Oral Surgery | Specialists and Information

For extensive jaw reconstruction or specific conditions such as a tumor in the oral cavity, it makes sense to consult a specialist in oral surgery, as their range of treatments extends beyond that of a general dentist.

Oral surgery can be divided into three areas: treatments in the oral cavity, procedures on the jaw, and dental procedures. In dentistry, oral surgery is not only required when patients want dental implants; doctors also surgically remove wisdom teeth or provide assistance when a root canal treatment has not yielded the desired results. In such cases, a dental specialist in oral surgery can remove the root tip.

The procedure known as a hemisection is also part of oral surgery. Put simply, this involves splitting a molar into two halves to preserve the healthy portion and use it, for example, as an abutment for dental implants.

Oral surgery is also used to correct jaw misalignments and to treat dislocations or fractures of the jawbone. In the field of implantology, jawbone augmentation is often necessary, which is also part of the range of treatments offered by oral surgery.

An accident resulting in bone fractures and tooth loss is therefore also treated by dental specialists in oral surgery. They coordinate the treatment of the jawbone with any necessary implantology procedures to ensure that dental implants are placed at the optimal time, if required.

In the oral cavity, oral surgery is particularly important when cavities form in the tissue (cysts), which can also press painfully against the tooth roots. Another subfield of oral surgery is surgical periodontology, which involves, among other things, the removal of pockets where bacteria accumulate.

Correcting short frenula of the lips and tongue, as well as orthodontic treatments, are also part of oral surgery. One example is palatal expansion, which is used in oral surgery when the upper jaw is too small. The jaw is gently pulled apart at the natural growth plate to widen it. This oral surgical procedure replaces or supplements braces for misaligned teeth.

Last but not least, oral surgery is also used when swellings (tumors) in the oral cavity need to be surgically removed.

An oral surgeon performs surgical procedures in the oral cavity, such as on the jaw, the jawbone surrounding the tooth root, teeth, and gums @ andrey_orlov /AdobeStock

Many dental specialists in oral surgery now list implantology separately when detailing their range of services. The use of dental implants has become increasingly important, primarily due to medical advances.

Implantology, as a subspecialty of oral surgery, has undergone significant development since the mid-1980s. Today, the placement of dental implants can be considered a routine procedure.

In a long-term study, Swiss researchers at the Dental Clinics (ZMK) in Bern demonstrated that the failure rate of dental implants is low and that complications are rare in this form of oral surgery.

Such findings have led to growing acceptance of implantology, despite the associated costs. While most areas of oral surgery involve medically necessary procedures that are fully covered by public health insurance, the situation is different for dental implants. Tooth replacement can also be achieved through other methods, such as bridges.

As a result, health insurance plans pay only a fixed subsidy. The amount of this subsidy depends, among other factors, on the location of the tooth being replaced. The patient pays the difference out of pocket or covers it through supplemental dental insurance. For dental implants, therefore, a higher out-of-pocket cost is typically required in most cases.

A bridge closes a gap in the teeth that can span one or more teeth @ piyaset /AdobeStock

In oral surgery, and particularly in implantology, careful planning is crucial to the success of the treatment. Dental implants can only be placed if the jaw meets certain conditions. In addition, dental surgeons specializing in oral surgery and other implantology specialists must determine the exact methods to be used and work with great precision.

Therefore, the placement of dental implants in oral surgery is always preceded by a thorough diagnostic evaluation.

Orthopantomogram (OPG)

The standard procedure in implantology is the orthopantomogram (OPG). This is an X-ray device used in oral surgery to produce two-dimensional images of the oral cavity. Before placing dental implants, the dentist can use this image to measure the height of the jawbone, but not its width. In implantology, this diagnostic method is sufficient in most cases.

An orthopantomogram, or OPG for short, is a two-dimensional X-ray image of the upper and lower jaws @ Evgeny Panov / AdobeStock

Computed Tomography (CT)

For more complex cases, additional imaging techniques are available in oral surgery. Computed tomography (CT) is a well-established technique in implantology. This three-dimensional imaging technique is superior to the OPG because it shows anatomical structures in every spatial direction, allowing the dentist to assess the details of the bone structures before placing dental implants.

However, even specialists in oral surgery rarely own the necessary equipment themselves and must first refer patients to a specialist colleague or a clinic as part of the preliminary examinations for implantology. Computed tomography is used in oral surgery only when an OPG is insufficient, as this examination involves higher radiation exposure.

Dental Volumetric Tomography (DVT)

In recent years, dental volume tomography (DVT) has gained popularity in implantology and is now also used in other areas of oral surgery. This is another three-dimensional imaging technique that provides a highly accurate representation of the oral cavity before dental implants are placed.

The key factor here is how the data is processed for implantology: The device generates highly detailed 3-D images that help oral surgeons better assess the conditions for dental implants.

However, as with 2D imaging, the radiation exposure for patients seeking dental implants is higher with 3D imaging than with a two-dimensional scan. Experts point out that in oral surgery, the method that provides adequate results with the lowest possible radiation exposure should be chosen.

3D imaging methods are therefore primarily recommended for implantology in the following special cases:

• Unusual anatomical variations that could complicate the placement of dental implants
• Uncertain success of a bone graft
• The 2D image did not provide sufficient results and, for example, did not delineate the adjacent teeth clearly enough
• Pathological changes affecting the implant site have been observed
• There is a history of previous surgeries or pre-existing conditions involving the maxillary sinus that could affect the dental implants, such as sinusitis
• Previous oral surgery procedures have led to complications, such as damage to nerves or the roots of adjacent teeth
• The dentist is planning special implant procedures, such as immediate restoration

In implantology, many specialists now advertise the use of DVT (digital subtraction tomography) devices. To date, however, there is no study in the field of oral surgery that proves DVT is qualitatively superior to CT. It is recommended, however, in cases where the planning of dental implants is to be computer-assisted.

This is because, for more complex oral surgery procedures, a specialist often plans the treatment on a computer. In implantology, this means simulating, among other things, the exact position of the dental implants, as well as any necessary bone augmentation or soft tissue grafting.

In this case, a DVT is the better option for oral surgery because it facilitates the computer simulation. For this virtual planning in implantology, the dentist has access to databases containing dental implants from various manufacturers. He can thus select the type and size and position the dental implants in the image to verify the outcome of the planned procedures.

For oral surgery, this procedure in turn opens up new possibilities: static or dynamic navigation during the placement of dental implants.

Dental volume tomography (DVT) is one of the modern methods of X-ray diagnostics that produces 3D X-ray images @ coldwaterman /AdobeStock

3D drilling template

In oral surgery, static navigation is also referred to as a 3D drilling template. Simply put, implant planning is used to mill computer-aided templates. The dentist places these on the jaw to precisely locate the desired position of the dental implants during surgery. Ideally, the guides should rest on the remaining teeth or, for example, on temporary dental implants. The results are then even more precise than when they are supported by the mucosa or the jawbone.

For the actual implant placement, the specialist drills through thin metal guide tubes.

In oral surgery, specialists make use of this option, for example, when jaw reconstruction is very complex or when implant surgery could pose greater risks to patients—such as those with diabetes mellitus or an increased tendency to bleed.

3D Navigation

Dental implants can also be placed using dynamic or 3D navigation. The patient wears a rigid splint in their mouth with reference points marked on it. During the procedure, live X-rays are taken so that the specialist can track the position of their instruments in real time on the screen and compare it with the implant treatment plan.

However, radiation exposure is higher when 3D navigation is used for dental implants. In implantology, it is therefore only recommended for particularly complex procedures.

To date, oral surgery experts have not been able to identify significant differences in accuracy between static and dynamic navigation. When considering these implantology options, patients should bear in mind that such procedures are associated with higher costs for their dental implants.

Implantology is a special case. Although the placement of dental implants is, from an anatomical perspective, part of oral surgery, the term “implantology” is not protected and is therefore not tied to any specific requirements. In principle, therefore, any dentist may practice implantology, even without specific experience in placing dental implants.

For patients, it is therefore all the more important to inquire about their dentist’s qualifications in the field of implantology if they are considering dental implants. Responsible dentists collaborate with specialists in the field if they themselves are not specialized in implantology.

If the dentist is not a specialist in oral surgery, the designation “Focus on Implantology (TSP)” is an important indicator of the dentist’s experience in performing dental implant surgeries. This designation is verified by the Federal Association of Dentists Specializing in Implantology (BDIZ). It is awarded only if the dentist in question

• has completed a comprehensive continuing education program (Implantology Curriculum),
• has placed or restored at least 200 dental implants, and
• has at least three years of experience with dental implants.

In addition, the “Specialist in Implantology” designation is valid for a limited period of five years. Renewal is only possible if evidence of continuing education is provided. This ensures that the respective dentists or specialists in oral surgery remain up to date in the field of implantology.

The designation “EDA Specialist in Implantology” goes one step further. The European Dental Association (EDA), in collaboration with the BDIZ, conducts exams several times a year for this designation, during which participants must, among other things, document dental implants they have placed themselves.

In addition to dentists and specialists in oral surgery, specialists in oral and maxillofacial surgery may also offer dental implants. They, too, have the opportunity to qualify for the described area of specialization in implantology.

Diagnostic tools are also used in oral surgery to determine the timeline for treatment. With regard to implantology, this addresses the question of exactly when dental implants should be placed.

Immediate Implantation

So-called immediate implantation is possible. In this form of implantology, doctors remove the existing teeth and place the dental implants during the same procedure.

The oral surgeon or another dentist specializing in implantology must first determine whether there is sufficient bone material for this method. Additionally, there must be no inflammation present if dental implants are to be placed immediately.

Early Implantation

In oral surgery, the term “early implantation” refers to waiting to place the dental implants until the soft tissue has healed. “Late implantation” describes the most common procedure in implantology. By this time, both the wound and the bone have fully healed. If necessary, the dentist may have performed a bone graft. Only then does the dentist place the dental implants.

Structure of Dental Implants

The actual procedure for placing dental implants is always the same. The specialist inserts a post into the jawbone. These posts come in various shapes. In addition, oral surgery uses different types of threads for dental implants when the post—also called the abutment—is screwed into the bone.

In implantology, the same material is typically used as for internal medical implants: titanium or titanium alloys. An alternative for dental implants are models made of zirconia ceramics. These are also considered well-tolerated, which is an important factor.

The so-called abutment is placed on top of the body. In dental implants, this is the area that is later surrounded by the gums and serves as a base for the crown. The crown, in turn, visually closes the gap in the row of teeth in oral surgery.

Once again, implantology offers various options in terms of materials. Solid-cast gold crowns are rarely used anymore. All-ceramic dental implants are considered the best—but also the most expensive—option.

In contrast, a porcelain-fused-to-metal crown features a metal framework covered with a layer of porcelain, which significantly reduces the cost of this oral surgery option.

A resin-veneered crown is the most affordable option for a dental implant. Instead of ceramic, the metal cap is coated with resin. In any case, a specialist will always match the color and shape of the dental implants very closely to the natural teeth.