Jaw Surgery

Oral and maxillofacial surgery deals with conditions of the mouth, jaws, face, jaw joint, upper jaw sinuses and surrounding areas that need surgical treatment. This page covers the four most common topics:

• Impacted teeth, especially wisdom teeth
• Jaw cysts
• Jaw and facial fractures
• Cleft lip and palate

Implants, orthognathic surgery and jaw joint disorders are covered on separate pages (see Orthognathic Surgery, TMJ Disorders).

An impacted tooth is a tooth that has developed but has not been able to erupt into its place in the mouth and has stayed inside the gum, jawbone or palate. Lower and upper wisdom teeth, canines and premolars are the teeth most often impacted. Sometimes people notice this themselves; more often it is found during an examination or on an X-ray.

Some never cause any problems; others cause problems over time.

When should an impacted wisdom tooth be removed?

Not every impacted wisdom tooth needs to be removed. Teeth that are completely inside the bone, cause no symptoms and do no harm to their surroundings can be monitored with X-rays at intervals. Removal is usually recommended when there is:

• Recurrent gum inflammation, pain, swelling or bad breath around a partly erupted tooth (pericoronitis)
• Decay in the wisdom tooth or the tooth in front of it; damage to the root of the tooth in front in an area that cannot be cleaned
• A cyst forming around the tooth
• A need to remove it because of orthodontic treatment or jaw surgery plans
• Recurrent infections

Healing is usually easier when removal is done at a young age, before the roots have fully formed. The decision is made together after assessing the tooth's position and its closeness to the nerve on an X-ray or CT scan.

How is an impacted tooth removed?

Because an impacted tooth is covered by bone or gum, it is not removed like a normal tooth; it is a minor surgical procedure.

1. Assessment. A panoramic X-ray shows the position of the tooth. If the root is close to the nerve that supplies sensation to the lower lip, a 3D CT scan is taken.
2. Numbing. The area is numbed with local anaesthesia; you feel no pain during the procedure, although you may feel pressure. For anxious patients and when several teeth are removed in one session, other options are discussed.
3. Removal. The gum is lifted with a small incision and, if needed, some of the bone over the tooth is reduced. The tooth may be divided into pieces for removal; this causes less damage to the surrounding tissues.
4. Closing. The area is cleaned and closed with stitches. Depending on the tooth's position, the procedure usually takes 20–60 minutes.

A jaw cyst is a cavity, usually filled with fluid, that forms in the jawbone or soft tissues. Most cysts are benign; however, if left untreated they can grow over time, thinning the bone, moving teeth or pressing on a nerve.

Some cysts cause no symptoms and are found by chance on an X-ray. When they do cause symptoms, these can include:

• Swelling, pain or burning in the area
• Discharge of pus inside or outside the mouth
• Loose or shifting teeth
• Numbness of the lip or chin due to pressure on a nerve
• Limited mouth opening

Cysts are seen on panoramic X-rays and 3D CT scans. Treatment is usually surgical removal of the cyst. For large cysts, a staged approach to shrink the cyst first may be planned. The removed tissue is always sent for pathological examination; the definitive diagnosis is made by this examination. Whether the cyst comes back is monitored with regular X-rays.

Falls, traffic accidents, sports injuries or assaults can cause fractures of the lower jaw, upper jaw, cheekbone and the bones around the eye. These injuries are called maxillofacial trauma.

Fractures that are not treated, or treated late, can lead to facial deformity, biting and chewing problems, limited mouth opening and difficulty speaking. If you have any of these symptoms, seek care without waiting:

• Teeth no longer meeting as they used to
• Pain or restriction when opening or closing the mouth
• Facial asymmetry, a sunken area or marked swelling
• Numbness of the lip, chin or cheek
• With cheekbone fractures, restricted jaw movement or double vision

If there is loss of consciousness or a suspected eye, neck or other serious injury, go to the emergency department first. Treatment depends on the location and type of fracture: some fractures are treated with closed methods and appliances attached to the teeth, others by putting the broken pieces back in place and fixing them with small titanium plates.

Cleft lip and palate is a condition present at birth, caused by the lip and palate not fully joining in the early weeks of a baby's development in the womb; it occurs in about 1 in 1,000 births. Families need not panic; it is treatable and is managed as a team.

The baby should be assessed by an oral and maxillofacial surgeon and an orthodontist soon after birth. Depending on the type of cleft, appliances can be made to make feeding easier and support the orderly development of the tissues. The timing of lip and palate operations is decided according to the baby's weight, general health and the type of cleft; operations are usually done in infancy, at the recommended ages. As the child grows, speech therapy, orthodontics, bone grafting if needed and corrective jaw surgery in later years can also be part of the process. Follow-up is done together with specialists such as an ENT doctor, a paediatrician and a speech therapist.

The following apply to the most common procedure, impacted tooth removal; for cyst and fracture surgery, risks are discussed separately according to the extent of the procedure.

• Swelling, bruising, pain and limited mouth opening in the first days (expected and temporary)
• Dry socket (alveolitis): increasing pain a few days later when the blood clot in the socket breaks down early; smoking increases the risk, and it is treated with a simple procedure
• Infection or bleeding
• Change in sensation: if the root of a lower wisdom tooth is close to the nerve, numbness of the lower lip, chin or tongue. It is usually temporary and rarely permanent; that is why teeth near the nerve are planned with a CT scan.
• With upper wisdom teeth, an opening between the sinus and the mouth (rare)
• Damage to the neighbouring tooth or its filling (rare)

• First 24 hours. Bite on the gauze for the recommended time. Apply cold compresses; do not rinse, spit, drink through a straw or smoke. Choose lukewarm, soft foods rather than hot ones.
• Day 2–3. Swelling is at its greatest and then starts to go down. Take the recommended medicines regularly; on your dentist's advice you can start gentle rinsing with mild salt water.
• First week. Continue a soft diet and do not chew on the extraction side. Stitches are removed on day 7–10, or if dissolving stitches were used, they are left to dissolve.
• 2–4 weeks. The gum heals. It takes a few months for the bone to fill in completely, but daily life is normal during this time.