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.)

    Evidence of this comparative surgical ease lies in complication rates associated with the various types of impactions, with disto-angular and horizontal surgeries associated with a higher degree of swelling and reduced mouth opening postoperatively than vertical ones. (Bello 2011) [page references]

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.)

 

Written by: Animated-Teeth Dental Staff

Content reference sources.


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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.

Age 50

I am nearly 50 and have just noticed a sore bump in the gum and a what appears to be a white bit of hard tooth breaking through, at the bottom left, side of my teeth, at the very back, slightly alongside/parallel to my final back molar. I have never had conventional wisdom teeth and years ago a dentist who saw my X-rays told me I did not have them - but in my 20s and 30s I had one tiny wisdom tooth break the gum behind my top molars and in both cases, a dentist removed them. They were very small and undersized, not like a proper wisdom tooth. I will try to see a dentist asap as this tooth breaking through is very sore - I assume it is another of these undersized wisdom teeth? I want to ask you how difficult it will be to remove - I am concerned that is appears to be breaking through alongside my back molar and may mean that both teeth need to be removed? Have you seen these tiny undersized wisdom teeth on your patients? I have also noticed a similar corresponding bump in the gum on the opposite side of my bottom teeth, though no tooth is breaking through and it is not inflamed or sore. If an X-ray reveals that is another wisdom tooth causing the bump, should I ask the dentist to remove it too as a precaution against future problems? Thanks you for any info and advice!

LISA

It's going to take your dentist to fill you in on what's actually going on but we Googled around some, using a strict literal interpretation of what you describe.

We ran across this published report that describes what is referred to as a "paramolar."

A paramolar is a small, frequently under-formed, supernumerary (extra) molar. (Here's a picture of a supernumerary tooth on our pages.) The article states that a person may have one or more (like you).

Low down in the article it specifically states that a common location for these is on the buccal (cheek side) of molars. It also says they frequently remain impacted (unable to erupt). In your case, late in life it seems it has finally been able to come through. The article describes how it can be difficult to identify unerupted paramolars, which fits your bill.

As far as level of difficulty goes, we'd anticipate that removing the tooth won't be a major issue. (It's come near the surface, is probably small in size, the fact that it has recently made an appearance through your gums suggests that it is not fused to your molars.) But of course your dentist will need to fill you in.

We can see how related to its removal that some bone deficit might result next to the remaining tooth/teeth. But if so, likely some sort of bone grafting could be done (probably much more of a minor procedure than you might anticipate).

And yes, if your dentist feels that the other one can be identified and uneventfully removed and suggests doing so, taking their advice might save you some trouble later on.

38 year old

Hello. My top right wisdom tooth grew out like a normal tooth. Just recently while eating the tooth craked. I visited my local dentist because their was a sharp edge rubbing against my gum. They grinded it down and said that I need to extract it and at an oral surgeon they recommended. They also did a panoramic and I have all 4 wisdom tooth. 1st being the top right that craked. 2nd top is slightly beginning to come out of the gum. 3rd is button and is horizontal with 3mm distal probing and the 4th is buttom and is horizontal with 11mm distal probing. My question is should I remove all 4 using coronectomy techniques. I know the 1st need to be removal for sure, the surgone said he will be use coronectomy because of the nerours attached to it. Also I thinking also of doing the 4th one. Any suggestions ?

Aaron

For others reading, a coronectomy refers to a procedure where only the crown (top) portion of a tooth is removed. After the crown has been sectioned off, the roots of the tooth are left in place. This is a procedure most associated with impacted wisdom teeth. And usually just lower ones whose roots have a close proximity to the mandibular nerve.

The general idea is that the removal of the tooth's crown resolves issues its positioning was causing (or had potential to cause) such as pericoronitis, damage to neighboring teeth, gum disease, etc....

The roots are left in place because there is fear that removing them will traumatize the adjacent nerve, resulting in paresthesia (persistent numbness).

We anticipate that your oral surgeon has only recommended the coronectomy for your lower wisdom teeth. We'd be unclear as to the purpose of this procedure for the upper ones. You mention the potential for nerve damage but paresthesia associated with removing upper wisdom teeth is not common.


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