Impacted Wisdom Teeth
Third molars, commonly known as wisdom teeth, are located at the back of the mouth and are the last of the adult teeth to erupt (come out into the mouth).
Impacted Wisdom Teeth
Third molars, commonly known as wisdom teeth, are located at the back of the mouth and are the last of the adult teeth to erupt (come out into the mouth).
When these teeth are not able to come out and line up with the adjacent teeth, remaining retained inside the bone, they are known as impacted wisdom teeth.
Evolutively, human skulls and jaws used to be big enough to allow third molars to erupt. Third molars were very important to our ancestors for dietary reasons, they needed powerful jaws and teeth to chew their food. As humans and our diet evolved, we no longer needed big jaws nor three molars. Unfortunately, the size of our jaw did not change along with the number of teeth, and we ended up with four sets of third molars with less space available to develop and erupt. Consequently, it is highly common to find patients with unerupted wisdom molars, retained into their jaws in awkward positions (titled or horizontal), especially in the lower jaw, causing numerous problems.
Causes:
Wisdom teeth usually erupt between 17 and 25 years. Their size, shape and position vary on each patient, and so does the possibility for their eruption. Therefore, third molars are less likely to remain retained in people with bigger jaws or smaller teeth. In such cases, they erupt and line up with the other teeth in front of them, they are completely functional and allow adequate hygiene.
On the other hand, when the size of the jaws and the teeth differ, third molars will develop in a tilted or horizontal position toward the front tooth or will become trapped (impacted). In other cases, they can partially erupt and a small portion of their crown will remain covered by gum or bone. These last ones are the more dangerous for your oral health, as they tend to retain more plaque, their position makes hygiene difficult and sometimes painful.
Symptoms
Impacted wisdom teeth can continue unnoticed throughout life, particularly if they are retained deep inside the bone. However, many other times, impacted molars may damage the surrounding tissues or the tooth in front of it, especially when wisdom teeth have partially erupted. In such cases, the wisdom molars cause inflammation of the surrounding gum (opercle), which could produce severe pain that radiates to the ear and head. You may experience the following symptoms:
- Red or swollen gums which are tender or bleed.
- Jaw pain or difficulty to open your mouth.
- Bad breath or an unpleasant taste in your mouth.
However, not always problematic impacted wisdom teeth are symptomatic. Hence, the importance of consulting your dentist regularly. With a panoramic X-Ray (OPG), your dentist can find out if your wisdom teeth are developed, what is their position and what are the chances of them to properly emerge. Therefore, you can monitor their growth and keep a close eye for any arising complication associated.
Complications
Asymptomatic impacted wisdom teeth have been associated with a number of conditions and pathological changes. Some examples are:
- Inflammation of the gums.
- Resorption of the root of the adjacent tooth.
- Decay affecting the wisdom teeth or the teeth in front of them. This is due to food trapped in areas where it gets difficult to brush and floss, or the toothbrush does not reach. Bad oral hygiene habits worsen this condition.
- Development of cysts and tumours.
- There is no significant scientific evidence linking impacted wisdom teeth and dental crowding nor relapse of dental crowding after orthodontic treatment. Neither there is conclusive evidence proving an association between impacted lower third molars and headaches.
Some research states that only 12% of truly impacted teeth are associated with pathological conditions, additionally, there is no clear evidence of the influence of impacted third molars as a cause for anterior teeth crowding.
Diagnosis and treatment
Usually, the diagnosis is easily made by the dentist based on a full oral examination and a detailed questionnaire about your hygiene habits and general health.
To complete the diagnosis, the dentist will be using a set of X-Rays that will give an image of the status of your wisdom teeth, including their position within the jaw. A panoramic X-Ray will be used to evaluate the position of the wisdom teeth, their closeness with other anatomical structures such as the mandibular nerve or adjacent roots. Although the chances are low, in case some abnormality is found, your dentist may ask for more specialised 3D images.
Once the diagnosis is made, you and your dentist will take the decision to get your wisdom teeth extracted. Otherwise, if they are not causing symptoms, you can decide to just monitor them in time and see if any abnormality appears. However, if you want to be on the safe side and would like to get them extracted even though they are asymptomatic, you can opt for a prophylactic extraction.
Prophylactic Extractions
The removal of impacted third molars with no signs of disease. A prophylactic extraction is performed to prevent the development of pathological changes. Therefore, in most developed countries the procedure is considered as appropriate. However, according to the American National Institute of Health guidelines, the removal of asymptomatic third molars is not indicated, but a close and detailed monitoring must be performed instead.
Thus, there are absolute indications or contraindications for the removal of third molars have been established. Nevertheless, some oral and maxillofacial institutions and general dentists recommend the extraction of retained third molars, based on the lack of evidence that supports the predictability of unerupted pathology-free wisdom teeth will cause a disease.
Conservative Approach
When there is little to no-evidence suggesting your asymptomatic retained wisdom teeth are causing problems, they are less likely to cause trouble in the future. In such cases, especially for patients with underlying systemic problems, the risks of the procedure do not outweigh the benefits. Thus, a more conservative approach consists in monitoring your teeth for decay, gum disease or other complications. If problems arise, your dentist might consider removing them.
Surgical Removal
Impacted wisdom teeth that are not crucial for chewing function, are causing pain, decay and other dental problems must be extracted. In this category, we can almost always find partially erupted wisdom teeth, partially covered by bone or soft tissue where hygiene is extremely difficult and therefore produce inflammation or infectious complications. Thus, Extraction of a wisdom tooth is usually required for.
- Infection or gum disease (periodontal disease) involving the wisdom teeth.
- Tooth decay in partially erupted wisdom teeth.
- Cysts or tumours involving the wisdom teeth.
- Wisdom teeth that are causing damage to neighbouring teeth.
Extraction is almost always done as an outpatient procedure, so you’ll go home the same day. The process might include the use of pharmacological sedation or Intravenous (IV) sedation.
Conscious sedation differs from general anaesthesia in the level of consciousness you have. Pharmacological sedation relaxes your nervous system while keeping you conscious and responsive and IV sedation depresses your consciousness. There is no reported difference in the outcomes of the procedure by doing it under IV sedation, which prompts a substantially decreased anxiety before and during the procedure.
To know more about the surgical and non-surgical tooth extraction click here.
References:
- Dias, M. J., Franco, A., Junqueira, J. L., Fayad, F. T., Pereira, P. H., & Oenning, A. C. (2020). Marginal bone loss in the second molar related to impacted mandibular third molars: comparison between panoramic images and cone-beam computed tomography. Medicina oral, patologia oral y cirugia bucal, 25(3), e395–e402. https://doi.org/10.4317/medoral.23443
- Fernandes, M. J., Ogden, G. R., Pitts, N. B., Ogston, S. A., & Ruta, D. A. (2009). Incidence of symptoms in previously symptom-free impacted lower third molars assessed in general dental practice. British dental journal, 207(5), E10–219. https://doi.org/10.1038/sj.bdj.2009.804
- Friedman J. W. (2007). The prophylactic extraction of third molars: a public health hazard. American journal of public health, 97(9), 1554–1559. https://doi.org/10.2105/AJPH.2006.100271
- Mayo Clinic (2018). Impacted wisdom teeth. Retrieved from: https://www.mayoclinic.org/diseases-conditions/wisdom-teeth/diagnosis-treatment/drc-20373813
- Mettes, T. G., Nienhuijs, M. E., van der Sanden, W. J., Verdonschot, E. H., & Plasschaert, A. J. (2005). Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. The Cochrane database of systematic reviews, (2), CD003879. https://doi.org/10.1002/14651858.CD003879.pub2
- Stanaityte, R., Trakiniene, G., Gervickas, A. (2014). Do wisdom teeth induce lower anterior teeth crowding? A systematic literature review. Stomatologija, Baltic Dental and Maxillofacial Journal. 16 (1) 15-8.
- Zawawi, K. H., & Melis, M. (2014). The role of mandibular third molars on lower anterior teeth crowding and relapse after orthodontic treatment: a systematic review. TheScientificWorldJournal, 2014, 615429. https://doi.org/10.1155/2014/615429
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