How Doctors Remove Wisdom Teeth

Image of X-ray Showing Path For Wisdom Tooth Removal Unblocked

Path For Wisdom Tooth Removal Unblocked
Courtesy Craig Sommer DDS

Image of Wisdom Tooth X-Ray Showing Blocked Eruption Path

Wisdom Tooth X-Ray Showing Blocked Eruption Path or Impacted Wisdom Tooth
Courtesy of Craig Sommer DDS

When you sit down and begin your consultation with your doctor about your wisdom teeth be prepared for a discussion that will be unique to you.  One of the first considerations that your doctor will observe and discuss with you is whether there is a path or direction along which the tooth can be moved in order to bring the root out of the bone.

Do you remember the last time you or a friend had to relocate households? Do you remember moving a piece of large furniture all of the way into a back bedroom. Planning is everything. Will the table fit through the front door, all of the openings and around the corners? Will it’s legs have to be removed and be put back on later after it is in the destination location? Will a door have to be taken off it’s hinges to allow the table to be brought into the room?

Removing teeth is sometimes similar to moving day. With tooth removal there has to be a clear path for moving the tooth that is not blocked by another tooth. If it is blocked it is called an impacted wisdom tooth. And if the teeth involved are in good position it makes life much easier. If not, some trimming or tooth division may be required to remove individual pieces in a controlled fashion.

If that sounds a little too exciting to be done while you are fully awake and aware of sights and sounds you’ll want to discuss your options for anxiety reduction or sedation.

After you discuss the level of your anxiety with your doctor you may jointly decide to use oral medications or laughing gas, otherwise known as nitrous oxide for your surgery.  You may even decide to use IV sedation where medications are introduced into a vein in your arm or hand to profoundly relax you during treatment.  Your doctor will discuss the risks and benefits of each the variety of anxiety reduction techniques available for you, the preparations required and the need for special transportation arrangements.

Regardless of the orientation of the teeth the next steps are the same for the surgical procedures.

First, you’ll have a topical numbing agent rubbed on the gum tissue to prepare for an injection of local anesthetic. Our goal is to make this as comfortable as possible if you decide to use nitrous oxide gas or go without any anxiety reduction medications. Second, your dentist will get you numb, using an optimum amount of  local anesthetic.

Yes, unfortunately, injections are necessary to remove most teeth. I am all in favor of being numb during my dental procedures. I have had enough dental work done over the years myself that I know I would rather be comfortable and not feel much if at all possible.

Your dentist will try to make your injections as painless as possible for you, but you will probably feel a little discomfort during the process. This is where I encourage you to use hand signals.  I ask my patients to raise their hand if they are having difficulty during or after the numbing process. I agree to stop for a moment and assess the situation. In most cases, because the nerves that run to the teeth come from different directions and sides of the teeth, multiple injections are necessary.

After waiting a sufficient amount of time for the local anesthetic to take effect, your dentist will evaluate whether or not the tooth and the gum tissue surrounding it are numb enough to proceed. After the testing process, your dentist will assess how easily your tooth can be moved. He will try to wiggle the tooth in different directions using a variety of different instruments. The wiggling process allows your dentist to determine the next step he will use in the process of removing your tooth.

If you have a single root on your tooth, or if multiple roots are fused together like a large single root it may simplify the removal process. Your dentist may grasp onto your tooth after loosening with an instrument that I call a wiggler or elevator. The technical term for the grasping instrument is a forcep.  But forcep is a scary term so I use terms that sound less scary. The forcep is used to hold onto the tooth during the second stage of the loosening process. As the wiggling and lifting process continues, your dentist will be able to see the tooth begin moving out of the bone.

Once the tooth is lifted completely out of the bone, your dentist will verify that all of the root or roots are removed and that there are no pieces left behind. Sometimes, during the lifting and wiggling process, one or more of the tips of the roots may separate from the body of the root, and require your dentist use smaller instruments to gently remove the tips of the roots remaining in the hole or socket where the tooth was removed.

Once the tooth and root tips have been removed from the socket your dentist will remove any infected tissue and may gently scrape the socket to remove a layer of tissue that is called the periodontal ligament. This speeds along healing and prevents future complications.

If the wisdom tooth is completely encased in gum tissue and bone, or unfavorably positioned, the process is a little more involved.  Your doctor may have to make a window through the gum and bone large enough to see the wisdom tooth and accomplish it’s removal. Sometimes the window allows the whole wisdom tooth to be removed in one piece. Other times it is divided up into multiple pieces and delivered through the window.

There will always be some seepage of blood from the socket and your dentist will attempt to control that seepage in several different possible ways. In most cases, moist gauze is placed over the socket and you will be asked to maintain light pressure on the gauze with your opposing teeth. If the gauze stays steady and holds the seeping blood in place until a blood clot forms, you will usually have minimal discomfort and a more rapid healing process. That’s why your dentist will tell you not to talk while the gauze is in place, or to talk while keeping your teeth together.

It sounds funny, but if you can keep the blood clot stable, you minimize bleeding, provide for good healing and make for a much better outcome for you. He will probably also tell you that you cannot smoke, rinse, spit, and or drink liquids through a straw. Because all of those can potentially loosen the blood clot which can result in extended bleeding time.  Sometimes, in spite of your best efforts and careful following of instructions, part or all of the blood clot is lost from the socket creating something called a dry socket.

You may have heard of the term dry socket from friends, coworkers or family. In essence, it means that the blood clot that formed in the socket got washed out and the boney socket walls are no longer protected, exposing naked bone. That usually happens three or four days after your surgery and can be quite painful unless your dentist places protective medication or medicated gauze in the socket for the next several days. This is one of those things that your dentist wants to hear about from you so he can help you. It doesn’t happen very often, but when it does it’s very uncomfortable. So you need to really follow the instructions that are given to you by your dentist after surgery.

In most cases, if appropriate, your dentist will recommend the short-term use of an anti-inflammatory medication and a pain medication. These are usually required only for a few days.

In some situations an antibiotic will also be recommended, but not always. Follow your dentist’s instructions as to how this can best be done to maximize your comfort, and minimize the interruption to your normal activities. Your dentist my encourage you to use probiotics along with your antibiotics to avoid intestinal bacterial disruption leading to diarrhea or yeast overgrowth.

It may take several days or even weeks before the area where the tooth was removed becomes comfortable enough to allow brushing and eating near the socket. As soon as you can, resume maintaining your teeth normally in that area. The cleaner your mouth is the faster healing will occur.

In some situations, your dentist may also consider the use of a special type of material that will help to form a good blood clot and reduce your chances of a dry socket. He places this into the socket before the moist gauze is placed over it. Or he may decide that it would be best for you to place a couple of small sutures or stitches to hold that material in place and to stabilize loose gum tissue so that it will hold the blood clot in place and speed along the healing process. This is done on a case by case basis.

Thinking ahead, your dentist may also suggest, if appropriate, a bone graft be placed to minimize your chances of bone shrinkage that could affect surrounding teeth. This also improves your chances of tooth replacement using dental implants. It is more important for teeth closer to the front of your mouth than wisdom teeth. You may want to bring this up during your discussion with your dentist while planning your tooth removal procedures.

I’ve described what’s done for most every tooth removal. Some are straight forward, others are more difficult. Your dentist will prepare you with information for your individual situation, but it is important to ask the questions on your mind. Get those concerns out in the open.

Look for more articles in the series- Questions You Must Ask Your Dentist Before Having Your Wisdom Teeth Removed.