Wisdom Teeth (3rd Molars)
Wisdom teeth or third molars are routinely removed as an adolescent. They are the last tooth in our mouth to develop and erupt. Wisdom teeth may first appear radiographically as early as age 14. Since wisdom teeth are the last teeth to develop, they frequently become impacted. Impacted simply means something is obstructing the normal eruption of a tooth. This can be soft tissue, bone, another tooth or even a tumor. In the case of routine third molars, they are classified according to the degree of impaction. Soft tissue impaction, partial bony impaction or complete bony impaction. This degree of impaction will determine the difficulty of extraction and may dictate the degree of pain a patient experiences with an extraction. A wisdom tooth that is impacted may create an adult “teething” experience where a patient complains of pain and swelling behind the second molar. This is termed pericornitis. Complete bony impacted teeth may still cause the same symptoms but are less likely too. Do not be fooled, lack of symptoms is not a reason to ignore wisdom teeth.
I explain to my patients that wisdom teeth removal is best accomplished at a young age, with or without symptoms. The reason is ones age. The younger a patient at time of surgery the better they respond to the surgery or in other words the shorter the recovery time. This is assuming that the patient is emotionally mature enough to understand and participate in the surgery. An unwilling participant will make the surgery and recovery period longer. The bone structure or density is less in a younger patient. The outer covering of bone, the cortical bone, is thinner and less “calcified” in teenagers. The bone gives way when removing an impacted third molar or wisdom tooth. This means that the wisdom teeth are easier to be removed and less bone manipulation and a smaller flap is required. A younger patient heals faster and has less complications associated with any surgery. The complications associated with wisdom teeth removal will be discussed later.
Patients who choose to wait for wisdom teeth removal are statistically at risk for developing problems associated with their impacted third molars. Impacted teeth may cause pain, swelling and a local infection that can spread into the neck, periodontal disease, erosion of adjacent roots, tumor or cyst development, or cavities. Unfortunately I find many patients have waited until the wisdom tooth “was hurting” and many of these associated symptoms have developed. These patients are no longer teenagers and the surgery becomes complicated when the recovery period is extended. The majority of the patients who develop pain or swelling do so during times when taking a week off from work or away from the family is impossible. This scenario compounds the patients’ experience.
Example Reasons for Early Extraction:
 Partial Erupted Wisdom Tooth with a Large Cavity |
 Partial Erupted Wisdom Tooth with Associated Cyst |
 Impacted Third Molar Crowding 2nd Molar |
 Kissing 3rd & 4th Molar with Associated Cyst |
 Kissing 3rd & 4th Molar with No Associated Cyst |
 The Third Molar "Migrated" up the Ramus (Jaw Bone) |
 3rd Molar Erupted First, Crowding 2nd Molar |
 Impacted 3rd Molar with Large Cyst |
A common question is the need to extract erupted upper third molars. In this case, notice that the lowers are impaced and need to be removed. The uppers are "super-erupted" and will continue to migrate down if not extracted. This will cause many patients to return to have them removed when they occlude on the cheek and cause trauma. Dr. Johnson would recommend the upper third molars being extracted at the same time the lowers are removed.
This patient has two large cyst (red arrows) associated with his impacted third molars.
At Advanced Faces, Dr. Johnson can offer three options for the removal of wisdom teeth. The first is with local anesthesia only. An injection is administered to “numb” the tooth and the extraction is competed. For individuals who are hesitant about sedation or going to sleep then this is the best option. Extractions should not hurt. The experience is filled with sounds and an unfamiliar environment which translate into a stressful experience. In these cases, IV sedation or general anesthesia are offered to help reduce the anxiety with wisdom teeth extractions. Sedation is offered in a safe out patient environment that is reviewed by the Florida Department of Health and the Florida Society of Oral & Maxillofacial Surgery. The standards that are met in the Oral & Maxillofacial Surgery office are the same as you can expect in a local hospital operating room. Dr. Johnson is certified in Advanced Cardiac Life Support (ACLS) and CPR, the assistants are CPR trained, the office has a crash cart and is located a few minutes from South Lake Hospital. If Dr. Johnson feels that a board certified anaesthesiologist is required then Dr. Stone from Pediatric Dental Anesthesiology Associates is available to provide the anesthesia within the office setting. Dr. Stone provides these services once every two years. If you require some form of relaxation but IV sedation is not right then we offer Nitrous Oxide or laughing gas as an alternative.
Complications:
| Discomfort: | Age <20 | 3-5 Days |
| Age 20 – 35 | 5-7 Days | |
| Age >35 | 7-14 Days | |
| Bleeding | Will stop within 24 hours, however, blood will mix with your saliva and make it appear that the bleeding is excessive. | |
| Swelling | Peaks in 3 Days, use ice as frequent as possible for 72 hours | |
| Numbness | Typically Resolves after 24 hours from the local anesthesia | |
| If Extraction Induced Numbness | 90% Resolve in 6-8 Weeks | |
| 95% Resolve within 6 Months | ||
| 5% Permanent, this is also age related | ||
| Infection | Less than 5% chance to occur in general population | |
| Dry Socket | Also called Localized Alveolitis, occurs in 5% non smokers, 20% smokers. Refrain from Smoking, Straws and Spitting for 72 Hours After the Procedure | |
| Sinus Exposure | Occurs in less than 5% of upper wisdom teeth extractions and the majority of times will close without surgical intervention. Dr. Johnson will discuss in greater detail at your consultation. | |
| Damage to Adjacent Teeth | In my office the most common adjacent tooth complication is loss of a cemented crown. In these cases a new cavity might be present that weakened the adjacent tooth’s ability to hold the crown. We recement them with a temporary cement and your general dentist needs to evaulate the area as soon as possible. | |
| Mandible Fracture | Extremely rare and occurs almost exclusively with an age >40. If this is a remote possibility, Dr. Johnson will discuss this complication in detail at your consultation. | |
Understanding the risks associated with any surgery is important. The risks need to be placed into context with an understanding that these are possibilities seen across the spectrum in all operations throughout the world. When millions of patients undergo this type of a procedure a year, these are the risks that can occur, but are unlikely. Do not let these possibilities stop you from seeking out the appropriate care. This statement is true for any surgery. There must be a trust between you and your doctor and surgical risk should not be a deterrent but a responsibility for the doctor to review with their patients.
Cost associated for wisdom teeth extractions will vary depending on the degree of impaction. This can range from $225.00 to $550.00 per tooth. With insurance your copay will also vary greatly and can only be finalized after the initial consultation. Additional costs associated with the extraction include sedation and any radiographs needed to make the diagnosis. If the patient chooses local anesthesia, in other words being awake during the procedure, the procedure can be done the day of the consultation pending a medical review. If the patient chooses a sedation then a separate procedure day will need to be selected. IV sedations require a patient to have not eaten and a ride. The office also needs to be prepared to perform the IV sedation. IV sedations are performed Monday through Friday. Please call our office to make an appointment at 352-242-0627.