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• Tooth Surgery

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:

1. Acute gum infection or pericoronitis that happens around the wisdom tooth (Most common).
2. Infection on the pulp or pulpitis in the wisdom teeth due to decay
3. Infection on the pulp or pulpitis in the second molar due to prolong food trap that causes dental caries.
4. Infection on the bone or osteomylitis which occur if infection spread into the bone.
5. Infection around the facial tissue or cellulitis. This happens when the infection spread into the soft tissue around the facial region (Below).
   
   

   Facial cellulitis
6. Gum abcess – if pus present  in the gum or facial abcess if it’s in the face region
7. 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

1. Pain on surgical site
2. Limited mouth opening
3. Swelling around the cheek
4. Bruise over the cheek (not usual)

2) Complication (Rare!!)

1. Infection on surgical site (Higher risk for smoker and diabetic patient)
2. Lower jaw fracture (Will only happens in very thin jaw or a rough surgery)
3. Bleeding (Can be from arteries which usually can be controlled with compression)
4. 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.)