The removal of wisdom teeth (third molars) is a common surgical procedure in dentistry. These teeth typically erupt between the ages of 17 and 25, often causing issues because the jaw lacks sufficient space for their proper emergence. When they become trapped beneath the gum line or bone, they are considered impacted. Impaction can lead to pain, infection, crowding of other teeth, or the formation of cysts, necessitating extraction.
The Role of the General Dentist
A general dentist performs many routine extractions, categorized as simple extractions. These procedures are reserved for wisdom teeth that have fully erupted through the gum tissue and are readily visible in the mouth. When the tooth is not impacted and has a simple root structure, the general practitioner removes it using only local anesthesia.
This type of removal involves loosening the tooth from the socket with specialized instruments before carefully extracting it. The general dentist’s scope is limited to these less complex cases, ensuring predictable outcomes for easily accessible teeth.
The Specialist: Oral and Maxillofacial Surgeons
For complex cases, the general dentist refers the patient to an Oral and Maxillofacial Surgeon (OMS). These specialists complete extensive training beyond dental school, including a hospital-based surgical residency lasting four to six years. This residency includes rotations in anesthesiology, general surgery, and emergency medicine, equipping them with expertise for intricate surgical procedures.
The OMS is uniquely qualified to manage deeply impacted teeth, those requiring significant bone removal, or cases where the tooth’s position is near vital anatomical structures. Their advanced training in various sedation techniques, including intravenous (IV) sedation and general anesthesia, ensures patient comfort during lengthy or challenging operations.
Determining Factors for Referral
The decision of who performs the surgery relies on a detailed diagnostic process focused on the tooth’s complexity and its relationship with surrounding anatomy. The initial assessment involves a panoramic X-ray, which provides a two-dimensional view of the entire jaw and the position of the third molars. This image helps to identify the impaction type, such as vertical, angular, or horizontal positioning.
If the panoramic image suggests close proximity between the lower wisdom tooth and the mandibular canal, which houses the inferior alveolar nerve (IAN), a more advanced image is necessary. A three-dimensional Cone Beam CT (CBCT) scan is then used to accurately map the precise relationship between the tooth roots and the nerve bundle. Damage to the IAN during extraction can result in temporary or permanent numbness in the lower lip and chin.
Cases involving significant pathology, such as a large cyst or tumor associated with the impacted tooth, also necessitate a referral to the OMS. Primary factors driving the referral to the surgical specialist include:
- The presence of bony impaction.
- The need for advanced surgical techniques.
- The intimate relationship to critical nerves.
- The requirement for deep sedation.
The Procedure and Post-Extraction Care
The extraction procedure begins with the administration of anesthesia, ranging from local numbing injections to IV sedation or general anesthesia. For impacted teeth, the surgeon makes a small incision in the gum tissue to expose the tooth and underlying bone. A high-speed handpiece is often used to carefully remove bone blocking access to the tooth.
The tooth may need to be sectioned into smaller pieces to facilitate removal and minimize bone removal. Once extracted, the surgical site is cleaned, and sutures are placed to close the gum flap and promote healing. A gauze pad is then placed over the area to manage initial bleeding and encourage the formation of a blood clot.
Post-operative care is crucial for minimizing the risk of complications, particularly alveolar osteitis, commonly known as dry socket, which occurs if the protective blood clot is dislodged. Patients must avoid creating suction in the mouth, meaning no smoking or using straws for several days. A diet of soft, cool foods is recommended initially, and physical activity should be limited for the first 24 to 48 hours to prevent increased bleeding. Gentle rinsing with warm salt water, starting the day after surgery, helps keep the area clean, but vigorous spitting or swishing must be avoided to protect the clot.