Painless wisdom tooth Surgery

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Wisdom teeth often known as third molars are the last teeth to erupt in the permanent dentition. These teeth are the last or most posterior teeth in the dental arch. If they erupt smoothly and without any interruption in normal occlusion, then they can be proved as an asset. But the problem with third molars is that in case they do not erupt properly or are misaligned (impacted), they would need to be extracted. If they are poorly aligned, then they can damage the adjacent teeth or leads to multiple problems.

One usually gets wisdom teeth in late teens or early twenties. However, even instances of eruption of wisdom teeth in late adulthood are common. It is also possible for some or all of the third molars to never develop or a person to have more than four wisdom teeth. In many individuals, the wisdom teeth aren't visible because they have become impacted (not normally erupted through the gums) under the gingival tissue.

You know if you have wisdom teeth by examining your mouth and finding three permanent molars in each dental quadrant. Most wisdom teeth can be visualized erupting through the gingiva in early adulthood, between the ages of 16 to 23. Sometimes, a person will feel the effects of the wisdom teeth before they are able to visualize them in their mouth. Erupting wisdom teeth will usually produce a feeling of pressure or dull throbbing in the back of the jaws. Pain sometimes radiate to the ear or forehead.

If you can visualise your wisdom teeth and they are straight and not causing above symptoms, you need to focus on properly cleaning your wisdom teeth area. Sometime cleaning wisdom teeth is difficult due to lack of space. You can use smaller brush to clean you wisdom teeth. In case of any symptoms, you need to consult Oral and Maxillofacial Surgeon. If the tooth is impacted under the tissue, presence of the tooth needs to be verified by a radiograph. A panoramic radiograph is usually the preferred X-ray to help assess the angle of eruption and state of development of the tooth. Your oral and maxillofacial surgeon will often be able to inform you of the condition of these erupting teeth.

It is not necessary to remove wisdom teeth as long as they are not causing any problem. They would have to be removed if they are impacted or causing crowding. If you do not remove the wisdom tooth, it will remain impacted. Your mouth might not provide space for it to erupt as a result it will erupt at the wrong angle which can damage the adjacent tooth. You may also be getting food stuck around your wisdom teeth. Food and bacteria can build-up plaque and calculus on wisdom tooth or adjacent tooth.  Which can lead to:

• Tooth Decay (dental caries)- The decay may get to the extent that the tooth in front has to be removed as well.
• Gum Disease- (also called gingivitis or periodontal disease)
• Pericoronitis–when plaque causes an infection of the soft tissue that surrounds the tooth
• Cellulitis– a bacterial infection in the cheek, tongue or throat
• Abscess– a collection of pus in your wisdom teeth or the surrounding tissue as a result of a bacterial infection
• Cysts and Benign Growths – very rarely, a wisdom tooth that hasn't cut through the gum develops a cyst (a fluid-filled swelling)

A variety of home remedies have been suggested for help with symptomatic wisdom teeth. While home remedies can be helpful if used to provide temporary relief, they are not alternatives to seeking a diagnosis and proper treatment from an oral and maxillofacial surgeon. With prolonged use, they can actually worsen the condition by making the symptom less noticeable while allowing the source of infection, tooth decay, or pain increase until it spreads or causes more severe consequences.

In certain situations, however, the following home remedies can be helpful:

1. Clove oil
2. Saltwater
3. Tea bag
4. Numbing gel. A numbing dental gel may help reduce feeling in the gums and dull the pain.  
5. Pain killer.  Pain killer is an over-the-counter pain relief medication that helps reduce inflammation.
6. Ice pack.

Not all wisdom teeth need to be extracted. When a wisdom tooth erupts cleanly through the tissue without compromising the adjacent tooth, the wisdom tooth can be retained in the mouth with little concern as long as the person is able to brush, floss, and clean it thoroughly.Your Dentist can continue to review your wisdom teeth along with the rest of your teeth when you attend for your routine checkup. 

If the wisdom tooth is in a position where it has not been causing problems and there is a low risk of a problem developing then an option can be for the wisdom tooth to be left where it is. However over time, circumstances may change and the risk of a problem with your wisdom teeth may increase and treatment will then be needed. The time of when treatment is needed is a decision that can be made with you and the Specialist. It is important to keep your wisdom teeth under review as problems may develop without you knowing about them until severe symptoms develop.

If your wisdom teeth are not causing problems, it may be difficult to decide whether to have these teeth removed to prevent possible dental problems later in life. Think about the following:

• You may never have any problems with your wisdom teeth.
• It is rarely harmful to your health to have your wisdom teeth removed, but there are slight risks involved with any surgery.
• In younger people (late teens and early 20s), the wisdom tooth's roots are not fully developed and the jawbone is not as dense, so it is easier to remove the tooth. The easier it is to remove the tooth, the easier your recovery is likely to be.
• Most problems with wisdom teeth develop between the ages of 15 and 25.
• If you are older than age 30, you have only a small risk of having problems with your wisdom teeth. Few people older than 30 develop problems that require removal of their wisdom teeth.
• If you have a medical condition that may get worse over time and your teeth may cause problems, consider having your wisdom teeth removed while you are healthy.
• Possible complications include dry socket (alveolar osteitis), infection, bleeding, and numbness.
• Delaying can also lead to severe surgeries and heavy bleeding or can even cause a minor loss of movement in your jaw.

Many of the problems due to wisdom teeth can be treated with antibiotics and antiseptic mouthwash. Wisdom teeth removal is usually recommended when other treatments haven't worked. 

If there is swelling, infection, difficulty swallowing or breathing, fever or intense pain, priority needs to be given to getting the wisdom teeth out as soon as possible. Antibiotics may be prescribed to help keep an infection from getting worse or spreading for a very short while. Warm saltwater rinse or antibacterial mouth rinse and OTC painkillers can be used as short-term remedies for tooth pain until more definitive treatment can be obtained. 

It is also advisable to electively remove wisdom teeth before starting treatment for some medical condition. Such treatment can leads to difficulties in wisdom teeth removal at later date or interfere with healing. Such medical conditions are, Radiation after Oral Cancer, Immunosuppressants or medicines that affects the bone physiology, decayed or impacted wisdom teeth before planning pregnancy. 

Women on birth control pills who decide to have their wisdom teeth removed should try to schedule the surgery for the end of their menstrual cycle (usually days 23 through 28). There seems to be less risk of dry socket during this time. 

If you are intending to travel abroad for a long length of time and access to a dentist or a specialist is difficult the consideration may be given about having treatment for your wisdom teeth and other teeth before you leave. Dental treatments may be very expensive in other countries.

Humans have two upper (maxillary) canines and two lower (mandibular) canines. Canine teeth are sometimes referred to as cuspids, fangs, or “eye teeth” because of their direct positioning beneath the eyes. Canine teeth have thicker and more conical roots than incisors and thus have an especially firm connection to the jaw. Canine teeth often have the longest root of all teeth in the human mouth and are the last to fully erupt and fall into place, often around age 13. 

An impacted tooth essentially means that it is blocked, stuck, or unable to fully erupt and function properly. Third molars (wisdom teeth) most commonly fall victim to impaction, but the upper canine is the second most common tooth to become impacted. Wisdom teeth serve no important function in the mouth and are frequently removed; however, impacted canines are a critical condition and require treatment for the following reasons:

• Chewing and tearing food
• Guiding teeth into proper bite alignment
• Preventing other teeth from coming into unhealthy contact with each other
• Aesthetically shaping the smile

• Insufficient space
• Inability to follow proper track along the adjacent teeth
• Alignment problems with other teeth
• Early loss or removal of primary teeth
• Genetics

• Sequence of eruption: All other front teeth are fully established
• Size: Permanent canine teeth are much larger than the temporary teeth they are replacing
• Slow development: Canines have longer roots than most other teeth, therefore a longer eruption path
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• Observing the position and angulation of adjacent teeth
• Feeling the gum line for evidence of the missing tooth
• X-rays (possibly several types)

• Determine if the tooth is actually impacted
• Clarify tooth position relative to adjacent teeth and jaw
• Identify problems the impaction may be causing to other teeth and structures
• Create the best treatment plan for the patient’s unique circumstances

Occasionally, a CT scan may be recommended to acquire 3-dimensional information regarding the impacted tooth. 

The objective is to aid the eruption of the impacted canines, and this can be skilfully done by an oral surgeon and an orthodontist.

The exposure will generally be performed under local anesthetic by an oral surgeon. The un-erupted canine will be exposed by lifting the gum, and guided into place using a special bracket fix by an orthodontist.

In the case of younger patients, an orthodontic brace may be fitted to create a space on the dental arch for the impacted canine. Surgery for impacted canines usually does not require an overnight stay. Pain medication will be prescribed as necessary, and you’ll be given post treatment advice for your recovery.

• Ankylosis (tooth will not move due to fusion with bone)
• Resorption compromising the tooth
• Extremely severe impaction
• Adjacent teeth are seriously jeopardized
• Pathological changes (cysts and tumors)

Procedure for extraction of impacted canine is more or less similar to wisdom teeth surgery. Please read following session further details and post operative care after implacted canine removal surgery.

Consult your Oral and Maxillofacial Surgeon about any concerns you have before the procedure. Inform surgeon about your medical condition, any medications or allergy. They will advise x-ray (IOPA, OPG) or CBCT before the procedure to know the angulation of wisdom tooth and other vital information. They can tell you what to do in the days before surgery and how to plan for recovery time afterward. They can also talk to you about the type of anesthesia that will be used and how you’ll feel after the surgery. Our Oral and Maxillofacial Surgeon follow nationally approved guidelines for the removal of wisdom teeth.

Wisdom teeth removal surgery is usually performed at Oral and Maxillofacial Surgeon’s Office under local anaesthesia. Surgery is performed as outpatient procedure and its completely painless and comfortable. 

If you are scared of dental office or procedure, surgery can be performed under sedation or general anaesthesia in hospital setup as day care procedure.

Follow your surgeon’s directions for eating and drinking before surgery. Instructions may vary depending on the anaesthesia used.

If procedure is done under local anaesthesia then it is advisable to have light snacks one hour before surgery.

If you are getting intravenous anesthesia, you won’t be able to eat or drink anything after midnight the night before the procedure so your stomach is empty.

The risk of bleeding problems can increase with medications such as aspirin, warfarin and clopidogrel. 

Let your oral and maxillofacial surgeon know if you're taking these or any other medications before wisdom tooth surgery. They will let you know if you can keep taking your current medications or when you should stop taking them in preparation for surgery.

To avoid complications, let your doctor know about all of your medications, including prescription or over-the-counter drugs, vitamins, or other supplements.

Sometimes, your surgeon will recommend you to start antibiotics before surgery.

Your surgeon will probably advise you to make arrangements for someone to bring you home from the surgery, since you’ll be groggy after sedation or general anesthesia. This person can wait for you in the waiting room, if desired.

Avoid tobacco, smoking and alcohol for at least eight hours before the surgery and one week after surgery.

The surgery should take about 20-45 minutes. With anesthesia, you shouldn’t feel any pain or discomfort. Depending on what type of anaesthesia is used, you may be asleep or conscious during the surgery.

These are the steps for a typical procedure:

• Sedation or General Anaesthesia: Many people will choose conscious sedation or general anaesthesia (being put into a sleepy state where pain signals are blocked) so they have little or no memory of having the wisdom teeth extracted. If you are receiving nitrous oxide (laughing gas), you will be fitted with a small mask to fit over your nose to inhale the sedative, allowing you to be awake but remain relaxed. If intravenous (IV) sedation is chosen, the assistant will place a needle in the vein in your arm to administer a sedative throughout the surgery. This is generally considered the most comfortable option since you drift in an out of consciousness and are unlikely to remember the procedure afterward.
• Local Anaesthesia:  Your surgeon starts by numbing the wisdom teeth and their surrounding tissues with a local anesthetic.
• Tissue removal: The surgeon removes any gum tissue covering the area where the wisdom tooth is located to access the tooth.
• Bone removal: An impacted wisdom tooth could be fully or partially covered with bone. If this is the case, a high-speed handpiece is used to drill through and remove the bone covering the tooth.
• Loosening and sectioning of the tooth: When the impacted wisdom teeth are visible to the dentist, various surgical instruments are used to gently loosen them from any connective tissue in the tooth's socket. The surgeon may also cut the tooth into sections to allow for easier removal.
• Tooth removal: Once the wisdom tooth is loose or has been completely sectioned, it is ready to be removed. The surgeon will use surgical instruments specially designed to fully remove the tooth.
• Stitches: Now that the wisdom teeth are gone, the surgeon may add stitches to close up the area. This is sometimes necessary when impacted wisdom teeth are removed or when the practitioner feels the patient will better heal with stitches in place. These stitches may either be dissolvable stitches that come out on their own after two to three weeks or stitches that need to be removed by the surgeon after a certain period of time.
• Pressure Pack: After the procedure is complete, the Surgeon will provide gauze for you to bite down on to help blood clot in the area. 
• Recovery: If procedure is done under local anaesthesia, then you will remain fully awake during procedure but you will not feel any pain. You can immediately go home after necessary instructions for post op care. In case of sedation or general anaesthesia, you will be brought to a recovery room where you will be monitored. Once a specialist has determined that you are stable and breathing normally, you'll be cleared to go home. Usually you'll spend 3-4 hours in the recovery room. Immediately after surgery, you may feel mild effects of the general anesthesia, including nausea, dizziness, and shivering.

• It is normal to have slight bleeding (oozing) from the site considering the surgical procedure performed. The minor bleeding (oozing) after extraction should start to ease after the first 24 hours.
• Avoid spiting, gargling, rinsing your mouth vigorously. It may dislodge blood clot and induce severe bleeding.
• Extra oral ice application for 24 hrs. This will help to reduce pain, swelling and bleeding.
• When the anesthesia wears off, there may be jaw stiffness, difficulty opening the mouth all the way, and some pain. Pain medication such as paracetamol or ibuprofen is often prescribed to help with any postoperative symptoms and discomfort. 
• Make sure you finish any course of antibiotics  you've been given. 
• Some pain, bleeding, and swelling in your mouth and cheeks are likely to persist for up to several days after the surgery. You may not be able to open your mouth all of the way during this time.
• Avoid brushing your teeth next to the extraction site. Use a soft manual toothbrush, which is gentler than an electric one. Gently rinse the extraction site with antiseptic mouthwash after 24 hours, and repeat this regularly over the next few days, particularly after eating – you can also use warm water with a teaspoon of salt as mouthwash to reduce gum soreness and inflammation.
• Don’t drink alcohol or use mouthwash with alcohol.
• Avoid smoking during the healing process. Smoking will delay the healing process and increase the chance of postoperative pain and complications.
• The best remedies for pain following extraction are rest and giving the area time to heal. Adhering to the postoperative instructions of the surgeon is important to minimize any complications. Complete healing of the gums may take three to four weeks.
• The extraction site can take up to six weeks to heal, but most people can resume normal activities the next day. That said, avoid strenuous activity for a week after the surgery to avoid breaking off the blood clot.

Your Surgeon will give you suggestions for what and when you can eat after surgery. The soft tissues in your mouth will likely be sensitive for several weeks. 

• Once the effect of local anaesthesia is gone, Cold Juice or Ice cream can be consumed. 
• For the first day or two, it is best to eat mostly soft foods or liquids like smoothies, yogurt, shakes, pureed foods, soups, pudding, etc. 
• It is best to avoid drinking through a straw and eating extremely hot or spicy foods. Also, foods that can get caught in the extraction socket like nuts, rice, seeds, and popcorn should be avoided. 
• As the extraction areas start to heal, regular foods that require chewing can be slowly introduced back into the diet depending on the comfort of the person.

It's usually recommended that you take a day or two off work after having a wisdom tooth removed. It is always better to plan surgery during last working day of week. Normally you will be comfortable in 2-3 day and can resume work.

You can drive immediately after the procedure if local anaesthetic was used, but you should avoid driving for at least 24 hours if a sedative was used, or 48 hours if the procedure was carried out under general anaesthetic.

It can take up to 2 weeks to fully recover after having your wisdom teeth removed.

During this time, you may have:

• a swollen mouth and cheeks – this will be worse for the first few days but will gradually improve; gently pressing a cold cloth to your face helps reduce the swelling
• some mild visible bruising of your cheek – the skin may be bruised for up to 2 weeks 
• a stiff, sore jaw – this should wear off within 7 to 10 days 
• pain – this is worse if the extraction was difficult or complicated 
• an unpleasant taste in your mouth
• tingling or numbness of your face, lips or tongue (although this is uncommon) 

After your wisdom teeth have been removed and any swelling and bruising has disappeared, your mouth and face should return to normal. You'll usually be able to brush your teeth normally after a few days. A check-up appointment may be arranged for about a week or so after the procedure. At this point, any remaining stitches may be removed.

It is likely that there will be some discomfort and swelling both on the inside and outside of your mouth after surgery. This is usually worse for the first three days but it may take up to two weeks before all the soreness goes. You may also find that your jaw is stiff and may not be able to open fully. You will need to eat a soft diet for a week or so. There may be some bruising of the skin of your face that can take up to a fortnight to fade away. The application of an ice pack during the first 24 hours post-operatively may help. Do not apply the ice pack directly to your skin - wrap the ice pack in a towel first. The older you are having a wisdom tooth removed the longer it will take to recover.

As with any type of surgery, wisdom tooth removal carries some risks. However, these risks are usually very rare.

Dry socket (alveolar osteitis) is one of the most common complications of wisdom tooth removal. It's where a blood clot fails to develop in the tooth socket, or if the blood clot becomes dislodged or disappears. This can happen 3 to 5 days after surgery.

The empty socket causes an ache or throbbing pain in your gum or jaw, which can be intense like a toothache. There may also be an unpleasant smell or taste from the empty tooth socket. If you look into the socket, you might be able to see exposed bone rather than a blood clot.

Two nerves lie quite close to the lower wisdom teeth. The nerves can vary in their proximity to wisdom teeth. The lingual nerve provides sensation in your tongue whilst the inferior dental nerve gives sensation to the lower lip and skin overlying the chin. Occasionally these nerves may be bruised during tooth removal. If this happens then you may have either numbness or pins and needles in either the tongue, lower lip, skin over the chin or any combination of these. If the wisdom tooth is away from the nerve the risk to the inferior dental nerve is less than 1%, however if the nerve is in very close contact the risk may be as high as 9%. The risk to the lingual nerve is less than 0.5%. It may take up to 18 months for this to recover. Rarely the nerve may not recover fully and you may be left with small patches of numbness to your lip or chin. Taste is rarely affected.

Infection signs include a high temperature, yellow or white discharge from the extraction site, and persistent pain and swelling 

There may be a little bleeding at the time of the extraction this usually stops very quickly and is unlikely to be a problem. If you are at home and the area bleeds again this can usually be stopped by applying pressure over the area for at least 10 minutes with a rolled up sterile swab. If the bleeding does not stop, please contact your surgeon where you had your operation.

In exceptional cases wisdom tooth removal can cause significant weakening of the jaw with the resultant possibility of jaw fracture. The incidence of this happening is extremely low and is less than 1% (less than 1 in 100).

General anaesthetic is occasionally needed for the removal of wisdom teeth. It carries some additional risks, but complications are very rare, occurring in less than 1 in every 10,000 cases.

Contact your surgeon immediately if you have any symptoms of heavy bleeding, dry socket, significant pain or any other unusual symptoms.

You may have heard that having your wisdom teeth out can change the shape of your face or jawline. In over 15 years of removing wisdom teeth, we have never seen this happen. Changes may appear while you are recovering from wisdom tooth extraction and in the weeks after, but once swelling goes down and you resume your regular diet, your face will go back to normal.

Decays and cavities or pulp infections causes black teeth surfaces.

The gums surrounding the impacted wisdom tooth are delicate and are prone to get infected easily, and the wound-infecting bacteria release foul-smelling sulfur compounds.

This is a variable. Some wisdom teeth may take only a few minutes to remove. More difficult wisdom teeth that need to be cut into pieces to remove can take around 20 minutes to extract.

It depends on the type of anesthesia you choose for wisdom teeth removal. You will remain awake during procedure if only local anesthesia is given. You will be sleeping when sedation or general anesthesia given during procedure. 

It takes around 3-4 weeks for wisdom teeth holes to heal completely and form a gum over tooth socket.

Food will probably get stuck in the sockets until they close over completely. This may cause problems with bad breath and a bad taste in your mouth. You can rinse with salt water, which will help to remove food stuck in the socket.

You probably experience a dry socket if you can look into your open mouth in a mirror and see the bone where your tooth was before. The explicit throbbing pain in your jaw represents another telltale signal of dry sockets. The pain may reach your ear, eye, temple or neck from the extraction site.

Here are a few ways you can prevent dry socket:

• Avoid straws. The suction movement of air and cheek muscles when you use a straw may dislodge your blood clot. 
• Avoid smoking and tobacco.
• Soft food. 
• Ask about medication interactions. 
• Proper oral hygiene.
• Follow your surgeon’s instructions.

As a Board Certified Oral & Maxillofacial Surgeon with over 15 years' experience in Mumbai, we believe removing all four wisdom teeth at once (if indicated) is the best option for most patients. Number of teeth that are removed at one time does not affect the level of discomfort our patient’s experience. On the other hand, undergoing two surgeries doubles the discomfort. For obvious reasons, it’s more expensive to have a separate surgery for each wisdom tooth extraction than one for all four. When priced out individually, you’ll be paying for multiple office visits, more surgical expenses, and doubled or tripled anesthesia costs.

Limit talking. The more you talk, the more your tongue and associated muscles move disturbing the clots. This may initiate bleeding by causing the blood clot that has formed to become dislodged.

Unfortunately, you will need to sleep on your back. Depending on your recovery time, you will need to sleep on your back for around three to seven days. It is not recommended to sleep on your side or on your stomach because it can squish your cheeks, adding extra pressure to the area.