Wisdom Teeth Surgery
The risks and benefits of retention vs removal of wisdom teeth
Wisdom teeth (or third molars) are the last (and 8th tooth) to erupt into each quadrant of the mouth... Usually in your late teens or early twenties.
They are located at the back of your upper and lower jaws, on the right and left sides. Most people have four wisdom teeth, however it is not uncommon for people to have less than this (anywhere from none to four). They are also called 18 (upper right), 28 (upper left), 38 (lower left) and 48 (lower right) 3rd molar teeth.
Sets of 4 perfectly healthy wisdom teeth, without caries or gum disease, and in normal occlusion, are occasionally seen. However, for the remaining 99% of us, having all four erupting into a perfect position and remaining healthy over a lifetime... Just doesn't happen.
OPG of a general dentist, showing normally erupted wisdom teeth. Previous orthodontic removal of 4 premolar teeth have provided "dental room", and have allowed for normal eruption of wisdom teeth.
Four perfectly normal wisdom teeth, in a normal occlusion is rare, and is seen in less than 1% of a normal adult patient population. Usually such people are highly motivated in their dental care, and have a higher degree of knowledge on dental health care techniques.
For most people there is inadequate space in their jaws to allow eruption of the wisdom teeth fully into their mouths. When this occurs the wisdom teeth are considered to be impacted. The degree and type of impaction is dependant on the position of the wisdom teeth, and the relationship to adjacent teeth and surrounding structures (such as the inferior dental nerve).
OPG showing impacted wisdom teeth. Whilst the patient is asymptomatic, and the wisdom teeth remained buried, the decision to prophylactically remove the impacted teeth is made by considering a balance between the risks of surgery, and the problems that may arise if you leave the wisdom teeth alone.
In general, the decision to remove wisdom teeth is based on a decision that the risks of keeping wisdom teeth, far outweigh the risks of removing them.
Risks of wisdom teeth removal are greatly reduced by having the procedure performed by specialists who have a broad experience of surgery generally, and who have a specific and almost exclusive interest in dentoalveolar surgery.
Always have your wisdom teeth removed by an oral and maxillofacial surgeon in order to maximise the benefits of removal, as well as maximally reduce the chance of adverse consequences from surgery.
Vertical Impaction Mesio angular impaction
Horizontal Impaction Disto angular impaction
Different types of lower right wisdom teeth impactions seen, with variations in orientation requiring differing styles of surgery, as well as representing different levels of surgical difficulty.
Read more on the following questions...
What are the risks of leaving asymptomatic impacted wisdom teeth?
People can often obtain an OPG so their dentist can see all their teeth in one x-ray. Often this is the first time they become aware of impacted wisdom teeth, which thus far may have been hidden and asymptomatic. When you are advised to "Leave them alone until you get a problem", you should ask "What does a problem mean" and "By removing my impacted wisdom teeth, could I potentially prevent problems from arising?".
What are the surgical risks of removing wisdom teeth?
Having surgery by a specialist as opposed to a generalist doesn't necessarily mean you are going to be more financially out of pocket. It should mean that you are seeking specialised treatment to reduce the chance of surgical complications arising... And if they do arise, that your specialist practitioner has a way of quickly, and easily treating you; before the complication takes on a life of it's own. Wisdom teeth removal does have complications, and some occur randomly, whilst others occur due to a reduced level of surgical skill or lack of surgical experience. Whilst having an absolute guarantee that "complications will never occur" is impossible, treatment by a surgical specialist does help in confirming that you're under the best possible care, and in the best possible circumstances of treatment.
Can you have wisdom teeth removed in the presence of infection?
Many people think that having a tooth abscess, or local infection means you have to have the infection treated before you can have any teeth removed. The truth is, this is a myth. Whilst possibly having some veracity in exceptional and unique circumstances, for the vast majority of people, removing the cause of sepsis remains a tenet and basis for good surgical practice... Meaning getting your wisdom teeth removed in the presence of infection, is the treatment for the infection they have caused.
Who should remove wisdom teeth? Should I get a dental surgeon or an oral surgeon? What is the difference?
Steeped in myth and controversy, the answer to who should remove wisdom teeth is simply... A dentist. But it should not be just any dentist. It should be someone who is a dentist, and a specialist in dentoalveolar surgery, and also someone who can deal with wider surgical issues; such as surgical complications, local infection, or in dissecting away tissues deeper than superficial gum tissue. What is an oral & maxillofacial surgeon, and why are such widely qualified people almost exclusively focused on the practice of wisdom teeth removal?.
Is there any such thing as prophylactic removal of wisdom teeth?
This is another controversy of dentistry generally. Most oral & maxillofacial surgeons agree that prophylactic wisdom teeth removal by Oral & Maxillofacial surgical specialists reduces both the risks of retaining (currently non-problematic) wisdom teeth, and the surgical risks of removing wisdom teeth. An analysis of an individual's risk vs benefit ratio should be made for any person considering wisdom teeth removal, with general advice being that the analysis is conducted by a surgical specialist who will conduct the surgery.
Do I need to have my wisdom teeth removed before I start playing contact sports?
Not all wisdom teeth lead to a predisposition to jaw fracture, and not all jaw fractures involve wisdom teeth. The overwhelming majority of jaw fractures that occur on the sporting field (in contact sports), involves the region containing the hidden and impacted wisdom tooth. Many sports physicians, sports dentists, and club trainers recommend for prophylactic screening of wisdom teeth (and for general dental disease) during the off season, and to actively prevent dental and jaw problems arising during the playing season.
Do wisdom teeth affect the teeth in front of them? Are erupting or impacted wisdom teeth a mythical cause of late dental crowding?
The objective evidence suggests otherwise, but anecdotal and specialist clinical experience suggests there is a direct link. Certainly wisdom teeth can adversely affect the periodontal health and enamel integrity of the forward second molar, and disease processes beginning in the impacted wisdom tooth can profoundly affect both global dental and jaw health.
Where do you get wisdom teeth removed? Does it require a general or a local anaesthetic?
There are three situations where wisdom teeth can be safely removed. Under local anaesthesia (LA), or under LA with intravenous (IV) sedation in the Honeysuckle rooms, or with LA and general anaesthesia in a private hospital. All three options have equal efficacy in terms of recovery from wisdom teeth surgery, but have different costs and insurance benefits depending on your level of private health insurance.
If they aren't causing me any problems, should I get my upper wisdom teeth removed?
Impacted upper wisdom teethcause just as many problems as lower impacted wisdom teeth, and even if they have erupted normally, can over erupt if the opposing wisdom tooth (in the lower jaw) is not present. There are a few complicatiosn or retetion, and some of removal you should know about when you make a conscious decision on removing them.
Should I get all four wisdom teeth removed at once, or should I divide my operations into one per side?
The practicality of any operation means time away from school or work for recovery, organising an admission to hospital, drug management and pharmaceutical purchases,and of course costs. Having one operation is cheaper is so many different ways to having two operations.
Surgical Tooth Extraction
The surgical extraction of teeth
Everyone eventually has to have a tooth removed. Most dentists do this quickly using extraction forceps, but an easier and less traumatic way is to remove teeth through surgery. Surgical tooth extractions preserve surrounding tissue, and lead to less tissue bruising, and importantly maximally preserve bone and gum tissue. If you are considering an implant replacement to your extracted tooth, we recommend that you acquire a specialist oral surgeon to remove the tooth in the first place.
Full Dental Clearance
Complete removal of the hopeless dentition
There comes a point where a hopeless dentition needs removal, and planning for formal prosthodontic management can begin. Hopeless may mean extensive periodontal disease, multiple carious or abscessed teeth, or that the reminaing teeth that remain are just functionless. Removing hopeless teeth often means a dramatic improvement in one's oral and general health. Planning to coordinate what replaces your teeth is even more critically important.
Medically Compromised Patients
Oral surgery in patients compromised by chronic medical conditions
When you are already unwell, having decayed or periodontally diseased teeth can often make you more unwell. Your general medical condition may also be affected by the dental treatment you receive.
Some dental conditions that require formal combined medical-dental management, and the Medicare Enhanced Primary Care Programme assists with the cost of private specialist dental care.
Oral Surgery treatment in the presence of Osteoporosis & Fosamax & other Bisphosphonate therapy.
Fosamax and the bisphosphonate family of medications are presumed to offer benefit to slowing down the process of osteoporosis, or reduce bone metastatic disease of some neoplasms such as prostate or breast cancer. The medications themselves offer great benefits for those that suffer from these debilitating diseases. Medical GP prescriptions of these drugs should only be provided on the background of a thorough dental screening, and with ongoing dental reviews through placement onto an Enhanced Primary Care Programme so as to reduce the risk of jaw osteonecrosis.
Oral Surgery treatment in the presence of Diabetes
Diabetes, especially the insulin dependent form, can dramatically alter tissue healing, effect salivary gland function (xerostomia), and rapidly advance inflammatory diseases of the mouth such as periodontitis. Patients with diabetes should be placed by their Medical GP's onto Enhanced Primary Care Programmes, with primary and regular review of dental states through general dentists.
Oral Surgery treatment in the presence of Head & Neck Radiation therapy
Radiation therapy in the head and neck can be curative for local malignancy, but can lead to a life time of salivary gland hypofunction. Xerostomia has other effects such as higher rates of dental decay and periodontal disease. The primary effects of radiation therapy on bone and mucosal healing can also dramatically effect how jaw bone can respond to tooth extractions. Whilst pre-radiation dental reviews are important, post radiation hyperbaric oxygen therapy is an important adjunct to oral surgery in such patients, and can prevent for the development of osteoradio jaw necrosis.
Oral Surgery treatment in the presence of Warfarin, Aspirin, Clopidogrel or Persantin therapy
A modern foundation for physician management of cardiovascular disease is through reduction of blood clotting time. Warfarin, aspirin, clopidogrel and persantin therapies are important for prevention of arterial or venous thrombus, and actively prevent for pulmonary emboli, myocardial infarction or cardiovascular occlusal stroke. Cessation of these drugs to prevent oral surgery bleeding are usually high risk events, that should be balanced against maintaining normal therapeutic drug levels maintaining the low potential for prolonged bleeding from oral surgical procedures.
Oral Surgery treatment in the presence of Cardio- Cerebro-Vascular Disease
Oral surgery, and the drugs involved with treatment may compromise the chance that previous heart attack or stroke re arising. Similarly not treating abscessed or infected teeth potentially may raise your risk of heart attack or stroke. Screening for odontogenic disease, and actively managing dental disease in at risk patients is actively promoted through the dental Enhanced Primary Care Programme, and which is administered by your medical GP.
Oral Surgery management in the presence of a primary Blood Clotting Deficiency
Having von Willebrand's, Christmas Disease, or any form of hemophilia sounds like you are dangerous to treat. Contrary to popular belief, oral surgery treatment can be expeditiously arranged with management involving your hematologist, a medical maxillofacial surgeon and your local pharmacy, and may not necessarily involve expensive in-patient management.
Oral Surgery management of patients with Rheumatoid Arthritis, Sjogrens Syndrome, & other Disease & Medications that lead to Xerostomia
Xerostomia is often a feature of either primary or secondary Sjogren's disease. Many drugs also lead to Sjogren's like symptoms, but without formal evidence for the disease. Proper diagnosis of the cause of your xerostomia is important in defining your treatment, as well as looking for other manifestations of Sjogren's, like primary salivary lymphoma.The effects of Sjogren's is also important to consider, like increased rates of tooth decay.
Impacted Canine Surgery
Surgery to expose and provide traction to the Impacted Canine
An impacted tooth is a tooth that is in such a position in the jaw that it is unable to erupt. Wisdom teeth are the most common teeth to be impacted. However upper canine (maxillary eye teeth) are also commonly impacted.
Impacted canines need to be treated because they can cause damage to adjacent teeth. They can be in contact with the roots of adjacent teeth, causing resorption of the roots. This is often not visible on x-rays until after they have been treated.
The untreated impacted canine can also form cysts (a fluid-filled sac) around the unerupted crown. This can destroy surrounding structures such as the jaw bone or roots of adjacent teeth.
There are two treatment options for impacted canines.
Surgical removal of the impacted canine by an oral and maxillofacial surgeon.
Surgical exposure of the impacted canine by and oral and maxillofacial surgeon and orthodontic extrusion into the dental arch by and orthodontist.
The best option for each individual will be assessed by an orthodontist and an oral and maxillofacial surgeon. Options available to each individual will be dependant on the position of the impacted tooth, compliance of the patient in undergoing the treatment, and the position of the rest of the teeth in the dental arch. However if possible the best option is to surgically expose the impacted canine then orthodontically extrude it.
The maxillary canine is a major support for the inside cheek & nasal rim. Loss of the canine accentuates the appearance of a flattened upper lip. One sided (unilateral) canine loss can lead to considerable mid-facial asymmetry, as well as an off-centre position of the maxillary dental midline.
x-rays pre-treatment and 10 months post treatment
Treatment series showing… 1. Presence of primary (deciduous canine) with
2. Exposure of palatal canine & presence of orthodontic traction chain and elastic
(baby canine removed), and
3. Formal orthodontic positioning of permanent canine into arch.
Further orthodontic fine-tuning occurs after extrusion.
13 YEAR OLD FEMALE WITH PALATALLY IMPACTED UPPER CANINE
Progressive OPGs showing change of palatal canine position utilising gold chain.
Progressive photos showing change of palatal canine position utilising gold chain. Further orthodontic treatment is required to align adjacent teeth, as well as specifically rotate, & stabilise the canine tooth into a perfect arch position. Overall orthodontic treatment length can approach 2-3 years; a substantial proportion of which is dedicated to treatment of the impacted canine.
Surgery to modify the dento-alveolus for dental pre-prosthetic rehabilitation
Wearing dentures is never pleasant, but techniques exist that can enhance and make more comfortable the process of fitting the ideal denture for you. Many pre-prosthetic surgical services are Medicare covered (when provided by accredited oral & maxillofacial surgeons), and surgeons work closely with your dentist or dental prosthetist to design something right for you.
Gum Graft Surgery
Grafting procedures to augment dento-alveolar attached gingiva
Somtimes gums just disappear. Heavy brushing, plaque traps, and just the peculiarities of your local anatomy predispose to gums dissolving over roots of teeth. This leaves your teeth vulnerable to more gum loss... And eventually... You lose the tooth. Gum grafting is a quick, successful way of achieving your gum lines back... and all with very heavy specialist surgical Medicare subsidies.
Gum grafts are usually harvested from the palate, where the after effects are often likened to a hot-pizza burn. Regrowth of palatal mucosa after graft harvesting is very predictable, and graft uptake in other areas of the mouth is usually very stable.
Gum grafting is also used to augment previous bone graft surgery, particularly where later implant surgery is anticipated.
Click on the following patients to find out more on the treatment benefits of gum graft surgery, and some of the applications where gum graft surgery may be recommended.
This 52 year old female was tortured by the continued gum loss associated with her lower anterior incisor. Multiple dental visits had only resulted in worsening of the condition, with serious threat to the continued longevity of the tooth. On presentation to the oral & maxillofacial surgeon, a gum harvest was taken from the palate and grafted to a prepared graft bed over the area of dehiscence.
This 32 year old lady had darkening upper front teeth, and deteriorating gums in the lower jaw. Coming from the country, she required overall definitive care that maximised the efficiency of a 4 hour one-way drive.
Traction Screw Tooth Movement
Traction screw assistance in moving teeth
Somtimes teeth are just in the wrong position, and no matter how much your orthodontist tries, the tooth just won't go to the right place. Traction screws are Medicare subsidised procedures, which are simple, cheap, and very quick... And importantly assist in providing just that right amount of traction pull on that stubborn tooth (or teeth).
Click on the following cases to read more on how traction screws can assist in orthodontic repositioning of teeth.
This 18 year old girl had never developed her left lower second premolar tooth. The orthodontist wanted to have the deciduous molar removed, and to move the permanent first molar into the tooth space, but the length of movement was considerable, and the forces were more likely to move her front teeth backwards, than her back teeth forwards. A traction screw was employed to provide a stable anchorage, and gradually the first molar was moved into ideal position.
This 23 year old female had an impacted lower second molar tooth, and several attempts were made to help it self erupt. The impaction had caused the opposing maxillary second molar to over erupt, and so traction screws were used to intrude the tooth into a normal position.
This 16 year old girl had an anterior open bite, and required classical LeFort orthognathic maxillary surgery to correct it. Instead of orthognathic surgery, traction screws were placed into the posterior maxilla, and used to intrude the posterior teeth, allowing for a reduction of dento-alveolar height, and an elimination of her anterior open bite.
This 15 year old, but skeletally well developed female, had a long lower jaw, which had caused her lower anteriors to be forward of her upper anterior teeth. Classically treated only with orthognathic jaw correction surgery, traction screws were instead employed to "pull-back" the entire lower arch to help approximate a normal Class I occlusion. In this way she avoided major orthognathic corrective surgery.
Management of fractured teeth and the injured dento-alveolus
Fallen flat on your face? Been kicked in the mouth by a horse? Been punched in the lip by your friendly bikie? Knocking front teeth, and fracturing the brittle and fragile local bone and gums surrounding your teeth requires more than just shoving that displaced tooth back in. If you want lasting care, with your front teeth firmly in place, and without a lifetime of dental and medical bills, seek the care of an oral surgeon right from the start. Most trauma surgery is treated with considerable Medicare subsidies when provided by oral & maxillofacial surgeons.
Dental Abscesses & Cysts
Oral Surgery to treated abscessed or cystic teeth
Odontogenisis Cysts & Abscesses are common in the alveolar part of your jaw bone. Root canal therapy may assist, but treatment often requires multiple practitioners for care. Sometimes it is better to go tail first and seek the specialist first... This way, you have him refer you back to your dentist for root canal work... If you need it (rather than the other way round). Abscesses and cysts are Medicare subsidised conditions when treated by oral & maxillofacial surgeons.