Dr. Paul T. Akers
 

Proper Timing of Wisdom

Tooth Removal

Why Remove the Third Molars?
                                                                             
The average mouth cannot physically accommodate these four additional teeth.  Completely impacted or partially impacted wisdom teeth, if not removed, may cause pain, swelling and gum or bone disease.  In addition, cysts may form and adjacent teeth may be damaged or lost.  Even if fully erupted, wisdom teeth are very difficult to keep clean and may become decayed or create hygiene problems.  If it is determined that the wisdom teeth will not erupt fully, it is best to remove them between the ages of 16 and 22, before root development is complete. 

Poorly positioned wisdom teeth will not function as an integral part of the dentition.  These are best removed early to prevent future irreversible damage to adjacent teeth and bone structures.

Good preventative dentistry suggests that we advise teenage patients and parents regarding early removal to prevent irreversible problems.  This recommendation should be documented in the general dentist's chart to prevent any “lack of diagnosis" law suits.  This can be an issue if the patient loses teeth or develops serious oral health problems due to over-retention of the wisdom teeth.  As a practicing oral surgeon for over 30 years, I have often seen life-threatening space infections, loss of distal bone on second molars, decay and/or resorption of  adjacent molar roots, as well as pharyngeal abcess, all secondary to over-retained wisdom teeth.  Even the rarer cases of cyst and tumor formation arising from the epithelium of over-retained wisdom teeth is still too common in this modern day of prevention-oriented dentistry. One-third of ameloblastoma tumors arise from the cyst wall tissue of over-retained wisdom teeth. 

High School Age or College Age?

In most cases it is best to remove wisdom teeth in high school.
- The roots are usually not fully developed and
       complications are rare.
- Removal   is much easier with less bone removal   
- Post op edema and echymosis is
       minimal.                              

Why Should they be Removed before Root Completion?

It is usually much easier to remove them before apical root development.  If the roots are allowed to complete development beyond the age of thirty, additional problems can occur.  Apical extension of the roots near or into the mandibular canal can occur.  Hook-shaped patterns of root formation can make removal more difficult and put the patient at a higher risk of a paresthesia or lip anesthesia.  Most oral surgeons have their own child’s wisdom teeth removed at high school age due to these reasons as well as the threat of the severe problems that over-retention may cause.

Why Not Remove them Earlier than High School Age?

Except for a few rare exceptions it is usually better to remove at  high school or early college age.  This age allows for easier patient management both intra-operatively and post-operatively for the patient, parents and the oral surgical team.

How are W isdom Teeth Removed in Contemporary Oral Surgical Offices?

In most cases, a consultation is scheduled first. The purpose of this is to educate patient and parents regarding the procedure and complications as well as the beginning of the informed consent process.  A panormaic x-ray is typically required for complete diagnosis of all four third molars.  On occasion, new digital on-site I Cat CT scans are used in the office to aid in positional details of severely impacted wisdom teeth.

At the time of the surgery, the patient has been NPO for six to eight hours. A comfortable IV deep sedation technique is used with medications such as Versed or Valium, a narcotic such as Fentanyl or Demerol, and possibly an ultra short acting hypnotic such as Brevital or Propofol.  On occasion, patients are given a single dose of an IV steroid such as Decadron or Solu Medrol to keep intraoral and extraoral edema to a minimum.  Patients are monitored with ekg, pulse oximetry, sternal stethoscope and  visually monitored by trained anesthesia and surgical assistants.   If indicated, antibiotics and narcotic pain medications are prescribed.

The procedure of removing all four third molars is usually completed in less than 1 hour.  Having the procedure done in one visit prevents the patient from having to go through additional procedures, repeated anesthesia, as well as repeated healing time.

In summary, the removal of all four wisdom teeth is a safe, comfortable procedure in modern day oral surgical offices.

Dr. Paul T. Akers 
Diplomate, American Board of Oral & Maxillofacial Surgeons