Wisdom Tooth Removal

Wisdom teeth, or third molars, sit at the very back of the jaw and in most people come through between the ages of 17 and 25. If there is not enough room in the jaw, they may not come through fully, may lie on their side or may stay entirely inside the bone. Wisdom teeth that cause problems are among the most commonly extracted teeth; but the idea that every wisdom tooth should come out is not true.

This page deals with the questions specific to wisdom teeth: which ones should come out, what pericoronitis is, what it means for a tooth to be close to the nerve and how the swelling progresses. For general information about extractions, see the tooth extraction page.

Which wisdom teeth should come out, and which can stay?

The decision rests on whether the tooth is causing a problem today and on what we see on the X-ray.

Removal is usually recommended for

• Repeated inflammation of the gum around the tooth (pericoronitis)
• Decay in the wisdom tooth, or in the molar in front of it, caused by food trapped between the two
• Bone loss or root resorption behind the tooth in front
• A cyst or other lesion around the tooth; in that case cyst removal is planned for the same appointment
• An upper wisdom tooth with no opposing tooth, which over-erupts and makes you bite your cheek

It can stay

• A fully erupted tooth that meets the opposing tooth and can be cleaned with a toothbrush
• A tooth sitting completely within the bone, causing no symptoms and showing no problem on the X-ray

Routinely removing symptom-free, healthy-looking wisdom teeth because they "will cause trouble one day" is controversial; many guidelines recommend monitoring such teeth with regular check-ups and periodic X-rays instead. It is also widely believed that crowding of the front teeth comes from wisdom teeth pushing forward, but research does not strongly support this. We do not recommend an extraction on that ground alone.

Pericoronitis: swollen gum at the back

Food and bacteria get trapped under the flap of gum that partly covers a half-erupted wisdom tooth. The result is throbbing pain at the back of the mouth, swollen gum that bleeds when touched, a bad taste, pain when swallowing and being unable to open your mouth fully. Sometimes the lymph nodes under the jaw swell and a fever develops.

In the acute phase we first calm the inflammation: the area under the flap is rinsed at the clinic, and warm salt-water mouthwashes and painkillers are recommended; antibiotics are added if there is a fever or spreading swelling. Where possible, the extraction is done once the inflammation has settled. A single episode of pericoronitis does not always mean the tooth has to come out; but if it keeps coming back, the tooth will most likely go on causing trouble.

Emergency: If the swelling spreads to the cheek, under the eye, to the neck or under the tongue, if swallowing or breathing becomes difficult, or if you have a high fever, this is no longer just a problem inside the mouth. Contact your dentist or go to the nearest emergency department without delay.

What we look for on X-rays and CBCT scans

A panoramic X-ray shows the angle of the tooth (upright, tilted forwards or horizontal), the shape of the roots and their relationship to the nerve canal in the lower jaw. The nerve that gives feeling to the lower lip, the chin and the teeth on that side runs through this canal. If the roots overlap the canal, or the X-ray shows signs of close contact, we ask for a 3D cone-beam CT (CBCT) scan. Structures that seem to overlap on a two-dimensional image often turn out on CBCT to be separate, with bone between them; sometimes they really are in contact. At our clinic in İzmir we do not decide on an extraction without looking at an X-ray.

Wisdom teeth close to the nerve: risks and options

Removing a lower wisdom tooth can affect one of two nearby nerves: the nerve in the canal, causing numbness or tingling in the lower lip and chin, or the lingual nerve, which runs on the tongue side of the tooth, causing the same on one side of the tongue. This happens in a small number of patients and usually resolves within weeks or months; permanent changes are rare. Before the extraction we look at the CBCT scan with you and discuss what the risk is for your particular tooth.

For some teeth whose roots appear intertwined with the nerve, coronectomy is an option: only the crown of the tooth is removed, and the roots lying against the nerve are left in place. It reduces the risk to the nerve, but it is suitable only if the tooth is alive (vital) and the roots are free of infection; if the roots move later on, a second procedure may be needed.

The day of the extraction and how the swelling progresses

Wisdom teeth are usually removed under local anaesthetic. A fully erupted upper wisdom tooth may come out in a few minutes; a lower wisdom tooth lying in the bone needs the gum to be opened and the tooth to be divided. We describe these steps, and possible problems such as dry socket, in detail on the surgical tooth extraction page. If you are very anxious, sedation can also be discussed.

Removing the upper and lower wisdom teeth on the same side in one appointment is a common choice; you can chew on the other side while it heals. Taking out all four at once is also possible, but when both sides swell at the same time, eating is difficult for the first few days.

• Day 1: Numbness and some oozing of blood. Hold something cold against the outside of your face, on and off.
• Days 2–3: Swelling at its peak; you may not be able to open your mouth fully, and bruising may appear on the cheek or even the neck. On its own this is not a cause for concern.
• Days 4–5: The swelling starts to go down. From this point, gentle warmth can ease the tightness.
• Days 7–10: Most of the swelling has gone and the stitches are checked. Jaw stiffness may last a few more days.

Food may collect in the lower socket for a while. Leave the socket alone in the first few days; after that, clean it with warm water the way we show you.