WISDOM TEETH

third molar removal

Wisdom teeth are also known as third molars. They are present on each side of the upper and lower jaws. Also, they are the last teeth to come. They are called wisdom teeth because they come out when a person is mature, usually, in late teens or in the early twenties.

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WHY TO REMOVE WISDOM TEETH?

1. Prevent periodontal disease – The presence of wisdom teeth reduces the amount of bone on the back side of the adjacent  2nd molar and the gum infection-causing bacteria can gain entry to a large portion of root surface causing severe periodontal disease.

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2. Preventing dental caries on the back surface of the 2nd molar and front surface of the 3rd molar.

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3. Prevent pericoronitis, which is an infection of the soft tissue around the tooth.

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4. Prevent root resorption of adjacent tooth.

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5. Prevent the formation of pathologies like the odontogenic cysts and tumours.

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6. Prevent ulcers or pain. After tooth removal and placement of denture, there is a slow destruction of the alveolar bone, and the wisdom tooth becomes closer to the surface. The overlying soft tissue is compressed by the denture causing ulcer and pain.

horizontally impacted wisdom tooth

7. Treatment of unexplained pain. When no other cause is found the removal of 3rd molar (wisdom tooth) often relieves the pain.

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8. Prevent fracture of the mandible, in case, if the tooth is too large and weakens the mandible.

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9. Facilitates braces treatment. If the 3rd molar (wisdom tooth)  interferes with retraction of the front teeth, it is recommended to remove the third molar tooth.

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10. A decayed wisdom tooth that is not restorable.

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11. Before orthognathic surgery at times

12. Precautionary removal in presence of specific medical and surgical condition. For example, bacterial endocarditis or organ transplant or radiotherapy, etc.

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DO ALL WISDOM TEETH NEED REMOVAL?

No, not all wisdom teeth are removed. cases in which wisdom teeth are removed are:

  • unerupted or partially erupted wisdom teeth
  • infected wisdom teeth
  • Swelling
  • Trismus
  • Pain
  • Fetid odor
  • Partially erupted 3rd molar (wisdom tooth) or deep caries.
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WHAT WILL DOCTOR CHECK IN YOU?

The patient is carefully checked before surgically removing the 3rd molar (wisdom tooth).

1. The eruption status of the 3rd molar (wisdom tooth) and its position in the oral cavity is carefully examined, as it gives an idea of the amount of surgical time needed for tooth removal.

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2. Presence of infection. The patient may have an infection, swelling and pain radiating to the head or neck and lower jaw on the affected side or is limited in the form of pericoronitis around the erupting tooth. Antibiotics are advised before removing the wisdom tooth.

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3. Caries present on the wisdom tooth or its adjacent tooth, i.e. 2nd molar is examined and the tooth filling in done(if needed). Sometimes, it is necessary to remove a badly decayed 2nd molar and allow the wisdom tooth to erupt without obstruction so that it is later used as an abutment for fixed prosthesis.

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4. Periodontal condition of the adjacent teeth is examined.

5. Regional lymph nodes are palpated to check for infection.

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6. The temporomandibular joint function is examined because the pain from an infected wisdom tooth very often radiates to the TMJ causing limited movements.

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RADIOGRAPHIC ASSESSMENT OF IMPACTED WISDOM TEETH

  • IOPA
  • OPG
  • Lateral mandibular 30-degree oblique
  •  IOPA’s are used in most of the patients. Sometimes, however, the patient is not able to open the mouth wide enough to place the film due to infection or due to gagging sensation or pain. Or Sometimes, the doctor is not able to place the film far back to get the complete tooth in the intraoral film or the tooth is associated with some pathology, and, in such cases, extraoral radiograph is taken.
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PROCEDURE FOR REMOVING IMPACTED WISDOM TEETH

Anaesthesia

First of all,  local anaesthesia is given. General anaesthesia is given only when the surgeon feels that the surgical time is too long either due to the deep-seated impacted tooth or in mentally retarded patients or in small children.

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The Incision

The incision is given for elevating the mucoperiosteal flap. Care is taken not to extend the incision into the mucobuccal fold. A wider working area is  required in some patients, e.g. deeply-placed tooth, or  horizontal impaction etc

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The Flap

The flap is elevated and reflected, following all the general principles. Hence, making sufficient space for bone cutting.

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Bone Removal

The bone cutting is done using either chisel or bur or both. The bone is removed buccally, distally and superiorly. While distal bone is removed the soft tissue is protected with a retractor.

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Removing the Tooth

The bone is removed in sufficient quantity to clear the crown of any obstruction. Also, sufficient space is created for the application of an elevator. The bone distal to the tooth is sufficiently removed to make space into which the impacted tooth is moved while removing it. The straight elevator is applied mesially on the cementoenamel junction of the impacted tooth, and sufficient force is applied so that it rotates and it is removed out of the socket. If required an extraction forcep is also used.

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Wound Toilet

The socket is then carefully cleaned and Flushed to remove all the debris.

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Wound Closure

The 1st suture, is placed as close to the distal surface of the second molar as is possible. No suture is required along the vertical limb of the incision, as the two ends will remain well-approximated post-surgery.

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COMPLICATIONS DURING SURGERY

1. Exposure of the inferior alveolar canal and its injury can cause bleeding which is very severe.

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2. Fracture of the root of the maxillary wisdom tooth may force into the maxillary sinus.

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3. The mandibular tooth or roots can dislodge through thin lingual cortical bone into the submandibular space.

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4. Trauma to the adjacent tooth causing non vital tooth.

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5. Vigorous instrumentation causing injury to the lip, cheeks or mucous membrane. Sometimes,  extensive lacerations can also occur.

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6. Fracture of the maxilla or the mandible while extracting the teeth, but this happens only when the operator uses uncontrolled forces, or there is some bony pathology.

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POST SURGERY

1. If there is an injury to the alveolar nerve – prolonged numbness or paraesthesia of the lip.

2.  Severe trismus-  difficulty in eating food.

3.  If there is an injury of the palatal blood vessel –  necrosis of palatal flap.

4. If ecchymosis occurs – discolouration of the soft tissue. This is due to postoperative bleeding.

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5. Opening into maxillary sinus can also cause an oroantral fistula.

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6. Postoperative dislodgement of the clot can cause dry socket.

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7. Sometimes, there is a loss of a large portion of the alveolar bone. This occurs because of over traumatization of the bone. Excessive elevator pressure or dull chisel or heated bone or use of burs that are used with reduced saline irrigation.

8. Exposure of the roots of adjacent teeth may cause their premature loss.

impacted third molar

9. Pain is normally expected but sometimes is very severe.

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RECOVERY TIME AFTER REMOViNG WISDOM TEETH

Wisdom teeth are usually larger than the other teeth, so stitches are usually placed after tooth removal. Tooth removal causes swelling and some bleeding for the first few days. So, your dentist will provide painkillers for the same.