Wisdom Teeth
Wisdom teeth or 'third molars' are the last adult teeth to erupt into the mouth, one develops in each corner of your mouth, there are four in total.
Our jaws grow to adult size by our late teens. Unfortunately, this size is often too small to hold the developing wisdom teeth. Nowadays, our jaws are smaller than those of early humans who needed large jaws and more teeth for their tougher diet.
When there is not enough room for your wisdom teeth, they may become impacted, or partially trapped in the jawbone and gums. The crown, or top of the tooth, may erupt, or partially break through the gum, or it may remain completely buried within the bone.
The only effective treatment for impacted wisdom teeth is to have the offending teeth removed as they are inaccessible to brushing and flossing.
It is best to have troublesome wisdom teeth removed while you are young. In young people, a tooth’s roots have not formed totally and the bone surrounding the tooth is softer. This allows for easier removal of the tooth, and there is less risk of damage to nerves, bone or other teeth.
What are the most common reasons for removing wisdom teeth?
1. Gum infection.
When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection called a pericoronitis, this is by far the most common problem associated with lower wisdom teeth. This may result in pain, swelling, bad taste and bad breath and the inability to open your mouth fully. The infection can spread to involve the cheek and neck. This infections tends to recur with each subsequent attack becoming more frequent and severe than the last. This is a painful and occasionally serious infection. Treatment often involves use of antibiotics. It is preferable to remove such teeth before they become infected, as there are fewer complications with healing and less damage to adjacent teeth.
2. Tooth decay.
When the wisdom tooth is impacted, bacteria and food particles can collect around an impacted wisdom tooth, causing it, or the tooth next to it to decay. It is very difficult to remove such decay until the offending wisdom tooth is removed.
3. Pressure pain or root resorption.
Pain may also come from the pressure of the erupting wisdom tooth against other teeth. Pressure from a wisdom tooth pushing on the second molar tooth in front, will occasionally cause the root of the second molar tooth to be resorbed, with subsequent damage to, or loss of, the second molar tooth.
4. Orthodontic reasons.
Many orthodontists believe that pressure from the developing wisdom teeth can cause the front teeth to become overcrowded, and removal of wisdom teeth is often recommended before or immediately after orthodontic treatment is completed.
5. Prosthetic reasons.
Patients who are to have dentures constructed should have any wisdom tooth removed. If a wisdom tooth erupts beneath a denture it will cause severe irritation and a new denture may need to be constructed as the shape of the gum will have changed.
6. Cyst formation.
A cyst (fluid filled sac) can develop from the soft tissue around an impacted wisdom tooth. Cysts cause bone destruction, jaw expansion and displacement or damage to nearby teeth. The removal of the tooth and cyst is necessary to prevent further bone loss. Tumors are a rare complication of these cysts or the jaw may fracture spontaneously if the cyst grows very large.
First consultation.
This is often an emergency procedure where we will provide pain relief, prescribe antibiotics and arrange for the appropriate radiographs.
Consultation with Radiographs.
An OPG or panoramic X-Ray is very important to have available during the consultation for wisdom teeth removal. This X-ray not only shows all the patients teeth but also shows the closely related anatomical structures, nerves, sinuses, blood vessels, etc. With this X-Ray the surgeon is able to evaluate all four wisdom teeth and all the related anatomy with one film. This same X-Ray can also be used for an overall examination of all the other teeth in your jaws.
We will assess level of surgical difficulty, tooth impaction and the your anxiety levels in making a recommendation for treatment. We will discuss with you the risks and benefits of treatment and prepare a fully itemised quotation.
Recommendations for treatment.
Do nothing - if we feel the wisdom teeth are on track and further jaw growth may accommodate them or allow for an easier removal at a later time.
Remove under local anesthetic - you will be awake but numb.
Remove under local anesthetic with sedation - a premedication with diazepam and/or we may use nitrous oxide or laughing gas (link) in the dental chair.
Remove under general anesthetic - If we feel you would be best to be asleep for the procedure we may refer you to a specialist oral surgeon to have the surgery done in hospital.
The decision to have wisdom teeth removal is always your decision. If you have any questions regarding the proposed treatment please ask.
Removal
The wisdom teeth removal commonly involves an incision to open the gum, and sometimes a portion of the bone may need to be removed to provide access to the wisdom tooth. The wisdom tooth may also need to be divided into segments so it can be removed safely and easily.
Sutures are placed at the time of surgery and will dissolve after about five days.
Healing and Complications
What to expect - pain, swelling, bruising with a little skin discolouration, limited jaw opening and numbness. The healing process begins immediately after surgery as your body sends blood to nourish the tooth socket. Simple pressure from a piece of gauze is usually all that is needed to control the bleeding and to help a blood clot to form within the socket, which promotes healing. Within a day or two, soft tissue begins to fill in the socket, aided by the blood clot. Eventually, the bone surrounding the socket begins to remodel, filling in the socket completely.
In up to 10% of patients, the condition of “dry socket” may occur following wisdom tooth removal. This happens when part of the blood clot lining the tooth socket is lost, usually after about three days it is very painful and associated with a bad taste. Treatment is simple, consisting of gently washing out of the socket and placing a sedative dressing which quickly relieves the pain. Smoking is the most common factor associated with dry socket.
Post-operative infection is uncommon and treated with antibiotics when it occurs.
Occasionally a nerve may be bruised or otherwise damaged when the wisdom tooth roots are removed, resulting in temporary numbness of the lip and chin, which may last for 3 - 9 months.
It is usually, although not always, possible to determine from the pre-operative x-rays, whether such nerve injury is likely. Permanent nerve damage is also possible but extremely rare.
Post operative care
Below are some tips to assist you after your appointment.
1. Control of bleeding.
A pack made of folded sterile gauze pads will be placed over the socket. It is important that this pack stay in place to control bleeding and to encourage clot formation. The gauze is usually kept in place for 30 minutes. If the bleeding has not stopped once the original pack is removed, place a new gauze pad over the extraction site.
2. Do not disturb the wound.
Disturbing the wound may invite irritation, infection and bleeding.
3. Do not smoke or drink alcohol for 24 hours.
Tobacco and alcohol will promote bleeding and delay healing.
4. Control of swelling.
After surgery, some swelling is to be expected. This can be controlled through the use of cold packs which slow the circulation. A cold pack is usually placed at the site of swelling during the first 24 hours in a cycle of 20 minutes on and 20 minutes off. After the first 24 hours, it is advisable to rinse with warm salt water every two hours to promote healing (one teaspoon of salt to a glass of warm water). Avoid rinsing your mouth out during the first 24 hours as this disturbs the blood clots that are part of the healing process.
5. Medication for pain control.
Anti-inflammatory medication such as paracetamol or ibuprofen may be used to control minor discomfort following oral surgery. Stronger analgesics may be prescribed if necessary.
6. Diet and nutrition.
A soft diet is recommended for a few days following surgery. You can gradually return to a normal diet once any jaw stiffness has settled. Very hot drinks and spicy food can increase pain and bleeding and should be avoided until the gum has healed.
Wisdom Tooth FAQs
Why remove an impacted wisdom tooth if it hasn’t caused any trouble?
Impacted wisdom teeth are almost certain to cause problems if left in place. This is particularly true of the lower wisdom teeth. Such problems may occur suddenly and often at the most inconvenient times.
When is the best time to have my wisdom teeth removed?
It is generally recommended that impacted wisdom teeth be removed between the ages of 14 and 22 years whether they are causing problems or not. Surgery is technically easier and patients recover much more quickly when they are younger. What is a relatively minor operation at 20 can become quite difficult in patients over 40. Also the risk of complications increases with age and the healing process is slower.
Travel and wisdom teeth?
It may be advisable to have them removed before traveling if you are going to an area where specialist dental services and antibiotics are not readily available. It may be best to tie up loose ends before you leave.
Should a wisdom tooth be removed when an acute infection is present?
Generally, no. Surgery in the presence of infection can cause infection to spread and become more serious. Firstly, the infection must be controlled by local oral hygiene, antibiotics and sometimes the extraction of the opposing wisdom tooth. Antibiotics are a short term solution for impacted wisdom teeth but they do allow us some 'breathing space' to allow thorough planning to take place.
What type of impactions are there?
Impacted wisdom teeth fall into several categories. Mesioangular impaction is the most common and means the wisdom tooth is angled forward, towards the front of the mouth. Vertical impaction means the tooth is angled backwards, towards the rear of the mouth. Horizontal impaction means fully 90 degrees forward. Most of the time wisdom teeth with distoangulation are the easiest to extract in the maxilla and the most difficult in the mandibule. The wisdom teeth with mesioangulation are easier to remove in the mandibal and more difficult in the maxilla.
