Estimating the difficulty of wisdom tooth extractions. -

General guidelines and rules of thumb: Upper vs. lower. / Erupted vs. impacted. / Difficulty by impaction type. | How the expected level of difficulty will affect the planning of your extraction procedure.

Root shape
factors.

Link to extraction difficulty animation.

Tooth
sectioning.

Link to tooth sectioning animation.

How hard will your wisdom tooth extraction be?

It's important for your dentist to have an idea.

Long before the day of your procedure, your dentist will have made an estimation about the level of difficulty they expect when they remove your teeth.

  • Their determination will influence factors about your case such as how many of your wisdom teeth should be removed per visit, the length of your appointment(s) and whether or not a recommendation for some type of sedation is made.
  • Their pre-treatment evaluation will also help with planning your procedure, so it's performed in a manner that helps to minimize the chances for complications both during your extraction(s) and the healing process that follows.

A) Factors that influence extraction difficulty.

A panoramic x-ray is frequently used to evaluate 3rd molar positioning.

A panoramic dental x-ray.

If more detail is needed, an individual "intraoral" x-ray of each tooth may be taken too.

1) The tooth's position in the jaw.

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 the healing process that follows 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 difficult than bony ones (teeth still substantially or completely encased in the jawbone). (Graphic: Soft-tissue vs. bony impactions.)
  • 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. (Graphic: Impaction orientations.)
Takeaways from this section.
  • Fully erupted wisdom teeth (teeth that have come all of the way into place) are often no more difficult to extract than other molars.
  • Impacted wisdom teeth that have a pronounced tilt are more likely to need to be sectioned (cut into pieces) when extracted.

    This technique (see animation below) is used as a way of limiting the size of the wound that needs to be created. In extreme cases, sectioning might be the only way of getting the tooth out.

2) Tooth depth.

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

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

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

Removing this wisdom tooth can be expected to be of "moderate" difficulty.

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.
 
Takeaways from this section.

Obviously, the deeper the positioning of a tooth, the more bone tissue that must be removed to reach it. And generally, that means creating a larger wound.

The larger the surgical area, the more involved the extraction site's healing process (as well as its potential for complications like a dry socket) will be.

Beyond those issues, deeply positioned teeth are more likely to be near anatomical obstacles such as nerves or sinuses. If so, the risk for surgical complications involving them is higher too.

3) Root anatomy.

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.

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.

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

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

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 facilitates the extraction.
  • Teeth whose roots are just 1/3 to 2/3rd formed typically make for an easier extraction that those whose roots are fully formed.

    This factor is dependent upon the age of the patient. We discuss this and other age-related issues here: What's the ideal age to have your wisdom teeth extracted?

B) How anticipated extraction difficulty affects treatment planning.

More so than with any other type of tooth, removing wisdom teeth routinely poses an assortment of challenges (ranging from just minor to significant). And this level of difficulty must be factored into the way your dentist plans your case.

1) Some wisdom teeth are quite easy to remove.

You don't have to expect the worst. In the case of fully erupted 3rd molars (those that have come all of the way into place), the extraction process may be no more difficult than with any other molar, and possibly less.

Examples.
  • When compared with the molars in front of them, there's a tendency for wisdom teeth 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.
Takeaways from this section.

This page outlines the steps that take place during routine (simple) extractions. The type of extraction process typically used to remove erupted teeth.

The term "simple" is used because the oral surgery techniques used are straight forward and relatively uninvolved (as compared to surgical extractions, see below).

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2) Some wisdom teeth will require "surgical" intervention.

With impacted third molars, the dentist will of course need to gain access to the tooth they're removing. 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. Use the link above for more details.

Takeaways from this section.

You shouldn't be overly apprehensive about the need of having a surgical extraction.

While with many cases it might be impossible to remove a tooth without taking surgical steps, even with borderline cases doing so frequently allows the patient's whole extraction process to go more predictably, quickly and easily.

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) How extraction difficulty can affect patient aftercare and the post-extraction healing process.

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 post-operative inconvenience and aftercare needs 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.

Which scenario applies to you will simply depend on how difficult your extraction process has been. And thanks to the type of indicators discussed on this page, your dentist should be able to give you an idea of what to expect even before your procedure is performed.

Aftercare guidelines and instructions.

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

When it comes to preventing or minimizing post-operative complications, nothing is more important than following your dentist's instructions, period. (Use the links above for more information.)

 

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Comments

Thank you.

My son is about to have a wisdom tooth, which is at his gum line pulled. I am so nervous. This posting really helped me understand what is going on. I wish I had such a source years ago when I went through this.

Roger

You mention that it's your "son" - Implying a person of youngish age. Generally speaking age is a factor that favors experiencing an uneventful wisdom tooth extraction process.

You also mention that the procedure will happen fairly soon, as in possibly you are using the holiday as the recuperation period which makes a good plan just in case he needs an extended recovery period (like in the case where there is post-op swelling that needs to come down).

And you also mention that the tooth is "at his gum line." That implies a partially erupted wisdom tooth. The kind are the most troublesome to maintain and therefore make good candidates for extraction.

Sounds like you are doing everything right. Good luck with your son's procedure.

Horizontal wisdom tooth removal

Hi,

Tomorrow I am scheduled for the surgery required to remove my horizontally grew wisdom tooth (down, right). I am 27 years old. At the 3d scan I took 2 days ago it showed that the roots of the tooth are ‘hooked’ to the nerve and the doctor had said that there are chances in the moment they will pull the tooth out for the nerve to be damaged. I will experience numbness for hours, or days, or weeks, or months or it the nerve will never fully recover and the numbness will stick forever. We won’t know until it is done..
i am quite concerned and I am trying to make a list of questions to ask the doctor before the surgery. Maybe you could give me some ideas, please.
Thank you!

Ana

Good luck tomorrow.

We'd like to think that possibly what your dentist has stated is simply very thorough "informed consent" information, to the point of overstating what they actually anticipate is most likely to happen. Hopefully your actual level of risk is substantially less than what you currently imagine.
--
Where the potential for complications with paresthesia are comparatively higher, we would make sure we were in the most capable hands possible, meaning an oral surgeon as opposed to a general dentist.

Based on your mention of a "3d scan" (a type of imaging that most general dentists don't have in their office), we're assuming you have that issue covered.
--
There should be clear reasons why the tooth needs to be removed, including an explanation of why the issues associated with leaving it exceeds the expected risk for permanent nerve damage. (We have pages that discuss general reasons why wisdom teeth should be extraced and others that may not be such valid reasons.)

--
In terms of questions to ask about how the procedure will be performed to help prevent nerve trauma from occurring, only your doctor can determine the approach that's best.

For a horizontally positioned tooth, we would imagine some degree of sectioning would be planned for (see above on this page). That would be positive to know because usually that means the tooth can be removed relatively less traumatically.

--
Generally, we would just focus on the fact that the tooth has good reason to be removed. That we are in the hands of a highly trained and skilled practitioner. And that you and they want the exact same thing, the most uneventful extraction process for you possible. Once again, good luck.


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