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.

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.

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.

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.