Third molars, most commonly known as wisdom teeth, are the last molars to develop in the dental arches and are located in the back part of the mouth. Most people will begin to feel these teeth in their mid-teens to early twenties. As these teeth are the last to mature and a persons upper and lower jaws have ceased to grow, the wisdom teeth frequently will have inadequate space to erupt into a normal functional and hygienic position. These teeth are considered to be impacted and can cause a number of problems, most frequently, pain, swelling and infections.
Frequently Asked Questions about Wisdom Tooth Removal
This presentation has been designed to answer your many questions regarding Wisdom Tooth Removal.
Click the picture to begin an interactive educational presentation.
Having trouble viewing the presentation? Please make sure you have Flash 5 browser plugin installed.
Impacted teeth are any teeth that are unable to erupt into a normal position within the dental arches. Many teeth can be impacted but, by far, the third molar teeth are the most commonly impacted teeth seen in a dental practice. Not all impacted wisdom teeth are the same. The following is a common classification of impacted teeth.
Soft Tissue Impactions: These impacted teeth lack adequate space to break through the gum tissue to allow for normal cleaning.
Partial Bony Impactions: These impacted teeth not only have soft tissue covering the tooth but some amount of surrounding bone still in place over the tooth. These teeth are typically removed by sectioning the tooth (cutting it into pieces) and/or removal of bone that may be over the tooth surface.
Full Bony Impactions: These impacted teeth are often not seen in the mouth but only on a radiograph (x-ray) although it is possible to have symptoms (i.e. pain or swelling) associated with these teeth. These teeth remain within the bone of the jaw and typically require both the removal of overlying bone and sectioning (cutting the tooth in pieces) of the tooth for removal.
Difficult Bony Impactions: These impacted teeth may be in an unusual position within bone, have unusually well developed roots, or even roots that have unusual shape or morphology (for instance, the root that looks like a “fish hook”.) More commonly seen in patients age 25 and older, these teeth require a more extensive surgical procedure.
Why should patients have wisdom teeth removed by Dr. Brown and Dr. Marshall?
The average age for eruption of wisdom teeth is typically around age 18-20 although the age can vary from age 15 to even age 25. If these teeth are unable to erupt into normal position, a number of problems can arise.
Infection: As impacted teeth are not cleansible, infection of the surrounding tissues can lead to swelling, redness, and pain around the tooth. Infections can vary from mild to severe sometimes causing swelling visible on the side of the face. These infections may also cause difficulty with chewing and swallowing.
Damage to Adjacent Teeth and Bone: Impacted wisdom teeth are often in close proximity to the adjacent second molar and can lead to premature bone loss on the distal (back) root of the second molar as well as decay on that root that is often not restorable. This can lead to the premature loss of the second molar as well as the surrounding bone (periodontal disease) prematurely and unnecessarily. Early removal of the impacted tooth (teeth) increases the likelihood of normal bony regeneration on the second molar root and eliminates the risk of caries (decay) associated with the impacted tooth.
Pathology: The majority of cysts and benign tumors that we see occur around impacted teeth including wisdom teeth. When teeth remain impacted, the associated follicle sac (tooth bud) tissue from which the tooth develops is also retained. The follicle can begin to enlarge and become filled with fluid. As the sac enlarges it begins to behave as a cyst, typically slowly expanding and causing bone destruction and occasionally damage to adjacent teeth or movement and mobility of adjacent teeth. Odontogenic (meaning “tooth related”) tumors can also arise from the follicle around the impacted tooth (teeth.) Although tumors are relatively uncommon and typically benign (not cancerous,) they can, at times, be very aggressive causing extensive bone destruction and premature loss of otherwise healthy teeth. Any impacted tooth with any indication of a surrounding cyst or tumor must be removed.
Unexplained Pain: Many patients often present with unexplained pain in the retromolar region of the jaws (back part of your jaw.) Although similar symptoms can arise with myofacial pain (muscle pain often associated with teeth clenching and grinding) and/or temporomandibular joint disorders (often called “TMJ”,) it is our experience that an impacted tooth can also cause this pain. Often, removal of the impacted tooth will resolve the pain.
Orthodontic Treatment: The presence of impacted third molars may interfere with the proper positioning of the other permanent molar teeth. These third molars should be removed to facilitate your orthodontic treatment.
Dental Crowding: Although a controversial issue, many practitioners feel that the development of the wisdom teeth (especially lower jaw wisdom teeth) can contribute to crowding of the erupted teeth, most commonly the lower jaw front teeth. Orthodontists often refer patients for removal of impacted third molars after orthodontic treatment is complete. Our belief is that impacted wisdom are probably contributory to the development of crowding but are likely not the sole cause and caution patients to continue wearing any orthodontic retainers after removal of the wisdom teeth. Given the many other problems that impacted teeth can cause, we believe it is prudent for patients with a healthy dentition to have the wisdom teeth removed early to minimize the risk of crowding as well as all of the other problems that can occur.
Should Patients “wait and see”?
Many patients in the past were told to not worry about their impacted wisdom teeth as long as they were not causing problems for the patient. This approach can lead to the necessary removal of the teeth when the patient is past the age of 30. These teeth are almost always more difficult to remove with a higher complication rate and prolonged healing. Complications that do occur are typically more difficult to treat as well.
In fact, in our office, once the patient has reached the age of 35 or greater, removal of impacted teeth may not be advised unless they exhibit a localized problem either on physical exam or on radiograph (i.e. caries, swelling, pain, loss of periodontal bone support, cysts, tumors, etc.,). In some cases, the potential risks of removal of the impacted tooth (teeth) may outweigh the benefits and the procedure should possibly be deferred.
Only a thorough examination and discussion with the oral surgeon may allow you to make a good decision about possible treatment of these teeth.
Potential Risks and Complications:
All surgical procedures entail risk to surrounding structures and possible complications after surgery. Although the incidence of these risks and complications is low, it is important that patients are aware of these. The following is a description of the most common complications:
Inferior Alveolar Nerve Trauma: The removal of impacted mandibular (lower jaw) wisdom teeth can lead to trauma of this nerve. This nerve provides sensation to your lower jaw and your lip and chin on the operated side. Frequently, advanced root development can lead to the roots lying in close proximity to this nerve. In some very rare cases, the roots can develop around the nerve itself. It is our impression that patients over the age of 25 are most likely to experience trauma to the nerve although it can occur at any age. Patients less than age 20 are least likely to experience trauma to the nerve as their impacted tooth roots are typically less well developed and thus do not lie in close proximity to the nerve. If the nerve is traumatized, patients may experience a tingling or “numb” sensation of the lower lip and chin area. The sensation of numbness is typically partial in nature (“like Novocain wearing off”) and does not cause any deformity in appearance of the lip. It will typically begin recovering within two weeks after surgery and gradually resolve over a 6-8 week period. Older patients (especially over age 35) may have small areas of persistent decreased sensation of the lip and chin area that can last up to six months but this is rare. Even more rarely, permanent decreased sensation can occur but is most often seen in the older age group or the very difficult impacted teeth.
Lingual Nerve Trauma: The lingual nerve supplies sensation to the side of your tongue. This nerve can also be traumatized during wisdom tooth surgery although it is very rare. In those rare cases though, patients will experience a decreased sensation in the side of the tongue that can alter the taste sensation and cause a “metallic” taste. This is usually temporary and will begin to resolve within 2 weeks but may require 6 – 8 weeks to fully recover. Many “numb” tongue patients we see in our practice are not patients that we have performed treatment on, but instead, have had routine dental restorative procedures. The trauma to the nerve in this case is likely the inadvertent trauma caused by local anesthetic (i.e. Novocain) injection. These can occur during oral surgery as well but seems to recover in the same fashion as described above.
Maxillary Sinus Trauma: Upper wisdom teeth are often closely associated with the posterior wall of the maxillary sinus. Although complications are rare and typically not serious, the following can occur:
-During surgery, the sinus floor and associated membrane can be perforated and cause a small amount of blood to collect in the sinus that will “drain” from the patients nose or pass into the back of the mouth. Neither is serious and poses no threat to the patient. If either occurs, simply wipe it from your nose or gargle warm water in your throat to clear the blood.
-Rarely, a sinus perforation will not heal and a fistula develops that represents a communication between your mouth and sinus cavity. An open fistula can lead to fluid and debris getting into your sinus through the opening and draining from your nose. If we feel you are risk of developing a fistula after your surgery, we will make every effort to repair the area at the time of surgery. After surgery, we ask you to not “blow” your nose and if it is necessary to sneeze, you should sneeze with your mouth open but covered to prevent excessive pressure from developing within the sinus. If a fistula does develop after surgery in spite of our efforts, please be aware that most fistulas resolve spontaneously but please call our office for instructions. Rarely is a second surgery necessary to close the fistula.
Alveolitis or “Dry Socket”: By far the most common problem patients may experience after wisdom tooth removal, dry sockets are painful sockets that can develop primarily in the lower jaw 3-5 days after surgery. Although the incidence is low, dry sockets are most commonly associated with difficult extractions and patients that smoke. Please see the “Surgical Instructions” section of this website for management of this problem.
Post-Operative Infections: Post-operative infections are uncommon but can occur especially in chronically-ill or immunocompromised patients. Taking antibiotics as prescribed will often prevent and treat infections after surgery. Common symptoms of infection after initial recovery are
Swelling that increases in size (especially 5-7 days after surgery)
Swelling in unusual places such as beneath your jaw or under your tongue
Increasing pain (especially 5-7 days after surgery)
Fever greater that 101.5 Fahrenheit
Please call our office if you suspect you may have an infection as you may require additional medication or even surgical care. (See “Surgical Instructions” for a description of a normal post-operative recovery.)
Conclusion:
In general, all impacted teeth should be considered for removal including wisdom teeth. We consider the ideal age for removal of impacted wisdom teeth to be between ages 15 to 20. At this age, complications are few and manageable and patients tend to recover relatively quickly. Early diagnosis and treatment will often prevent many of the problems associated with extraction of third molars in older patients. Consultation with your dentist and/or orthodontist is advisable. If you are referred for evaluation in our office, we will make every effort to formulate an accurate diagnosis and provide recommendations for your continued good dental health. As with most anything, an ounce of prevention is worth a pound of cure.
Wisdom Teeth in FL
