THIRD MOLARS

•There are many good reasons for removing wisdom teeth also known as third molars, there are also

some risks and complications that are possible when extracting these teeth and sometimes there

are some good reasons for leaving them alone. The decision on a specific course of action must be

determined by a well informed doctor and patient working together .

•Consider first the many reasons that people choose to have their third molars extracted. By far one of

the most common findings is that the mouth is just too small for these teeth to fully erupt into a good

functional position. This leads to one of several situations

•1 .The teeth remain completely buried in the bone of the upper and lower jaws in which they developed, a

condition known as impaction. In the case of the fully impacted tooth, it may continue to sit in the bone,

surrounded by the normal cyst in which all teeth develop. It may also happen that the normal cyst, later in life,

enlarges and may even develop changes in the cells that line the cyst. When such cysts get large enough, they

should be removed and examined by a pathologist .•2 .The teeth begin to erupt but are not able to assume

their correct upright position. Most commonly the upper third molars will tend to face out towards the cheeks

while the lower third molars will lean forward with just a small portion of the crown protruding through the gum.

Teeth that are partially erupted lead to two problems.

•A) First they make hygiene of the second molars difficult leading to increased possiblity of decay and gum disease (periodontal

disease) around these important teeth .•B) Second the pink flap of gum tissue which partially covers the

erupting tooth creates a warm, moist and dark pocket where bacteria which normally live in the mouth can use the food you

eat to flourish, multiply and cause an infection known as pericoronitis. In fortunate cases, the swelling and pain of this

condition will be relieved when the infection drains back into the mouth. In those less fortunate, the swelling persists, does not

drain back into the mouth but rather extends laterally and if not treated can become a very serious infection. The treatment of

choice for pericoronitis is extraction of the offending tooth. Antibiotics, operculectomies and other adjuncitve treatments

may be helpful from time to time but the problem has a propensity to return as long as the conditions which allowed it to

develop in the first place continue to exist .

•It is easy to understand why many people choose to hedge their bets and have their wisdom teeth extracted while they are young and healthy and the teeth are surrounded only by a small normal

developmental cyst rather than have to undergo a more extensive surgical procedure later in life when their recovery may not be as

easy and their general state of health may not be as good.

Finally, some dentists subscribe to the theory that wisdom teeth may push the other teeth in the mouth forward and cause

crowding and misalignment. You should be aware however, that not all oral surgeons believe this to be the case.

Now however, it is important to consider the possible risks and complications involved in the removal of third molars. There are

some risks/potential complications which are common to all surgical procedures however major or minor they might be. These

are:

•PAINRemoval of third molars is a surgical procedure and some

discomfort should be expected. It is also reasonable to expect that this discomfort will be taken care of by the pain medication

prescribed.INFECTION

In the absence of preexisting infection it is uncommon to see an infection resulting from the removal of third molars however, there are more bacteria per square inch in the oral cavity than anywhere

else in the human body and so often patients are placed on antibiotics prophylactically during the initial healing period.

SWELLINGPost operative swelling and bruising are both within the spectrum of normal. The exact amount of each of these varies from patient

to patient as does the time required for complete resolution of these symptoms. Surgical edema is a normal consequence of

surgery and also normally resolves without extraordinary measures

•BLEEDINGIt is not possible to do surgery without some bleeding but when you leave

your surgeon's office you should expect that the minimal oozing you are experiencing can be easily controlled by biting on clean gauze or a tea bag.

Bleeding that cannot be controlled in such a fashion warrants an immediate call to the surgeon.

and the risk of the ANESTHETIC itself. Most wisdom teeth COULD be removed without any anesthesia at all...but

that would make for a very unhappy patient and an equally unhappy doctor. For patients whose medical condition contraindicates general anesthesia,

third molars can safely and effectively be removed with local anesthetic only. Local anesthestics as used in the oral surgeon's office are among the safest of

drugs around and true allergic reaction to a properly administered local anesthetic is so rare as to be worthy of publication in scientific journals. Most persons prefer, however, to be "asleep" for the removal of their third molars.

There is a somewhat greater risk for this than for the use of local anesthetic alone

and if this is your desire, your oral surgeon should discuss your medical history and your particular risks with you prior to your procedure. You should

be aware that in the young healthy individual, those risks are often minimal and acceptable but they do exist and should be discussed with the doctor.

•Finally there are some risks/complications that are unique to the removal of third molars .

•The upper third molars have roots which often are separated from the maxillary sinuses by only a very thin layer of bone. Occasionally, a small communication is established between

the sinus and the oral cavity when one of the upper third molars is removed. If this is the case, the normal procedure is

for the area to be sutured closed, the patient to be informed of the finding, appropriate antibiotics and decongestants to be

prescribed, the patient to be instructed to avoid Valsalva maneuvers (tasks which build up pressure in the sinus like nose

blowing and bearing down forcefully) and the patient reappointed for followup. Most often this results in an

uneventful healing period with no further treatment being required. Occasionally, the area will heal open rather than

closed in which case an additional small surgical procedure will be required to close the communication

•The lower third molars often have roots that lie very near or even wrapped around the inferior alveolar nerve. This is the nerve that

supplies feeling to the lip, teeth and part of the gums on each side of the mouth. Occasionally, when a lower third molar is removed, that nerve

will be bumped or bruised and if so a change in sensation may be noted on that side. It is important to understand that this is a sensory nerve and does not affect the ability to move the parts of the oral cavity to

which it gives sensation (feeling). In most cases, the nerve heals itself but, because nerves heal slowly, it may take six months to one year

before return of normal sensation. Very rarely, the damage to the nerve is permanent. Likewise, the lingual nerve, which supplies sensation to

the tongue and the tongue side of the gums often lies in close proximity to the surgical site and may be disturbed in the process of removing

these lower third molars. Once again, most alterations in sensation are temporary but ocasionally the change may be permanent.

Finally, the normal precautions, risks and benefits of extraction of any tooth (which are beyond the scope of this discussion) also apply here

and should be discussed with the surgeon prior to beginning any procedure.

•Thanks•DEEMA MAJID

ALGRBI