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Wisdom teeth are the most commonly removed teeth, because the jaw often has no room for them. A tooth with nowhere to go comes in sideways, half-covered by gum, or not at all, and from there it can damage itself and the tooth beside it. A wisdom tooth that has come in straight and can be kept clean can stay for life. At Vizcaya Dental Arts we assess each one with a 3D scan, remove most of them in the office under local anesthesia, and refer the ones that sit against the nerve, or that need intravenous sedation, to an oral surgeon. Ordinary extractions have their own page.
What goes wrong with wisdom teeth
The problems come from position. A wisdom tooth that is tilted, rotated or partly buried under the gum is hard to clean and hard for its neighbor to live with.
- Decay on the second molar. The gap between a tilted wisdom tooth and the molar in front traps food and plaque, and the second molar decays on its back surface, where it cannot be seen or restored easily.
- Deep pockets. An impacted wisdom tooth leaves a pocket behind the second molar where the gum detaches and bone is lost.
- Pericoronitis. The flap of gum over a partly erupted wisdom tooth becomes inflamed and infected, with swelling, severe pain and difficulty opening or chewing. This is one of the commonest dental emergencies we see.
Some wisdom teeth cause none of this. The consequence of leaving one in place ranges from nothing to losing the tooth next to it, and only an assessment tells you where yours falls.
Timing
Wisdom teeth, the third molars, usually begin to come through in the late teens and early twenties, though some never erupt and some arrive later. Their roots keep forming for several years after the crown appears, which is the reason behind the timing advice: a tooth whose roots are still short and open is simpler to remove, further from the nerve, and heals faster. Upper wisdom teeth are generally more straightforward than lower ones, which sit in denser bone near the nerve that supplies feeling to the lip and chin.
Remove or watch?
When we can see that a tooth will never have room and is heading for impaction, we generally recommend removing it sooner rather than later. In a younger patient the roots are still forming, the bone is more forgiving, the extraction is simpler, the risk is lower and the recovery is noticeably easier.
When the picture is uncertain, when the tooth may still find room or is coming in reasonably straight, we prefer to watch. Some patients would rather have the teeth out and be done; others would rather wait and see. We lay out the evidence and the choice is yours.
Assessment
For wisdom teeth we usually start with a CBCT scan, a three-dimensional X-ray, because the question that matters most is not visible on a flat film: how close the roots of a lower wisdom tooth sit to the nerve that runs through the jaw. Nerve injury is the main risk of lower wisdom tooth removal, and the scan shows how real that risk is for your tooth.
When a root wraps around the nerve, we discuss alternatives, including a coronectomy, in which only the crown of the tooth is removed and the roots are deliberately left in place. Cases like that are referred to an oral surgeon, as are patients who need intravenous sedation or general anesthesia.
The procedure
- Step 1 of 5 Medication the day before
For many cases we prescribe medication to start the day before surgery. These medicines do a lot to limit swelling and discomfort afterward, and we consider them a key part of a good experience.
- Step 2 of 5 Anesthesia
For most of our cases local anesthesia alone is enough. Once the area is completely numb there is no pain, only pressure. Nitrous oxide and oral sedation are available if you would like them.
- Step 3 of 5 Removal
Done carefully and as minimally invasively as the tooth allows, which is the other half of a comfortable recovery. Bring headphones; patients listen to music and most describe the procedure as boring.
- Step 4 of 5 Closing
Stitches as needed. Unlike ordinary extraction sites, wisdom tooth sites are not bone grafted. You leave with written instructions and any further prescriptions.
- Step 5 of 5 Follow-up
Dissolving stitches need no removal; non-dissolving ones are taken out at a short visit. We may see you at about two weeks, or as needed for a simple case.
Recovery
- Rest for a couple of days, then most people go back to work or school; a Friday procedure with a Monday return is common.
- For the first days, no spitting, no vigorous rinsing, no straws, and a soft diet.
- Clean gently and avoid the surgical site, including no water flosser there for now.
- Starting two or three weeks after the procedure, we give you a small curved syringe to flush food out of the healing sockets until they close over.
Dry socket. The main avoidable complication is a dry socket: the blood clot that should fill the empty socket is lost in the first days, exposing bone and causing a deep, throbbing ache that starts two or three days after the procedure. Smoking, straws, spitting and hard rinsing are the usual causes, which is why the first-days instructions are so specific. If it happens, call us; a dressing placed in the socket relieves the pain within hours, and the socket heals, more slowly.
The nerve. For lower wisdom teeth, the risk we assess most carefully is to the nerve that runs through the jaw below the roots. Injury can leave altered sensation in the lip or chin, usually temporary, rarely lasting. The scan shows how close your roots sit, and when the relationship is unfavorable we talk about a coronectomy with a surgeon rather than take a risk with a tooth that could be managed another way.
Patients often expect a swollen face for a week. In our experience, with careful technique and the right medications, swelling is often minimal and discomfort modest, and the surgeons we work with see the same. Some swelling is still a normal response to surgery and is not a sign of a problem. Complications are uncommon when the precautions are followed, and we go through every one of them with you before the day.
Frequently asked questions
Do all wisdom teeth need to come out?
No. Many people keep all four for life without trouble. Removal is recommended when a tooth is trapped, repeatedly inflamed, decaying or causing a deep pocket or decay on the tooth in front of it, or when we can see that it will never have room. A wisdom tooth coming in straight with space to spare is left alone and watched.
Is there a best age?
When removal is going to be needed, sooner is easier: in a younger patient the roots are less developed, the extraction is simpler, the risk is lower and the recovery is quicker. When the outlook is uncertain, we prefer to wait and see rather than remove teeth just in case.
Will I be put to sleep?
For most of our cases local anesthesia alone is enough; once the area is fully numb there is no pain, and the procedure is more boring than dramatic. Nitrous oxide and oral sedation are available if you want them. Cases that call for intravenous sedation or general anesthesia are referred to an oral surgeon.
How much swelling should I expect?
Often much less than people fear. With careful, minimally invasive technique and the medications we prescribe, many patients have little swelling and modest discomfort. Some swelling is still a normal response to surgery, and it does not mean anything went wrong.
What can I eat afterward?
Soft foods for a couple of days, cool rather than hot at first, chewing away from the site. Avoid spitting, vigorous rinsing and straws for the first days to protect the clot. We give you written instructions.
How long before I am back to normal?
A couple of quieter days. Many patients who have the procedure on a Friday are back at work or school on Monday. Healing of the gum takes a few weeks; we may see you at about two weeks, or as needed for a straightforward case.
Sources
Professional guidelines and peer-reviewed reviews this page draws on.
- Ghaeminia H, Nienhuijs ME, Toedtling V, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. Cochrane Database of Systematic Reviews. 2020;5:CD003879. Cochrane
