Wisdom Teeth

Wisdom teeth, formally known as third molars, are the four teeth farthest back in the mouth -- one on each side of the upper and lower jaw. Not everyone has wisdom teeth. About 85 percent of people between the ages of 16 and 20 have all four, some or all of which may be impacted, and 95 percent have at least one. The wisdom teeth are the last to come through. Nowadays people often have jaws that are too small for all 32 teeth - 28 are often the most we have room for. So if all the other teeth are present and healthy there may not be enough space for the wisdom teeth to come through properly.

Why don't wisdom teeth grow in right?
The shape of the modern human jaw is often too small to accommodate wisdom teeth, which make their first appearance in young adults between the ages of 16 to 25. Over the course of time in the evolutionary process, humans learned to harness fire for cooking foods and developed blade tools to better process food before consumption, they reduced the need for strong jaws to chew food.

What does impacted mean?
When wisdom teeth don't have room to grow or they haven't reached their final position by age 25, they are considered impacted. Third molar impaction is the most prevalent medical developmental disorder. Scientists say third molars are probably an evolutionary leftover from prehistoric humans, who had larger jaws. Today, many people's jaws are too small to comfortably accommodate a third set of molars. The result is that a developing wisdom tooth's path is often blocked by bone, gum or another tooth -- in which case the tooth is considered to be impacted. 

Can you ever keep your wisdom teeth?
Mother nature is generous when it comes to our teeth. First we get baby teeth, then permanent teeth, and finally around age 16 or 17, we start getting a set of molars called wisdom teeth.     Often times, wisdom teeth become trapped or impacted in the jawbone, or simply fail to erupt. This can cause crowding or displacement of other teeth, or lead to the development of localized tooth decay, infection, or gum disease.  It probably is true that wisdom teeth cause more problems than any other tooth in the mouth. They will either partially break the gum tissue and grow in crooked or remain underneath the gum. In nine out of ten people, at least one tooth remains impacted, causing symptoms of future problems of varying degrees.  However, all that does not mean that we have to take all of the wisdom teeth out.  There are certain patients that do not require their wisdom teeth to be removed.   In some cases we only take the approach of wait and watch as long as the patients will return for the bi-annual evaluation.  

Do they always cause problems?
No. If there is enough room they will usually come through into useful position and cause no more problems than any other tooth. Often there will be some slight discomfort as they come through, but this is only temporary and will disappear once the tooth is fully in position 

Are there different types of impacted wisdom tooth?
Some teeth are fully impacted, failing to break through, or "erupt," at all, while others are partially impacted, with part of the tooth poking out through the gums. Sometimes an impacted tooth lies in the jaw at an angle instead of sitting straight up.

Impaction is a term used in dentistry when a tooth is stuck under the gum and jawbone.  It could be because it does not have enough space or it is positioned in such a way that is impossible to erupt in your mouth.  Lack of space occurs because our jaws have become smaller (through evolution), we do not loose teeth through decay as frequently as in the past, and our diet is such that our teeth do not wear down as much.  An impacted tooth could be completely or partially covered with bone, hence called bony impaction or it could be under the gum, and then it is called soft tissue impaction.  

Horizontal Bony Impacted Tooth		Vertical Bony Impacted Tooth
Angular Bony Impacted Tooth		Partial Bony Impacted Tooth

What problems should I be prepared for?
If part of the wisdom tooth has appeared through the gum and part of it is still covered, the gum may become sore and perhaps swollen. Food particles and bacteria can collect under the gum edge, and it will be difficult to clean effectively.

Your dentist will advise you whether this is a temporary problem that can be dealt with by using mouthwashes and special cleaning methods (and possibly antibiotics), or whether it is better to have the tooth removed.

What are the common signs of wisdom teeth problems? 
Swelling
Infection
Pain
Headaches
Earaches
Restricted mouth openings

What problems occur with impacted wisdom teeth?

From our past experiences we have learned that if impacted wisdom teeth left untreated they can potentially cause serious dental problems such as cysts or tumors. Basically, teeth develop in sacs resting deep in the bone. The sac disappears when the tooth comes through the jaw normally. If the tooth is impacted the sac can fill with fluid (like a water balloon) and enlarge, forming a cyst, which can grow, possibly unnoticed.  As the cyst expands it pushes against the bone and roots of other teeth as well as the nerves in the area causing major harm. In rare instances, a tumor can develop in the wall of the cyst and may require more complicated surgery.

Potential For Trouble: Silent Danger or innocent victim!
Although surgeons have seen many complications with wisdom teeth and millions are removed every year because of the following reasons as described bellow, but we are at present time studying to see if there is a scientific basis to predict the possibility of these condition happening in future.  We are now looking to see if we can avoid removing many wisdom teeth by just observing them for many years to come.

Becoming Infected, inflamed or painful
Damaging other teeth
Leading to cyst formation or cause a fractured jaw

Reasons for wisdom teeth to be removed:
Constant pain
Recurrent infection (Pericoronitis)
Tooth decay
Abscess
Associated cysts
Tumors
Diseases of tissues around the tooth, (decay in adjacent teeth, periodontal problems)
They may be in the way of planned future surgery

What can I do to help myself?
Warm salted water or a warm mouthwash could help to clean around your gum and teeth and reduce the inflammation. Swish the solution around the tooth; trying to get it into the areas your toothbrush cannot reach. An antibacterial mouthwash such as Peridex can also be very useful to reduce the inflammation. Over the counter pain medications including Tylenol, Motrin, Alive, Advil, Ibuprofen can also be useful for short-term use. But you must be seen as soon as you can to check the problem.

But what if it does not help?
If the pain does not go away or if you find it difficult to open your mouth, you should see a dentist. They will be able to see the cause of the problem, and advise you accordingly. It may be useful to clean around the tooth very thoroughly, and an antibiotic may be prescribed.

Are x-rays needed?
The dentist will usually take x-rays to see the position of the root, and to assess whether there is room for the tooth to come through into a useful position.

Are wisdom teeth difficult to take out?
It all depends on the position and the shape of the roots. Your dentist will advise you as to how easy or difficult each tooth will be to remove after looking at the x-rays. Upper wisdom teeth are often more straightforward to remove than the lower ones, which are more likely to be impacted. Your dentist will advise you whether you should be referred to a specialist (oral surgeon) at a hospital. Very occasionally there is a possibility of some numbness of the lip after the removal of a lower tooth - your dentist will tell you if it is possible in your case.

Will it make any difference to my face or mouth?
Removing wisdom teeth may produce some swelling for a few days but as soon as the area is healed, there will be no difference to your face or appearance. Your mouth will feel more comfortable and less crowded, especially if the teeth are impacted.

When should wisdom teeth be removed?
Wisdom teeth should be removed before the age of 24, according to a clinical study conducted by five Detroit area oral surgeons. The study, published in the Journal of Oral and Maxillofacial Surgery, involved 9,500 patients ranging in age from 12 to 83 and more than 16,000 impacted third molars. Basically, it showed that incidence of complications was four times higher among patients older than 24 years. In most cases, the extraction of wisdom teeth is a simple procedure. Patients can expect to resume their normal activities in a day or so.

Is there a need for consultation before my surgery?
Certainly.  After all, even if your teeth are impacted they don’t have to be removed.  It is our standard to meet with the patient (and parents if applicable) prior to the surgery date. At that time the patient is evaluated for those contributing factors, which might weigh in the decision as to the most appropriate setting for the surgery. Additionally, the meeting allows us to evaluate the x-rays and discuss the surgical procedure. Meeting the doctor fact to face prior to the surgery also allows the patient to establish a comfort level with the doctor and staff which is hard to do minutes before the actual performance of the anesthesia surgery.

Who can a person see if they are concerned about their wisdom teeth?
Oral and maxillofacial surgeons are specialists in the diagnosis and treatment of health problems associated with the mouth, jaw, joint and jawbone and are qualified to handle wisdom teeth complications. Regular visits to the dentist can assure early detection of possible wisdom teeth problems. At that time, proper treatment can be determined depending upon the individual case.

What are the most common reasons to have wisdom teeth removed?

1. Tooth Decay: As a partially impacted tooth tries to erupt the gum lifts and if the tooth stays in that position for a long period the saliva, bacteria and food particles can collect around it, causing decay in it, or the next tooth to it. It is very difficult to remove such decay. Pain and infection will usually follow.

2. Gum Infection (Pericoronitis): When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and trismus (inability to open the mouth fully). The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe.

3. Pressure Pain: Pain may also come from the pressure of the erupting wisdom tooth against other teeth. In some cases this pressure may cause the erosion of these teeth.

4. Orthodontic Reasons: Many younger patients have had prolonged orthodontic treatment to straighten teeth. Wisdom teeth may cause movement of teeth (particularly the front teeth) when they try to erupt and this will compromise the orthodontic result.

5.    Prosthetic Reasons: Patients who are to have dentures constructed should have any wisdom tooth removed. If a wisdom tooth erupts beneath a denture it will cause severe irritation and if removed, the patient will need to have a new denture constructed, as the shape of the gum will have changed.

6. Cyst Formation: A cyst (fluid filled sac) can develop from the soft tissue around an impacted wisdom tooth. Cysts cause bone destruction, jaw expansion and displacement or damage to nearby teeth. The removal of the tooth and cyst is necessary to prevent further bone loss. Rarely, tumors may develop within these cysts or the jaw may fracture spontaneously if the cyst grows very large.

7. Travel to Inaccessible Places: If you are going to an area where specialist dental services are not available and your wisdom teeth are impacted, it may be advisable to have them removed beforehand.

When is the Best Time to have my Wisdom Teeth Removed? 
It is now recommended by specialists that impacted wisdom teeth be removed between the ages of 14 and 22 years whether they are causing problems or not. Surgery is technically easier and patients recover much more quickly when they are younger. What is a relatively minor operation at 20 can become quiet difficult in patients over 40. Also the risk of complications increases with age, and the healing process is slower.

Should a Wisdom Tooth be Removed When an Acute Infection (Pericoronitis) is Present?
Generally no. Surgery in the presence of infection can cause infection to spread and become more of a serious problem. The infection must be controlled by antibiotics first before rushing to extract an infected tooth.  Sometimes the extraction of the opposing wisdom tooth may be needed first.

How do you keep my mouth open during surgery when I’m asleep?
A small rubber cushion is placed between your teeth before you go to sleep, and this holds your mouth open.

What is a " dry socket "?
Dry socket is a term that refers to a healing complication that used to be seen somewhat frequently, but is rarely a problem today. With current techniques we have all but eliminated "dry sockets", although we encourage you to call us if you experience anything postoperatively that is not improving day by day or just doesn’t feel right.

When can I go back to work or school?
Every individual has a different healing response to surgery, but on average there is not much disruption of one’s activities, and generally not for more than a few days. We frequently see people back at work or school on the day following surgery, even when all four wisdom teeth have been removed.

When can I brush my teeth after surgery?
Teeth can be brushed immediately, being careful to avoid the surgical areas for the first day or so.

When will my stitches dissolve?
Unless you are told otherwise, your stitches will dissolve after about a week.

When can I take the gauze out that I was biting on when I left your office?
The gauze may be removed when you get home; to be replaced with new gauze if significant bleeding continues, or if it feels better to have gauze in place. If the bleeding does not taper off within a few hours of surgery, you should call our office. A small amount of blood on your pillow on the night following surgery is nothing to be alarmed about if there is no active bleeding.

When should I start the prescription mouth rinse?
The prescription mouth rinse should be used for the first time before you go to bed on the night following surgery. Rinse very gently, because your blood clots are still somewhat fragile.

If I’m a smoker, how long should I wait to smoke after surgery?
Smoking is harmful to the healing process and makes numerous complications more likely. Smoking in the first two weeks is especially harmful.

Are there any reasons to remove my fully erupted wisdom teeth?
Erupted wisdom teeth may also be indicated for removal. The dentist may recommend this if the tooth is non-functional, interfering with the bite, badly decayed, involved with or at risk for periodontal disease, or interfering with restoration of an adjacent tooth. Once again, every case is different and only your dentist can determine if there is a reason for you to have a tooth removed.

What should I do to prepare myself for surgery?
The following are tips to help you prepare for your surgical appointment.

1.      You may need to take a day or two off work or school to give yourself time to recover. 

2.      Make sure not to eat or drink anything six hours before your surgery. 

3.      Arrange for a responsible adult to drive you home after surgery.  An escort is mandatory for surgery. The patient must be escorted to the office and the escort must stay at the office during the surgery.

4.      Advise us if you have any major medical problems or you are taking any medications. 

5.      Stop taking aspirin and any other blood thinner after you consult with your primary physician. 

6.      Continue to take any blood pressure medication, antibiotics, thyroid medications and so on. 

7.      Please advise us if you are taking insulin or are diabetic for specific instructions.

8.      Clothing - Wear loose, comfortable clothing with sleeves that are easily rolled up.

9.      Jewelry - Remove watches and bracelets.

10.  Specific post-operative instructions will be given to you after your surgery.

11.  A follow-up visit should be scheduled one week after the surgery date to check your healing progress.

How long is the surgery?
Expect the procedure itself to last about an hour.  But allow a two hours time in our center.  This time is allocated for preparation and recovery as well.  

How is the surgery done?
Wisdom tooth surgery is usually performed with an IV anesthetic technique in our center.   Our state of the Art facility allows us to perform almost all our impacted teeth removal in an office setting.  After medicines are given intravenously the surgeon pushes the gum tissue out of the way thereby exposing the tooth and the bone overlying it. Since the art to the science is to remove the tooth with as little brute force as necessary, the surgeon will carefully remove any bone in the way. This is done with a high-speed instrument under water irrigation. After the tooth is exposed, it usually requires sectioning into pieces to be removed. Once again, the tooth is removed with as little force as necessary and with as little bone removal as possible. Sectioning the tooth accomplishes this goal and protects important surrounding 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 dissolvable and do not require removal.

What should I expect after a wisdom tooth is taken out?
The amount of discomfort will depend on how easy the removal of the tooth was. There is usually some swelling and discomfort for a few days afterwards, and it is important to follow any advice you will be given about mouthwashes etc, to help with the healing. Some people also find homeopathic remedies helpful in reducing discomfort. Usual pain-killers such as Tylenol, Advil, Motrin or ibuprofen will usually deal with any pain. It is best to stay fairly quiet and relaxed for 24 hours afterwards to make sure there are no bleeding problems. There may be some stitches to help the gum heal over - your dentist will probably want to see you again about a week later to check on the healing, and to remove any stitches.

What does it cost?
Every procedure has a different fee.  The cost of surgery generally ranges from about $265 to $350 per tooth, depending on whether a tooth is covered by soft tissue or bone; more complicated extractions can cost more. Add at least another $150 if the surgery is done under general anesthesia. Dental insurance typically covers at least part of the cost of surgery. Please make sure to ask our staff prior to your appointment.  It is also your responsibility to bring any dental as well as major medical insurances (if in US) with you.  It is important that you discuss costs and payment methods with our staff before starting treatment. 

What should I do after surgery?
We'll ask you to rest for 15-20 minutes after your surgery in our center to be certain all bleeding is under control. You may be given a prescription for pain, swelling and antibiotics as well as instructions for home recovery. Plan to rest at home for the remainder of the day.

Do I need a second opinion?
Many oral & maxillofacial surgeons as well as general dentists say impacted, disease-free wisdom teeth completely covered by bone and gum should be monitored, not removed. Most also say there's no reason to remove wisdom teeth that are completely erupted into normal position and not causing problems. If you have good teeth, you should keep them, as long as a dentist keeps an eye on your wisdom teeth.  Don’t wait for them to hurt you before your next exam appointment.  If you have any doubts or lingering concerns, get a second opinion. Opinions and expertise vary among practitioners, and another dentist may very well give different advice, such as monitoring the teeth for problems rather than removing them.

Sometimes your wisdom teeth are healthy and well positioned. But frequently they can bring problems. Sometimes your dentist may recommend that you have your wisdom teeth extracted even before problems develop -- and the sooner, the better. That's because the younger you are, the less likely there'll be complications with the extraction.

If your dentist isn't sure that your wisdom teeth will cause problems or if you decide against having them removed, your dentist probably will recommend that you have them evaluated and x-rayed periodically -- just to be on the safe side.

Did our ancient ancestors have as much impacted teeth?
Probably no.  They certainly did not today’s means to take them out!  According to some scientist the human jaws are becoming smaller over time.  This is happening because the children are maturing much faster today than in the past. An excavation in 1990 of some graves in Griswold, Connecticut, dated to the late 1600s—l700 seems to confirm their research. There were 13 children's remains discovered. Only one was found with initials on the wood of the coffin. It read NB age 13 and was written in brass tacks.

When the teeth of the lower jaw were examined at the Armed Forces Institute of Pathology (AFIP) in Washington, D.C., the root and crown development indicated that, by today’s standards, these teeth should have belonged to a female child of 9 1/2 years, or a male child of 10 years, yet the child was 13. This may mean that 300-400 hundred years ago a child took 13 years to reach the stage that our children today do in 9 1/2 to 10 years. This points to a rapid maturation today.

Wisdom teeth need more space than can develop in our shortened jaw growth period. Children are taller today, and mature earlier, probably because of improved early nutrition.  But the facial bones need more than nutrition — they need time.

It is this fact, that the wisdom teeth are trying to erupt into a jaw space too small for them, which causes many of the problems. Scientists believe that there are other problems also with the eruption of wisdom teeth, and that many people do not even develop wisdom teeth today.

The Effect of Wisdom Teeth (Third Molars) on the Bottom Teeth
The effect of wisdom teeth on the lower teeth is a topic of debate amongst dental professionals. During the 1980's, the wisdom teeth were often blamed for tooth movement after the braces were removed. In 1990, Dr. Amin Ades, and several other authors published a research article in the American Journal of Orthodontics and Dentofacial Orthopedics 1990; 97: 323-35, called “A long-term study of the relationship of third molars to changes in the mandibular dental arch.” This article studied people who had been out of retainers for an average time of 13 years and concluded that the recommendation for lower third molar removal with the objective of alleviating or preventing mandibular lower front incisor irregularity may not be justified.   Recurring infections in the wisdom tooth area, inadequate space on the jawbone for the wisdom tooth itself, and wisdom teeth that are impacted or stuck under the bone and pose a problem are still valid candidates for removal.

Make your appointment online now for consultation & evaluation.

Dr. Madani is one of the pioneers of a laser surgery and radiofrequency treatments of snoring, chronic nasal congestion and tonsillar problems.  His main field of interest in orthognathic surgery.  He is board certified by the American Board Of Oral & Maxillofacial Surgery. The material contained herein is provided for informational purposes only and should not be considered as medical advice or instruction. Individuals with jaw deformity, sleep apnea or other conditions discussed in this site should consider a personal evaluation in our facility for further treatment.

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