Oral Surgery
Both minor and major oral surgical procedures may be undertaken within the Dental & Implantology Unit or operating theatres. Minor and intermediate procedures such as wisdom tooth surgery, implants, bone grafting, etc. may be performed under local anaesthesia with or without intravenous sedation. Major procedures are carried out under general anaesthesia within the operating suite.
Wisdom Teeth
One of the most common oral surgical procedures carried out is wisdom tooth extraction. Wisdom teeth, also known as third molars, normally erupt into the mouth between the ages of 17 and 25. Unfortunately, wisdom teeth become impacted either due to lack of space for the teeth or because the developing wisdom tooth has an abnormal position to allow normal eruption.
There are various forms of wisdom tooth impaction; the tooth could be deeply impacted, that is, totally covered by bone and gum or partially erupted, that is, part of the crown of the wisdom tooth visible in the mouth. The crown of the impacted wisdom tooth may be facing forward, upwards or backwards. The roots of the wisdom teeth continue to develop despite its failure to erupt into the mouth and occasionally may become closely associated with a nerve that runs within the lower jaw. This nerve supplies the lower teeth and lower lip with sensation on that side of the jaw.
Impacted wisdom teeth do not always cause problems and many people retain them without developing any significant symptoms. However, a good percentage of people are troubled by impacted wisdom teeth as follows:
- Infection around the wisdom tooth (pericoronitis). This is caused by food trapping, difficulty to keep the tooth free of plaque and trauma to the inflamed gums by the opposing tooth.
- Caries or tooth decay in the wisdom tooth or adjacent molar tooth. Due to food trapping or difficulty cleaning the area, plaque may cause tooth decay in either of the mentioned teeth resulting in pain.
- Cysts. As the teeth develop within a sac (known as a follicle), an impacted wisdom tooth may develop a cyst around it.
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Nowadays, we do not believe that impacted wisdom teeth cause crowding (twisting) of the anterior teeth. This process will happen in many people whether wisdom teeth are present or not. It is known as ‘mesial drift’.
Reasons to remove Wisdom Teeth include:
- Infection
- Caries/Tooth Decay
- Cysts
- Chronic food trapping which will lead to infection /caries.
- Occasionally prior to orthodontic treatment.
- Prior to other operations such as an osteotomy (an operation to shorten or lengthen the jaw).
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Surgery to remove wisdom teeth
Once it has been decided that the wisdom tooth / teeth need to be removed, an X-ray is required to assess the wisdom tooth anatomy, position and relationship to other structures within the jaw. The surgical procedure normally involves reflecting the gum away from the wisdom tooth site, removing some bone and / or splitting the wisdom tooth to allow the tooth to be fully removed and finally suturing the gums back in place again.
This treatment may be performed under local anaesthesia, intravenous sedation and local anaesthesia or general anaesthesia. The surgeon will prescribe post-operative pain killers and may or may not prescribe antibiotics.
Once the operation has been performed, recovery varies between one patient and the next. The post-operative symptoms would depend upon the severity of the impaction, the number of teeth removed and patient’s tolerance to discomfort. It is normal to have swelling, which may last from a few days to a week, discomfort, difficulty opening and closing the mouth and bruising. There is a tiny chance that the nerve below the lower wisdom tooth may be traumatised, resulting in transient numbness of the lower lip on the same side and extremely rarely, permanent numbness. The risk of this actually happening is assessed pre-operatively by means of an X-ray and must be discussed with you.
Advice to patients following wisdom teeth extraction
- You are advised to go home and rest.
- Take any medications prescribed.
- Thorough attention to MOUTH care is vital to prevent post-operative infection. As from the day after surgery you may regularly use lukewarm salt-water mouthwashes to clean your mouth. It is advisable to purchase a soft toothbrush to clean the gum areas gently. Vigorous brushing will cause trauma and bleeding.
- In the first 12 – 24 hours, post-operatively you should avoid hot drinks because they can trigger off bleeding from gums.
- If you experience bleeding from your gums you should take wet tissue/gauze, place it in your mouth and bite very hard on it for 20 minutes. If bleeding continues you should contact your Dental Surgeon.
- You may experience swelling around your mouth, this will subside after a few days.
- If you have had general anaesthetic or intravenous sedation you MUST not drive or operate machinery for 24 hours, as your responses will be impaired, even if you feel back to normal.
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Oral Surgery Frequently Asked Questions:
Adults can have up to 32 teeth. The wisdom teeth are the last to come through, right at the back. They usually appear when you are between 17 and 25, although sometimes they appear many years later.
Nowadays people often have jaws that are too small for all 32 teeth – 28 is often the most we have room for. So if all the other teeth are present and healthy there may not be enough space for the wisdom teeth to come through properly.
No. If there is enough room they will usually come through into a useful position and cause no more problems than any other tooth.
Often there will be some slight discomfort as they come through, but this is only temporary and will disappear once the tooth is fully in position. |
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If there is not enough room, the wisdom tooth may try to come through, but will get stuck against the tooth in front of it. The wisdom tooth will be at an angle, and will be described by the dentist as ‘impacted’. |
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If part of the wisdom tooth has appeared through the gum and part of it is still covered, the gum may become sore and perhaps swollen. Food particles and bacteria can collect under the gum edge, and it will be difficult to clean the area effectively.
Your dentist will tell you whether this is a temporary problem that can be dealt with by using mouthwashes and special cleaning methods (and possibly antibiotics), or whether it is better to have the tooth removed.
If your gums are sore and swollen, use a mouthwash of medium hot water with a teaspoonful of salt. (Check that it is not too hot before using it.) Swish the salt water around the tooth, trying to get into the areas your toothbrush cannot reach. An antibacterial mouthwash such as Corsodyl can also reduce the inflammation. Pain-relieving tablets such as paracetamol or aspirin can also be useful in the short term, but see your dentist if the pain continues.
If the pain does not go away or if you find it difficult to open your mouth, you should see a dentist. They will be able to see the cause of the problem, and tell you what to do. It may help to clean around the tooth very thoroughly, and the dentist may give you a prescription for an antibiotic.
Are x-rays needed?
The dentist will usually take x-rays to see the position of the root, and to see whether there is room for the tooth to come through into a useful position.
- When it is clear that the wisdom teeth will not be able to come through into a useful position because there is not enough room, and they are also causing some pain or discomfort.
- If they have only partly come through and are decayed – such teeth will often be more likely to decay as it will be difficult to clean them as thoroughly as your other teeth.
- If the wisdom tooth is causing a cleaning problem and has no real use.
Dental & Implantology Unit| St James Hospital| George Borg Olivier Street| Sliema |SLM 1807|Malta
- If the wisdom tooth starts to ‘over-grow’. This often happens if the lower one has already been removed or is impacted and cannot come through, and the upper one has no tooth to bite against. The upper one will come down too far, looking for a tooth to make contact with.
- If they are painful.
It all depends on the position and the shape of the roots. Your dentist will tell you how easy or difficult each tooth will be to remove after looking at the x-rays. Upper wisdom teeth are often easier to remove than lower ones, which are more likely to be impacted. Your dentist will say whether the tooth should be taken out at the dental practice, or whether you should be referred to a specialist (oral surgeon) at a hospital. Very occasionally there is a possibility of some numbness of the lip after the removal of a lower tooth – your dentist will tell you if it is possible in your case.
You will probably have either a local anaesthetic – as you would have for a filling – or sedation. You could also have a general anaesthetic (where you would be asleep), but this will usually be given only in a hospital.
Taking wisdom teeth out may cause some swelling for a few days. But as soon as the area is healed, there will be no difference to your face or appearance. Your mouth will feel more comfortable and less crowded, especially if the teeth were impacted.
The amount of discomfort will depend on how easy it was to take the tooth out. There is usually some swelling and discomfort for a few days afterwards, and it is important to follow any advice you get about mouthwashes and so on, to help with the healing. Some people also find homeopathic remedies help to reduce discomfort. Usual painkillers such as paracetamol, aspirin or ibuprofen will usually deal with any pain. It is best to stay fairly quiet and relaxed for 24 hours afterwards to make sue there are no bleeding problems. There may be some stitches to help the gum heal over. Your dentist will probably want to see you again about a week later to check on the healing, and to remove any stitches.
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