Cure_Paarl_Dr Thirion_ Article_March_2024

When is it wise to let go of your wisdom teeth?

Article written by Dr Duan Thirion, Dentist from Healthsmile in Paarl

Insights into their role, potential problems and the removal of wisdom teeth.

Why do we call them wisdom teeth?

Although formally known as third molars (third molar from the front), wisdom teeth earned their name, presumably, because the age that they are supposed to erupt into the oral cavity is between 17 and 21 years of age. These are the last teeth to erupt and would then be a sign that you are no longer a child and now possess some wisdom. However, they are normal molar teeth and, if space allows, they will follow the normal eruption process and their purpose will be to support the anterior teeth in function when chewing food.

Potential problems:

A lack of space in the jawbone might lead to compromised eruption of the third molars into their normal functional position, which will then lead to impacted wisdom teeth. Impacted wisdom teeth is a state where normal eruption is impeded by the adjacent teeth and bone. They might be totally or partially covered with gum. Impacted wisdom teeth are frequently associated with complications such as pain, discomfort and pathology.

There is no debate over the removal of wisdom teeth associated with signs and symptoms of disease, but I could not find clear guidance with substantial evidence and consensus on prophylactic removal of wisdom teeth in the absence of signs of disease. This then raises the question: why do we sometimes prefer to remove the wisdom teeth in the absence of any pathology? I will answer this question after I have explained the risks involved in removing third molars.

Removal of Wisdom teeth:

Apart from all the risks associated with any surgical procedure under general anaesthesia or sedation, the lower wisdom teeth are usually in very close proximity with two important bilateral nerves. First is the Lingual Nerve that provides the tongue with taste. Second is the Inferior Alveolar Nerve that provides sensation to the lower chin and lip. Injury of any one of these nerves can lead to temporary or permanent loss of sensation on the lip/chin area, or loss of taste on the relevant side of the tongue. Furthermore, injury to these nerves could alter your taste and/or sensation, and could cause a permanent state of neuralgia in the areas affected.

The upper wisdom teeth are in close proximity to the upper maxillary sinuses and can sometimes be challenging to remove without the risk of pushing the tooth or any of the root rests into the sinus. This can be corrected with additional surgery and does not cause any permanent problems to the patient if attended to correctly.

Studies have shown that age does play an important role in the prevalence of post-operative nerve damage and more persistent post-operative pain. The older you are, the more mature the root formation of the tooth and surrounding bone. This will have an impact on the difficulty to remove the tooth and, although younger patients initially present with more immediate discomfort such as trismus and swelling, older patients (higher than 25 years) have more persistent pain and swelling following third molar surgery. We also know that if there was pathology in the third molar area pre-operatively, it will also be more likely to be more painful after surgery.

The article that helped me the most was the guidance for indications on when to remove asymptomatic wisdom teeth written 10 years after the National Institute for Health and Care Excellence (NICE) guidelines were implemented into the UK. The NICE guidelines is a systematic approach to determine when to remove wisdom teeth and the reasoning was to stop funding for removal of asymptomatic wisdom teeth in patients. Although they saw an immediate decrease in the amount of third molar removals in the younger age group, the prevalence of third molar removals was the same as before the NICE principles were implemented after a few years. It was just the age at which the teeth were removed that changed.

Removal of wisdom teeth at an older age (above the age of 25) will be associated with higher prevalence of more intense post-operative pain management, dealing with more persistent pain and swelling. There is also a higher incidence of patients associated with nerve damage and decay of neighbouring teeth if left longer in the mouth. This will also have a negative socio-economic impact in comparison to a child or adolescent missing a few days of school or tertiary education. We usually try to do these procedures before a weekend or school holiday to minimise the loss of educational days.

When I have to decide if we need to take action in removing asymptomatic wisdom teeth, I take the following factors in consideration:

  1. Is there possibly enough space in the lower jaw for the eruption of the third molars? If not, I will strongly advise in removing these molars before disease forms.
  2. If there is a strong possibility that the retained third molars might have an impact on the alignment of the rest of the teeth, I would advise on asymptomatic removal.
  3. If the retention of these molars might have a negative impact on the health of the neighbouring teeth and gums and possibly cause decay on the neighbouring teeth, it is also better to remove the third molars before disease is present.
  4. If in doubt, I would advise a consultation with a maxillofacial surgeon or orthodontist for further guidance.

What do we do to minimise the risks during removal of wisdom teeth and post-operative care?

The minimum standard of care in diagnosing and planning to remove third molars will be to obtain a 2D panoramic x-ray photo of the upper and lower jaw. This will help to see the stage of development, angle and proximation of the wisdom teeth in relation to the important neighbouring anatomical structures.

If we find that the teeth are in very close proximity to the inferior alveolar nerve, or has a complex root formation, or very angulated, it is recommend to obtain a 3D Cone beam CT (CBCT) of the area to help visualise the relation of the tooth and roots to the neighbouring structures. This will help the surgeon to plan the best way to remove the tooth with the least amount of damage to the surrounding tissue.

Most CBCT system software will help you to map the nerve and display it in colour that aids in explaining the risks involved during surgery and obtaining informed consent from your patient for this procedure. Operator skill level is also an important factor and it is of great importance to educate yourself in the signs that are associated with higher risks of complications, to know when to refer the case to a maxillofacial surgeon rather than to run into a difficult situation during surgery. Especially if this procedure is done under general anaesthesia.

We usually prefer to do this delicate procedure in hospital, as we have a more controlled and clean environment. With the patient under general anaesthesia, patient fatigue will not affect the surgeon. Patients are not required to stay overnight in hospital, therefore a day clinic is an ideal choice for treating these patients. After care is also done better in hospitals where supporting nurses can apply cold packs immediately after surgery and attend to all the post-operative medication and care to make sure the patient is comfortable and has a good experience.

Below are screenshots that illustrate a recent experience where the 2D x-ray hides some of the risks, and on careful examination of a CBCT, the close proximity of the nerves on the lower molars, as well as the root entanglement of the upper left third molar with the second molar, can be seen. Group

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