Interested in Advertising here? Contact me! My brother-in-law had his wisdom teeth removed the other day. His crazy dentist took a picture of him while he was under anesthesia and my brother-in-law was good enought to share that picture with the family and with the readers of shmula 1. Below is my brother-in-law. I do not share his name because I want to protect the ridiculously-looking innocent. It’s a crazy picture. Enjoy!
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What is an Impacted Wisdom Tooth (Impacted Wisdom Teeth)
An impacted wisdom tooth falls into one of several categories. Mesioangular impaction is the most common form (44%), and means the impacted wisdom tooth is angled forward, towards the front of the mouth. Vertical impaction (38%) occurs when the formed wisdom tooth does not erupt fully through the gum line. Distoangular impaction (6%) means the impacted wisdom tooth is angled backward, towards the rear of the mouth. And finally, Horizontal impaction (3%) is the least common form, which occurs when the impacted wisdom tooth is angled fully ninety degrees forward, growing into the roots of the second molar. A typical distoangular impacted wisdom tooth is the easiest to extract in the maxilla and most difficult to extract in the mandible, while mesioangular impactions are the most difficult to extract in the maxilla and easiest to extract in the mandible. An impacted wisdom tooth 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 impacted wisdom tooth has erupted out of the jawbone but not through the gumline, it is called a soft tissue impaction. Sometimes the impacted 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. Additional cleaning techniques can include using a needle-less plastic syringe to vigorously wash the impacted wisdom tooth with moderately pressured water or to softly wash it with hydrogen peroxide. However, debris and bacteria can easily accumulate under an operculum, which may cause pericoronitis, a common infection problem in young adults with a partially impacted wisdom tooth that is often exacerbated by occlusion with opposing 3rd or 2nd molars. Common symptoms include a swelling and redness of the gum around the eruption site, difficulty in opening the mouth, a bad odor or taste in the mouth, and pain in the general area which may also run down the entire lower jaw or possibly the neck. Untreated pericoronitis can progress to a much more severe infection. If the operculum does not disappear, recommended treatment is extraction of the impacted wisdom tooth.
What are Wisdom Teeth
The wisdom tooth is the third molar to appear in the mouth. For most people, a wisdom tooth will begin to grow in during the late teen years, or early twenties. Sometimes a wisdom tooth can grow in with no resulting problems, but usually, a wisdom tooth will require removal. A misaligned wisdom tooth can cause problems on a number of levels. A poorly aligned wisdom tooth can push against and damages surrounding teeth, it can injure the jawbone, or even cause damage to surrounding nerves. A misaligned wisdom tooth also presents the possibility of increased tooth decay, as food and debris can be trapped between the wisdom tooth and another molar.
Does Everyone Have at least One Wisdom Tooth?
Not everyone has a wisdom tooth. Although unusual, not having a wisdom tooth is not something to worry about. However, sometimes a person will have a wisdom tooth that simply never erupts through the gum line. This is called an impacted wisdom tooth. Unfortunately, this kind of wisdom tooth can still cause problems below the gum line. Your dentist will be able to determine if you have a wisdom tooth or not. The simplest way to find out is with a painless panoramic X-ray.
Wisdom Teeth Impaction
Impacted wisdom teeth fall 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 forward, growing into the roots of the second molar. Typically distoangular impactions are the easiest to extract in the maxilla and most difficult to extract in the mandible, while mesioangular impactions are the most difficult to extract in the maxilla and easiest to extract in the mandible. Impacted wisdom teeth may also be categorized on whether they are still completely encased in the jawbone. If wisdom teeth are completely encased in the jawbone, it is a bony impaction. If the wisdom teeth have 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. Additional cleaning techniques can include using a needle-less plastic syringe to vigorously wash the tooth with moderately pressured water or to softly wash it with hydrogen peroxide. However, debris and bacteria can easily accumulate under an operculum, which may cause pericoronitis, a common infection problem in young adults with partial impactions that is often exacerbated by occlusion with opposing 3rd or 2nd molars. Common symptoms include a swelling and redness of the gum around the eruption site, difficulty in opening the mouth, a bad odor or taste in the mouth, and pain in the general area which may also run down the entire lower jaw or possibly the neck. Untreated pericoronitis can progress to a much more severe infection. If the operculum does not disappear, recommended treatment is extraction of the wisdom tooth. An alternative treatment involving removal of the operculum, called operculectomy, has been advocated. There is a high risk of permanent or temporary numbness of the tongue due to damage of the nerve with this treatment and it is no longer recommended as a standard treatment in oral surgery.
Wisdom Teeth Extraction
A wisdom tooth is extracted to correct an actual problem or to prevent problems that may come up in the future. 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. Another reason to have wisdom teeth removed is if the teeth have grown in improperly, causing the tongue to brush up against them. The tongue can tolerate it for a limited time, until it causes a painful sensation, to the point where the sheer pain can numb the tongue affected, and the area around it (part of the lips, and the cheek). The numbness feels similar to the feeling of anesthesia, possibly meaning a nerve can be affected by the wisdom tooth improperly growing in. Also, it is a wise choice to have wisdom teeth removed if undergoing extensive orthodontic work because once the teeth have come in they could inflict some damage on expensive straightening. The extraction of wisdom teeth should only be performed by dental professionals with proper training and experience performing such extractions. The precise reasons why an individual’s wisdom teeth need to be extracted should be explained to them by their dentist, after an examination of their wisdom teeth which almost certainly will need to include x-rays. A panoramic x-ray (aka “panorex”) is the best x-ray to view wisdom teeth and diagnose their problems.
- A wisdom tooth is in humans any of the usually four third molars, including mandibular third molar and maxillary third molar. Wisdom teeth usually appear between the ages of 17 and 25. Most adults have four wisdom teeth, but it is possible to have more—in which case they are called supernumerary teeth—or fewer—a condition called hypodontia. Wisdom teeth commonly affect other teeth as they develop, becoming impacted or “coming in sideways”. They are often extracted when this occurs. Impacted wisdom teeth fall 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. Typically distoangular impactions are the easiest to extract in the maxilla and most difficult to extract in the mandible, while mesioangular impactions are the most difficult to extract in the maxilla and easiest to extract in the mandible. Frequently, a fully erupted upper wisdom tooth requires bone removal if the tooth does not yield easily to forceps or elevators. Failure to remove distal or buccal bone while removing one of these teeth can cause the entire maxillary tuberosity to be fractured off and thereby the tearing out the floor of the maxillary sinus or free wisdom teeth removal. 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. Additional cleaning techniques can include using a needle-less plastic syringe to vigorously wash the tooth with moderately pressured water or to softly wash it with hydrogen peroxide. However, debris and bacteria can easily accumulate under an operculum, which may cause pericoronitis, a common infection problem in young adults with partial impactions that is often exacerbated by occlusion with opposing third or second molars. Common symptoms include a swelling and redness of the gum around the eruption site, difficulty in opening the mouth, a bad odor or taste in the mouth, and pain in the general area which may also run down the entire lower jaw or possibly the neck. Untreated pericoronitis can progress to a much more severe infection. If the operculum does not disappear, recommended treatment is extraction of the wisdom tooth. An alternative treatment involving removal of the operculum, called operculectomy, has been advocated. There is a high risk of permanent or temporary numbness of the tongue due to damage of the nerve with this treatment and it is no longer recommended as a standard treatment in oral surgery. 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. Other reasons wisdom teeth are removed include misalignment which rubs up against the tongue or cheek causing pain, potential crowding or malocclusion of the remaining teeth (a result of there being not enough room on the jaw/ in the mouth), as well as orthodontics. Many dentists and most oral surgeons recommend routine extraction of third molars (wisdom teeth) supposedly to prevent future problems. However, there is risk of injury, especially of nerve injury. Evidence-based practice does not support prophylactic removal of wisdom teeth, even if they are “impacted.” There are several problems that might occur after the extraction(s) have been completed. Some of these problems are unavoidable and natural, while others are under the control of the patient. The suggestions contained in the sections below are general guidelines that a patient will be expected to abide by, but the patient should follow all directions that are given by the surgeon in addition to the following guidelines. Above all, the patient must not disregard the given instructions; doing so is extremely dangerous and could result in any number of problems ranging in severity from being merely inconvenient (dry socket) to potentially life-threatening (serious infection of the extraction sites). Bleeding and oozing is inevitable and should be expected to last up to three days (although by day three it should be less noticeable). Rinsing the mouth during this period is counter-productive, as the bleeding stops when the blood forms clots at the extraction sites, and rinsing out the mouth will most likely dislodge the clots. The end result will be a delay in healing time and a prolonged period of bleeding. Gauze pads should be placed at the extraction sites, and then should be bitten down on with firm and even pressure. This will help to stop the bleeding, but should not be overdone as it is possible to irritate the extraction sites and prolong the bleeding or remove the clot. The bleeding should decrease gradually and noticeably upon changing the gauze. If the bleeding lasts for more than a day without decreasing despite having followed the surgeon’s directions, the surgeon should be contacted as soon as possible. This is not supposed to happen under normal circumstances and signals that a serious problem is present. A wet tea bag can replace the gauze pads. Tannin contained in tea can help reduce the bleeding. Due to the blood clots that form in the exposed sockets as well as the abundant bacterial flora in the mouth, an offensive smell may be noticeable a short time after surgery. The persistent odor often is accompanied by an equally rancid-tasting fluid seeping from the wounds. These symptoms will diminish over an indeterminate amount of time, although one to two weeks is normal. While not a cause for great concern, a post-operative appointment with one’s surgeon seven to ten days after surgery is highly recommended to make sure that the healing process has no complications and that the wounds are relatively clean. If infection does enter the socket, a qualified dental professional can gently plunge a plastic syringe (without the hypodermic needle) full of a mixture of equal parts hydrogen peroxide and water or chlorohexidine gluconate which also comes in the form of a mouth wash into the sockets to remove any food or bacteria that may collect in the back of the mouth. This is less likely if the person has his/her wisdom teeth removed at an early age. A dry socket is a painful inflammation of the alveolar bone (not an infection); it occurs when the blood clots at an extraction site is dislodged, falls out prematurely, or fail to form. It is still not known how they form or why they form. In some cases, this is beyond the control of the patient. However, in other cases this happens because the patient has disregarded the instructions given by the surgeon. Smoking, blowing one’s nose, spitting, or drinking with a straw in disregard to the surgeon’s instructions can cause this, along with other activities that change the pressure inside of the mouth, such as sneezing or playing a musical instrument. The risk of developing a dry socket is greater in smokers, in diabetics, if the patient has had a previous dry socket, in the lower jaw, and following complicated extractions. The extraction site will become irritated and painful, due to inflammation of the bone lining the tooth socket (osteitis). The symptoms are made worse when food debris is trapped in the tooth socket. The patient should contact their surgeon if they suspect that they have a case of dry socket. The surgeon may elect to clean the socket under local anesthetic to cause another blood clot to form or prescribe medication in topical form (e.g. Alvogel) to apply to the affected site. A non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be prescribed by the surgeon for pain relief. Generally dry sockets are self limiting and heal in a couple of weeks without treatment. Swelling should not be confused with dry socket, although painful swelling should be expected and is a sign that the healing process is progressing normally. There is no general duration for this problem; the severity and duration of the swelling vary from case to case. The surgeon will tell the patient how long they should expect swelling to last, including when to expect the swelling to peak and when the swelling will start to subside. If the swelling does not begin to subside when it is supposed to, the patient should contact his or her surgeon immediately. While the swelling will generally not disappear completely for several days after it peaks, swelling that does not begin to subside or gets worse may be an indication of infection. Swelling that re-appears after a few weeks is an indication of infection caused by a bone or tooth fragment still in the wound and should be treated immediately. Preventive removal of the third molars is a common practice in developed countries. In 2006, the Cochrane Collaboration published a systematic review of randomized controlled trials in order to evaluate the effect of preventive removal of asymptomatic wisdom teeth. The authors found no evidence to either support or refute this practice. There was reliable evidence showing that preventative removal did not reduce or prevent late incisor crowding. The authors of the review suggested that the number of surgical procedures could be reduced by 60% or more. Likewise, Clinical Evidence published a summary, largely based on the Cochrane review, that concluded prophylactic extraction is “likely to be ineffective or harmful.” The website offered the following details: “While it is clear that symptomatic impacted wisdom teeth should be surgically removed, it appears that extracting asymptomatic, disease-free wisdom teeth is not advisable due to the risk of damage to the inferior alveolar nerve, especially among older patients.” Some non-RCT evidence suggests that the extraction of the asymptomatic tooth may be beneficial if caries are present in the adjacent second molar, or if periodontal pockets are present distal to the second molar.}} It may be argued, however, that these meta-analyses are inappropriate in that the lack of randomized control trials is likely the result of the expense and impracticality of studying diseases already strongly linked to third molar tissues. For example odontogenic cysts arising from the 3rd molar follicle and odontogenic tumors from the 3rd molar epithelium are relatively rare and can take decades to develop, making RCT’s extremely expensive and challenging (especially high loss to follow up). That being said, several dental textbooks encourage the removal of 3rd molars. From Contemporary Oral and Maxillofacial Surgery, 5th Edition: “As a general rule, all impacted teeth should be removed unless removal is contraindicated. Extraction should be performed as soon as the dentist determines that the tooth is impacted. Removal of impacted teeth becomes more difficult with advancing age. The dentist should typically not recommend that impacted teeth be left in place until they cause difficulty. If the tooth is left in place until problems arise, the patient may experience an increased incidence of local tissue morbidity, loss of or damage to adjacent teeth and bone, and potential injury to adjacent vital structures. Additionally, if removal of impacted teeth is deferred until they cause problems later in life, surgery is more likely to be complicated and hazardous because the patient may have compromising systemic diseases and the surrounding bone becomes more dense. A fundamental precept of the philosophy of dentistry is that problems should be prevented. Preventive dentistry dictates that impacted teeth are to be removed before complications arise unless removal will cause more serious problems.” The rationale of prophetically removing 3rd molars prior to its completed root formation is that the likelihood of nerve damage or other complications is extremely low. This is not the case however with symptomatic removal of a 3rd molar after root formation is complete and more intimate with the IA nerve and as the mandible becomes more dense with age. From Pediatric Dentistry: Infancy Through Adolescence, 4th Edition: “Evaluation of third molars is usually completed during mid- to late adolescence. Parents commonly ask about treating these teeth. The reasons for extraction of third molars include impaction or failure to erupt; potential or existing pathosis such as cysts or ameloblastoma; decay; posteruption malposition; nonfunction as a result of an absent opposing tooth; difficulty with hygiene; and recurrent pericoronitis. If any of these are considerations, third molars should be removed during adolescence…. The evaluation of developing third molars in adolescent athletes is of particular importance. Not only can an athletic season suddenly be interrupted by the annoying and often painful eruption of third molars with associated acute pericoronitis, but mandibular fractures in the gonial angle region of developing third molars can also occur in adolescent athletes. Studies showed that dentists graduated from different countries—or even from different dental schools in the same country — may have different clinical decisions regarding third molar removal for the same clinical condition. For example, dentists graduated from Israeli dental schools may recommend more often for the removal of asymptomatic impacted third molar than dentists graduated from Latin-American or Eastern European dental schools. In the U.K., the National Institute for Health and Clinical Excellence (an authority which appraises the cost-effectiveness of treatments for the National Health Service) has recommended that impacted wisdom teeth that are free from disease should not be operated on. In the U.S., the American Association of Oral and Maxillofacial Surgeons has published an extensive White Paper on Third Molar Data, which considers the most current research into the subject of third molar extraction. The White Paper states that, “The presence of visible third molars is associated with elevated levels of periodontitis . . . which involves adjacent teeth and is progressive and only partially responsive to therapy.” Periodontal bacteria causes gum disease, and may travel through the blood stream, resulting in systemic infections associated with the heart, kidneys and other organs. Further, studies have found such bacteria in amniotic fluid and is considered a factor in low birth weight infants. The AAOMS recommends that third molars be removed in patients who, in the opinion of their family dentists, suffer from periodontal infections where the probing depth exceeds 3 mm. Further, it is advisable to have the third molars of such patients removed in young adulthood to avoid the complications that may occur when third molars have grown to maturity. In these cases, there is a greater likelihood of nerve damage and other potential concerns. This would suggest that recommendations regarding the removal of third molars vary widely from country to country, depending on the stakeholders involved. The American Public Health Association recommends against prophylactic removal of asymptomatic, non-pathological wisdom teeth, including wisdom teeth that are unerupted or impacted. APHA opposes prophylactic removal of third molars and believes the removal of third molars (wisdom teeth), like the removal of any teeth, should be based on evidence of diagnosed pathology or demonstrable need, rather than anticipated future pathology. The APHA’s position is not based on scientific research, but rather on concerns about cost. ↩
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This post was written by Pete Abilla | ||||
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{ 2 comments… read them below or add one }
Im just glad that I had mine removed in Hospital and was asleep for all of this!
I have the last wisdom tooth coming out and I am so thankful to evolution that I have enough space to park a school bus back there.
I am sure your brother-in-law left the dentist that day handing over that lucky Doctor a down payment on a new BMW! Makes me wonder if we should change it from wisdom teeth to BMW teeth.