IMPLANT AND SURGERY
Wisdom Tooth Extraction
To extract or not to extract? — a decision-focused approach
Provided at our clinic in Altunizade, Üsküdar (Istanbul).
IN SHORT
When wisdom teeth cannot find enough room in the jaw, they cannot erupt fully and remain impacted or partially impacted. The decision to extract is made according to the position of the tooth and whether or not it causes a problem; not every wisdom tooth needs to be extracted. A wisdom tooth that has erupted properly, is free of decay and can be cleaned can stay in the mouth. In situations such as recurring inflammation, decay, damage to the neighbouring tooth or a cyst, on the other hand, extraction is required. The decision is made after clinical examination and radiographic assessment.
What is a wisdom tooth?
Wisdom teeth (the third molars) are the last teeth to erupt in the mouth. They generally come through between the ages of 17 and 25. There are four in total, one on each side of each jaw; however, in some people they never form or are fewer in number. This is not a problem.
The problem arises from the size of the jaw. The human jaw has become smaller over time, while the number of teeth has stayed the same. For this reason wisdom teeth may not find enough room to erupt.
Positions
A wisdom tooth can be found in three situations. Which situation it is in directly affects the decision to extract.
Fully erupted. The tooth is completely visible in the mouth and takes part in chewing.
Partially impacted. Part of the tooth remains under the gum. A pocket forms between the gum and the tooth.
Fully impacted. The tooth remains completely under the bone or gum; it is not visible in the mouth.
The angulation of the tooth is also important: it can be upright, tilted forwards, tilted backwards or in a horizontal position. Teeth tilted forwards and in a horizontal position press on the molar in front of them.
In which situations is extraction required?
Recurring inflammation (pericoronitis). In a partially impacted tooth, food debris and bacteria get into the pocket between the gum and the tooth. This area cannot be cleaned with a brush. The result: recurring pain, swelling and infection. It is the most common reason for extraction.
Decay. The wisdom tooth itself can decay. Because of its position, a filling or root canal treatment for this tooth is often difficult or not possible.
Decay in the neighbouring tooth. A wisdom tooth tilted forwards rests against the back surface of the molar in front of it. This contact area cannot be cleaned and decay develops there; it can cause the loss of a sound molar. In other words the problem appears not in the wisdom tooth but in the healthy neighbouring tooth.
Cyst formation. A cyst can develop from the sac surrounding the impacted tooth. The cyst can grow and cause destruction of the jawbone. It usually gives no pain; it is seen on an X-ray.
Root resorption of the neighbouring tooth. A wisdom tooth that is pressing can resorb the root of the neighbouring tooth.
Gum disease. Because the area cannot be cleaned, gum disease and bone loss can develop.
As required by an orthodontic or prosthetic treatment plan. In some treatments the extraction of the wisdom tooth can be part of the plan.
In which situations is extraction not required?
Not every wisdom tooth needs to be extracted.
A wisdom tooth that has erupted fully, is in the correct position, is free of decay and can be cleaned with a brush can stay in the mouth. This tooth takes part in chewing and is functional.
Fully impacted teeth that give no symptoms, show no pathology such as a cyst or decay and have no problem around them. In these teeth the decision to extract is made by also assessing the position of the tooth and its proximity to the nerve. The risk of extracting a tooth that is deep and very close to the nerve may be higher than the risk of leaving it in the mouth; in this situation regular radiographic follow-up is carried out.
There is no scientific consensus on the routine extraction of sound impacted teeth that give no symptoms. The decision is made on a patient-by-patient basis, weighing the risks and the possible benefits together.
Do wisdom teeth make the front teeth crowded?
This is a widespread belief, but scientific evidence does not support this claim.
The crowding seen in the front teeth in later years also occurs in people whose wisdom teeth never formed. It is reported that this change results from the teeth's natural tendency to move forwards and from age-related changes in the jaw and the soft tissues.
The practical consequence of this is the following: having a wisdom tooth extracted in order to prevent crowding is not a reliable method. What keeps the teeth in place after orthodontic treatment is the use of a retainer.
A wisdom tooth can be extracted to make room as part of an orthodontic treatment plan. This is a different reason from extracting it to prevent crowding.
The procedure step by step
Examination and imaging
A panoramic X-ray is taken. If the roots of the tooth are close to the nerve in the lower jaw, three-dimensional imaging may be requested to assess the relationship between the root and the nerve canal.
Planning
The position of the tooth, its angulation, the number of roots and their shape are assessed. Whether it will be necessary to remove bone or to divide the tooth is determined.
Anaesthesia
The procedure is carried out under local anaesthesia. In patients with a high level of anxiety, the sessions can be divided and breaks taken.
Surgery
In impacted teeth the gum is lifted and, if necessary, the bone over the tooth is removed. If the tooth is in a position where it cannot be removed in one piece, it is divided and removed piece by piece. This is not breaking the tooth; it is the way of removing it without harming the surrounding tissue.
Cleaning and sutures
The area is cleaned and, if necessary, sutures are placed. Sutures are usually removed after 7–10 days; if dissolvable sutures are used, they do not need to be removed.
Healing: the first 24 hours are decisive
A blood clot forms in the extraction socket. This clot is the foundation of healing; it protects the bone and the nerve endings. Everything done in the first 24 hours is aimed at protecting this clot.
Gauze is bitten on for 30–60 minutes; if bleeding continues, it is replaced with a new one.
Cold is applied to the face from the outside (apply for 15 minutes, break for 15 minutes).
The mouth is not rinsed, no spitting is done and no straw is used. These three actions create suction pressure in the mouth and can dislodge the clot.
No smoking. Both the sucking movement and the content of the smoke disturb the clot and healing.
Hot food and drinks are not taken.
After 24 hours: gentle rinsing with warm salt water can be done; soft and lukewarm eating is continued; tooth brushing is continued, but the extraction area is not touched in the first days.
Swelling usually reaches its highest level at 48–72 hours and then subsides. The absence of swelling on the first day does not mean it will not occur in the following days. Difficulty in fully opening the mouth (trismus) can last a few days and is an expected finding.
Dry socket (alveolar osteitis)
It develops as a result of the early loss of the clot in the extraction socket. The bone and nerve endings underneath are left exposed.
Its typical sign is the following: while the pain follows a normal course in the first 1–2 days after extraction, on days 3–5 the pain suddenly increases and spreads to the ear and the temple. Painkillers are not enough. There may be a bad smell and taste in the mouth.
Factors that increase the risk: smoking, using a straw, spitting, vigorous rinsing, inadequate oral hygiene and difficult extractions.
Dry socket is not dangerous but it is painful. It is treated by cleaning the area and applying a dressing containing a painkiller. It should not be expected to pass on its own; the clinic should be contacted.
The risk of nerve damage
The roots of the lower-jaw wisdom teeth can be close to the canal through which the nerve that supplies the lower lip and the chin passes. This proximity carries a risk of the nerve being affected during the procedure.
If the nerve is affected, numbness, tingling or loss of sensation occurs in the lower lip, the chin or the tongue. This situation is temporary in most cases and recovers within weeks or months. Permanent loss of sensation is rare.
To reduce the risk: if the roots are close to the nerve, the position of the canal is assessed with three-dimensional imaging. In some cases, if the roots of the tooth are very close to the nerve, a method in which only the crown of the tooth is removed and the roots are left in place (coronectomy) can be considered.
Why does age matter?
At a young age the roots of the wisdom tooth are not yet fully developed and the bone around it is more elastic. The extraction is easier and healing follows a faster course.
As age advances the roots develop fully, the bone hardens and the relationship of the roots with the nerve can become more complex. The procedure becomes more difficult, healing takes longer and the risk of complications increases.
However, this does not mean that “every young patient should have their wisdom tooth extracted”. The decision to extract is made according to whether or not the tooth causes a problem; not by age alone.
Risks and possible complications
Dry socket.
Infection.
The nerve being affected: numbness in the lower lip, chin or tongue. It is temporary in most cases; being permanent is rare.
Difficulty in fully opening the mouth (trismus). It can last a few days.
Damage to the neighbouring tooth or its filling.
Opening of the sinus cavity in the upper jaw.
Bleeding.
Jaw fracture. It is very rare; it has been reported in older age and in very deeply impacted teeth.
Knowing these risks is not in order to avoid the procedure but in order to make the decision consciously. In a tooth where extraction is necessary, postponing the procedure also carries its own risks.
The decision: should I have it extracted?
The real question the patient asks is this: should I have it extracted? The table below summarises the approach and its reason according to the condition of the tooth; the first two and the last row hold you back from an unnecessary extraction.
Compare the options
| Approach | Reason | |
|---|---|---|
| Fully erupted, decay-free, can be cleaned | Extraction not required | The tooth is functional and takes part in chewing. |
| Fully impacted, asymptomatic, no pathology | Radiographic follow-up | The risk of extraction may be higher than the risk of leaving it in the mouth. Especially in teeth close to the nerve. |
| Partially impacted, recurrent pericoronitis | Extraction | The gum pocket cannot be cleaned. The infection recurs. |
| Tilted forwards, resting on the adjacent molar | Extraction | Decay develops at the contact area and a sound molar can be lost. |
| Decay in the wisdom tooth | Extraction | Because of its position, a filling and root canal treatment often cannot be carried out. |
| Cyst around it | Extraction | The cyst grows and causes destruction of the jawbone. It usually gives no pain. |
| Root resorption of the neighbouring tooth | Extraction | The pressure resorbs the root of the neighbouring tooth. |
| Only to prevent crowding | Extraction not required | Scientific evidence does not support this reason. A retainer is used. |
Which option is suitable is decided together after an intraoral examination.
Frequently Asked Questions
No. A wisdom tooth that has erupted fully, is in the correct position, is free of decay and can be cleaned with a brush can stay in the mouth. In fully impacted teeth that give no symptoms and show no pathology, on the other hand, regular radiographic follow-up may be preferred instead of extraction; especially if the roots are very close to the nerve. The decision to extract is made according to whether or not the tooth causes a problem.
Scientific evidence does not support this claim. Late crowding in the front teeth also occurs in people whose wisdom teeth never formed. Extracting a wisdom tooth in order to prevent crowding is not a reliable method; what keeps the teeth in place is the use of a retainer. A wisdom tooth can be extracted to make room as required by an orthodontic treatment plan; this is a different reason.
The procedure is carried out under local anaesthesia and no pain is felt during it. Pressure and movement are felt. The pain and swelling lasting a few days after the procedure are expected findings; they can be brought under control with the medication your dentist recommends.
Swelling usually reaches its highest level at 48–72 hours and then subsides. Applying cold to the face from the outside in the first 24 hours reduces swelling. Difficulty in fully opening the mouth (trismus) can last a few days and is an expected finding.
It develops as a result of the early loss of the blood clot in the extraction socket. Its typical sign is the following: while the pain follows a normal course in the first 1–2 days, on days 3–5 the pain suddenly increases and spreads to the ear and the temple; painkillers are not enough. There may be a bad smell and taste in the mouth. It should not be expected to pass on its own; the clinic should be contacted. Smoking, using a straw, spitting and vigorous rinsing increase the risk.
In some cases it is possible and can be done in a single session. However, the healing period is more difficult; both sides swell at the same time and chewing is noticeably restricted. Extraction on one side or divided into two sessions may be preferred for comfort. The decision is made according to the position of the teeth and together with the patient.
The roots of the lower-jaw wisdom teeth can be close to the nerve that supplies the lower lip and the chin. If the nerve is affected, numbness or tingling occurs; this is temporary in most cases and recovers within weeks or months. Permanent loss of sensation is rare. To assess the risk, if the roots are close to the nerve, the position of the canal is determined with three-dimensional imaging.
At a young age the roots are not yet fully developed and the bone is more elastic; the extraction is easier and healing follows a faster course. However, this does not mean that extraction should be carried out for age alone. The decision to extract is made according to whether or not the tooth causes a problem.
It should not be smoked in the first days. The sucking movement that occurs while smoking can dislodge the clot; the content of the smoke, on the other hand, disturbs healing and noticeably increases the risk of dry socket. It is recommended not to smoke for as long as possible.
Unless there is an emergency (infection, severe pain), it is preferred to postpone the extraction until after the birth. If there is an infection, postponing treatment may be more risky for mother and baby; in this situation the second trimester is generally preferred. You must inform your dentist about your pregnancy.
Related treatments
The content on this site is for information only and does not replace a clinical examination. The suitability, duration and scope of treatment are determined after a clinical assessment.
This content was prepared by Dt. Mevlüt Yazıcı.
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Altes Diş Kliniği
Altunizade, Üsküdar, İstanbul
- PHONE+90 533 474 43 94
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- ADDRESSAlperen İş Merkezi, Valide-i Atik Mahallesi, Altunizade, Nuhkuyusu Cd D:191/B, 34664 Üsküdar/İstanbul
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