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Dental Implant Complications and Disciplinary Inquiries (3)

slchan@aestheticjawsurgery.com (S L Chan) — Sat, 25 Apr 2026 01:13:17 GMT

Disclaimer: The opinions expressed in this article are purely personal and do not represent those of any organisation or committee.

The Third Case

This case involved a nerve injury arising from the placement of two dental implants, resulting in permanent partial loss of sensation in the lower lip. The dentist was charged with an intentional and deliberate departure from the standard of care, specifically for failing to undertake proper planning and assessment, and for failing to monitor and review the patient in a timely manner.

Although the permanent partial loss of sensation was the central issue in the case, it was not expressly stated in the charge. In establishing professional misconduct, the actual harm suffered by the patient is not, in itself, determinative. If it is proven that the standard of care was not met, liability may be established even in the absence of harm. Conversely, where appropriate care has been exercised, a charge will not stand even if harm has occurred. This principle may appear counter‑intuitive to those unfamiliar with disciplinary processes.

The practice of medicine and dentistry is an art founded on science. Success cannot be guaranteed in every case, even when treatment is provided by the most skilled practitioners exercising the highest standards of planning and execution. Clinical practice is a service, not a product akin to a television set that comes with a warranty. Indeed, guaranteeing success may itself amount to professional misconduct, as it constitutes misrepresentation. Where a dentist has received the requisite training to provide a service—in this instance, dental implant surgery—and has properly documented the planning process and executed the treatment with due care, an adverse outcome such as permanent numbness does not automatically equate to professional misconduct.

However, where a dentist is shown to have omitted essential steps in diagnosis or treatment planning, he may still be found guilty of professional misconduct even if no harm ultimately results. The reasoning is that such conduct would be regarded as reckless, with the absence of an adverse outcome attributable merely to good fortune. In such situations, complaints are unlikely to arise, which may in turn give the dentist an unwarranted sense of confidence.

The incidence of altered sensation following implant placement in the mandible has been reported to be approximately 13% within the first ten days, decreasing to around 3% after one year. This is a recognised complication that patients should be informed of as part of the consent process. In the present case, there was no dispute regarding consent. Nevertheless, a patient’s consent to accept a risk does not indemnify a practitioner against liability for substandard care. The central question was whether due care had been exercised in performing the surgery. This case therefore served to clarify the expected standard of care in relation to pre‑operative planning and the documentation required in dental implant practice.

Competency of a General Dentist

The second charge concerned the post‑operative management of the patient. Expert witnesses for the respective parties disagreed on whether a general dentist is competent to monitor recovery from a nerve injury. The prosecution’s expert took the view that a general dentist lacks the training and experience necessary to determine whether a nerve injury will resolve spontaneously or requires surgical intervention. Ultimately, however, no evidence was adduced on this charge, as the respondent pleaded guilty without contest.

Had the respondent elected to proceed to trial on this issue, both parties would have had the opportunity to present evidence either in support of, or in opposition to, the assertion that a general dentist is not qualified to monitor nerve‑injury recovery.

The Dental Registration Act does not prohibit general dentists from performing any specific procedures. That said, the SDC’s Ethical Code and Ethical Guidelines require dentists to practise within the limits of their competence and to refer patients to appropriate specialists when necessary. Unless the Act is amended to expressly define the scope of practice for general dentists, it is unlikely that a Disciplinary Committee could impose a blanket prohibition on general dentists performing particular procedures. A more nuanced and fact‑specific approach is therefore required, with both parties relying on precedent from Singapore or other jurisdictions. The individual training and experience of the dentist in question is also a crucial consideration, as general dentists are not a homogeneous group.

The Disciplinary Inquiry

In this final article on the topic, I wish to address a common misconception regarding the disciplinary inquiry process. Prior to the enactment of the Dental Registration Act in 1999, dentistry in Singapore was regulated under the Dentist Act (Cap 76, 1985 Revised Edition). Under that statutory regime, disciplinary proceedings were inquisitorial in nature, and members of the Dental Board were empowered to cancel a dentist’s registration for a wide range of infractions, including “infamous or disgraceful conduct in a professional sense”.

With the introduction of the Dental Registration Act 1999, disciplinary inquiries became quasi‑criminal and adversarial. The Disciplinary Committee (DC), comprising a Chairman drawn from the Panel of DC Chairmen, a Council Member of the SDC, and another senior dentist or oral health therapist, functions as a neutral and impartial tribunal. The DC is assisted on questions of law by a legal assessor and observed by a lay person representing the public interest.

The respondent dentist is represented by legal counsel, either appointed through a professional indemnity provider such as Dental Protection Ltd or engaged privately. The SDC appoints a prosecutor through a tender process. Each party presents its case in a manner akin to criminal proceedings in the State Courts. As with a criminal trial, the burden of proof lies with the prosecution, and the respondent is presumed innocent unless proven guilty.

The role of the DC is that of an impartial adjudicator, with no vested interest in whether the prosecution or the respondent succeeds. Although DC members are dentists—and often specialists in relevant fields—they are not to assume the role of expert witnesses. Their clinical knowledge serves to assist them in appreciating the nuances of the evidence presented, nuances that may not always be readily apparent to a judge in a conventional court. Nonetheless, DC members must approach each case with an open mind, deciding matters solely on the evidence adduced, and not on assumptions regarding issues that were not raised. In matters of law, they must defer to the legal assessor.

While the Dental Registration Act provides that the DC is not bound by the Evidence Act, respondents retain a right of appeal to the High Court. Accordingly, both the conduct of proceedings and the written grounds of decision must be capable of withstanding judicial scrutiny.

The sanctions available to the DC following a finding of guilt are prescribed by statute and include suspension from practice for periods ranging from three to thirty‑six months, removal from the register, and fines of up to $50,000, guided by the SMC Sentencing Matrix. These sanctions are primarily punitive in nature. In my view, however, there is merit in considering the incorporation of a rehabilitative component in sentencing going forward.

Expert Witnesses

In disciplinary proceedings involving clinical issues, expert witnesses play a pivotal role. The Academy of Medicine Singapore conducts an annual Medical Expert Witness course to prepare doctors and dentists for this responsibility. Although experts are engaged by the respective parties, they are required to act impartially and to provide independent opinions regardless of who has instructed them. An expert’s overriding duty is to the court.

An expert report must set out the expert’s qualifications, identify the literature relied upon, and, where there is a range of professional opinion, summarise the differing views together with the reasons underpinning the expert’s own conclusions.

An expert’s authority derives from objectivity and independence. Experts should confine their opinions strictly to matters within their expertise and remain detached from the outcome of the proceedings. They are not advocates, nor are they “hired guns” for either side. Opinions must be supported by evidence and relevant medical literature, rather than by reputation or seniority alone. The Rules of Court also permit experts appointed by opposing parties to confer, with a view to identifying areas of agreement and disagreement and producing a joint statement summarising those points.

The Respondent

In my experience, respondents generally fall into three broad categories: the indignant, the fearful, and the comparatively rare calm respondent. The indignant respondent is firmly convinced that he has done nothing wrong and feels deeply aggrieved at having to endure the disciplinary process. This attitude often manifests in the tone of exculpatory statements, courtroom demeanour, and impatience during cross‑examination. Such behaviour is typically counterproductive. A respondent appears before a disciplinary tribunal because a Complaints Committee has already found probable cause. A confrontational stance may suggest a lack of insight or remorse and can create the impression that the respondent poses a continuing risk to the public.

Fearful respondents, by contrast, may defer entirely to their lawyers and elect to plead guilty simply to avoid the ordeal of cross‑examination. This approach is similarly unhelpful, both for the respondent and for the disciplinary system as a whole. Clinical cases are seldom clear‑cut, and a thorough examination of the evidence benefits not only the respondent but also the profession and the public. While cross‑examination is undoubtedly stressful, calm and candid testimony may, in some cases, mitigate what might otherwise develop into a career‑threatening episode.

Conclusion

Having served in numerous disciplinary hearings—first as an SDC member and later as Chairman—I have observed that some cases arise from a series of unfortunate events, compounded by a succession of minor yet erroneous decisions that ultimately culminate in serious professional lapses. These cases are often the most difficult to adjudicate. Others, however, involve conduct that clearly amounts to an intentional and deliberate departure from the standard of care and are correspondingly more straightforward to determine. That said, all else being equal, the adversarial system inevitably favours the party with stronger legal representation and more persuasive expert evidence. Regardless, prevention is always better than cure. Ongoing education and training, an ethical mindset that prioritises patients’ interests, respect for patient autonomy and self‑determination, and meticulous documentation can significantly reduce the risk of adverse outcomes.

Dental Implant Complications and Disciplinary Inquiries (2)

slchan@aestheticjawsurgery.com (S L Chan) — Thu, 23 Apr 2026 05:35:09 GMT

Disclaimer — The opinions expressed here are purely personal and do not represent any organisation or committee.

The second case

This case involved a senior dentist who was charged with carrying out grossly inappropriate treatment by replacing all the lower teeth of a patient with a 15 mini-implant-supported full-arch prosthesis. I will not describe the details of the case, as they are available online. Unlike the first case, which caused some disquiet when the decision was published, the profession’s reaction to this case was one of acceptance, reflecting the general view that the sentence was appropriate. However, I would like to highlight several aspects of this case that set new precedents which largely went unnoticed by the profession.

The first charge was one of “intentional and deliberate departure from the standard of care.” For this charge to stand, the prosecution needed to establish what the standard of care was. Among other criteria, the use of cone-beam computed tomography (CBCT) was stated to be the standard of care for the insertion of multiple implants for a full-arch prosthesis. Although many clinics have installed CBCT machines over the past twenty years, the technology is still not universally available, and no evidence-based guidelines have been published mandating it as the standard of care.

In addition, the standard of care adopted by the DC prescribed the use of bone grafting to increase bone width before implant placement. The DC further prescribed that “conventional” implants should be used instead of “mini” implants, and that open-flap surgery should be used instead of flapless surgery.

For the second charge, the dentist was accused of serious negligence for substandard technique in cementing the prosthesis, as well as for designing an inappropriate prosthesis that rendered oral hygiene difficult, leading to chronic inflammation.

Establishing a single standard of care has always been challenging, because there are often several ways to solve a clinical problem. Take the CBCT criterion, for example. Before the availability of CBCT, dentists had already been carrying out full-arch and even full-mouth implant treatment successfully. CBCT provides a three-dimensional view that is not available with the routine dental panoramic tomogram, and it is undoubtedly a major improvement. Does a DC stipulating it as the standard of care affect the practice of implant dentistry in Singapore? While it may not become a strict rule, it will certainly cause dentists to think twice before proceeding without a CBCT. What, then, of older, more laborious, albeit less accurate, methods of assessing bone dimensions, such as bone sounding?

In most cases of professional misconduct, the charges focus on pre- and post-operative management rather than the actual treatment itself. This is because it is usually difficult to prove that the execution of the treatment was negligent, as there is rarely another dentist present during the procedure to critique it. As such, most charges tend to focus on lack of informed consent, which is an administrative process and can be assessed objectively based on the documentation. Documentation of pre-operative planning is another area that can be assessed more objectively against an established standard of care. Likewise, postoperative management of complications can be judged more objectively. Charges relating to the actual treatment can generally be framed as either doing the wrong thing, or doing the right thing poorly.

In this case, the charge focused on the inappropriate treatment plan and the poor quality of the prosthesis — in other words, doing the wrong thing poorly. It demonstrated the confidence the prosecution had in the evidence it had gathered, and the dentist’s eventual plea of guilt before the hearing concluded proved that confidence well placed.

Evidence-based guidelines

Nevertheless, this case highlights the need for evidence-based clinical practice guidelines for complex cases. The Academy of Oral and Maxillofacial Implantologists (AOMI), a newly formed international sister organisation of the International Team for Implantology (ITI) that focuses on complex implant patients, was launched in Singapore last year, and the Singapore Chapter was inaugurated in February 2026. AOMI, whose mission is to focus on both the complex patient and complex indications, would be well placed to undertake such a project.

Rehabilitative vs retributive

Another unique aspect of this case was the use of corrective education and training in sentencing. A three-month discount was applied when the dentist agreed to undergo the dental implant course organised by NUS. In a conversation with Dr James Foster from Dental Protection Ltd, it was noted that Asian countries tend to adopt a more retributive or punitive approach to infractions, whereas Western jurisdictions tend to favour a more rehabilitative approach. The DC’s provision of re-education or training as a means of reducing the sentence was a progressive step in the right direction. The disciplinary process will achieve a greater good for Singapore not merely by punishing dentists for infractions, but by encouraging education and improvement of skills, so that after the period of suspension, the dentist is better equipped to serve patients.

Other forms of rehabilitative orders may include requiring the dentist to perform the relevant procedures under supervision a certain number of times before resuming that service, even after the suspension period. I hope this landmark sentence sets a precedent for future DCs in mandating remedial training for dentists who have been found guilty of professional misconduct in clinical treatment.

Sentencing matrix

This case also marked the adoption of the sentencing matrix first introduced by the Singapore Medical Council. Its purpose is to minimise gross discrepancies in sentencing between one case and another. Acknowledging that comparing different cases is like comparing apples and oranges, this matrix seeks to harmonise sentencing by assessing both the harm caused to the patient and the degree of culpability of the dentist.

By determining where a case falls on the matrix — for example, moderate harm and low culpability — similar past cases classified in the same category can be used as a reference point for determining the starting sentence, whether in terms of months of suspension, amount of fine, or other punishment. Aggravating and mitigating factors are then considered, and the appropriate additions or reductions are applied to the starting point to arrive at the final sentence. While there is still an element of subjectivity, it is a more transparent and consistent system.

Aggravating and mitigating factors

Counterintuitively, seniority and standing in the profession are aggravating factors. This is counterintuitive because a dentist who has contributed significantly, and who therefore enjoys a high level of respect from both the profession and the public, will be judged more harshly than someone less well known. The rationale is that an infraction committed by a prominent person brings greater disrepute to the profession, and that the privileges accompanying high social standing make any violation more egregious.

Not pleading guilty is not an aggravating factor, although pleading guilty is generally considered a mitigating factor. It is not treated as aggravating because it is the respondent’s right to claim trial. Pleading guilty implies remorse and contrition, and perhaps also openness to rehabilitation, while at the same time saving the system the time and resources that would otherwise be spent on the hearing.

An inordinate delay by the prosecution is considered a mitigating factor, and precedent has been set in the High Court for a reduction in sentence on that basis. The rationale is that undue delay in the prosecution process causes undue stress to the respondent. However, to justify a reduction in sentence, the delay must have been caused by the prosecution rather than by the respondent.

What causes delays?

The delay may arise from the SDC secretariat or the law firm appointed to conduct the prosecution. It may also be caused by the unavailability of DC members on the preferred dates. Scheduling is often challenging, as it requires many people to be available for a continuous period of one to two weeks for the hearing. All parties do take considerable pains to expedite the process, but some delays are inadvertent, and the courts are cognisant of the stress such delays place on the respondent. In some cases, they have ordered sentence reductions by way of compensation.

How was the sentence derived in this case?

The DC determined that the case fell within the category of severe harm and medium culpability. Based on precedent, similar infractions had attracted a suspension of 30 months. Due to the delay of more than three years in prosecution, and again based on precedent, a 40% reduction was applied, bringing the suspension down to 18 months. A further reduction of three months was granted because the respondent agreed to undergo the dental implant course at NUS, resulting in a final sentence of 15 months’ suspension. In addition, a fine of $15,000 was imposed.

I will discuss the third case in the next post.

Dental Implant Complications and Disciplinary Inquiries

slchan@aestheticjawsurgery.com (S L Chan) — Tue, 21 Apr 2026 09:32:41 GMT

I had my first experience speaking at a silent conference on Sunday. It was a rather strange experience: while the audience listened through headphones, I was the only one who could hear the ambient background noise, in addition to hearing my own voice through an earpiece. I became distracted during the opening minutes of the lecture and subsequently had to rush through the later slides, ultimately failing to deliver the key point I had intended to make.

For context, I was invited to speak at the International Dental Exhibition and Meeting (IDEM) 2026 on the topic of dental implant complications and their implications in professional misconduct allegations. Having spent the past 26 years serving on numerous Complaints Committees and Disciplinary Committees of the Singapore Dental Council, I have observed that many dentists—as well as members of the public—do not have a clear understanding of how a Disciplinary Committee (DC) operates. In this lecture, I attempted to illustrate my personal approach to the DC process by examining three past cases published on the SDC website, dissecting each case to demonstrate how the verdict was reached and how the appropriate sanction was determined.

I would now like to supplement the lecture by addressing the points I had intended to cover but was unable to present due to poor time management arising from my distraction with the (to me) novel silent conference format.

The first case I presented was published in 2016. It involved the placement of an implant into a previously bone-grafted site earlier than what most guidelines recommended. The outcome was an infection that eventually necessitated removal of the implant by a specialist, who subsequently took over the case and completed the restoration successfully. During the hearing, both the respondent and the prosecution referred to a set of consensus statements published by the International Team for Implantology (ITI) in 2003. In addition, expert witnesses were called by both parties, and there was consensus that a bone graft consolidation period of four to six months is physiologically required.

The case concluded with the dentist being found guilty as charged, and a fine and suspension were imposed. There was considerable disquiet within the dental fraternity at the time, as some felt that suspending a dentist for a failed implant was excessively harsh and were concerned about the potential implications for the practice of implant dentistry in Singapore.

While judgments by Disciplinary Committees can have a significant impact on clinical practice, each case has its own unique circumstances, and decisions are based on the aggregate of all evidence presented before the DC. In this case, the outcome resulted from a combination of factors including published guidelines, expert opinions (including those supporting the respondent), material witnesses (including both the dentist and the patient), the manner in which the respective legal teams presented the evidence, and the DC members’ interpretation of that evidence. No two cases are identical, and it does not follow that placing an implant before four months after bone grafting would automatically render a dentist guilty of professional misconduct.

This case partly relied on consensus statements published in 2003, which may have been outdated by 2016. Given the rapid pace of research and development in dental implantology, clinical practice guidelines generally have a validity period of approximately five years. For a more robust assessment of prevailing standards of care, it is necessary to review up-to-date literature, with particular emphasis on systematic reviews and meta-analyses published within the preceding five years.

I also took the opportunity to highlight that organisations and authors who publish clinical guidelines consistently include caveats stating that such guidelines are not intended to be dogmatic and should not be treated as law. Clinical decision-making ultimately remains the responsibility of the clinician. Strict adherence to guidelines does not automatically preclude professional misconduct, just as deviation from them is not necessarily improper.

In Singapore, the only set of clinical practice guidelines on dental implants was published jointly by the Ministry of Health and the Academy of Medicine in 2012. I had the privilege of chairing the workgroup responsible for drafting those guidelines, although an update is long overdue. Clinical practice guidelines are based on a thorough review of the scientific literature, and their recommendations are graded according to the strength of the supporting evidence. Recommendations founded on level 1 evidence—such as meta-analyses and systematic reviews of randomised controlled trials—are awarded a Grade A rating. In contrast, recommendations based on level 5 evidence, such as expert opinion and consensus statements, are assigned a Grade C rating.

In a DC hearing, expert witnesses play a critical role. An expert opinion substantiated by high-level evidence carries greater weight than one that relies on literature lower in the evidence-based medicine hierarchy. In cases of alleged professional misconduct, the prosecution must establish that there is a generally accepted standard of care and that the dentist charged has either intentionally departed from that standard or that the deviation was extremely severe.

An expert witness, regardless of whether engaged by the prosecution or the respondent, has a duty to present an impartial opinion grounded in the best available scientific evidence. Nonetheless, opposing opinions frequently arise because experts may interpret the same literature differently, and legal teams will naturally select experts whose interpretations best support their respective positions.

The Singapore Dental Council often appoints DC members based on the specific issues involved in a case. For example, where dental implant surgical complications are concerned, an oral and maxillofacial surgeon is often appointed to the DC. This approach has both advantages and disadvantages. As a DC member serves in a judicial capacity, having a practising specialist on the panel can facilitate a more nuanced understanding of the medical literature cited by expert witnesses and of the evidence presented by the respondent. However, such a member may inadvertently assume the role of the ‘ultimate expert’, potentially overriding the opinions of expert witnesses from either side. There is also a risk that such a member may cross-examine witnesses from the bench, which could give rise to a perception of bias. A high level of restraint is therefore required.

Personally, when chairing a DC hearing involving a surgical complication, I take great care to separate my personal professional views from the evidence presented by both sides, ensuring that any adjudication is based strictly on the evidence before the committee rather than on my own clinical practice.

I will continue with the discussion of the other two cases in my next few posts.

Cost of Dental Care in Singapore

slchan@aestheticjawsurgery.com (S L Chan) — Sun, 15 Sep 2019 02:00:00 GMT

I was preparing a treatment plan for a patient last night when a Whatsapp message from a colleague came in. He forwarded me a post for Malaymail.com entitled “Why Johor Dentists can expect even more Singapore patients than over before”. And another on Channel News Asia Facebook with a headline saying that “9 out of 10 Singaporeans are concerned about cost of dental care”. This is indeed a reversal of the trend 30 years ago when Europeans came to Singapore as dental tourists; they get their dental work done and have a holiday at the same time and pay a fraction of what they would have to pay if they had done the same work in their home country. Thirty years on, as a developed society, has Singapore Dentistry become like that of Europe?

In tandem with everything else, general costs have gone up. However, in some areas, cost has actually come down. In particular, the cost of dental implants has dropped significantly over the last twenty years, even without factoring in inflation.

The paradoxical fall in cost of dental implant treatment

Twenty years ago, there were only a handful of dental implant brands in Singapore. They were mainly the few top European and American brands. There were also not many dentists providing dental implant services. With limited competition and without economy of scale, dental implant treatment was expensive and only fairly affluent patients can afford it. Most patients have to make do with dentures with their attendant inconveniences and inefficiencies.

Today, the number of patients having dental implants to replace their missing teeth instead of dentures have increased significantly. This is because dental implants are a lot more affordable now. There are several factors that contributed to the falling prices.

Dental implant manufacturers

The number of dental implant manufacturers in the world have increased drastically over the years and many have set up operations in Singapore either directly or through distributors. Naturally, implant manufacturers cannot sell to consumers directly but rather they have to sell their products to dentists. However, only dentists who are trained to perform implant dentistry will buy their products. As such, implant vendors conduct training courses to train dentists to become competent in providing such treatment for their patients. This has drastically increased the number of dentists providing implant dentistry services.

Dentists providing implant dentistry

Historically, most dentists are trained by such vendor-organized courses or are specialists in oral and maxillofacial surgery and specialists in prosthodontics, whose specialty training includes the surgical and prosthodontics aspects of implant dentistry respectively. As demand for training from general dentists increased, universities began providing post graduate diplomas in dental implantology to cater to those who wants to be trained more comprehensively.

The interest in dental implantology became so pervasive that even the dental specialty of periodontology, whose mission is to save teeth that have gum disease, jumped onto the bandwagon and started to extract teeth and replace them with implants. Today, all specialist periodontology programs in the world focus a significant amount of their curriculum on dental implantology and periodontists, dentist specializing in periodontology, are among the most prolific users of dental implants.

Patients

Today’s patients are better informed than before and are looking for better solutions. Expectations of functional and aesthetic outcome of replacing missing teeth are high and patients’ awareness of implants is also prevalent. In the past, most patients seeking replacement for missing teeth were thinking of dentures. Today, many have turned to implants as the treatment of choice.

Financing

Affordability has also increased with the liberalization of the Medisave scheme. Twenty years ago, Medisave can only be used for payment of in-patient treatment in hospitals. As most dental implant treatments are done in outpatient clinics, access to Medisave funds was limited. Gradually, the Ministry of Health allowed Medisave funds to be used for outpatient surgeries and that opened up an additional source of funding for dental implant surgeries.

The confluence of these factors led to dental implant treatment being less costly and more affordable to a wider segment of the population. However, if one were to take a less granular view and compare the cost of replacing missing teeth today and twenty years ago, the difference would imply a huge increase in cost, which is largely that between a denture and an implant.

Comparing apples with oranges

Even comparing implant treatment cost today and that of twenty years ago is also challenging. Twenty years ago, both patient and dentist are happy if the implant integrates successfully with the bone and a functional crown can be attached to it for mastication. Today, patients expect the implant prosthesis to not just function well when eating but to be able to mimic a natural tooth in appearance as well. Aesthetics is a big part of dentistry and is something that today’s patients have come to expect. Aesthetics in implant dentistry involves creating a prosthesis that is difficult to differentiate from the natural dentition. This entails recreating the supporting structures around the implant such as the gum and underlying bone.

More challenging cases can be done now..

In the past, the indications for implants are limited. Only patients with sufficient bone to support an implant are candidates for implant treatment. Those without an adequate amount of residual jaw bone will have to settle for a denture or a bridge. Today, there is hardly a situation where implants cannot be done except in some medically compromised patients. Many surgical techniques have been developed and refined over the years to achieve consistently good results in cases which were previously deemed unsuitable for implants. Advances in biomaterials have also contributed greatly to rendering unsuitable cases suitable by improving the healing of surgical wounds.

What does the patient expect?

Let me illustrate with a recent patient who was referred to me for a second opinion. The patient is a middle-aged professional who had a cycling accident that resulted in the loss of three front teeth. He was referred to a dentist who removed the broken remnants of the teeth and replaced them immediately with three implants. The implants integrated successfully and the final prosthesis was fitted a few months later. At a routine check-up in another clinic, he was told that the work was not very good. After that, he became anxious and was eventually referred to me for a second opinion. At the point when he saw me, he had been functioning well with no pain or any symptom for about half a year. He did not like the prosthesis but accepted it as he did not know better. The treatment cost was very reasonable and that was also one of the reasons why he went ahead with the plan. He commented on how the prosthesis was not biting properly and was tilted to one side asymmetrically. He was also bothered by the lisping sound due to gaps in between the prosthesis and the gums and worried about infection.

After a thorough examination, I found nothing “wrong”. The implants were placed in the correct position, they integrated well and the prosthesis was functional, enabling him to eat without any problem. Twenty years ago, such a result would be considered an unequivocal success especially when compared with a removable denture. However, patients’ expectations are different today. The prosthesis though functionally successful, was an aesthetic failure. To be fair, the dentist did a decent job for the fee charged.

The whole nine yards..

To get an optimal result, a treatment will need to be done in several stages. First, the fractured bone needs to be rebuilt to the same level as the undamaged bone. This is followed a few months later by grafting gum tissue to restore the pink gum that is usually found around teeth instead of the red gum tissue that is often lying over the reconstructed bone. Then the implants can be placed a few months after that. When the implants have integrated with bone, a provisional prosthesis can be used to shape the gum through which the prosthetic teeth emerge. At this stage, the bite, the phonetics of speech, aesthetics can be adjusted to achieve the best aesthetic and functional outcome. When that is achieved, the final prosthesis can be made as a copy of the adjusted provisional. This is the workflow of how an optimum result can be achieved. Furthermore, such a plan is usually done by a team comprising an oral maxillofacial surgeon, a prosthodontist and a technician.

Is it expensive? Absolutely. And probably not every patient is willing to go through such an expensive and time-consuming process. However, there is no way of telling for sure which patient is willing and able to go through with an ideal plan and which one is not. Furthermore, explaining the various steps of such a plan requires a fair bit of time and understanding on the part of the patient as technical details can be quite complicated. As such, some dentist may simply offer the simplest treatment at the lowest cost that will restore function, only to find out after the treatment is completed that the patient expects more.

Medical Tourism

Overall, cost of everything in Singapore is more expensive compared with our neighboring countries simply because cost of living is higher. For the most basic work, it may not be worth the time and effort to travel to another country. However, it may indeed be feasible to get some intermediate level dentistry done in nearby countries. However, patients who do that should be aware of what kind of treatment are suitable for medical tourism and what are not. Some treatment requires more follow-up and multiple visits and the logistic cost needs to be factored in. For patients going for the high-end work, cost should be a secondary factor compared with having a dentist or team that he trusts and have rapport with. If that team happens to be overseas, then it is worthwhile making that trip despite the additional cost. Once, I had a patient who flew in from a neighbouring country for consultation. He made several trips, one trip for the initial consultation and taking of records, another visit to go through the treatment plan and as his plan included other specialties, he made another trip to consult the other specialists. However, after finalizing the plan and paying a couple of thousand dollars for the various consultations, he went back to his own country for treatment. This was not a bad thing to do as he got himself educated on what his diagnoses were and what treatment options were available and then he could compare with what he could get back home before making a decision.

Cost of having better trained dentists..

Finally, the news mentioned something about more mandatory training imposed on dentists by the authorities may contribute to even higher cost. My personal opinion is that it does not. A dentist who is better trained in a particular procedure will be able to do it in a more efficient way and in less time and using less resources which may actually translate into cost savings. Personally, my fee for placing a dental implant has not increased since 1995 despite rental having gone up 500% along with other expenses. This is because efficiencies gained through experience enable more work to be done within less time with better outcome. The caveat here is that any such mandatory training must be fit for purpose, that is does indeed bring about a quantum leap in ability and not just knowledge.

Loss of tongue sensation after wisdom tooth surgery

slchan@aestheticjawsurgery.com (S L Chan) — Mon, 09 Sep 2019 06:04:42 GMT

Recently, an article in The Straits Times featured a case of a chef suing a dentist for causing him to lose sensation of his tongue after a wisdom tooth surgery. Certainly, for a chef, such a complication can be a career-ending event. So, how does a wisdom tooth surgery lead to numbness of the tongue and what can be done about it.

Surgical removal of a wisdom tooth in the lower jaw is one of the most common oral surgical procedures. These teeth are usually impacted, meaning, they are aligned in the wrong direction and as a result, are unable to fully erupt into the mouth and are jammed against the neighbouring tooth. These impacted wisdom teeth commonly cause pain due to tooth decay and gum infection as they are difficult to clean.

Extraction of such teeth requires surgery, which involves

Injection of a local anaesthetic to block sensation of the jaw and teeth
making an incision on the gum around the tooth
peeling the gum off the bone to expose the tooth and bone
drilling away some bone that is holding on to the tooth
drilling the tooth into smaller parts for easier removal
sutures to stitch the gum back.

Two sensory nerves are potentially involved whenever wisdom teeth in the lower jaw is removed. One nerve enters the jaw bone from behind and runs internally within the bone until the region of the premolars where it exits the bone through a hole called the mental foramen, and enters the lip. This nerve, the inferior alveolar nerve, provides sensation to the lower jaw bone and associated teeth, and the lower lip and chin on the same side. Injury to this nerve causes loss of sensation to these structures. Because this nerve runs within the bone, it can be visualized on radiographs preoperatively and the dentist will be able to assess the risk level of associated with the surgery.

The other nerve is the lingual nerve. This nerve runs alongside the inner surface of the lower jaw. Studies have shown that the path of this nerve is highly variable. In many cases, it is very close to the lower wisdom tooth. The lingual nerve provides sensation to the tongue. Nerves providing taste as well as nerves controlling secretion of saliva joins the lingual nerve bundle as well. As such, the lingual nerve is a rather thick bundle. As it is not housed within bone, it cannot be visualized in radiographs and there is no way of preoperatively knowing the path of the nerve. Injury to this nerve affects not just the sensation of touch, but also the sensation of taste and secretory function of the minor salivary glands in the tongue.

How does the lingual nerve get injured?

Lingual nerve injuries may be caused by excessive stretching or compression, laceration and complete tearing. In stretch and compression injuries, the nerve is intact and there is usually a good chance of recovery. When the nerve is lacerated, this is a break in some of the fibers within the nerve that transmit sensation, resulting in a loss of some sensation, depending on which fibers are torn. When the nerve is completely severed, there will be a complete lost of all sensation. Most of compression or stretch injuries do not result in permanent or significant loss of sensation, but recovery generally takes place over several months. Laceration of the nerve comes in different degrees with varying levels of sensation loss with their corresponding chances of recovery. Severe cases may require surgical repair. Nerves that are completely severed needs surgical repair or maybe even nerve grafting to regain some sensation.

At every stage of the surgery, there is a chance of injury. Injection of the local anesthetic itself may cause injury to the nerve either by direct trauma from the needle or due to the toxicity of some local anesthetic drugs.

The lingual nerve may also be injured when making incisions on the gums. In a small minority of patients, the lingual nerve may actually lie just on top of the gum covering the crest of the bone where incisions are made. In such cases, the incision may actually sever the nerve resulting in complete numbness of the tongue. This is a rare occurrence but nonetheless exists. Up to 10% of lingual nerves may be found lying within the gum at the level of the bone, rendering it susceptible to injury during surgical removal of wisdom teeth.

After the incision is made, the gum needs to be stripped from the bone to expose the tooth. This act of stripping the gum may also cause stretch injuries to the nerve. Stretch injuries are usually temporary and spontaneous recovery is usually expected. Some dentists practice a technique that include stripping the gum on the tongue side of the wisdom tooth, in an attempt to prevent injury to the lingual nerve. However, it has been found that this procedure that was designed to prevent injury actually had been a cause of laceration injuries to the lingual nerve.

The next step involves the use of drills to remove bone and divide the tooth into small pieces. Any slippage of the drill beyond the tooth and bone may cause significant damage to the lingual nerve resulting in loss of sensation of the tongue. Finally, stitching gum together also pose a risk as the needle can be passed through or stretch the nerve.

Most of the time, injury to the nerve is unnoticed at the time of occurrence. This is because the nerve is embedded within soft tissue of gum, muscles and direct contact of any instrument is usually not visible. Furthermore, the patient would have been anesthetized for the surgery and would not be able to feel the trauma to the nerve intraoperatively. It is usually when the numbness persists beyond the expected duration that raises suspicion that the nerve may be injured. In the immediate postoperative period, there is usually some degree of swelling and pain which may also mask the effect of the nerve injury.

How often does this happen?

There are many epidemiologic studies reporting the loss of tongue sensation after wisdom teeth surgery. Reports indicated an incidence of temporary alteration of sensation ranging from 0% to 23% while that of permanent alteration of sensation ranges between 0% and 8%. These studies did not separate the wide variation in degrees of complexity of the impaction, the skill level of the dentist, the type of anesthesia used, age of patients, etc. As such, for someone considering whether to proceed with having the wisdom tooth removed, such a wide range in risk level is not particularly helpful.

What can be done when injury of the lingual nerve has happened?

As there is no actual visualization of the injury taking place, the first course of action is to document the degree and extent of the loss of sensation by testing with various instruments.

Mapping: the area of the tongue affected can be mapped by touching the tongue with a sharp pointed instrument and checking responses from the patient. The area of the tongue that is affected is then recorded either in a drawing or photograph. Lingual nerves do not cross over the midline and so the area affected is confined to the same side as the wisdom tooth surgery.

Two-point discrimination: this is a measurement of the ability of the tongue to discern between being touched with a single point or two points. The part where sensation is affected will require a greater distance between the two points before being able to differentiate it from a single point. This is compared with the uninjured side to assess the degree of injury sustained.

Temperature sense: heat and cold sensation are transmitted by different nerve fibers inside the lingual nerve. Separately testing temperature sense is needed to document if the injury extends to these fibers. This can be done easily with a heated instrument and some ice.

Pressure sensation: a calibrated force measurement device can be used to record the minimum pressure that needs to be exerted on the affected part of the tongue before it can be felt. The unaffected side is also measured for comparison.

Direction sense: a light brush is applied to the unaffected side in random directions and the rate of correct responses from the patient is recorded.

However, these measurements depend on the subjective feedback from the patient which may be variable. Objective measurements can be done in the form of testing nerve conduction through the use of electrodes to determine nerve function.

Recording the responses of the patient over time gives an indication of whether the sensation is improving or not. If there is a high degree of numbness with no discernible improvement after a few months, surgical repair may be considered.

Can surgery or medication help in regaining sensation?

Surgical repair of the lingual nerve can be beneficial in some cases. When there is complete loss of sensation for more than three months or a severe loss of sensation for more than four months, surgically repairing the nerve may help the patient regain some sensation. Surgical repair is also indicated when there is pain instead of numbness. In such a situation, there is likely to be a neuroma, akin to a nerve scar, which has formed when the injured nerve tried to grow back. Post-surgical repair, medication may be needed to manage any residual pain.

However, the outcome of nerve repair surgery is unpredictable and should only be done after weighing the risks against the potential benefits. It is advisable to wait a few months to observe for spontaneous recovery instead of performing early surgery.

What risk factors predispose to lingual nerve injury?

Studies have indicated that wisdom teeth that are impacted distoangularly are most prone to lead to lingual nerve injury. These are wisdom teeth are partially erupted pointing backwards towards the back of the jaw instead of pointing to the front. These teeth require a greater amount of bone removal at the back, close to where the lingual nerve usually lies. Careful physical examination and x-rays such as CT scans can provide the dentist with a clearer picture of the bone removal needed and the path of extraction of the tooth.

The patient’s age may also be a risk factor. Most wisdom tooth surgery patients are teenagers or young adults with relatively softer jaw bone. Surgery in an older patient whose bone has hardened will require greater force to be applied when stretching the gums as well as when removing the tooth. This may predispose to a higher incidence of lingual nerve injury.

The skill of the dentist is also a factor. Naturally, a dentist who has not performed a lot of such surgeries may pose a higher risk than one who has had a lot of experience. Specialists in oral and maxillofacial surgery have undergone additional years of supervised training in such procedures may be better able to avoid such injuries compare to dentists who are not oral and maxillofacial surgeons.

Surgical removal of wisdom teeth is one of the most common surgical procedures in dentistry. Like any other surgery, it has its potential risks and complications. Decision to undergo any surgery including wisdom tooth surgery, needs take into consideration the risk versus the benefits of the surgery. It is not possible to eliminate all risks and even in the best of hands, complications do arise.

Dental implants in an underbite patient

slchan@aestheticjawsurgery.com (S L Chan) — Sat, 20 Jul 2019 02:00:00 GMT

Rising affluence and awareness among patients in Singapore have led to an increase in demand for specialist procedures such as orthognathic surgery. Underbite deformity, where the lower jaw is disproportionately longer than the upper jaw is possibly the most corrected dentofacial deformity in Singapore today. However, not so a generation ago. Baby boomers, or in the Singapore context, the Merdeka Generation, often did not have the benefit of such services when they were young and many have uncorrected underbite. With advancing age and a lack of proper care in their younger days, total or partial loss of dentition is common. Many seek to replace their missing or decayed teeth with dental implants. In replacing teeth in a patient with an underbite, do we set the teeth in the original cross bite position or do we aim to reconstruct the dentition into an ideal Class I bite?

In my practice, such a situation warrants a thorough discussion. Most patients in such situations do not really know what the possibilities are, much less the pros and cons of various options. In our Asian culture, middle-age people are supposed to be not vain. In fact, vanity is often seen as a weakness. However, the reality is that most people, regardless of age, want to be good looking, whether they admit it or not is another matter. As such, treatment options need to include the whole range including orthognathic surgery to correct the underbite. The ideal treatment plan is one that takes into consideration the patient’s preference after understanding the risk-benefit ratio of each option.

Surgical correction of the underbite is relatively more invasive than dental implant surgery. It requires a general anesthetic and staying in the hospital for a day or two. The postoperative downtime is also longer and the potential for complication such as nerve injury is also higher. However, it offers a chance for the patient to have a more aesthetic facial appearance and the placement of implants in positions that enable the dental prosthesis to achieve optimal function and aesthetics. I will usually do an orthognathic surgical plan complete with simulation of post-operative facial changes to illustrate the effect of such a plan. As with conventional orthognathic surgery, perioperative orthodontic treatment is needed and that is yet another consideration that a patient will need to undertake as orthodontic treatment typically will take one to two years to complete.

In general middle-age patients take a longer time to recover from orthognathic surgery compared with teenagers and young adults. Those who have develop chronic illnesses like high blood pressure and diabetes may also have higher risks of complications with more invasive surgery. Within the milieu of a tertiary referral hospital, I have access to a full range of medical specialist to support the perioperative management of such patients. Nonetheless, while it is possible, it is not ideal.

For those who decide that the benefits do not justify the risks, an alternative plan of camouflaging the skeletal deformity can be formulated. The extent to which the skeletal discrepancy can be camouflaged with dental implants depends on the severity of the discrepancy and which teeth are missing. I will illustrate with a case.

This is a middle age lady seeking to replace her missing teeth with dental implants. She also had a mild underbite. The lower jaw is only mildly longer than the upper jaw.

However, over the years, she had developed a habit of posturing the lower jaw forward and that had resulted in the an underbite that appeared more severe than it really was. As with most skeletal jaw size discrepancies, the teeth compensated naturally. The lower teeth were tilted backwards towards the upper front teeth, in an attempt to maintain contact with the opposing teeth.

There were three options. We can start off with orthodontic decompensation to align the teeth within each jaw. Thereafter, the lower jaw can be surgically repositioned backwards to eliminate the underbite. This is then followed by dental implants to replace the missing teeth. However, the patient was not keen on orthognathic surgery.

Without surgery to correct the underbite, restoration with dental implants can either be conforming to the pre-existing occlusion whereby the jaw is postured forward into a deep underbite. Such a conformative plan is most expedient as it is simply filling up the missing teeth with dental implants that will not change the jaw relations. However, doing so means forgoing the opportunity to achieve an improved Class I occlusion, where the upper teeth overlaps the lower teeth slightly.

A compromise plan was eventually undertaken. Orthodontic treatment was done to open the bite, align the teeth and tilt the upper front teeth out and lower front teeth back to achieve a positive overbite and overjet. By raising the bite, more space is created for placement of implant supported crowns. This increase in vertical dimension also created better facial proportions. Originally, with the lower jaw postured forward, the bite was over-closed, shortening the height of the lower third of the face. Opening up the bite increases the vertical dimension of the lower third giving a more natural proportion. (Due to regulations in Singapore, after photos cannot be included.)

The whole treatment process took about three years to complete, with most of time taken up for orthodontic treatment. At the intial consultation, the patient only wanted to replace her missing teeth. However, with detailed discussion about what facial skeletal discrepancy she has and the options of treatment explained, she opted for one that is fairly complicated and prolonged as that was the plan that addressed her concerns.

Missing Teeth and Jaw Deformity in the older patient

slchan@aestheticjawsurgery.com (S L Chan) — Tue, 16 Jul 2019 01:30:00 GMT

Most dental implants patients are usually older adults who have lost some or all dentition over the course of many years. On the other hand, corrective jaw surgery patients tend to be younger, those in their late teens and twenties. However, there is a group of patients who have dentofacial deformities that require orthognathic surgery but somehow did not get around to doing it when they were younger but in their later years, require dental implants to replace their missing or failing dentition. For such patients, orthognathic surgery may be done in conjunction with dental implants to restore not just a functional dentition but an improvement of facial aesthetics as well.

In the Singapore context, the underbite, where the lower jaw is disproportionately longer than the upper jaw, is the least accepted dentofacial deformity and hence the most commonly corrected with surgery. Other deformities seem to be better tolerated. Deformities such as an overbite, where the lower jaw is significantly shorter that the upper jaw, and bimaxillary protrusion, where both the upper and lower jaws are disproportionately longer than the skull base, are often left uncorrected surgically.

When patients with such skeletal deformities age and lose teeth, a second opportunity to correct such deformity presents itself. I will illustrate what can be done in such cases using the following example.

A middle-aged lady with bimaxillary protrusion, short lower jaw, missing upper front teeth and missing lower molars and the remaining teeth with decay and gum disease. This lady would like to have her short lower jaw lengthened and a full mouth rehabilitation including replacement of missing teeth with dental implants.

What are the treatment options?

In a situation where both facial aesthetics and dental function are involved, I always plan the facial aesthetics first. Facial aesthetics takes priority because the dentition and occlusion can be restored aesthetically and functionally within an aesthetically proportioned face. However, a dentofacial deformity cannot be corrected without changing the pre-existing teeth alignment. If the teeth were restored first, any subsequent surgery to correct the dentofacial deformity will require a complete change of the dental restorations.

Looking at the facial proportions, the lower jaw is significantly deficient. The chin point is located close to the throat, giving the appearance of a non-existent chin. However, while the lower jaw is short, the teeth are protruding forward excessively. This excessive forward development of the lower front teeth causes the lips to be incompetent, i.e. unable to meet the upper lip passively without contracting the muscles around the lips.

The small lower jaw also poses a risk of obstructive sleep apnea, a sleep disorder whereby the airway is obstructed during sleep, causing prolonged periods where the body lacks oxygen.

The upper jaw has lost all the front teeth and the bone has receded. Otherwise, the front teeth will also be protruding. With the loss of the teeth and the shrinkage of the bone, the upper jaw proportion has “self-corrected”.

Looking inside the mouth, the teeth were found to be in bad shape. There is generalized gum disease and many teeth were decayed or infected. In the upper jaw, the back teeth are still present while the front teeth are missing. In the lower jaw, however, it is the opposite, the front teeth are present and the back teeth are missing.

This combination results in a poor masticatory function as there are no opposing teeth for proper biting of food. It has also resulted in “super-eruption” of the teeth due to a lack of contact against opposing teeth. The upper back teeth have migrated downwards towards the lower jaw and the lower front teeth have migrated upwards toward the upper jaw.

Overall, this patient has a small lower jaw which poses an aesthetic challenge as well as potential for obstructive sleep apnea. The teeth require extensive restorative work if they were to be saved. Bearing in mind the patient’s objective of improving her appearance and bite, several options are available.

First, an ambulatory sleep study can be done to screen for obstructive sleep apnea. Depending on the results of the study, options for treatment will be discussed. If the obstruction was found to be due to the small lower jaw, treatment of the OSA will coincide nicely with the overall facial aesthetic surgery as well as the restorative dentistry.

To improve facial aesthetic, the lower jaw will need to be lengthened. If surgery is done to lengthen the lower jaw alone, it will further exacerbate the protruding teeth. As such, any surgery to lengthen the base of the lower jaw will need to be accompanied by a surgery to set the front teeth backwards as a block followed by orthodontic alignment. However, in this particular case, the front teeth are not in a good state. Some are decayed, others have gum disease. As such, given the guarded long-term survival of the teeth, an alternative is to extract them and replace with dental implants instead of surgically repositioning them.

In addition to lengthening the lower jaw, the chin needs to be surgically repositioned into a more forward position. This additional procedure serves two purposes. Increasing the chin projection reduces the degree of lip incompetence and improves the aesthetic outcome. In addition, it also pulls the tongue muscles forward, further opening up the airway and hence reducing the risk of obstructive sleep apnea.

From the facial aesthetic perspective, the upper jaw does not need repositioning. However, as the back teeth has erupted excessively downwards, the back part of the upper jaw needs to be surgically repositioned upwards to re-establish a level set of teeth. Alternatively, the teeth can be extracted and replaced with dental implants.

Dental implants require sufficient bone mass for insertion. There is insufficient bone in the upper jaw for implants and as such, the bone needs to be augmented. This is done as a bone grafting procedure, whereby bone from the hip is harvested and transferred to the upper jaw. In parts of the jaw where there is sufficient bone for initial stable fixation of the implant, the implant and bone graft can be done simultaneously. Otherwise, the bone graft is allowed to consolidate and integrate with the recipient site for six months before the implants are placed.

While the treatment objective is clear, there are many different paths to achieving those objectives. Each option has its pros and cons. A complex case like this often requires several sessions of discussion to ensure a common understanding of what the goals are and what the limitations of each options are. An ideal plan is one that is suited to what the patient values. Restoring all the teeth and orthodontically aligning them in conjunction of with orthognathic surgery may be ideal for one patient but extracting all the teeth and replacing them with dental implants may be preferred by another. There are cost and time considerations which are unique to each individual.

Wisdom tooth surgery ; General Dentist or Specialist?

slchan@aestheticjawsurgery.com (S L Chan) — Thu, 30 May 2019 02:00:00 GMT

Continuing the story of debate on “Better Competency Development for Safe and Quality Dental Care”, this blog discusses the other oft-cited “higher risk” procedure, wisdom tooth surgery. So how complicated is wisdom tooth surgery? What kind of training do dentists need to perform this surgery properly.

Does NUS Dental Faculty teach undergraduates wisdom tooth surgery?

In the sole dental school in Singapore, wisdom tooth surgery has been part of the undergraduate curriculum for decades. Dental students go through a rigorous didactic program covering the etiology of impacted wisdom teeth, indications and contraindications for removal, surgical techniques, complications https://www.aestheticjawsurgery.com/blog/what-to-do-when-your-wisdom-tooth-is-touching-the-nerve-in-the-jaw and their management. They perform clerking of patients presenting with impacted wisdom teeth and present they findings and treatment plan to their supervisors. They also assist in at least four cases of wisdom tooth surgeries perform by instructors who are oral & maxillofacial surgeons and also participate in postoperative review of patients who had undergone such surgeries. In their final year, they are required to perform one or two cases of wisdom tooth surgery under supervision. There is one catch though. Despite a fairly rigorous educational process, the school does not require them to pass a competency test on wisdom tooth surgery. This is because performance of two wisdom tooth surgery cannot achieve competency. Requiring them to pass a competency test would probably need a schedule that requires at least ten cases before they can present for a competency test but that will take too much time and other aspects of the extremely packed curriculum will have to be sacrificed.

What about overseas dental schools?

Requirements for wisdom tooth surgery competency varies tremendously in different schools. Some schools only teach the didactic component with no clinical requirement. Their students may graduate without having done a single wisdom tooth surgery. Some schools may have enough time in their curriculum for ten or more wisdom tooth surgeries to be done by the undergraduates. In Singapore, a significant proportion of registered dentists are graduates of overseas dental schools and so the ability with regard to wisdom tooth surgery is correspondingly varied.

What is the current practice of wisdom tooth surgery in Singapore?

Most general dentists do perform wisdom tooth surgery. Although local graduates may only have done one or two cases in school, they have to serve a government bond of four years in various public health care establishments, such as polyclinics, school clinics, restructured hospitals and military clinics. Through their four years of rotation, many had the opportunities to perform wisdom tooth surgeries. Those who eventually leave for private practice often join established clinics where there are senior dentists to guide them. Of course, some do not like to perform such surgeries and choose to refer them to specialists instead.

Why the need for further training?

As with many surgical conditions, there are simple ones and there are complex ones. The simple ones are within the competency of most general dentists. While the complex ones are best managed by specialists in oral & maxillofacial surgery (OMS). Most impacted wisdom teeth are partially erupted and are located fairly superficially and above the gum. Some are deeply buried within the bone causing pain and resorption to the tooth in front and/or pressing on the nerve inside the jaw bone that provide sensation to the lips and jaw. Others may be located nearer to the lower border of the lower jaw due to cystic changes that pushed it down.

What is a specialist in oral & maxillofacial surgery?

Oral and maxillofacial refers to the mouth, jaws and face literally. A specialist in oral & maxillofacial surgery, aka oral and maxillofacial surgeon, manages diseases, deformities and any conditions in the mouth, jaws and face, usually by performing surgery. In Singapore, like other specialties, basic specialty training is conducted in the form of a residency of three years duration leading to a Master of Dental Surgery from the National University of Singapore. Like other specialties, an additional minimum of two years of practice to build a log book that fulfills a prescribed range and number of cases is needed before one can present for an exit examination. However, unlike other specialties, the cases prescribed in for the log book includes mostly in-patient type cases and surgeries that need to be done in a hospital operating room under general anesthesia. All hospitals, both private and public, have credentialing protocols. Private hospitals are not teaching hospitals and as such do not grant hospital privileges to non-specialists. This effectively limits the graduates of OMS residency programs to work in public teaching hospitals where credentialing can be done for specialist trainees under the supervision of a consultant.

As the scope of OMS is wide, logging the requisite numbers and variety often takes more than two years, depending on the case load of the hospital. In most cases, even after successfully completing the exit examinations and registered as a specialist with the Singapore Dental Council, additional years are spent in public hospitals to further develop surgical skills.

What is an oral & maxillofacial surgeon trained to do?

The scope of work ranges from removing impacted wisdom teeth and dental implants, to head and neck surgery. There is a lot of overlap with other surgical specialties such as ear nose and throat surgery as well as plastic surgery. With regard to wisdom tooth surgery, the broader scope of surgery that an OMS is trained to do enables a different perspective when it comes to minor oral surgery like wisdom tooth surgery.

Does a specialist in OMS better at doing wisdom tooth surgery than a general dentist?

Yes, almost invariably. The workload of an OMS resident consists of a huge volume of wisdom tooth surgeries on a daily basis. Furthermore, training in corrective surgery of jaw deformities, ablative surgery in jaw tumours and reconstructive jaw surgeries enable the OMS to perform wisdom tooth surgeries in many alternative ways to achieve a safe outcome. OMS specialists are also able to better manage the complications of wisdom tooth surgery such as numbness and infection.

Should I always see a specialist?

No, not always. There are many wisdom teeth that can be safely removed by a general dentist who has done a lot of such surgeries. The problem in Singapore is that we do not have a system of publicizing surgical success statistics. Patients seeking wisdom tooth surgery have no means of knowing whether the dentist they are consulting has undergone any additional training. Unlike dental implants, there are no diploma or a post graduate degree for wisdom tooth surgery that a general dentist can display on his name card or website. Good old fashion word of mouth is still the most reliable method of finding a general dentist for wisdom tooth surgery. Oral and maxillofacial surgeons as specialists can identify themselves as such on the internet or calling cards.

Do specialist charge more?

Like implants, treatment is as much a function of the skills of the dentist as well as the location and delivery of the service. It is likely that a specialist will charge more for a wisdom tooth surgery. However, there is a certain benchmark in Singapore which is set by the Medisave withdrawal limit. Most dentists, be it specialist or general, tend to charge at the withdrawal limit or slightly above.

For a large number of impacted wisdom teeth, the difference in final outcome may not be very different whether they are done by a specialist or general dentist. It is important for a general dentist to recognize the complicated ones and refer them for specialist management to maximize the chances of a good outcome for the patient.

Implant Dentistry; General Dentist or Specialist?

slchan@aestheticjawsurgery.com (S L Chan) — Wed, 29 May 2019 12:07:13 GMT

There has been much debate in recent weeks within the dental profession about the competency of dentists to do certain procedures. The issue has attracted a lively debate amongst various dental organizations. The Ministry of Health and the Singapore Dental Council has begun seeking feedback on “Better competency development for safe and quality dental care for patients”. Two of the oft-cited procedures that were considered to be of higher risk and may need additional training and certification are implant dentistry and wisdom tooth surgery. While this debate is on-going who should patients requiring such service go to? We will address the issue of implant dentistry first.

Implant dentistry

Today, it is well accepted that the treatment of choice for replacement of a missing tooth in a healthy patient with good jaw bone structure is a dental implant. Dental implantology as practiced today has gone through more than fifty years of development. Research has consistently showed a success rate of about 95-98% over the long term. However, it is not one of the core competencies taught in most dental schools around the world. Most dental schools will teach the theoretical aspects of implant dentistry and a few may teach the restorative part but not the surgical part.

So how do dentists learn implant dentistry?

There are two stages of dental implant treatment. The first stage involves surgically inserting the implant, which is a titanium screw, into the jaw bone. The implant is usually left to integrate with the jaw bone for about two months. Thereafter, the second stage involves fabricating a crown over the implant.

The specialist route

The surgical stage is within the curriculum of the specialist training programs of oral & maxillofacial surgery as well as that of periodontology. The restorative part is covered under the specialist training program of prosthodontics. Specialist training programs are usually full-time three-year residencies. Within the milieu of a residency, there are rigorous didactic programs as well as supervised clinical training culminating in an examination with an external examiner. Graduates of such programs are usually awarded a Master of Dental Surgery (MDS) degree as certification of completion of specialist training.

However, that alone does not qualify one to be a specialist. To be registered as a specialist with the Singapore Dental Council, a minimum of two additional years of practice experience is needed, during which a candidate must log a prescribed range and number of cases with complete documentation and present for an exit examination. It is only upon passing this exit examination that one can register as a specialist with the Singapore Dental Council. At this point, he can be admitted as a Fellow of the Academy of Medicine (FAMS).

The minimum time that one needs from graduation from dental school to registration as a specialist is about 7-8 years. In most cases, it is much longer as application to specialist programs is competitive and some may have to apply for a few years before gaining admission. After completion of residency, curating cases for the log book to present for the exit examination may also take more than two years, depending on the case load in the hospital or clinic. Realistically, it usually takes about ten years after dental school.

Does it take that long to learn implant dentistry?

No, the specialist training programs involve other areas. Implant dentistry is only one component within respective programs. The other areas of training while not directly related to implant dentistry provides the breadth of knowledge and experience in identifying potential problems and managing complications.

How does a general dentist learn implant dentistry?

Way before the specialist training programs, implant dentistry in Singapore was pioneered by general dentists. 30 years ago, the sole lecture on implant dentistry in the undergraduate curriculum in our local dental school was given by a general dentist. The academics and specialists had not embraced the concept of dental implantology then. There were no formal training programs in Singapore and most of the dentists who were doing implants learn it by attending courses overseas. Various dental organizations also invited foreign experts to come to Singapore to conduct courses. Such courses obviously need the special armamentarium and implants for participants to practice on and so implant manufacturers or vendors are usually involved. This brought an element of commercialization of dental implant training that still persists today.

Today, there are four main routes to learning implant dentistry for general dentists. The commonest way is to attendshort coursesranging from a weekend to six weekends. These courses are usually conducted by implant manufacturers and vendors in conjunction with a local key opinion leader. Each course typically involves a series of lectures, some practice on dental models, observing a live surgery done by the course instructor and some may include a couple of cases to be done by the participants under the supervision of the course instructor. Lessons are usually conducted over the weekend so as not to interrupt the dentists’ daily work schedule. This is probably the most common path taken by a general dentist to attain proficiency in implant dentistry.

The second way is to enroll in a universitydistance learning course. There are quite a number of such courses conducted by universities and colleges from the United Kingdom, Australia, Europe and America. Such courses are usually more rigorous academically as completion usually lead to a either a diploma or master’s degree from the respective universities. However, supervision of the clinical training is often the challenging part for a distance learning course. A clinical course involving actually performing a procedure on a real patient cannot be effectively or safely conducted over the internet. Some programs engage external non-university local experts to provide the clinical supervision needed. In addition, some programs have a short residential portion where the participating dentists have to travel to the university for a one to two-week attachment. These programs are expensive and time intensive and the degrees and diplomas that they award are usually not recognized by the Singapore Dental Council due to their distance-learning nature. As such, few dentists in Singapore are interested in this route.

The third way is to do a part-time residential courseconducted by a recognized university. These courses are part-time but all teaching and practice components of the courses are conducted within the university’s dental school premises. Think of it was an executive MBA. As there is only one dental school in Singapore, there is only one such program available locally. This is a two-year part time course that has a rigorous didactic program and it also requires the course participants to treat a minimum number of implant patients in the university dental clinic under direct supervision. There are examinations every year and candidates who completed the program successfully will be awarded with a diploma that is recognized by the Singapore Dental Council. As expected, such a course is not only expensive in tuition, it is also costly in terms of opportunity cost as it requires a significant amount of time to be spent away from the dentists’ private clinics. The National University of Singapore has capacity to take six students a year for this course which started in 2007.

The fourth and most rigorous route is to do a full-time Master’s degreein implant dentistry. This is only available overseas and may take about 1-2 years. It is rare for a Singapore dentist to pursue such a course as the opportunity cost is the greatest.

Is a specialist always better than a general dentist?

Not necessarily. There are good general dentists and there are no-so-good specialists. Some general dentists dedicate the bulk of their time to implant dentistry for many years and some specialists may be busy with other aspects of their specialty and only spend a fraction of their time in implants. Training provides a good starting point, but a high level of skill takes many extra years to hone. Furthermore, with advances in technology, things that are learned years ago become obsolete and continuing education is critical. All factors being equal, a specialist may do a better job but then these factors are never equal.

So how do I choose?

The lazy way is to just choose a specialist because he would have definitely gone through formal training. But do bear in mind that if you go that route, you need two, not one specialist. This is because the specialists by definition, do not do both stages of the implant treatment. You will have one specialist, either an oral & maxillofacial surgeon or periodontist (i.e. gum specialist) doing the surgical insertion of the implant and the prosthodontist to do the second stage of placing a prosthetic tooth on the implant. (the question of what is the difference between the oral & maxillofacial surgeon and the periodontist will be addressed another time). Having two specialists also ensure a check and balance whereby one specialist checks on the work of the other critically. A team that works together over many years will spur each other to greater heights. Sometimes, the two specialists may be in the same clinic, but they may also be located at different premises.

Another way is to go to a general dentist who has a recognized qualification related to implant dentistry. That will also ensure that he has undergone some formal training. The advantage of going to a general dentist is that he can do both stages of the treatment and can also provide a more holistic service if other treatment is needed. If you already have a general dentist and he does not do implants, ask him for a referral. Ask the dentist if they themselves need an implant, who would they go to. That will be quite a good choice. Reputation is harder to earn than a qualification. Some dentists, be it specialist or general, have built up a reputation over many years of doing excellent work and that is more valuable than any qualification.

Are specialists more expensive than general dentists?

Probably, but not definitely. Do bear in mind that when you seek specialist treatment for implant dentistry, you are seeing two specialists. However, the economics of healthcare services is not solely determined by the doctor or dentist. There are other obligatory costs such as rental of the clinic premises, staff salaries, equipment used, consumable materials needed, etc. A general dentist practicing in an upmarket Orchard Road practice using premium material and highly trained assistants and master technicians will cost more than a specialist team working in a less posh clinic in the suburbs using non-premium brands and a local laboratory.

Are there times that specialist care is definitely needed?

Yes. There are definitely situations where the expertise of a specialist team is needed to deliver optimal results. While a diligent general dentist can avail himself to the same literature and know the state of the art techniques, without the practical experience and exposure within the milieu of a formal residency, he may not be in a position to exercise judgment of the suitability of a certain treatment plan for a particular patient.

A dentist can only diagnose and treatment plan based on what he knows and has experience in. Fortunately, the majority of cases are simple. And for simple cases, the difference in outcome that can be achieve between a specialist and a general dentist is insignificant. The obviously complex cases are also not a problem as most general dentists will spot them and refer accordingly. However, some complex cases can appear deceptively easy. This does not mean that the specialist does not make mistake and does not have failures or complications. It is only human to err. It is just that the chances of success and the ability to salvage complications is likely to be higher.

Navigating through the dental specialties is not easy. Even our medical colleagues are none the wiser, what more the general public. Certainly, more education is needed, not just of dentists but the public as well.

Functional indications for corrective jaw surgery

slchan@aestheticjawsurgery.com (S L Chan) — Mon, 06 Aug 2018 05:15:27 GMT

Corrective jaw surgery is often perceived as cosmetic surgery. Indeed, the cosmetic enhancement is probably the most obvious outcome of the surgery. However, it is primarily a functional correction of a discrepancy in the bite disharmony caused by disproportionate growth of the jaws.

How does a disproportionate growth of the jaw affect function?

Inability to chew food properly.

The human jaws is designed or evolved, to have the upper jaw slightly in front of the lower jaw such that the upper teeth overlaps the lower teeth slightly. This is to ensure maximum inter-digitation of the teeth for efficient chewing of food. Each group of teeth has its own unique function. The incisors and canines cut food off into bite sizes and then premolars and molars mash it up before swallowing. If the teeth are occluding onto each other properly, biting efficiency will be compromised. Mastication will take longer and the food bolus in the mouth will be swallowed without completely being mashed up.

Inability to pronounce certain words properly

Speech is a complex coordination of muscle movement to create intelligible sounds. While muscular development is not directly involved in jaw deformities, abnormal jaw dimensions affects the function of the muscles. For example, having an open bite makes it difficult for the lips to achieve a proper seal which is needed in the pronunciation of certain words. However, since most patients who seek corrective jaw surgery are already in their teens or adulthood, the speech pattern would have been established and speech therapy may be needed in addition to corrective jaw surgery to achieve proper diction.

Temporomandibular joint disorder

The jaw joint is a joint unlike any others in the body. In the initial stages of mouth opening, the joint functions like a hinge joint, rotating around an axis the joins the left and right joints. This rotating movement only works for the initial opening of the mouth up to about 20mm. At the same time, it is also a ball and socket joint, allowing the jaw to move side to side while opening and closing. For wider opening of the mouth, the condyle slides forward, effectively dislocating the condyle (i.e. the “ball”) out of the fossa (“the socket”). This can be done with a side to side movement at the same time. All these movements are facilitated by a disc of soft tissue in the joint that allows the condyle to glide and rotate smoothly. The joint is also able to withstand a lot of force as evident from the biting force that can be generated. Given the complexity of the jaw movement, a jaw deformity will exert uneven and abnormal forces on the joint which may result in dysfunction. For example, in cases where the lower jaw is disproportionately short, excessive forward translation of the condyle is needed to achieve contact between the incisors. This causes repeated and excessive stretching of the disc and may cause it to be displaced. A displaced disc can cause clicking of the joint, pain and limitation of movement.

Obstructive sleep apnea

Sleep is an essential for normal physiological functioning of the body. It is a time of rest of the body to regenerate. However, sleep can be disturbed when the breathing is obstructed. This happens when the relaxed muscles in the tongue and soft palate collapse and fall back and block the airway thereby preventing air from entering the windpipe and lungs. This reduced air intake forces the heart to pump harder and faster to send enough oxygen to the body. The reduced oxygen concentration in the blood coupled with the excessive effort by the heart during sleep may lead to long term health issues such as hypertension and heart failure. The jaws form the skeletal framework upon which the tongue and muscles around the throat attach. If the jaws are underdeveloped, there will be excess muscular soft tissue present around the throat thereby narrowing the airway. This problem is made worse during sleep when the muscles are relaxed and results in further narrowing or even complete blockage of the airway. Corrective jaw surgery can correct this problem by repositioning the jaws into a more forward position which will then bring the muscles away from the airway and at the same time increase the tone of the muscles.

Premature wear of the teeth and gums

In many case of dentofacial deformities, the upper and lower teeth often do not meet completely. This results in some teeth bearing the brunt of the load of chewing while some teeth are unde-utilized. This often happens in open and underbite situations where the front teeth are not functional, leaving the molars to do all the work.

Drooling

When there is disproportionate growth of the jaw, the accompanying soft tissue such as the lips do not follow the same pattern of growth. This mismatch of soft tissue development with the bone growth may result in difficulty in closing the lips. This may result in drooling of saliva when speaking or at rest. While most patients habitually contracts the lip muscles to maintain closure, some drooling may happen inadvertently.

Teeth biting on opposing gum

In overbite situations where the lower jaw is underdeveloped, the lower incisors may be biting on the gums on the back of the upper incisors, effective stripping the teeth of the supporting bone and gum. Correcting the position of the jaws with surgery brings the teeth into proper occlusion.

Cheek or tongue biting

Proper interdigitation of the upper teeth with the lower teeth is needed not just for proper chewing of food but is also important for avoidance of cheek or lip biting. Properly aligned teeth have a slight overlap to avoid getting the cheek or lip caught during the chewing process. Disproportionate jaw development results in either excessive overlap of the upper or lower teeth causing the lip to be trapped. Conversely, the teeth may be meeting on in an edge to edge position without any overlap and that will predispose to cheek biting. A combination of surgical correction of the jaw and orthodontic alignment is needed to solve this problem.

Corrective jaw surgery is primarily a functional treatment with enhancement of facial aesthetics as an additional benefit. Dentofacial deformities causes both functional as well as aesthetic challenges. Orthognathic surgery corrects both function and aesthetics.