Exodontia.Info
Wisdom Teeth Treatment Options
There are a number of treatment options for ‘wisdom teeth’:


Improved & Targeted Oral Hygiene

A wisdom tooth that is only partially through the gum or has prone to decay, gum disease or inflammation-infection
of the tissues surrounding the tooth’s crown.

If the
wisdom tooth does not need to be removed (see the NICE Guidance on the Extraction of Wisdom Teeth),
then it can be kept but will need targeted oral hygiene.

This involves very scrupulous cleaning around the tooth (±
operculum) possibly using such adjuncts as antiseptic
mouthwashes or gels (
Corsodyl is very good for this).

Problems with the procedure:

Future flare-ups with the wisdom teeth can still occur especially if stressed, moving house, sitting exams etc.

May be regarded just as a stop-gap measure, delaying the day that the tooth may need to be removed.

The
NICE Guidelines emphasise the link between the presence of plaque and peri-coronitis (inflammation /
infection around the crown of the wisdom tooth,
NICE Guidance on the Extraction of Wisdom Teeth, 1.4).



Operculectomy ± Opposing Tooth Removal

If the flap of gum overlying the wisdom tooth (the operculum) is causing the problem, then this can be removed by
a number of means (‘cold steel’,
glacial acetic acid, laser or cautery).

Problems with the procedure:

It possible that this may grow back and the
operculectomy may need to be repeated.

In the area where the
operculum is removed, runs the Lingual Nerve that supplies sensation to the tongue (and if
this is effected by the
operculectomy, a numb tongue may result as well as loss of taste on that side of the tongue;
the numbness can last up several months) and sometimes aberrant blood vessels (that can be surprisingly vigorous
in bleeding).

Coupled with this, it can be quite sore afterwards and there may be limitation of mouth opening.

If the
wisdom teeth flare-ups have been quite episodic, then it may be hard to know if the operculectomy has in
itself, been successful.

An
operculectomy is sometimes considered if the upper, opposing wisdom tooth is traumatising the operculum.  
SIGN suggests pain associated with the lower wisdom tooth is commonly exacerbated by the upper wisdom tooth
biting on the gum flap (
operculum), causing pain and discomfort.

Alternatively, if the upper
wisdom tooth is easy to remove and is non-functional, then immediate removal of that
tooth will often dramatically relieve the pain from the area.  This is particularly useful where there is likely to be
delay in the removal of the lower
wisdom tooth and can be regarded as an interim measure (after referral but prior
to surgery).
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Last Updated 31st December 2019
Exodontia / Tooth Extraction


Wisdom teeth are removed only if the reason for removal is mentioned in the NICE guidelines.

Wisdom teeth cannot be prophylactically / preventively removed.

Just because
wisdom teeth are present, it does not mean they have to be removed.

The guidelines boil down to waiting for some pathology to develop – decay, gum disease,
infection around the tooth
crown, cyst development etc.  This is regarded by some as supervised neglect.

Problems with the procedure:


Patients should not be exposed to these risks of a surgical procedure unnecessarily.



Coronectomy

If the roots of the wisdom tooth seem to be in very close proximity to the nerve that supplies sensation to the lip
and chin (the
Inferior Dental Nerve) or if the tooth itself is deep within the lower jaw so that total removal of the
tooth may be impractical / ‘tricky’ / damage the nerves / lead to a possible
broken jaw, then only the crown of the
tooth may be removed (
coronectomy / intentional partial odontectomy).

Problems with the procedure:

If, when the tooth is being decoronated, the roots are found to be mobile, then the roots have to be removed as
well (hence, the original problems of nerve damage etc are not circumvented).

The roots left behind often migrate away from the nerve so that if they give any more problems, the roots can be
removed with reduced risk to the nerve.


Molar Uprighting

It is always worth considering, if there is enough space for the wisdom tooth and that it would be functional, to
orthodontically
disimpact the wisdom tooth and bring it into a position where it is in an optimal position, functional
and does not compromise adjacent teeth.  This is not a quick fix and may require the use of
mini-screws / implants
to provide
anchorage to facilitate the orthodontic movement of the tooth.  These screws / implants are removed
afterwards.

Problems with the procedure:

Uprighting wisdom teeth may be regarded as futile exercise as there may be:

  • Insufficient space
  • Abnormal root morphology (shape)
  • Not very actively involved in mastication (chewing)
  • Would need lot of bone removal to create space for the roots.
  • Proximity to vital structures like Inferior Alveolar Canal, Lingual Nerve etc
  • Difficult in 3 dimensional stabilisation
  • Difficult to maintain hygiene

I think the latter 2 may be more important as you would consider the others prior to uprighting the tooth; if these
were not valid, then you wouldn't proceed to molar uprighting.


Useful Articles:

The Angle Orthodontist 1998.  Uprighting Mesially Impacted Mandibular Permanent 2nd Molars

Int J Orthod Implantol 2011.  The Wisdom of Managing Wisdom Teeth.  Part III.  Methods of Molar Uprighting

Ortho J Nepal 2015.  Simple Mechanics to Upright Horizontally Impacted Molars with Ramus Screws

J Clin Ortho 2016.  Uprighting Mesially Impacted Lower 3rd Molars with Skeletal Anchorage

JOMS 2017.  Surgical Uprighting Is a Successful Procedure for Management of Impacted Mandibular 2nd Molars

The Open Dent J 2017.  Case Report.  Molar Uprighting - A Considerable & Safe Decision to Avoid Prosthetic
Treatment

Acta Sci Dent Sci 2018.  Uprighting & Protraction of Mandibular 2nd & 3rd Molars into Missing 1st Molar Spaces
for a Patient with T-Loop & Temporary Anchorage Device - A Case Report

J NTR Univ Health Sci 2018.  Orthodontic Uprighting of Severely Impacted Mandibular Permanent Second Molar
with TMA Spring

Progress in Orthodontics 2018.  Mandibular Molar Uprighting using Orthodontic Mini-Screw Implants - A Systematic
Review