What is wisdom teeth?
They are the last molar (or third molar) that usually erupt at the age of 18
to 25 years old (and sometimes older). The eruption of the tooth may cause pain
in some of the cases. There are usually 4 wisdom teeth in each person. However,
in some cases not every tooth will erupt into the oral cavity.
Impacted Wisdom Teeth
When a wisdom tooth cannot erupted properly either it tilt to the front or
back or half-way jammed it is consider as impacted. The impaction cause severe
pain especially when the tooth is erupting. This prevents the patient from open
his mouth wide or eat properly. Sometimes it interferes with his daily
activities. Impaction of wisdom tooth also will cause food trap easily (between
the second last molar and wisdom teeth) which will result in decay at the second
molar.
Impacted wisdom teeth can be divided into one of several categories.
Mesioangular impaction is the most common form (44%), and means the
tooth is angled forward, towards the front of the mouth.
Vertical
impaction (38%) occurs when the formed tooth does not erupt fully through
the gum line.
Distoangular impaction (6%) means the tooth is angled
backward, towards the rear of the mouth. And finally,
Horizontal
impaction (3%) is the least common form, which occurs when the tooth is
angled fully ninety degrees sideways, growing into the roots of the second
molar.
Impacted wisdom teeth may also be categorized on whether they are still
completely encased in the jawbone. If it is completely encased in the jawbone,
it is a
bony impaction. If the wisdom tooth has erupted out of the
jawbone but not through the gumline, it is called a
soft tissue
impaction. Sometimes the wisdom tooth fails to erupt completely through the
gum bed and the gum at the back of the wisdom tooth extends over the biting
surface, forming a soft tissue flap or lid around the tooth called an operculum.
Teeth covered by an operculum can be difficult to clean with a toothbrush.
Signs and Symptoms of Impacted Wisdom Tooth
Usually impacted wisdom teeth are presented with:
Pain
Gum Swelling
Cheek swelling
- pain (may disturb sleep and may extend to the back, neck and head)
- unable to open the mouth big due to pain
- infection of the gum around the wisdom tooth
- swelling on the gum
- swelling on the cheek of the affected side
- fever
Consequence of impacted wisdom teeth
Impacted wisdom tooth can lead to:
- Acute gum infection or pericoronitis that happens around the wisdom
tooth (Most common).
- Infection on the pulp or pulpitis in the wisdom teeth due to
decay
- Infection on the pulp or pulpitis in the second molar due to
prolong food trap that causes dental caries.
- Infection on the bone or osteomylitis which occur if infection
spread into the bone.
- Infection around the facial tissue or cellulitis. This happens when
the infection spread into the soft tissue around the facial region (Below).
Facial cellulitis
- Gum abcess – if pus present in the gum or facial abcess
if it’s in the face region
- Gum problem or periodontitis around wisdom tooth and second
molar.
Treatment Options
1. Leave it – If the symptoms are very mild, usually with
some mouth rinse and the pain will subside. However, sometimes the pain may come
back due to re-infection.
2. Take antibiotic and pain killer – Again the symptoms will
subside however re-infection still can occur.
Antibiotics
3. Incisional and Drainage - Removing of the pus accumulated
either in the gum or facial region then followed by removing of the wisdom
tooth.
4. Operculectomy – Removing the gum that cover the wisdom
tooth for easy cleaning. However, sometimes the gum might grow back and
infection can re-occur
Operculectomy procedure
5. Extraction – Removing the wisdom tooth (surgery or
without surgery)
Extraction
6. Root canal treatment – On the second molar if the pulp is
infected and the wisdom tooth required to be removed.
Indication of Wisdom teeth Extraction
Wisdom teeth are extracted for two general reasons: either the wisdom teeth
have already become impacted, or the wisdom teeth could potentially become
problematic if not extracted. Potential problems caused by the presence of
properly grown-in wisdom teeth include infections caused by food particles
easily trapped in the jaw area behind the wisdom teeth where regular brushing
and flossing is difficult and ineffective. Such infections may be frequent, and
cause considerable pain and medical danger.
According to
NICE
(The
National Institute for Clinical Excellence – UK), the routine
practice of prophylactic removal of pathology-free impacted third molar should
be discontinued. Third molar should be removed if there is evidence of pathology
includes unrestorable caries, non-treatable pulpal and/or periapical pathology,
cellulitis, abcess and osteomyelitis, internal/external resorption of the tooth
or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour,
tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is
involved in or within the field of tumour resection.
Pericoronitis
The degree to which the severity or recurrence rate of pericoronitis should
influence the decision for surgical removal of a third molar remains unclear.
The evidence suggests that a first episode of pericoronitis, unless particularly
severe, should not be considered an indication for surgery. Second or subsequent
episodes should be considered the appropriate indication for surgery.
Surgery or Not Surgery?
When a wisdom tooth erupts vertically just like the second molar and the
access is easily, then extraction of the tooth will be straight forward case.
Usually the surgeon will loosen the tooth and grip the tooth with a forceps to
remove it.
Horizontal impaction of wisdom tooth
However, most of the impacted wisdom tooth is embedded in the bone, tilted
either forward or backward. Sometimes the tooth is in a horizontal position
instead of vertical. This will make extraction with forceps impossible.
Therefore, surgery is required.
Surgical Removal of Wisdom Tooth
Usually done by a oral surgeon (Specialist) or an experience dentist and it
should be done in a sterile manner. After injections are given, a small cut will
be made on the gum to expose the wisdom tooth and bone surrounding it. Then some
bone near to the tooth will be removed to allow instrument to engage with the
tooth. Next, the tooth will be sectioned into half or more and the fragment of
tooth will be removed.
After the whole tooth was removed completely, the socket will be cleaned and
the surgeon will inspect the wound to make it is clean and bleeding stop.
Finally, the gum will be held together by stitches and the patient will be
allowed to go home with gauze, pain killer and antibiotic. Usually the whole
process takes about an hour or less.
For Anxiety Patient…
If in a case of an anxious patient come for wisdom tooth surgery, usually, we
will prescribe some
medication
of reduce anxiety before the surgery or patient will have to
inhale
nitrous oxide during the procedure so that he/she will feel relax and calm
all the time during surgery. If the patient is extremely phobia of surgery, then
he can opt for surgery done under general anaesthesia which required
hospitalization.
What Do I Need to Do During Recovery?
After your wisdom teeth are removed you may experience some swelling and mild
discomfort, which are normal symptoms and are part of the healing process. Here
is what to expect after the procedure.
1) The First 24 Hours:
Bleeding: This may occur for several hours after your wisdom teeth are
removed. To control it, place a piece of clean moist gauze or moistened tea bag
over the empty tooth socket and bite down firmly. This needs to be done for
about 45 minutes. You should avoid rinsing, spitting or sucking actions for 24
hours after your wisdom teeth are removed. For example, don’t drink beverages
through straws or smoke, and avoid hot liquids (such as soup or tea). You should
also avoid carbonated and alcoholic drinks. These activities can cause the clot
to dislodge, which will cause dry socket.
Facial Swelling: This can occur where the wisdom tooth was extracted. You can
apply a cold compress to ease the swelling and pain. Cold compress(ice packs)
should be used 20 minutes on 20 minutes off. Repeat as necessary during this
first 24-hour period. Avoid taking aspirin, ibuprofen (e.g. Motrin, Advil, etc.)
if you have a stomach ulcer.
Pain: Medications such as Mefenamic Acid (Ponstan) or Etoricoxib (Arcoxia)
can be taken to manage your pain. We may prescribe more potent pain relievers,
such as narcotics, if necessary.
Antibiotics: Antibiotics may be prescribed post-treatment and should be taken
until you have finished the prescription.
Food: Avoid hot liquids and alcoholic beverages for at least 24 hours. When
the extraction is more difficult, you will need to consume a soft or liquid diet
for at least 24 hours after removal of your wisdom teeth.
Brush your Teeth: You need to continue to brush your teeth, but avoid the
teeth adjacent to the extracted tooth during the first 24 hours. On day two, you
can resume the gentle brushing of your teeth. However, do not use commercial
mouth rinses because these can irritate the area of extraction.
2) After 24 Hours:
Facial Swelling: Facial Swelling in the area of your wisdom tooth extraction
needs to be man aged with heat after the first 24 hours of ice. Use a moist warm
towel and apply it to the area on a 20-minute on, 20-minute off schedule. Repeat
as necessary.
Rinse Your Mouth with Warm Salt Water: Use 1/2 teaspoon of salt in a cup of
warm water after before bed and after meals. Do not use commercial mouth
rinses.
Complete Healing: This will not occur for a few weeks to a few months
following the removal of your wisdom teeth. However, usually within the first
week or two, you will feel reasonably comfortable because enough healing has
taken place. We will explain what to expect regarding your healing process.
Complication of Wisdom Tooth Surgery
1) The usual problem the patient will experience after
surgery
- Pain on surgical site
- Limited mouth opening
- Swelling around the cheek
- Bruise over the cheek (not usual)
2) Complication (Rare!!)
- Infection on surgical site (Higher risk for smoker and diabetic
patient)
- Lower jaw fracture (Will only happens in very thin jaw or a rough
surgery)
- Bleeding (Can be from arteries which usually can be controlled with
compression)
- Injury to nerve (Damage to the nerve will happens when the wisdom tooth is
very near to the nerve and the event of removing it cause injury to the nerve.
This will result in numbness on the lower lipand usually it takes 6-12 months to
recover.)
