What are wisdom teeth?
Wisdom teeth are technically known as 3rd molars. Teeth erupt
appear in sets of four (upper right, upper left, lower right, lower
left); however, not everyone has wisdom teeth, and even if they are
present, the number of wisdom teeth can vary. You may have four wisdom
teeth or less or none or rarely more than four. |
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1st molar = 6-year molar
2nd molar = 12-year molar
3rd molar = wisdom tooth
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| Wisdom teeth, if present, don't always
erupt into the mouth, and when they don't they are
referred to as impacted. Wisdom teeth actually
begin forming before age 10, and if they erupt it is
usually between 17-21 years old (see Tooth Eruption
Chart). Third molars usually erupt in the late teen
years, which coincides with passage into adulthood
and is referred to by some as the age of wisdom; hence "wisdom
teeth". |
Wisdom teeth are not required for normal function,
have short roots, are tipped forward and cannot adequately
support bridges or partials for long. Unfortunately,
the wisdom teeth are now usually trying to erupt
into a jaw that is too small. Wisdom teeth are considered
vestigial organs (a vestige is a degenerative or
imperfectly formed organ or structure having little
or no utility, but in the earlier stage of development
of a species performed a useful function). |
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| panoramic x-ray: wisdom
teeth |
How Are Wisdom Teeth Evaluated?
Wisdom teeth are evaluated by oral examination and x-rays (usually
a panoramic x-ray). We also review your medical history. The x-ray
helps to determine the position of the tooth within the jaw and
its relationship to nearby nerves and teeth. |
| Healthcare Perspectives current problem,
definite future problem, likely reactive proactive
painful, expensive, inconvenient, increased damage
easier, more comfortable, less expensive, planned,
prevents greater damage My approach is proactive. |
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Problems Caused By Wisdom Teeth
Problem does not necessarily mean pain. Most people do not experience
pain with their wisdom teeth. Problems are more often silent and
progress slowly. By the time a problem does become evident to a
person, substantial damage has often already occurred. Specific
problems include the following 14 concerns, some of which are more
common, some are rare - each person is different and your concerns
are determined with a thorough examination and evaluation. |
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Pain
Of the problems wisdom teeth cause, the most common complaint associated
with impacted wisdom teeth is pain. A person may have soreness
or pain in the back part of the jaw, ear ache, sore throat or pain
in the side of the face. The impacted wisdom tooth itself may be
the source of the pain or there may be an infection associated
it. Food and debris containing destructive bacteria may become
trapped between the gum and the underlying wisdom tooth causing
a painful infection around the crown of the wisdom tooth even though
you don't see the tooth. People may mistake repeated soreness of
the gum tissue overlying the wisdom teeth as an effort by the teeth
to erupt. Usually this is a warning sign of an infection. |
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Gum Disease
This generally happens because these partly erupted teeth are difficult
to keep clean, and the accumulated food particles cause the gums
around the tooth to get infected. If untreated by removing the
wisdom tooth, the infection may cause destruction of the bone surrounding
the wisdom tooth and will affect the neighboring tooth. |
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Bacteria
In addition to affecting a neighboring tooth, the bacteria present
around a wisdom tooth don't just remain around that tooth, but
spread to other teeth, so that the wisdom tooth actually becomes
an incubation and re-inoculation source affecting other teeth.
This chronic infection is now recognized to have an impact beyond
merely oral health, and also has an impact on our general health
and organ systems. For people who have to premedicate before getting
their teeth cleaned these bacteria pose a constant daily risk.
For those with compromised immune systems, this chronic infection
again poses a burden on their already taxed health (e.g. diabetes).
See also Microscopic Examination. |
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Impacted
It often happens that there is not enough space in the mouth for
wisdom teeth to erupt. In such cases they may try to erupt in an
abnormal direction, or may get locked into the jaw. This locking
is known as impaction. The teeth remain completely buried in the
bone of the upper and lower jaws in which they developed, a condition
known as impaction. See below for Types Of Impactions. |
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Decay
The same types of bacteria that are responsible for infections can
also cause tooth decay or cavities in the impacted wisdom tooth
and/or the root of the adjacent tooth. A wisdom tooth may decay
unnoticed, as they are the most difficult teeth to keep clean,
being so far back into the mouth. |
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Damage to Adjacent Root
Just the constant pressure from the impacted wisdom tooth can also
lead to destruction of the tooth next to it when the tooth is impacted
mesioangular (see Types Of Impactions below). This is uncommon
and occurs in less than two percent of those with impacted wisdom
teeth. |
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Crowding
An impacted or erupting wisdom tooth can push on adjacent teeth,
causing them to become more crooked. Current information shows
that wisdom teeth do not alone cause teeth to become crowded and
crooked, but they certainly can exacerbate existing crowding. |
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Cyst
Although the overall occurrence of cysts and tumors associated with
the jaws is low, when they do occur it is most frequently around
an impacted wisdom tooth. If the sac that holds the crown of the
wisdom tooth remains in the bone, it can fill with fluid, forming
a cyst that can destroy surrounding bone. These are rare. |
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Pericoronitis
The flap of gum tissue, called an operculum, which partially covers
an erupting wisdom tooth creates a place where bacteria which normally
live in the mouth to flourish, multiply and cause an infection
known as pericoronitis (inflammation around the crown of a tooth).
Such an infection is felt as swelling and pain around the area.
Sometimes the tooth is trying to erupt, but has not yet broken
through the gums. When the upper tooth bites down onto this gum
pain can be caused. If the infection worsens, it can become a serious
infection. People may mistake repeated soreness of the gum tissue
overlying the wisdom teeth as an effort by the teeth to erupt.
Usually this is a warning sign of an infection. |
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Jaw Fracture
The presence of a wisdom tooth creates a potential for less strength
in angle of the jaw. The decreased structural strength increases
the potential for a jaw fracture. Although very rare, it is another
consideration for the detriment of wisdom teeth. |
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Interfere With Bite
If wisdom teeth erupt into the mouth, their position frequently interferes
with the harmonious movement of teeth. Over decades this destructive
impact affects the wisdom tooth itself, but more importantly it
puts stress and strain on the jaw joints and muscles of the jaw.
This bite discrepancy can lead to headaches, muscle spasms and
jaw joint problems. |
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Dentures
If a wisdom tooth erupts beneath a denture it will cause severe irritation
and if removed, the person will need to have a new denture constructed
as the shape of the gum will have changed. |
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Travel to Inaccessible Places
This is not a concern for most people, but if you are traveling for
an extended time to an area where dental services are not available,
wisdom teeth pose a different risk than for those with easy access
to emergency care. |
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How Wisdom Teeth Are Removed
Improvements in surgical technique and sedative medications allow
people to have their wisdom teeth removed comfortably and efficiently
in a pleasant environment. There are several anesthetic options
available to optimize comfort during their surgery and minimize
the postoperative side effects. |
The type of procedure performed will depend very much
on specific nature of each wisdom tooth. The surgery
may be carried out by a general dentist or by an
oral surgeon, depending on the complexity of the
operation. Whether a local or general anesthetic
is used also depends to a large part on the difficulty
of the operation. The addition of nitrous oxide (laughing
gas) can be very helpful when local anesthetic alone
is used. Surgery on the upper wisdom teeth is usually
simpler than on the lower wisdom teeth, because upper
jaw bone is not as dense. |
For teeth that are completely erupted, normal extraction
procedures are followed. After effective local anesthesia
is achieved, the tooth is loosed in its socket with
a an instrument much like a shoehorn. People often
have the impression that teeth are pulled out first,
and this is not the case - they are loosened and
elevated first, then they are grasped to remove them.
It is sometimes less traumatic to section a wisdom
tooth much as if it were impacted (see below) - each
situation is determined by that particular tooth,
and after consultation with you. Sutures may or may
not be required. |
Conscious sedation is the technique to put you to "sleep".
Different than when you are in the hospital with general
anesthesia, with conscious sedation you breathe on
your own. With conscious sedation you have no awareness
of the procedure, and you have local anesthetic as
well. |
Most impacted teeth are removed with an IV anesthetic
technique of conscious sedation (after medicines
are given intravenously local anesthetic is also
administered). The gum tissue is moved out of the
way thereby exposing the tooth and the bone overlying
it. The ideal is to use as little force as necessary,
therefore any bone in the way will be carefully removed.
This is done with a high speed cutting instrument
under water irrigation (much like the drill used
for fillings). After the tooth is exposed, it usually
requires sectioning into pieces to be removed. Once
again, as little force as necessary is used and with
as little bone removal as possible. Sectioning the
tooth accomplishes this goal and protects important
surrounding and nearby structures (nerves and blood
vessels). After the tooth is removed, the gum tissue
is repositioned back into it's proper place and sutured.
Sutures are often dissolvable and do not require
removal. If you do receive sutures that require removal,
be sure to keep your appointed time for removal,
so as not to cause swelling around the healing site.
Anti-inflammatory drugs are sometimes injected into
the area of the surgery to help reduce swelling. |
Most dentists agree that one surgery of all wisdom
teeth is best and that multiple trips to the oral
surgeon for the removal of wisdom teeth is not in
the best interest of the person and although minimal,
only raises the potential for complications. Additionally,
one surgery means one post-operative healing, rather
than multiple. People often wonder if there is some
discomfort when one tooth extracted, that it would
be many-fold for all four wisdom teeth, and that
is not the reality. |
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Types Of Impactions
When a wisdom tooth is blocked from erupting, it is termed impacted
(any tooth, baby tooth or permanent tooth can technically become
impacted). Wisdom teeth can be impacted in the gum tissue overlying
them. These are called soft tissue impactions. Unfortunately, for
the person, soft tissue impactions often end up being more difficult
than they sometimes appear because of the curvature of the roots
that may not be apparent on the x-rays. Wisdom teeth more commonly
are still enclosed in some bone. If they are fully enclosed they
are referred to as full bony impactions. If only partially enclosed
in bone, i.e. the wisdom tooth is partially erupted through the
bone, these are referred to as partial bony impactions. They are
either partially exposed in the mouth or completely under the gum
surface and identifiable only on an x-ray. Due to unavailability
of space in the jaws, the impacted wisdom teeth grow in many different
directions, commonly at an angle. The complexity of surgery depends
on the type of impaction. |
Each wisdom tooth in a person's mouth can erupt or
be impacted differently - their position and eruption
pattern is quite variable. |
A wisdom tooth may grow at an angle towards your other
teeth. This type of impaction is called as a mesioangular
impaction. A wisdom tooth which erupts at an angle
away from your other teeth is said to be distoangularly
impacted. A wisdom tooth facing your other teeth
horizontally is said to be horizontally impacted.
A tooth which is in normal direction but still unable
to erupt due to lack of space is said to be vertically
impacted. |
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Pre-surgical Recommendations
The following are tips to help you prepare for your surgical appointment: |
| wear loose clothing, comfortable clothing
with sleeves that are easily rolled up jewelry remove
watches and bracelets transportation an escort is mandatory
for surgery; the person must be escorted to the office
and the escort must stay at the office during the surgery;
surgery rarely takes longer than 60 minutes and the
recovery room stay is rarely longer than 20-30 minutes
diet people must refrain from eating AND drinking for
six hours prior to surgery medications people must
adhere to their normal medications prior to surgery;
all maintenance medications such as high blood pressure,
diabetes and thyroid medications must be taken on schedule;
take medicine with a small amount of water or juice
THIS IS THE ONLY EXCEPTION TO REFRAIN FROM DRINKING
OR EATING cleaning for a week prior to the surgical
appointment, clean your teeth very effectively to reduce
and/or eliminate as many bacteria as possible; additionally,
use a salt water rinse daily to kill the germs (one
teaspoon of salt per 1/2 cup of warm water - rinsed
at least one minute vigorously between teeth) |
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When Should Wisdom Teeth Be Removed
When it is obvious that the wisdom teeth will become impacted, they
should be removed. This decision can be made often by the time
the person is fifteen years of age. Removal of impacted wisdom
teeth in this age group has distinct advantages. At this age
the roots are seldom fully formed, even though the tooth has
become impacted. Removing an impacted wisdom tooth before the
roots are fully formed is usually less traumatic for the person.
Typically, people having impacted wisdom teeth removed in their
mid-teens have a more rapid recovery and have a shorter and less
complicated post-operative course. Most people experience minimal
disruption of their normal routines, and time off from work or
school is usually minimal. |
The degree of difficulty and post-operative complications increase
with age. It is easy to understand why many people choose to be
proactive and have their wisdom teeth extracted while they are
young and healthy rather than have to undergo a more extensive
surgical procedure later in life when their recovery may not be
as easy and their general state of health may not be as good. |
