Wisdom tooth extractions.

- Estimating their level of difficulty. / Sedation methods. / Aftercare.

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Link to extraction difficulty animation.
Link to tooth sectioning animation.

How hard will your extraction be?

Long before the day of your procedure, your dentist will have made a determination about the level of difficulty they expect with your case.

Their conclusion will influence factors such as the amount of time your appointment is scheduled for and whether or not a recommendation for sedation is made. (Sedating the patient often makes a good choice for more involved procedures.)

Additionally, this type of pre-treatment evaluation helps to minimize the chances for complications, both during your procedure and the healing process that follows.


A) Factors that influence extraction difficulty.

As a part of making their determination, your dentist will evaluate issues such as:

A panoramic dental x-ray.

Panoramic x-rays are frequently used to evaluate 3rd molars.

1) Tooth positioning.

Much of the difficulty associated with removing a wisdom tooth will be due to the way it's situated in the jawbone.

In general, the more normal the alignment of the tooth, and the further through the gum line it has pierced, the less involved its extraction and subsequent healing process are likely to be.

Rules of thumb.

  • You can expect that erupted wisdom teeth (those that have penetrated through the gums fully) will be easier to extract than impacted ones (those still significantly buried in the gum tissue or jawbone).
  • Soft-tissue impactions are typically less involved than bony ones (teeth still substantially or completely encased in the jawbone).
  • The tilt of the tooth will affect the ease with which it's removed. Vertical (upright) and mesio-angular (leaning forward) impactions are typically easier to remove than disto-angular (tilted backward) or horizontal (sideways) ones.

    For diagrams illustrating these various alignments, see our types of impactions graphics.

The depth of the wisdom tooth is compared to the neighboring 2nd molar.

The tooth's depth is compared to the neighboring 2nd molar.

2) Tooth depth.

A method used to estimate extraction difficulty is to make a comparison between the impacted wisdom tooth and its neighboring 2nd molar.

When making this calculation:

  • The 2nd molar's root is marked in thirds on an x-ray.
  • A point is then identified on the 3rd molar where the forces of the dentist's extraction instrument (an elevator) will be applied.

    This point is frequently that part of the tooth where its crown (enamel-covered portion) ends and root begins. (The white dot and arrow in our diagram.)

  • The level at which this point resides in comparison to the 2nd molar's root gives an idea of how hard the extraction will be.

3) Tooth shape.

Wisdom teeth have multiple roots. (Lower ones typically have two whereas uppers usually have three.) And there can be quite a bit of variation in the way they are shaped.

The shape of a tooth's roots affects the extraction difficulty.

Extraction difficulty is influenced by the tooth's root form.

In some cases, each root will be separate and distinct. In others, they may be fused together (fully or partially) or have an irregular shape or curvature.

These anatomical variations will affect the relative ease with which the tooth can be removed.

Rules of thumb.

If the "average" wisdom tooth is one where its roots are relatively straight, distinct and separate (see animation), in comparison:

  • Teeth with fused roots (partially or fully) are often easier to extract (this is especially true for upper third molars).
  • Teeth that have roots that are curved or irregularly shaped can be more difficult to remove. Although, in some instances the curvature may be such that it actually makes the extraction easier.
  • Teeth whose roots are just 1/3 to 2/3rd formed typically make for an easier extraction that those whose roots are fully formed.


B) The extraction process.

More so than with any other type of tooth, wisdom teeth routinely pose an assortment of challenges (ranging from just minor to significant).

1) Some will be quite easy to remove.

You don't have to expect the worst. In the case of erupted 3rd molars, the extraction process may be no more difficult than with any other tooth, and possibly less. (Erupted teeth are those that have substantially penetrated through the gums.)

  • When compared with the molars in front of them, there's a tendency for 3rds to be slightly smaller and more likely to have fused roots. Either of these factors can help to make their removal comparatively less difficult.
  • Upper wisdom teeth that have fused roots can be astonishingly quick and easy to extract.

2) Other 3rds will require "surgical" intervention.

With impacted wisdom teeth, the dentist will, of course, need to have access to the tooth they're extracting. So, in these cases the dentist will need to perform a "surgical" extraction.

This is the type of process where gum tissue is flapped back and, if needed, bone tissue cut away, so the dentist can visualize and manipulate the tooth.

Sectioning a 3rd molar during extraction.

Less bone removal is needed when a tooth is "sectioned" into parts.

3) Sectioning wisdom teeth.

A dentist may be able to minimize the amount of bone that must be removed during the extraction process by cutting the tooth into pieces.

Since each individual part is smaller than the tooth as a whole, they can be removed through a smaller access opening. This procedure is termed "sectioning" a tooth.


C) Conscious Sedation.

If an extraction is expected to be very difficult, a dentist may suggest that some type of conscious sedation should be used. This refers to the use of a sedative medication that causes the patient to become very relaxed.

The patient remains awake, in the sense that they're still responsive to stimuli (such as verbal commands or the sensation of pain) and all of their protective reflexes (breathing, coughing) remain functional.

The key benefit of this technique is that it makes the surgical procedure more tolerable (the patient becomes less bothered or concerned). And especially in the case of a difficult extraction, the extra degree of patient cooperation that it allows can help the procedure go more smoothly and quickly.

Choose sedation for the right reasons.

  • The use of any medication involves risk. And for that reason, when one is administered it should be for good reason.

    If you're not convinced that you need to be sedated, ask your dentist why they feel you do.

    The patient cooperation that it can provide can be a big help during a difficult extraction. But in some cases it may be utilized simply as a convenience or additional billable service for the dentist.

  • Keep in mind that conscious sedation technique is used to just control anxiety, not pain.

    Beyond administering the sedative, your dentist will still need to numb up your tooth (give you a "shot") using a local anesthetic so you won't feel discomfort during your procedure.

Ways conscious sedation can be administered:

1) Nitrous oxide / Laughing gas.

Nitrous oxide is commonly referred to as inhalation anesthesia or just "laughing gas." It produces its calming effect as a patient breathes it in (via a mask that's placed over their nose).

Its effects appear quickly. And once its inhalation is ceased, they disappear fairly rapidly too. Sometimes it's used in conjunction with oral or IV sedatives (see below).

Precautions.

Your dentist will need to give you specific instructions but in most cases a patient will be capable of driving home after having nitrous oxide sedation.

Oral sedatives.

Oral sedatives can help to put a patient at ease.

2) Oral Sedatives.

"Oral" sedatives are medications that are taken by-mouth (you swallow a liquid or pill). One common one used in dentistry is Valium.

Precautions.

Your dentist will provide you with the instructions that you need, and you must follow them. In most cases, the patient is instructed to take their sedative about one hour before their dental appointment.

Because this type of medication will likely affect your behavior and ability to function normally for some hours, once it's been taken you must have someone tend to and assist you. This includes both delivering you to and driving you home from your dentist's office.

3) I.V. Sedatives.

Intravenous ("IV") sedatives are administered by way of injecting them into a blood vein. Some of the terms used for this technique (when it's used for conscious sedation) are "twilight" or "sleep" anesthesia (although the patient actually remains awake and aware).

As an advantage, it provides a way of creating a predictable and controllable effect.

Things to know.

Intravenous sedatives are more likely to be administered by an oral surgeon, as opposed to a general dentist, because they have the specialized training and monitoring equipment that's needed when these types of medications are used.

Some drugs create an "amnesic" effect, meaning the patient has little or no memory of the dental procedure that has taken place (from the time the medication kicks in until it has worn off).

If the fact that the drug is administered via the use of a needle is upsetting to you, ask if nitrous oxide or oral sedation can be given first.

Precautions.

Your dentist will need to provide you with instructions and it's very important that you follow them. They usually include rules about not eating or drinking for some hours prior to the administration of the medication.

When this type of sedation is used, you will need to make arrangements for someone to drive and escort you home after your appointment as well as monitor your activities until its effects have worn off.

4) Numbing up your tooth.

Even when conscious sedation is used, your dentist will still need to numb up your tooth and the gum tissue that surrounds it using a local anesthetic. (That means getting a "shot.")

A syringe used to give dental injections.

Local anesthetic is administered via an injection.

What's involved isn't that much different, or worse, than having a tooth numbed before a filling is placed. Although, to adequately anesthetize both a wisdom tooth and its surrounding gum tissue, more than one injection will need to be given.

Why is this needed?

The term conscious sedation is descriptive of the fact that you remain responsive to events, like feeling pain. You wouldn't be able to tolerate your procedure without being numbed up.


E) Aftercare / Post-extraction healing.

In general, the quicker and easier it's been for the dentist to access and remove a wisdom tooth, the less tissue trauma that's created and the more uneventful the extraction site's healing process should be.

As examples, the inconvenience and aftercare associated with the routine extraction of an easily accessed, fully-erupted third molar may be surprisingly minimal, to almost non-existent.

At the other extreme, the swelling and pain resulting from a difficult impaction may require several days of recuperation.

Aftercare guidelines and instructions.

For the most part, extraction aftercare is broken into two general time frames:

 

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