Are you suffering from impacted wisdom teeth? If yes, then you should read this article. This condition is quite common and affects millions of people worldwide. Around 90% of us have at least one impacted wisdom tooth. Understanding what’s involved with third molar removal and recovery will aid your healing after surgery.
Impacted wisdom teeth occur when the third molar (wisdom tooth) fails to erupt into its proper position. The result is that the tooth gets stuck within the gums and jawbone. As time passes, the pressure caused by the growing bone and tooth pushes the tooth further down, causing pain and discomfort. In addition, an impacted wisdom tooth may be partially visible (partially impacted), or it may never break through the gum line (fully impacted).
Wisdom teeth erupt between the ages of 15 and 25. Some people have no issues during this process, whereas others experience pain and discomfort. In addition, lack of adequate space is the most common reason tooth impaction occurs.
Impacted wisdom teeth can cause serious complications such as infection, abscesses, cysts, swelling, and even nerve damage. They also increase the risk of developing dental problems later in life. Therefore, it is crucial to remove them as soon as possible.
Impacted wisdom teeth can lead to many symptoms, including pain and swelling. You must inform your dentist if you have any of the symptoms below. Early intervention offers the best chances of treatment success, so don’t put it off. Sometimes unerupted wisdom teeth will have no symptoms and will be discovered by your dentist or orthodontist after a panoramic x-ray.
The causes of impacted wisdom teeth are variable; however, the most common reason is due to lack of adequate space in the mouth. The second molar is the last visible tooth before the wisdom tooth erupts. Therefore, people with small mouths won’t have enough room for the third molar to erupt, leading to tooth impaction. Other causes include:
Inadequate space – Wisdom teeth erupt behind the last molar and before the jaw bone. This space can be insufficient due to patient stature (shorter people have smaller bones and less room for teeth) or a small mouth.
Tooth angulation – Teeth not positioned upright can be angled in many directions and inhibit proper tooth eruption. The most common tooth angulation is mesial impaction, pointing towards the second molar (towards the midline). The anatomical crown of the second molar can act as a barrier and hold down the erupting third molar.
Genetics – Patient genetics also plays a role in tooth impaction. For example, genetics is the most common reason people are missing teeth. In addition, if your parents or siblings are missing wisdom teeth, chances are high you will be missing some too.
Soft vs. hard tissue impaction
Soft and hard tissue impaction classifications dictate how difficult wisdom tooth removal will be. In addition, wisdom teeth can be impacted by the gums or the bone. Understanding the difference between them will help you better understand the surgical procedure.
Soft tissue impaction – This occurs when the wisdom tooth has erupted through the bone but not yet through the gum tissue. Often the wisdom tooth will be impeded by surrounding bone, tooth angulation or the second molar. Tooth extraction is less invasive than hard tissue impaction.
Hard tissue impaction – This occurs when the bone fully encapsulates the wisdom tooth, which is the most common type of wisdom tooth impaction and requires more invasive treatment. Hard tissue impaction is further classified as partial bony or complete bony impaction. In addition, tooth extraction involves the removal of bone tissue and splitting the tooth into pieces for removal.
After the removal of impacted wisdom teeth, a large void in the bone will be left behind the second molar. As a dentist, I recommend placing bone graft material in the tooth socket after the extraction if an inadequate amount of bone is left to support the second molar. Discuss bone graft options with your oral surgeon before treatment.
Bone graft is vital to replace lost bone after impacted wisdom teeth extractions.
Partial vs. complete bony impaction
If the wisdom tooth is considered a hard tissue impaction, it’s further classified into partial or complete bony based on much bone is still covering the wisdom tooth. For example, if the impacted wisdom tooth has broken through the bone level, it’s considered partial bony. However, if the bone fully encapsulates the wisdom tooth, it’s considered complete bony.
Partial bony impaction – Involves a portion of the wisdom tooth above the bone level but below the gum tissue level. Partial bony impaction may require sectioning the tooth to remove in pieces.
Complete bony impaction – Involves the complete obstruction of the wisdom tooth due to tooth angulation or encased within the bone. These are the most difficult teeth to remove and involve removing large portions of bone and sectioning the wisdom tooth to pieces.
Impacted wisdom teeth classifications
Bony and tissue impaction isn’t the only method to classify impacted wisdom teeth. There are four types of impacted wisdom teeth classifications involving the positioning of the tooth. The type of impaction is vital for the surgeon to analyze on the panoramic x-ray before surgery.
Mesial impaction – Mesial impaction is the most common type. It occurs when your wisdom tooth is angled toward the front of your mouth (midline).
Distal impaction – Distal impaction is the rarest type; it happens when your wisdom tooth is angled toward the back of your mouth.
Vertical impaction – Vertical impaction is when your wisdom tooth is in the correct position for eruption, but it’s still trapped beneath your gums. Often, the wisdom tooth will get stuck under the anatomical crown of the second molar.
Horizontal impaction – Horizontal impaction is when your wisdom tooth is lying entirely on its side, trapped beneath your gums. Horizontally impacted wisdom teeth are often painful because they place excess pressure on the teeth in front of them. In addition, they can be more difficult to surgically access and remove.
Why do impacted wisdom teeth need to be removed?
Removing impacted wisdom teeth when you are younger (15 to 25) is crucial because you will heal quicker and recover faster, and the bone is thin. In addition, removing wisdom teeth before they are fully grown allows for easier access and extraction for the oral surgeon. In addition, it will be challenging to brush and floss wisdom teeth to prevent cavity-causing bacteria from forming.
Untreated, impacted wisdom teeth will harbor harmful bacteria. Oral bacteria can travel from your mouth through the gum tissue and into the bloodstream leading to systemic infections affecting the heart, kidneys, and other organs. Diabetes, heart disease, and kidney disease are common systemic health conditions associated with oral bacteria invasion. In addition, problems can occur when the roots are fully grown and cause difficulties for the oral surgeon during the procedure.
Crowding – According to a recent study, some dentists believe that lower third molars cause teeth crowding, whereas others deny this theory. Retained impacted wisdom teeth may be a contributing factor in teeth crowding; however, there are other factors to consider, including gum health, tooth shape, size, and patient’s age.
Tooth decay – Malposed (crooked) wisdom teeth can be difficult clean, and this encourages cavity-causing bacteria growth. In addition, cavities can form deep below the gum line and are nearly impossible for the dentist to manage.
Cyst formation – Cysts are fluid-filled “sacs” within the jaw that can develop due to impacted wisdom teeth. Cysts are challenging to manage and can destroy adjacent teeth, gums and bone. In addition, cysts can expand into essential elements, including the IAN (Inferior alveolar nerve) and various blood vessels.
Damage to adjacent teeth – Impacted wisdom teeth angled toward the adjacent teeth can inadvertently grow into the tooth roots and cause tooth resorption. This irreversible process can affect both teeth and requires tooth extraction. Unfortunately, tooth resorption cannot be repaired or prevented.
Bone loss/periodontal disease – Impacted wisdom teeth can resorb bone tissue supporting the adjacent teeth. The disease process results in moderate to severe bone loss around the “healthy” second molar and may require removal if inadequate bone support is present.
Studies have found that periodontal disease in expectant mothers may be associated with a greater likelihood of preterm and low birthrate babies.
Impacted wisdom tooth removal
Impacted wisdom teeth are removed while the patient is sedated. On the day of your surgery, it’s essential that you don’t eat or drink 8 hours before the procedure. However, the dentist will advise you to take the medication you generally take (unless it interferes with the procedure – your surgeon will discuss this with you).
Generally, wisdom teeth can be extracted with little to no pain, and the procedure will take 30-60 minutes to complete. Plan accordingly as you and your driver will be in the office for approximately 90 minutes. Wisdom teeth extractions are considered an outpatient procedure, so you will be able to go home afterward.
The oral surgeon or anesthesiologist will administer anesthesia/sedation. General anesthesia is the most common method, allowing you to “fall asleep” and not recall the procedure. In addition, the dentist will monitor your vitals, including blood pressure, heart rhythms, pulse, and blood oxygen.
Local anesthesia will be administered to numb the teeth adequately. In addition, the dental assistants will support your head, neck, and jaw as you cannot actively support them.
An incision will be made behind the second molars to allow access to the bone and wisdom teeth.
After the gums are retracted, a surgical handpiece will be used to remove bone above and around the tooth. The surgeon will carefully cut bone to access the teeth without disturbing the nerve and other vital elements.
The tooth is “sectioned” (split into pieces) to allow easier removal within the small, confined space.
The tooth is then carefully elevated (rocked back and forth) and extracted.
The tooth socket is rinsed with sterile saline (salt water) to remove any tooth or bone particles that may be left behind.
Sutures/stitches will be placed over the tooth socket to allow a blood clot to form and prevent food debris from entering the space. Dissolvable stitches will be placed and will last for 3-5 days before dissolving.
Medication will be administered to reverse the general anesthesia and cause you to wake up from the sedation. In addition, you will be sleepy for most of the day, so be sure to rest and recover.
Gauze packs will be placed and keep firm pressure for 30-60 minutes to encourage blood clot formation.
Most common complications after wisdom tooth removal
According to a recent study, the most frequent complication was alveolar osteitis (dry socket), occurring in 3.9% of cases. The second most common complication, occurring in 1.5% of cases, was a post-operative temporary or permanent sensation disorder. Managing post-operative complications becomes more challenging if immediate care is not taken. When in doubt, call your dentist if you have any questions or concerns.
How to manage surgical complications
Dry socket (alveolar osteitis) – Dry socket is the most common complication and occurs when the blood clot falls out, exposing infected bone. This condition is excruciating and most often occurs around days 3 and 4. Dry socket is managed with dry socket paste (eugenol + cloves) at the oral surgeon or irrigated with sterile saline to initiate a new blood clot formation.
Temporary/permanent numbness (paresthesia) – This complication can occur from trauma to the inferior alveolar nerve (IAN) that runs adjacent to lower wisdom teeth. According to a recent study, inferior alveolar nerve (IAN) paresthesia occurs 0.35% to 8.4% of the time. Although these figures are relatively low, they are still significant for patients and clinicians.
Excessive bleeding – Bleeding and oozing are expected up to 24 hours after surgery; however, if you are actively bleeding after 24 hours, call your dentist as soon as possible. Patients taking blood thinners or other platelet management medications may experience this complication. Bite on a tea bag until your dentist can see you.
Damage to adjacent teeth – During the surgery, the oral surgeon uses tremendous force to pry and loosen the wisdom teeth from the bone. It’s not uncommon for the surgeon to inadvertently damage adjacent teeth, specifically crowns or fillings. However, most complications can be quickly resolved by your dentist.
TMJ damage/clicking/popping – The TMJ can be stretched and traumatized during the procedure as the surgeon and assistants access the wisdom teeth. Although it’s uncommon, clicking or popping after your wisdom teeth have been removed may occur, and if there is no pain, there is no cause for concern.
Jaw muscle strain – Similar to TMJ trauma, the muscles that support the jaw will be stretched during the procedure. As a result, sore, stiff or tender muscles are common for 1-2 weeks after the surgery. Use a cold compress for the first 36 hours to minimize swelling, followed by alternating cold and warm packs afterward. In addition, it’s not uncommon to have limited jaw opening after surgery because of jaw muscle strain.
Swelling & infection – Swelling and bruising are expected after wisdom teeth removal; however, if you notice signs of infection, including an elevated temperature, contact your surgeon as this may indicate that you need antibiotics. In addition, use OTC anti-inflammatory medications (Ibuprofen, Motrin, Advil) as is necessary to minimize inflammation and pain.
Poor nutrition – It’s essential to stay hydrated after the surgery and consume adequate carbohydrates, protein, vitamins and minerals. Stick to a soft food diet for 1-2 weeks. Consume foods such as mac & cheese, applesauce and protein shakes. Poor nutrition will lead to poor healing and immune response. In addition, be sure to get enough sleep to allow your body to recover after surgery.
Best methods to recover faster
Wisdom teeth removal is a standard outpatient procedure for patients between the ages of 15 and 25. Recovery after wisdom teeth removal takes 3-4 days, but it can take 1-2 weeks for symptoms to subside. Your oral surgeon will provide detailed post-op instructions, including contact information. In addition, you must follow the at-home care instructions that your surgeon gives you to prevent complications and improve healing.
Your mouth is designed for optimal healing and regeneration; however, expect the tooth socket to heal completely in 3-6 months.
Follow these steps to minimize complications and recover quicker:
Take prescribed medication before the local anesthesia wears off
Rest and recover for the first 3-4 days to allow the mouth to heal
Avoid sucking, spitting, smoking or vigorously swishing to prevent dry socket.
Use cold compress up to 36 hours after surgery to reduce inflammation, pain and swelling
Alternate between hot and cold packs after that to stimulate healing
Gently rinse mouth out with warm salt water 2-3x/day
Gently massage TMJ and jaw muscles to decrease soreness
Keep head elevated up to 72 hours after surgery to minimize pain and swelling
Sleep often and stay off of your feet
Avoid physical activity for 3-4 days
Consume adequate amounts of fluid and electrolytes (Gatorade)
Consume sufficient amounts of nutrients (soft-food diet)
As a dentist, I’ve fielded many questions about tooth removal, specifically impacted wisdom teeth. Questions are essential to help gain insight into the procedure and feel more comfortable on the day of the surgery. However, no question is a dumb question.
Are impacted teeth more painful to remove?
During the procedure, you will be sedated and won’t experience any pain. However, the more impacted the tooth is, the more likely pain will be present. Why is that? A complete bony-impacted wisdom tooth requires more bone removal than a partial bony or soft tissue-impacted wisdom tooth.
Do all wisdom teeth need extracting?
No, not all wisdom teeth need to be extracted. Similar to an asymptomatic impacted wisdom tooth, some wisdom teeth will erupt on schedule without any issues. Patients with larger mouths have more space for the teeth to erupt. The challenge becomes keeping the asymptomatic, disease-free wisdom teeth clean from gum disease and tooth decay.
The risk of future disease requiring the removal of wisdom teeth in patients who don’t have them removed exceeds 70% after 18 years.
Wisdom teeth extractions can be a daunting experience, especially if they are impacted. Patient education is key to understanding what’s involved and how to recover faster. Take it easy after surgery and give yourself plenty of time to heal.
The more you know, the more healthy habits you can develop, saving you and your family from avoidable and potentially expensive dental procedures. Talk to your dental professional for more suggestions on improving oral health and check back for more blog posts and relevant information. Please share this site and let us know what else you’d like to know!
Dr. Advocate is an actual board-certified dentist with clinical practice experience and a mission to provide accurate dental patient education. He believes everyone should access easy-to-read dental resources presented in layman’s terms with relevant, up-to-date dental research and insight to improve their oral health.