Wisdom teeth

Oral Surgery in Birmingham, Solihull and Sutton Coldfield

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The whole time was made so easy and pleasant. The help and attention I had help things go wonderfully. Mr Elledge and his team should have a gold star.
Patient satisfaction survey, Solihull Hospital 2019
I regularly undertake day surgery lists for the removal of impacted teeth (including the removal of wisdom teeth) as part of my NHS role and am also involved in the training and supervision of higher trainees in both my parent specialty and Oral Surgery. I also undertake open and closed exposure of unerupted or buried teeth as part of agreed treatment plans in conjunction with colleagues in orthodontics. This is a technique whereby crowded or unerupted teeth can be "guided" into the dental arch. I have performed in excess of 1,000 oral surgery procedures in my higher surgical training, covering dental extractions, repair of oro-antral fistulae, exposure of teeth and third molar removal among others.

What are wisdom teeth?

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Wisdom teeth (or third molars) are the last teeth to develop in the adult dentition, appearing at the very back of the mouth. Some people don't develop wisdom teeth at all, and some people's wisdom teeth never erupt, remaining completely buried. For some of us however, wisdom teeth partially erupt due to a lack of space in the dental arch and that's where problems can begin. Partially erupted wisdom teeth can become difficult to clean and prone to recurrent infections and decay.

Do I need my wisdom teeth removed?

Wisdom teeth do not have to be removed simply because they are impacted or "stuck". In fact, there is clear national guidance on when wisdom teeth should be removed although this is beginning to be revised. You may need your wisdom teeth removed if one or more of the following applies to you:

  • Your wisdom tooth has signs of decay (caries);
  • Your wisdom tooth is causing damage to the tooth in front of it (your second molar);
  • Your wisdom tooth has associated pathology such as a cyst or tumour;
  • Your wisdom tooth has caused recurrent infections around the crown of the tooth (pericoronitis) necessitating antibiotics.

There are other, less common reasons for active treatment of impacted third molars but the important consideration is that asymptomatic impacted wisdom teeth that are not causing problems do not necessarily warrant treatment. In addition, wisdom teeth cannot be blamed for "crowding" of the anterior dentition (and this is not a reason for their removal).

What kind of x-rays (radiographs) do I need for my wisdom teeth?

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I will usually ask for a panoramic radiograph (orthopantomogram or OPG) of your mouth which gives a good overview of all of your teeth and jaw joints. It is particularly good at showing the relationship of your wisdom tooth to the inferior alveolar nerve (IAN), a nerve that runs within your lower jaw and supplies sensation to your lower lip and chin. It is not great at picking up early decay in your teeth, and if this requires clarification, I will recommend that you attend your dentist for smaller intra-oral radiographs called bitewings.

In a small number of patients, the OPG will demonstrate a potentially close relationship between the IAN and your wisdom tooth. If this is the case, I will ask for a cone beam computed tomography (CBCT) scan. This is a low radiation dose 3-D image of your wisdom tooth and the nerve so I can gain some additional information about the relationship between these two structures.

I will relay all this information to you to help you make a decision regarding treatment that is right for you. I will always say that I treat patients……not x-rays!

All your scans will be arranged in Edgbaston, Birmingham at Cavendish Imaging within The Westbourne Centre. I will touch base with you following your investigations by telephone at no additional charge to you or your insurer.

What are the risks of wisdom teeth removal surgery?

All surgery has risks and "simple" surgery such as third molar surgery is no exception. Fortunately these risks are uncommon and I will take every step to minimise these risks (or make you aware in advance if your risk is higher than average based on the OPG and/or CBCT scans).

It is not uncommon to have some low grade pain and discomfort following third molar surgery. This can vary from case to case but I would usually advise patients that pain and swelling will be a its worst within the initial 48 hours following surgery, but that recovery is almost universal within one week. A small number of patients may develop an infection or "dry socket" which may cause pain to last longer than this, but this is not common at all.

I recommend all patients use ice packs and regular paracetamol with codeine phosphate as required, provided there are no contraindications. If your wisdom teeth have been particularly difficult, I will use a longer acting local anaesthetic as a "top up" at the end of the procedure to make the initial few hours as comfortable as possible. I will not routinely prescribe post-operative antibiotics as this is rarely justified and the evidence does not support their use prophylactically.

There are two important nerves near wisdom teeth: the lingual nerve (supplying sensation and taste to the anterior two thirds of the tongue) and the inferior alveolar nerve (IAN) (supplying sensation to the lower lip and chin). There is a risk of temporary or permanent sensory alteration to both of these nerves that in extremely rare circumstances can result in complete sensory loss (numbness) and/or neuropathic pain. These are seen on average in less than 1 in 250 patients and I aim to identify if you are at a heightened risk of nerve injury, advising you on steps to mitigate against this risk.

What are the alternatives to wisdom tooth or third molar surgery?

Clearly there is always the option of having no treatment. This may not be desirable if you are having regular infections and/or there is pathology associated with the impacted tooth. Lower risk strategies can include:

  • Operculectomy: removing just the inflamed gingiva around the wisdom tooth to make the area easier to clean;
  • Coronectomy: removing just the crown of the wisdom tooth, leaving the roots behind and "burying" these.

Coronectomy is a treatment option that is gathering favour and if you are at a higher than average risk of complications I will discuss this treatment option with you. It may not be applicable in some circumstances, however I will let you know why this is not an option for you if I feel this is information you should have to reach an informed decision.

Coronectomy minimises risk to the IAN, but anywhere up to around 20% of patients will require subsequent removal of the "buried" roots, as these will become infected. Strong proponents of the technique argue that these roots "migrate" away from the IAN, lowering the risk regardless. The evidence is still emerging and I will do my utmost to make sure you have all the information to hand at our initial consultation or well in advance of our scheduled treatment session.

I can arrange treatment awake (local anaesthesia) or asleep (general anaesthesia). If you decide to have the former, I will arrange for your treatment to take place at The Westbourne Centre in Edgbaston, Birmingham which is a daycase hospital with dedicated dental suite facilities. If you decide to have treatment under general anaesthesia, then I have admitting rights at Spire Parkway Hospital in Solihull, The Priory Hospital in Edgbaston, Birmingham and HCA The Harborne Hospital in Edgbaston, Birmingham.

Can other teeth become impacted?

Yes, any tooth can become impacted. Canines are particularly prone to be impacted or buried due to a lack of space in the developing arch. I regularly deal with these teeth in my NHS practice in conjunction with orthodontists planning fixed appliance treatment (braces) for younger patients.

What is the treatment for buried teeth?

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Some buried teeth can simply be left alone. This may particularly be the case if they are not damaging neighbouring teeth and patients are not seeking to have active orthodontic treatment to "straighten" their teeth. In these instances, I will make sure you are aware of all the treatment options (including providing this in writing to you) and that we have excluded the possibility of damage and/or associated pathology with appropriate radiographs.

After you have seen an orthodontist, you may wish to have the buried teeth either removed or exposed. I can do either of these treatments under an agreed treatment plan from a specialist in orthodontics. "Exposing" the buried teeth enables your orthodontist to bring them into the line of the arch as part of an agreed treatment plan, often using a gold chain bonded to the buried tooth.

It is important to realise that in these cases the treatment plan is agreed between you and your orthodontist and I am providing a technical service in exposing or removing the impacted teeth.

What is an oro-antral fistula or oro-antral communication?

Oro-antral communications are recognised complications (albeit uncommon) of upper molar extractions in particular. The "sinuses" we commonly refer to when talking about sinusitis are air-filled spaces within our upper jaws. The roots of molar teeth are not a million miles away from these spaces and sometimes when they are removed the result is a communication being created between the sinus and the mouth. The other name for the maxillary sinus is the maxillary antrum - hence the name oro-antral communication. When these communications are allowed to become better established they become epithelium lined tracts, or oro-antral fistulae.

Symptoms of these communications can include:

  • a "whistling" sound in the area;
  • hypernasal speech;
  • the sensation of air "escaping";
  • an inability to create negative pressure to suck fluids through a straw;
  • reflux of fluids from the mouth out of the nose.

Repairing these involves advancing gum over the opening and borrowing fat from the cheeks (a buccal fat pad and buccal advancement flap repair). In cases refractory to standard treatment I can work in conjunction with colleagues in ENT to do joint repairs via oral and nasendoscopic approach.

For some time afterwards, it will be important to avoid nose-blowing and smoking, maintain optimum oral hygiene using antiseptic mouthwash, use regular nasal decongestants and a short course of oral antibiotics.