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Wisdom Teeth

To Be Or Not To Be?

By Dr. Priveer Sharma

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Considerations For Removal Of Wisdom Teeth

We'll leave the “how” to your oral surgeon, but the timing of removal can be critical. If wisdom teeth need to be removed, it is better to remove them early when you are young rather than waiting until periodontal disease has started. However, regardless of age, removing impacted third molars can potentially have a negative impact on the periodontal tissues of your adjacent second molars. The prior existence of a periodontal defect, your age, and your level of oral hygiene may serve as predictors of adverse outcomes.

As individuals age, the effects of retained and impacted wisdom teeth can be more consequential. Periodontal defects tend to get worse in the presence of retained third molars as you age. So too does the prevalence of caries (tooth decay). And the incidence of postoperative morbidity (ill effects of disease after surgery), including symptoms following third molar removal, is higher in people over age 25.

It is also important for dental professionals to remove wisdom teeth carefully so that they don't accentuate or start a periodontal problem. While there currently is no single surgical approach for removing third molars that will particularly minimize loss of periodontal attachment, there are many techniques available to remove them carefully while promoting good healing outcomes. Some of these include:

  • Scaling, root planing, and plaque control have the potential to reduce the loss of gum attachment after surgery.
  • Periodontal surgical techniques may be beneficial in instances where there is evidence of significant pre-existing periodontal attachment loss. See the previous article on periodontal surgery (“Periodontal Surgery — Where Art Meets Science”).

Orthodontic And Other Considerations

Controversial statements have long existed with regard to the prophylactic (preventive) removal of asymptomatic or disease-free impacted wisdom teeth. In fact, a systematic review of the scientific literature found some reliable evidence that suggests removing impacted third molars cannot be justified in adolescents as a step towards reducing or preventing late incisor (front teeth) crowding.

Despite good intentions, we are not able to explain, predict, or prevent dental crowding no matter what the cause as there can be many contributing factors. While it is likely that third molars may play a role in crowding, this is only one factor to consider when making a decision about removing or keeping them. For some people, third molars may cause significant concerns; however, to date there is no scientific evidence for identifying with accuracy who is at risk.

While it is likely that third molars may play a role in crowding, this is only one factor to consider when making a decision about removing or keeping them.

Another factor is that the position and disposition of un-erupted wisdom teeth has been found to be both dynamic and unpredictable. This is critical for anyone considering having an impacted third molar removed that is currently under an existing or planned removable prosthesis (denture). Therefore, the ultimate decision regarding the management of such teeth is best made by an expert dental health professional. And this decision should only then be made after clinical examination and review of factors such as your age, position of the tooth, anticipated difficulty of removal, type of overlying prosthesis, and risks associated with the removal. As with all areas of medicine, proper assessment and diagnosis of a situation is paramount to successful surgery, healing, and prevention of unfavorable effects.

Prevention, Evaluation, And Management of Third Molars

A variety of clinical and radiographic (x-ray) techniques are available to image and assess the position of wisdom teeth and their proximity to other structures. Standard 2D (Dimensional) x-ray techniques are used to provide information about the shape and position of wisdom teeth roots and adjacent structures. However, the evolving method for obtaining the exact position of impacted third molars is a 3D CT (“C” – Computed; “T” – Tomography; “tomo” – slice or cut) image that is like thinly slicing a plum cake so you can see what is inside each slice. (Imagine cutting through a plum cake, where the tooth is the plum and the bone is the surrounding cake [Figure 6].) While this innovative technology warrants further investigation to standardize its use, it is proving very beneficial in individual situations.

Nerve Damage: A common occurrence with lower wisdom teeth is their proximity to the neurovascular bundle (“neuro” – nerve; “vascular” – blood vessel; “bundle” – trunk) that runs in the lower jaw, as well as the nerves to the tongue that affect feeling and taste respectively. And while damage to these nerves can occur during extraction, only a small percentage have complications. Of that small percentage at least 50% of people who experience this recover spontaneously.

The Advantages Of Early Removal Of Wisdom Teeth

The early removal of the tooth crown before root development may be linked to fewer problems after surgery. In other words, by predicting impaction and thus removing wisdom teeth as they are forming, it may make removal and healing easier with fewer complications.

Conclusions

Wisdom teeth and their associated problems are commonplace in the practice of dentistry. An oral surgeon who is trained in their assessment and surgical removal typically performs this routine procedure that is just one aspect of an oral surgical practice.

Note: General dentists with special training in surgical techniques may also be comfortable in accessing and removing third molars.

However, prior to any procedure it is critical that your dental professional conduct a proper evaluation — not only to assess the clinical health of the wisdom teeth but also the health of neighboring teeth and other vital structures. X-ray and digital imaging techniques play an important role in determining the exact position of third molar teeth in the jaws, which in turn has a direct impact on the ease or difficulty associated with their removal and the prevention of complications.

Questions to ask your dentist or oral surgeon

  1. When is the right time to remove my third molars?
  2. How difficult will it be to remove my third molars?
  3. Are any of my wisdom teeth close to the nerve?
  4. What should I expect after the extraction of my wisdom teeth?

Most often surgical removal of wisdom teeth will involve some mild to moderate post-operative discomfort. Wisdom teeth removal, third molar surgery, has provided a model system for post-operative pain control research and therefore much is known about it. Non-steroidal, anti-inflammatory drugs like aspirin or ibuprofen for a few days after surgery will provide pain relief, and control most swelling and symptoms. Codeine or other opiate derivatives may be helpful following some surgical cases depending upon the degree of ease or difficulty in removal. Antibiotics may be prescribed particularly if grafting is needed to promote bone growth or regeneration and to ensure infection-free healing. Dry socket, an occasional complication of wisdom tooth removal, can be avoided by keeping the socket area clean and by washing and rinsing with saline or other antibacterial rinses. But more importantly, careful surgery will promote good healing with minimal periodontal consequences to adjacent second molar teeth.

A full assessment and consultation with an oral surgeon or your dentist that includes all the risks, benefits, likely consequences, and alternative treatment options, will provide you with the facts (and wisdom) you need for determining what is best for your wisdom teeth.