidence of about 4%.  Injury to the inferior alveolar nerve will cause numbness of the lower lip and the skin of the chin and the teeth and gums on the affected side.

Many of these injuries are only temporary, the sensation slowly returning to normal within a few days or weeks but in a few cases the numbness can be permanent.  The nerve can also be injured during other dental procedures including the placement of dental implants and root canal treatments in the mandible (lower jaw).

When a sensory nerves is injured the patient experiences numbness, loss of sensation which may be profound if there is a significant nerve injury.  In the case of a crush injury, where the structure or the nerve remains grossly intact, the numbness can last up to three months before slowly returning towards normal, which can take up to a year.  When the injury is more severe, such as a nerve section, the numbness can be permanent.  

When there has been no recovery of sensation three months after the injury, the probability that it  is a more severe injury should be considered, and the need for  surgical intervention, either microsurgical repair or neurolysis.

Patients with a severe nerve injury, where there is no recovery of sensation three months after the injury should be referred for specialist assessment and treatment.

Orthognathic surgery literally means “straight jaws”.  This type of treatment will improve a person’s ability to chew and speak.  Breathing may also become easier for some people and it may be recommended as a treatment of obstructive sleep apnoea.  The teeth are straightened with orthodontics, and corrective jaw surgery repositions a misaligned jaw.  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 may affect chewing function, speech, or 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 repositioning is necessary.

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 symptoms can exist at birth, be acquired after birth as a result of hereditary or environmental influences, or as a result of trauma to the face.  A consultation will help you to understand what treatment is possible and how you may benefit, and what treatment would be required.

Most treatments require a course of fixed orthodontics before surgery, but some procedures involving only the chin, a genioplasty, do not require any orthodontic treatment.

Link to the BOS - British Orthodontic Society website which offers excellent video information.

https://www.bos.org.uk/Public-Patients/Your-Jaw-Surgery1

Your cheekbone has been fractured.  The cheekbone forms part of the eye socket, protecting the eyeball and supporting it from below, and is also associated with the side of the nose and upper jaw.  Your surgeon will examine you and determine the number of fractures and the treatment required.  This will involve a general anaesthetic.

What does the surgery involve?

Once you are under the anaesthetic the cheekbone will be repositioned into the correct place.  This usually involves a small incision about an inch long through the hair in the temple.  Sometimes this is all that is required.  Your surgeon may insert small metal plates and screws to hold it in place.  Placing these plates and screws into the cheekbone may require one or more alternative incisions, including:

• An incision hidden in the hairline above your ear.
• An incision close to the outside end of the eyebrow.
• An incision made on the inside of the mouth through the gum above the back teeth.
• An incision made in the skin crease just below the lower eyelashes or on the inside of the lower eyelid or between the eyelid and eyeball.

These incisions are stitched together at the end of the operation.  Stitches on the skin need to be removed after a week and any stitches inside the mouth are usually dissolvable.  They may take a fortnight or longer to dissolve completely.

Your lower jaw has been fractured.  You surgeon will examine you and establish the number of fractures and what treatment you will require to correct the problem.  The treatment you will undergo will require a general anaesthetic.

What does the surgery involve?

Once you have been put under the general anaesthetic, the fracture sites will be opened up.  This involves making an incision on the inside of your mouth through the gum.  The broken bones are then repositioned together and held in place with small metal plates and screws. The gum is stitched back into place with dissolvable stitches.  It can take up to a fortnight or even longer for them to dissolve.

During the surgery, in rare circumstances, wires or metal braces must be placed around your teeth.  This is so that elastic bands can be attached to them and guide your bite into the correct position after surgery.  Screws inserted into the jawbone above the teeth are occasionally used instead of these wires or metal braces.  Any elastic bands are not usually attached until the day after your operation.  i.e. you will be able to move your jaws freely when you wake up.

The salivary glands produce all the saliva that keeps our mouths moist.  We have six major salivary glands.  Most of all our saliva comes from the two submandibular glands, which lie under the tongue at the bottom of the mouth.  

The parotid glands, lie just in front of the ear on each side, and the sublingual glands, which lie right under the tongue. Each of the three pairs of major salivary gland connects to the mouth by a thin tube, or duct.

Salivary gland calculi or stones

A common cause of salivary gland disease is a blocked salivary gland duct. This is usually due to a salivary gland stone. These tiny but solid calcium deposits are termed sialoliths. If one of them breaks free from the main gland and passes into the salivary gland duct, it can get half way and then get stuck.

A blocked duct means that no saliva can escape and the gland can become swollen and painful.

If bacteria build up and start growing in the blocked off gland, this can escalate into a serious infection that can spread into the blood.

Other causes of swollen salivary glands

Viral infections; these often cause salivary glands to swell. This can happen if you get ‘flu, mumps or cytomegalovirus infections.

Salivary gland cysts;   these are benign growths inside the gland that can have various causes.

Salivary gland tumours; benign tumours and cancers can form in the salivary gland itself or in the duct.

Sjögren’s syndrome; an autoimmune disease that is common in patients with lupus, rheumatoid arthritis or scleroderma.

Sometimes one of the salivary glands can enlarge but no reason can be found and the gland is not painful.

Salivary gland tumours

Not all salivary gland tumours are cancerous. Some are benign but they may need treatment as they cause swelling in the gland. The three recognised non-cancerous tumours that occur in the salivary glands are.  Cancerous tumours that arise in the salivary glands are not very common at all, but when they are diagnosed they are usually in people in their 50s and above.

What are mucous cysts?

A mucous cyst, also known as a mucocoele, is a fluid-filled swelling that occurs on the lip or the mouth.

The cyst develops when one of the minor salivary glands in the mouth is damaged and mucous collects under the surface.  Most cysts are on the lower lip, but they can occur anywhere inside your mouth. They are usually temporary and painless. However, cysts can become permanent if they are not treated.

What causes mucous cysts?

Mucous cysts are most commonly caused by trauma to the oral cavity, such as:

• lip biting (most common cause)
• cheek biting
• piercings
• accidental rupture of a salivary gland
• adjacent teeth causing chronic damage

How are mucous cysts treated?

Many mucous cysts will resolve spontaneously without treatment but when they persist they should be surgically removed t to confirm that they are a mucous cyst and not a benign tumour.