Cincinnati Center for Corrective Jaw Surgery

How Will You React to Anesthesia? Sedation Facts for Patients

How Will You React to Anesthesia?  Sedation Facts for Patients
Dr. Michael B. Lee, Cincinnati Oral and Maxillofacial Surgeon


Our Patient’s Experience is Unique


Delivering office intravenous sedative and anesthesia is the cornerstone of Dr. Lee’s Oral and Maxillofacial surgery profession.  No other dental or medical specialist is better trained to deliver this safe and cost effective service.  Dr. Lee and his nursing staff carefully evaluate each patient’s medical history before performing office IV anesthesia.

No two patients react the same way to IV anesthesia.  The Cincinnati Center for Corrective Jaw Surgery is prepared for any response because so many things affect how one may react to sedating medications. They include:

  1. Age
  2. Weight / Size
  3. Genetics
  4. Physical characteristics
  5. Medications you take
  6. “Medications” you don’t want to admit you take

A patient’s age is very important to take into consideration when planning an office IV anesthesia procedure.  Children are not “little adults”.  They react differently to medications both physically and psychologically.  They have very different physical characteristics in the size of their mouths and airways. Not only are they smaller, but they usually have large tonsils blocking their throats.  Older patients are quite different too.  They are universally more sensitive to medications, more compromised by their other ailments, and more prone to medication altercations – because they take so many other medications.

Weight / Size
No other factor has changed the delivery of IV sedation in the office setting more than the increased size and weight of the patient population.  30% of Americans are now obese, and another 10% are overweight.  Add to this the general increase in the size of young women and men (from increased muscle mass), and you have a population that generally can take much more medication to achieve sedation and anesthesia.

The increasing amounts of medication given is directly proportional to the increasing numbers of complications.  Overdosing a patient on both ends of the weight spectrum is problematic but especially on the patients who are overweight.  Their increased weight effects their neck size and breathing, and ultimately, their airways are harder to control.

From a genetic standpoint, there are some patients who are resistant to the medications we give to accomplish IV sedation and anesthesia.  Also, there are some patients who seem to just naturally fight the effects of the drugs that we administer.  These are usually the patients who hate to be out of control of their emotions or environment, or patients who are naturally aggressive.  If these genetic traits describe you, you may want to reconsider the location of where you have your surgery and what technique is used (i.e. IV anesthesia verses inhalation anesthesia with gas).  No one successfully fights a gas anesthetic and wins – the anesthetist or anesthesiologist always does.  While Dr. Lee is good at picking up these traits, he isn’t 100% successful.  That is why he and the nursing staff are trained to handle all types of situations.  If it seems likely that you will have a problematic response to the medication we use, Dr. Lee will recommend an outpatient setting for your surgery with a qualified anesthesiologist.

Blood tests are being developed and will be available soon to help detect problematic genetic markers. Anecdotally, we see special problems with patients genetically featuring red hair.  We know from experience that they will take more local anesthesia to get numb during the procedure and that they are more likely to bleed during the surgery.

Physical characteristics of the mouth and airway
When considering a patient for office IV sedation or anesthesia, we carefully evaluate their airway size and the access we will have in their mouth to efficiently and successfully perform surgery.  Not all mouths open as wide as the next.  Some tongues are larger than others.  Some cheeks are fuller.  Some gag reflexes are stronger.  All of these factors can add to surgical difficulties and increased surgical time.

Increased surgical time increases medication given.  An increase in medications given is proportionality related to increases in complications.  Remember, airway sizes also affect office IV sedation and anesthesia.  A large neck sometimes means a smaller airway.  Larger tongues certainly mean a smaller airway.  Smaller lower jaws and recessed chins definitely equate to more difficult airway management. Add to any of these physical characteristics an increase in body weight and the job of keeping your airway open and you breathing gets more problematic.  However, Dr. Lee’s top priority is to avoid problems.

Medications you take
Many of medications that Dr. Lee’s patients take can influence and alter the medication we use in IV Sedation and anesthesia.  These interactions are beyond the scope of this review, but during Dr. Lee’s evaluation of your medication list and your medical history, potential interactions will be carefully considered.  If potential interactions are problematic and increase your risks, Dr. Lee and the nursing staff will contact your medical doctors and consult.  Sometimes medications are changed, sometimes Dr. Lee’s IV sedition and anesthesia techniques are changed and sometimes the setting for your surgery is switched to an outpatient facility.  Safety first!  This problem frequently arises with patients on medications for depression and for hyper activity disorder.  All of these medications can affect the medications used for office IV sedation and anesthesia and can cause physical and psychological issues.

Medications you don’t want to admit you are talking
Even more problematic than the medications you are taking are the medications you don’t want to admit you are taking – alcohol, pain killers, stimulants, psychedelic medications and marijuana.  Nothing ads more variability to a patient’s response to IV sedation/ anesthesia medications than “recreational” medications.  That includes routine use of alcohol and marijuana.  All recreational drugs increase resistance to the medications Dr. Lee and his nursing staff give you. Additionally, they can all increase their effect causing prolonged sedation and even breathing difficulties and depressed heart function. Therefore, always be honest about the recreational drug and other “medications” you use. Dr. Lee and his staff don’t care what you use.  All they care about is your safety and putting you to sleep in the safest environment possible.  Remember the old saying, “You don’t pay the doctor to put you to sleep, you pay the doctor to wake you up”.

Click here for more information on the surgical procedures performed at the Cincinnati Center for Corrective Jaw Surgery. Or contact us at 513.232.8989/[email protected]

Dr. Lee Completed Advanced Training with New Technology for TMJ Arthroscopic Surgery

Dr. Lee Completed Advanced Training with New Technology for TMJ Arthroscopic Surgery 

Encouraged by the technological advances made in arthroscopic surgery by noted TMJ surgeon Dr. Joseph McCain, Dr. Lee returned to Miami in early February to undergo advanced training.

Dr. McCain has recently introduced a remarkably repeatable and simplistic technique for arthroscopic surgery of the temporal mandibular joint (TMJ or jaw joint). In concert with Nexus-CMF arthroscopes have been redesigned and instrumentation simplified.

While the fall course was intense and included the use of fresh cadaveric specimens to practice on, the early February course offered advance training.

“You can never practice enough when new technology intersects new ways to use it. The learning curve gets steeper the more advanced surgeries are introduced using this less invasive technique to treat TMJ problems,” Dr. Lee said.

While arthroscopic surgery of larger joints such as knees and shoulders is widespread and common, arthroscopic surgery of smaller joints like the jaw joint is not as common.  It is divided into an upper compartment and a lower one.  It holds less than a teaspoon of fluid making it difficult to find and even more difficult to operate in. The McCain system increases visibility and his techniques for entering the joint and operating is more predictable and safer.

“Getting into this small joint which is situated close to the ear and surrounded by facial nerves that control the muscles of the face has always been the challenge.  Access is much improved with the McCain/ Nexus – CMS System.”  Dr. Lee added.  Advances in arthroscopic surgery of the TMJ offers a more conservative approach to treating many conditions that plaque patients like painful popping, clenching and locking of the jaw joint.

“With these newer techniques we will be able to offer some patients a procedure to clean and re-lubricate the joint, not to mention the possibility of structurally altering the internal joint anatomy to save patients from undergoing more invasive joint surgery,” Dr. Lee predicted.

Dr. Lee practices Oral and Maxillofacial Surgery and with the Staff of the Cincinnati Center for Corrective Jaw Surgery, focuses on the correction of Jaw deformities and bite problems through the use of orthognathic surgery and Dental Implants reconstruction.  A high percentage of patients with Jaw misalignment and bite problems have jaw joint issues as well.  Dr. Lee’s office is adjacent to Mersey Hospital – Anderson.  Mersey will be the first community hospital to offer arthroscopic surgery of the TMJ using the McCain./nexus – CMF System.


Dr. Lee Further Establishes Himself as One of the Region’s TMJ Arthroscopy Experts – Pt. 2

Dr. Lee Further Establishes Himself as One of the Region’s TMJ Arthroscopy Experts – Pt. 2
Dr. Lee attended two continuing education conferences and trainings in January:

  • The 17th Annual Arnett Orthognathic Surgery Forum on January 26th-28
  • McCain Arthroscopy System Training on January 30th and 31st

Rounding out his recent continuing education in jaw reconstruction, Dr. Lee attended the 19th annual Arnett Orthognathic Surgery Forum in Santa Barbara, California. Dr. Lee has attended since 2006 and has presented at the conference on several occasions.  In 2014, he lectured on an intraoperative jaw positioning instrument to increase surgical accuracy.

“This year we were fortunate to have maxillofacial surgeons from Europe and South Africa lecture on new techniques to treat disfiguring facial asymmetries and those with skeletal malformations of the jaws,” Dr. Lee reported.Drs. Michael Lee and Joe McCain at the Arthroscopy System Training

More importantly, Mike Gunson D.D.S., MD, one of the Foundations principal contributors, lectured on “surgical revisions” and the complications he has addressed over his long career.

“Jaw surgery is hard. We are trying to perform complex “carpentry” on the jaws and do it within a millimeter of tolerance in three planes of space,” Dr. Gunson said.

Drs. Michael Lee and Joe McCain at the Arthroscopy System Training

Drs. Michael Lee and Joe McCain at the Arthroscopy System Training

Complications happen and revision surgery is sometimes necessary.  Dr. Lee’s philosophy is to recognize the problem, propose a way to fix it and always listen to the patient’s concerns.

Dr. Lee practices in Cincinnati Ohio at the Cincinnati Center for Corrective Jaw Surgery. Surgical Expertise/Technology -Focused / Committed to Patient Recovery.

Dr. Lee Further Establishes Himself as One of the Region’s TMJ Arthroscopy Experts

Dr. Lee Further Establishes Himself as One of the Region’s TMJ Arthroscopy Experts


Like most industries, technology in the dental industry is ever-changing. This pushes the industry forward, allowing us to refine techniques and provide the most efficient and advanced treatments possible.  As an Oral Surgeon, it is imperative that Dr. Lee stays up-to-date with the latest advancements in technology, diagnostics acumen and treatment. This is why he is constantly seeking the very best in his field of Oral and Maxillofacial to expand his knowledge specialty.

This October, Dr. Lee completed the Miami Anatomy Research Center TMJ Arthroscopy Mini-Residency Program further establishing himself as one of the region’s leading Oral and Maxillofacial Surgeons.  This week, he will be completing part two of the training.

What is TMJ and TMJ Disorder?

The temporomandibular joint (TMJ) is the joint that connects the jaw to the temporal bones of the skull in front of each ear. The temporomandibular joint is a ball and socket joint. In between the ball and socket is a disk. Temporomandibular disorder (TMJ disorder) occurs when there are problems in the relationship of the ball and socket.

The temporomandibular joint is one of the most complex joints in the body, responsible for the opening and side to side movement of the jaw.  Any incoordination of the ball and socket that inhibits the intricate system of muscles, ligaments, discs and bones from working is sometimes referred to as “TMJ”.  Often, TMJ feels like your jaw is popping, clicking or “getting stuck”.

What are the symptoms of TMJ disorders?

There are many symptoms of TMJ disorders, including:

  • a sudden change in the way the upper and lower teeth fit together
  • a clicking or popping sound during normal jaw function
  • pain while chewing or yawning
  • headaches or migraines
  • earaches

Unfortunately, these TMJ symptoms can also be present for many other reasons. Your dentist can help correctly diagnosis TMJ disorder by examining your dental and medical history and performing a clinical examination, but appropriate X-rays for this condition are usually obtained only at the oral surgeon’s office. When the jaw joints are affected and basic treatments have been unsuccessful, jaw joint surgery may be recommended.

Dr. Lee is one of the Region’s TMJ Arthroscopy Expert

Dr. Lee recently completed a TMJ Arthroscopy Mini-Residency program, further establishing himself as one of the region’s leading Oral and Maxillofacial Surgeons for temporomandibular joint disorders and corrective jaw surgery. This didactic and cadaver mini-residency course was established by a faculty of internationally recognized TMJ surgeons who have dedicated their careers to the practice of TMJ arthroscopic surgery.  It provided a unique opportunity to further develop the skills and knowledge needed to incorporate arthroscopic surgery into a full scope oral and maxillofacial surgery practice.

Unique for this course was the extensive cadaveric surgery portion.  Fresh cadaver heads were used to simulate clinical conditions and, thanks to Dr. Joseph McCain and Nexus Corporation, all surgical procedures were performed with new, state-of-the-art arthroscopic instrumentation.

Areas that were specifically addressed included: diagnostic and treatment approaches to TMJ internal derangements, surgical techniques for disc repositioning and arthroscopic approaches to TMJ lavage and visco-therapeutics.

In January,  Dr. Lee attended part two of the conference, where he receive advanced training in TMJ arthroscopy.

Reach out to Dr. Lee and the staff at the Cincinnati Center for Corrective Jaw Surgery at any time with questions relating to TMJ disorder, its symptoms and treatment options:

513.232.8989 / [email protected] / [email protected]

Stop Striking Out at Night: A Lesson in Obstructive Sleep Apnea from World Series Champion, Mike Napoli

In November of 2014, Cleveland Indians’ star first basemen Mike Napoli (then with the Boston Red Sox) underwent bimaxillary advancement surgery to treat his debilitating obstructive sleep apnea, a procedure that he says was life-changing and career-saving.

Napoli had struggled with obstructive sleep apnea for over a decade, fighting fatigue from the disorder that affected his personal life and professional career. It started with chronic snoring and incidents of gasping for air while sleeping. As time went on, he found himself constantly tired during the day, which hindered his ability to pay attention during team meetings. During the Red Sox’s historic 2013 season, Napoli’s situation became so bad, he was allowed to take naps during pre-game batting practices in a secret room in Boston’s Fenway Park.

He underwent a sleep study that showed he was waking up 40-100 times each hour, struggling to breathe and never falling into REM sleep. When he was on the road during the long season, he would leave his hotel room door unlocked so that the paramedics could enter if need be. He never felt rested and didn’t dream at night for almost a decade. However, it wasn’t until he started dozing off at the wheel of a car that he admitted to himself that something drastic needed to be done to treat his obstructive sleep apnea.

The 2013 World Series Champion explored a number of different treatment options for his sleep disorder before ultimately deciding upon surgery, including two different oral devices, medication and a CPAP device, but found he couldn’t sleep with the mask on his face or with air being forced down his throat. He said at that point, he knew that he couldn’t continue in the career he loved with untreated sleep apnea.
“I couldn’t do it anymore, the way I was feeling,” Napoli told reporters at the Red Sox’s Baseball Winter Weekend in 2015. “I was like, I’ve got to have surgery or I’m not going to play anymore. That’s how bad it was.”

“When I was younger, I could get away with (not wearing a CPAP mask),” Napoli added. “Now that I’m getting older, it was tougher. I came in and I’m like I need to go see the doctor now. I want to have this surgery yesterday.”

Napoli and his doctors decided on bimaxillary advancement surgery. The operation which advances both the upper and lower jaw in order to increase the size of the airway involved a significant recovery time. He spent the off-season undergoing the procedure, spending several days in the hospital, and eating a limited diet. By Spring Training, he was back on the field and feeling like a changed man.

“It’s crazy how I feel,” Napoli told Bleacher Report. “When I wake up now, it’s like, ‘Man, I was in a deep sleep.’ I can tell. Just being motivated and wanting to do stuff.”

Dr. Michael Lee, a Board Certified Oral and Maxillofacial Surgeon and the Clinical Director of the Cincinnati Center for Corrective Jaw Surgery said, “While Napoli’s surgery required a stay in the intensive care unit, a soft diet and weeks of recovery, surgeons who perform these procedures routinely are able to offer their patients a cure for Obstructive Sleep Apnea through jaw advancement, without wiring the jaws together and without difficult to tolerate liquid diets.”

“Additionally, jaw advancement surgeries with experienced surgeons are less painful than other airway surgeries that remove soft tissue from the palate, throat or tongue.”

Dr. Michael Lee and the surgical staff at the Cincinnati Center for Corrective Jaw Surgery work with sleep medicine and ENT doctors across the region. He and his staff are available to answer questions about the growing health problems associated with OSA and the options for treatment.

For patients who are tired of dealing with CPAP masks and jaw repositioning appliances that are uncomfortable to wear, jaw advancement surgery is an option that may be the definitive answer. Contact the Cincinnati Center for Corrective Jaw Surgery to learn more.

For more information on OSA Surgery.

Case Study: Thinking Outside the Airway, Treating Obstructive Sleep Apnea with Maxillomandibular Advancement Surgery.

Thinking Outside the Airway – Treating Obstructive Sleep Apnea with Maxillomandibular Advancement Surgery

Recently, Dr. Lee was asked to share his expertise on the treatment of Obstructive Sleep Apnea for the Northern Kentucky Medical Society Fall newsletter. Below is the article he contributed.

If you or a loved one are experiencing Obstructive Sleep Apnea, please give us a call at 513.232.8989. We are always here to answer your questions!

By Michael B. Lee, DDS – Cincinnati Center for Corrective Jaw Surgery

Obstructive Sleep Apnea continues to be a major medical problem affecting all patient population groups, whether male, female, young, old, obese or even underweight. While more prevalent in males and those who are overweight, obstructive sleep apnea affects an alarming percentage of the population. One in fifteen adults in the United States has obstructive sleep apnea. 1 It is one of the top ten most costly healthcare issues we face.

Obstructive Sleep Apnea is estimated to occur in seventy percent of obese patients. Thirty-four percent of all National Football League linemen have Obstructive Sleep Apnea. According to the Journal of The American Medical Association, a major contributor to vehicular and work-related accidents is daytime sleepiness associated with Obstructive Sleep Apnea. The health ramifications of Obstructive Sleep Apnea are well-documented and include hypertension, cardiac arrhythmia, stroke, neurocognitive disorders and glucose intolerance. 2, 3, 4 Clearly on the rise, more articles have appeared in peer-reviewed journals in the last eight years dedicated to Obstructive Sleep Apnea than appeared in peer-reviewed journals in the prior twenty. In keeping with this, there are now nineteen different surgical procedures that can be performed for Obstructive Sleep Apnea in eight different intrapharyngeal and extrapharyngeal sites documented along the airway.

CPAP Therapy

While CPAP remains the gold standard for conservative management of Obstructive Sleep Apnea and mandibular repositioning appliances are finding wider acceptance for conservative interventional therapy, these two modalities of treatment are not without their limitations. CPAP therapy has a high failure rate over time and compliance night to night is quite variable. (See Figure 1 and 2) Mandibular repositioning appliances also have non-compliance issues and worse, can lead to temporomandibular joint symptoms and changes in occlusion. Additionally, these appliances are not recognized as therapeutic for more moderately severe and severe cases of Obstructive Sleep Apnea and more disconcerting, they are rarely titrated to a known apnea hypopnea index.

Surgical Procedures for OSA

Surgery for Obstructive Sleep Apnea spans all sites in the pharyngeal airway. Surgical procedures are best classified as either intrapharyngeal or extrapharyngeal. Intrapharyngeal surgeries, or surgeries inside the airway, include the removal of excess tissue in the soft palate and other palatal procedures. They also include tongue base surgeries as well as the removal of tonsils and adenoids in specific patients. Extrapharyngeal surgery includes advancement surgeries of the maxilla and mandible commonly known as maxillomandibular advancement surgery, as well as advancement procedures on the chin and genial tubercle. In essence, intrapharyngeal procedures remove tissue within the “tube” and extrapharyngeal procedures increase the size of the “tube” by expanding it through advancement of its anterior skeletal support – the maxilla and the mandible. Whereas intrapharnygeal procedures have been notoriously variable in their success rate, extrapharyngeal procedures have been very successful and very stable long-term when treatment is carefully planned to include the following:
1. Orthodontic intervention to establish as large of a skeletal base discrepancy between the maxilla and mandible as possible.
2. Midfacial advancement to its full esthetic extent.
3. Counter-clockwise rotation of the midface.
4. Mandibular advancement with counter-clockwise rotation.
5. Genial tubercle advancement through the use of genioplasty or a pull-through genial tubercle window.
6. Rigid skeletal fixation.

OSA Image

Treatment following this protocol has been reported to not only rival the success of continuous CPAP therapy as measured by percentage change in AHI but to surpass all other forms of surgical intervention for Obstructive Sleep Apnea. 5, 6, 7

Maxillomandibular advancement surgery results in increased airway volume, increased lateral wall tonicity, decreased airway length, and decreased airway turbulence, all of which contribute to the successful management of Obstructive Sleep Apnea.


In conclusion, although maxillomandibular advancement surgery appears painful, and more difficult for patients to tolerate, it is not. When done by experienced surgeons following the treatment protocol referenced earlier, patients experience only mild to moderate pain. Rigid fixation allows the patient to function immediately post-operatively. Maxillomandibular advancement requires only an overnight stay at the hospital. While numbness to the upper and lower lip can be problematic post-operatively, function is not affected and the neuro sensory deficit is well tolerated by patients. Long-term stability has been documented and when properly treatment planned, facial harmony of the lower face is maintained or improved.

Michael B. Lee, DDS
Cincinnati Center for Corrective Jaw Surgery
Dr. Lee practices oral and maxillofacial surgery in Cincinnati, Ohio. He is a diplomate of the American Board of Oral & Maxillofacial Surgeons. He practices with a special interest in and commitment to the management of OSA through maxillomandibular advancement surgery.

1.Young, et al. Risk factors for obstructive sleep apnea in adults. JADA 2004; 2013 – 2016

2.Peppard, P.E. et al. Prospective study of the association between sleep disordered breathing and hypertension. M. Eng J Med 2000; 342:1378-84

3.Kim H, et al. Sleep disordered breathing and neurophysiological deficits. AmJ Crit Care Med 1997; 156:1813-9

4.Punjabi, TM et al. Sleep disordered breathing on insulin resistance… AmJ Respir Crit Care Med 2002; 165:677-82

5.Prinsell, J.R. A review of the literature using mean percent reduction in AHI as a measurement of therapeutic efficacy. Journal of Oral and Maxillofacial Surg 70: 2012; 1659-1677

6.Li, KK Maxillomandibular advancement in obstructive sleep apnea J. Oral Maxillofacial Surg 69:2011; 607-694

7.Caples, SM et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. SLEEP 2010; 33 (10): 1396-1407

Expanding Our Scope of Corrective Jaw Surgery

Dr. Lee attends ACOMS conference to expand service offerings and better serve patients.

From February 15-21, Dr. Lee joined industry colleagues at the annual American College of Oral and Maxillofacial Surgeons (ACOMS) midwinter meeting. The event showcased world-renowned lecturers from across the United States and Europe, who introduced new procedures for corrective jaw surgery of the upper and lower jaw. The procedures use CAD-CAM Models, as well as 3D computer software specifically created to help correct severe bite deformities and facial imbalances.

The highlight of the six-day conference was the introduction of novel approaches to corrective jaw surgery, specifically in reshaping and realigning the jaws of transgender patients. Reconstructive surgeries of this nature are important for cosmetic and emotional reasons, as patients who have undergone other sex change procedures or modifications often have a facial structure that does not properly reflect their sexual identity. By implementing these advanced procedures to modify the facial structure, patients can be given an overall appearance that properly reflects their sexual identity.

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Oral Surgery – Using State-of-the-Art Technology to Advance Our Practice in the 21st Century

Today, oral surgery in Cincinnati is very different than it was even 10 years ago. Whether the procedure is the removal of wisdom teeth, the placement of dental implants or jaw reconstruction for a bite problem, oral surgery has come a long way in a short period time—so short, in fact, that some oral surgery practices in Cincinnati and most family dental practices in Southwestern Ohio are still practicing to old standards set in the late 20th century.

At The Cincinnati Center for Corrective Jaw Surgery, we strive to be on the cutting edge of technological advances in oral surgery, sleep apnea surgery, dental implant surgery, corrective jaw surgery, nerve repair surgery, and conservative management of temporomandibular joint (TMJ) disorders. We do this by regularly using important technologies—technologies such as Cone Beam Computer Tomography.

CT scanning has been the standard of care in the medical profession for decades, and has since transformed the practice of medicine. The introduction of that technology eliminated a common procedure performed when I was a student known as “exploratory surgery.” Exploratory surgery was basically this: if a doctor didn’t know what was wrong with the patient, they would simply operate to get clarification or determine appropriate next steps. That procedure has (thankfully) all but disappeared from the medical world due to the rise of Computer Tomography or CT Scans.

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Fall 2013 Quarterly Update

In order to expand as a person, and as a professional, it is important to keep up to date on new findings and studies. At our office we like to let everyone know what we find in the form of our quarterly newsletters.

This quarter we looked at several articles focusing on Third Molar Extraction techniques and studies. After sifting through many informative and well written articles we selected three that we felt would best help our office and our patients.

To see our full review on the articles please follow the link below:

Fall 2013 Newsletter: Third Molar Extraction

Fall/Winter 2015 Quarterly Update

Dear Colleague,
This Quarterly update looks back on an issue that remains important for your patients and touches on two topics that are new and somewhat controversial in oral surgery. The old issue deals with the continuing debate over the indications for third-molar extractions, a topic that has taken on new and more important significance now that several large national insurance carriers are refusing to reimburse your patients for the removal of “asymptomatic” third molars. The second deals with the controversial subject of placing dental implants in patients who have taken bisphosphonates. Lastly I have included an article dealing with the use of statins to arrest the loss of alveolar bone secondary to extractions and periodontal disease. This is a very timely article and exposes us to a completely new and novel approach to an age old problem of alveolar bone stabilization after surgical intervention or bacterial contamination.

The indications for third-molar extraction

Dr. Lee’s Note –
In this article the author simplifies the categorization of implants into three groups. Group A are symptomatic and disease is present. Extraction is usually the treatment of choice, but an argument can be made for treatment options if they are possible. Dentists make this algorithmic decision process with each case and refer those patients who they believe need to be operated. Interestingly, insurance carriers are more frequently disagreeing with the necessity for extractions. Aetna and Blue Cross and Blue Shield have gone so far as to mandate radiographic evidence of pathology before they will cover surgery. The lack of eruption space is not an indication for surgery anymore. Neither is periodontal pocketing unless it can be verified on a radiographic image. As far as third molars in Group D: Symptoms and Disease Absent- there are no exceptions in spite of the fact that data from the 6,793 participants in the 2011 Atherosclerosis Risk In Communities Study revealed that fewer than 2% of participants with a retained visible third molar were free of coronal caries and periodontal pathology.

Effect of Dental Implants on Bisphosphonate-Related Osteonecrosis of the Jaws

Dr. Lee’s Note –
This article contradicts the past position of the AAOMS whose guidelines have suggested in cases of oral administration of BPs, dental implants can be safely inserted if the patient has been undergoing this treatment for less than 3 years. In other articles, authors have sited beneficial effects of oral BPs on Osseo integration and peri-implant bone healing. This article, while small in sample size and not adjusted for clinical co-morbidities, i.e. poor prosthetics etc., did cast some doubt on what has been preached as gospel concerning the benign nature of the placement of dental implants in patients who have received IV and oral bisphosphonates for less than 4 years. In this study, the authors found an accelerated and greater risk of developing osteonecrosis when implantation was performed after the start of or during BP therapy. This seems true for oral as well as IV bisphosphonate therapy. This is disconcerting, since several BP medications have been approved for use in osteopenia and osteoporosis resulting in an increase in our patient population. It appears that there is a link between bisphosphonate therapy and osteonecrosis of the jaw when dental implants are placed during or at the conclusion of administration of the drug. Drug route and duration of the dose were not factors. While a drug holiday of 3 months prior to the placement of implants, and 3 months after has been advocated by some, the evidence to support this treatment timeline is lacking, but still recommended.

Statins and Alveolar Bone Resorption: A Narrative Review of Preclinical and Clinical Studies

Dr. Lee’s Note –
This 21 study review opens up a whole new avenue for therapy to control bone loss associated with periodontal disease and the extraction of teeth. Statins have been used for a number of years to stabilize the condyle in orthodontic patients with temporomandibular joint disease. Its mechanism of action has been known for years, working as an inhibitor of osteoclastic activity and as a stimulant of bone morphogenic protein. It is exciting to see it used in this new role and, based upon cumulative research, it is only a matter of time until we see it used clinically to minimize bone loss in dento-alveolar surgery and periodontal disease.