IMPACTED WISDOM TEETH
What are impacted wisdom teeth?
Wisdom teeth are molar teeth, which are the last to erupt into
the mouth, usually after the age of 15 years, or even much
later. They are four in number – one each situated in the four
corners of the mouth, behind the second molar teeth and have no
clearly defined shape or form unlike the other permanent teeth.
They are often called wisdom teeth as they erupt at an age when
the person is in the transition phase from childhood to
adulthood. The remaining 28 teeth normally erupt into the oral
cavity by the age of 13 years.
Wisdom teeth are considered impacted when they are unable to
erupt into their normal functional positions, mainly due to lack
of space for their eruption. Approximately 20% of the population
has impacted wisdom teeth. Less than 5% of the population has
sufficient room to accommodate the wisdom teeth. Of the other
permanent teeth in normal individuals, very few are found
impacted except the canines.
What are the causes for impaction of wisdom teeth?
It has been found that during the process of evolution, the jaws
are progressively becoming smaller in size and the braincase is
expanding at the expense of the jaws. This is said to occur
because with the passage of time, man is increasingly using his
brain whereas the use of the jaws for chewing has been
progressively on the decline, as the diet we are having has
become refined and soft. Hence the chewing efficiency of the
jaws is not put to full use. Masticatory force (force exerted
while chewing) has been found to be contributory to jaw growth.
Soft diet thus adversely affects jaw growth. An underdeveloped
jaw will not be able to accommodate all 32 teeth. This reduces
the space for the wisdom teeth, which erupt last, to erupt into
place. Evolutionary trends also point to a gradual reduction in
the number of teeth, though this may occur only over a
considerable period of time.
Another important factor, which predisposes to development of
impacted wisdom teeth, is heredity. It has been found that
parents who have impacted wisdom teeth are likely to pass on the
trait to children. However, this may only be a very small part
of the evolutionary design.
Certain disease conditions such as rickets, endocrine
dysfunction, anemia, achondroplasia, cleidocranial dysostosis,
Treacher Collins syndrome etc. have also found to be associated
with impacted teeth. Here, impactions of teeth other than that
of the wisdom teeth are also found frequently.
What are the problems associated with impacted wisdom teeth?
Infection is the most common problem encountered associated with
impacted teeth. It may range from a localized gum infection to
acute, extensive, life-threatening infections involving the head
and neck. Localized gum infections tend to recur intermittently
when complete eruption of the tooth is not possible. Recurrent
infections (which may be subacute and not painful for the
patient) will frequently lead to gum disease and decay on
adjacent teeth, which can ultimately result in the loss of these
teeth in addition to the wisdom teeth.
Sometimes wisdom teeth erupt in abnormal positions and
angulations making them non-functional, as they are unable to
contact their corresponding opposing wisdom teeth. In such
situations, frequent cheek biting or tongue biting can result
from the abnormal positioning causing injuries to the cheeks and
tongue while chewing. Besides this, the unsupported upper wisdom
tooth also starts over-erupting, lengthening out from the
supporting gums, thereby leading to food trapping, decay and gum
infections in the region.
There are situations when the wisdom teeth do not erupt at all
into the mouth. They lie buried within the gum tissue or bone.
Often, patients do not experience problems in such situations.
There are also instances where wisdom teeth are totally absent
in certain individuals.
DRYMOUTH / XEROSTOMIA
Impacted Wisdom Teeth
Dentistry in the new Millennium
Things You Always Wanted to Know About Dentists
Cosmetic Dentistry & Cosmetic Dentofacial Treatment
Bad breath (Halitosis)
Oral Health and Hygiene in Pregnancy
you can do to maintain good oral health?
What can I do about bad breath?
Dental management during pregnancy
pain or tenderness of the gums (gingiva)
unpleasant taste when biting down on or near the area
visible gap where a tooth did not emerge
redness and swelling of the gums around the impacted tooth
swollen lymph nodes of the neck (occasionally)
difficulty opening the mouth (occasionally)
prolonged headache or jaw ache
What can happen if impacted wisdom teeth are not treated?
Serious problems can develop from partially blocked teeth such
as infection, which may turn life threatening and possible
crowding of, and damage to adjacent teeth and bone. Another
serious complication can develop when the sac that surrounds the
impacted tooth fills with fluid and enlarges to form a cyst
causing an enlargement that hollows out the jaw and results in
permanent damage to the adjacent teeth, jawbone and nerves. Left
untreated, a tumor may develop from the walls of these cysts and
a more complicated surgical procedure would be required for
Rare instances have been found when the impacted wisdom teeth
remain asymptomatic without causing any problems. However, no
prediction can be made as to when an impacted molar will cause
trouble, but trouble will probably arise, and that too at
inconvenient times. When it does, the circumstances can be much
more painful and the teeth can be more complicated to treat.
Here, the tooth cannot be removed until the infection or other
complications have been treated. This means loss of more time
and added expense along with some added risk. It's best to have
impacted teeth removed before trouble begins.
How are impacted wisdom teeth treated?
X-rays of the wisdom teeth are made to help assess the
positions, shapes and sizes of the crowns and roots, the
surrounding bone and the nerve, which usually runs below the
roots of the teeth. X-rays also help in identification of
associated disease conditions such as cysts and tumors in
relation to the teeth, apart from aiding in planning of the
In certain cases of impacted teeth, where there seems to be
adequate space available for eruption, the dental surgeon may
advise a pericoronal flap excision (removal of the gum tissue
overlying the impacted tooth) and observation. In such cases,
the tooth may erupt into place after the procedure. However, in
many cases, infection of the overlying gum tissue has been found
to recur. Here, there is no other choice other than the removal
of the offending wisdom tooth.
In light of the clinical experience that most impacted teeth
will ultimately give rise to some type of problem or disease, it
is generally felt that preventive removal of impacted third
molars is indicated. Because complications are significantly
reduced when the impacted tooth has no associated disease
conditions, and because difficulty of removal increases with
age, it is recommended that impacted teeth be removed early. It
is best done as soon as it becomes apparent that there is
insufficient space or that they are not positioned for normal
eruption. Generally, this will occur somewhere between the ages
of 16-18. At this age, the roots of the developing tooth are
usually between one half to two thirds formed and the bone is
less dense, which makes their removal easier and the
post-operative recovery smoother. A young patient usually is
also in optimal general health, which facilitates safe
anesthesia and rapid, complete healing. In older patients,
removal before complications develop is key to shorter recovery
and shorter healing time, besides minimizing discomfort after
Before the removal of the impacted wisdom tooth, the patient is
normally put on a course of antibiotics and anti-inflammatory
drugs to eliminate existing infection and inflammation in the
area. The removal of an impacted tooth is normally a minor
surgical operation, lasting 10 - 45 minutes. It often requires
incision of the gum, cutting the tooth and probably some removal
of bone too. The oral surgeon may provide anesthesia options of
local anesthesia, intravenous sedation, or general anesthesia to
make the procedure more relaxing for the patient. The surgical
wound is often sutured with silk (non-absorbable) or with
absorbable suture materials. Some surgeons advise extraction of
the corresponding upper wisdom teeth also during the same
When taken up under local anesthesia (LA), removal of impacted
teeth is done on one side at a time. This allows a patient to
chew on the other side, facilitates faster healing and recovery.
In certain situations, impacted wisdom teeth on both sides are
removed under general anesthesia (GA) as a single procedure. If
the impacted teeth are very deeply situated, or if they have
abnormal shapes and forms making the procedure difficult to
undertake, GA may again be required for surgical removal. If the
surgical procedure is found to be complex, then the dental
surgeon may refer the patient to an oral and maxillofacial
surgeon, who is trained in surgical treatment of such problems.
After the surgery, the patient is asked to continue the
antibiotics and anti-inflammatory drugs which should be
meticulously taken by the patient without break in order to
facilitate better wound healing without complications. The
patient is given pressure packs to bite on over the surgical
area and ice packs to be placed over the jaw, immediate
post-operatively. The patient is advised to rinse the mouth with
ice-cold water about half an hour after the procedure, after the
gauze / cotton pressure dressings in the area are removed. After
12 hours have elapsed, the patient may start having warm
foodstuffs. However, it would be ideal if the patient has
semi-solid or liquid food (yogurt, eggs, fruitjuice, milkshakes,
protein supplements etc.) for about a day or two after the
surgery, after which he/she may have normal food, without
disturbing the surgical area. The patient should also abstain
from smoking and drinking during the post-surgical phase, to
facilitate better healing and to avoid complications. The
patient may also rinse the mouth with luke-warm saline twice or
thrice a day after the 24-hour period.
What are problems the patient faces after surgical removal of
impacted wisdom teeth?
Swelling, mild pain, mild bleeding (ooze) from the surgical site
and restriction in mouth opening are common problems, which the
patient faces after surgical removal. This may be associated
with tenderness in the area and difficulty while swallowing.
Normally these problems are found to gradually increase after
the surgery reaching the maximum by 12–24 hours
post-operatively. These problems gradually decrease over the
next one-week almost disappearing totally, after suture removal
after 1 week in case of non-absorbable sutures. There may be
instances where problems persist for longer periods.
The patient should report back to the surgeon if the following
problems are seen persisting or increasing even after a period
of 4 days after surgery – bleeding, severe pain, swelling,
restriction in mouth opening, loss of sensation over the chin
and lips, inability to chew properly, jaw joint pain etc.
Are there any complications or risks associated with the
In rare instances, numbness or odd sensation of the lower lip,
chin or tongue may occur. The nerves involved are sensory so
there is no change in appearance or function. Numbness can last
from a few days to several months and in extremely rare
instances can be permanent. However, recovery is usually
uneventful. Usually X-rays made prior to the surgical procedure
helps predict the possibility of involvement of the nerve with
respect to the surgery. However, this is not applicable in all
cases. Very occasionally, a filling in the tooth next to an
impacted tooth may be dislodged or the adjacent tooth broken, in
spite of immaculate care and technique. Filling of the ensuing
defect may solve the problems once the surgical wound heals.
Rarely, pain and/or sensitivity of the adjacent second molar
tooth may also occur, which can be totally rectified. It will
not cause any hollowing of the cheeks as many people suspect.
Potential complications include postoperative infection,
temporary numbness from nerve irritation, jaw fracture, and jaw
joint pain. An additional condition, which may develop, is
called dry socket. This happens when a blood clot does not
properly form in the empty tooth socket, or is disturbed by an
oral vacuum (such as from drinking through a straw or smoking),
the bone beneath the socket is painfully exposed to air and
food, and the extraction site heals more slowly.
It is always important to discuss about the procedure with the
surgeon, prior to surgery, so that the patient is able to clear
all doubts that he/she might have concerning the surgery.
The wisdom teeth, being positioned far behind all the other
teeth, are difficult to clean while brushing and flossing. As a
result, in spite of normal eruption and positioning, wisdom
teeth are increasingly associated with problems such as decay
and gum infections. About 50% of the population needs to have
their wisdom teeth removed (made “wisdomless”) before the age of
40 years, in spite of not having them impacted, in many cases.
As these teeth do not play a very important role in chewing,
their removal does not compromise the chewing efficiency of
individuals. On the contrary, removal of wisdom teeth have found
to improve the chewing efficiency by eliminating problems in the
gums behind the second molar teeth and facilitating better oral
hygiene measures in the area which may not be otherwise
possible. Hence, once removed, wisdom teeth are not generally
replaced. It is extremely important for all individuals to get
the status of their wisdom teeth assessed early by a dental
surgeon, so that necessary treatment if indicated, may be
instituted before much damage is done.
Dr. Prasanth Pillai K.S., BDS,MDS-OMFS.