The Extraction of Wisdom Teeth:Information on Procedures and Problems

By GARY C. MORTENSON AND LAWRENCE W. KOLAR, D.D.S.

upper and lower teeth. This view helps determinespatial relationships for surgical purposes. As thirdmolars develop, it is advisable to have panoramic X-rays taken and examined by an oral surgeon. Ide-ally, one would have this done at the age of sixteen.In most cases a general dentist refers a patient to anoral surgeon for this purpose.

When oral surgeons study panoramic X-rays withregard to third molar development and possible ex-traction, they are concerned about two crucial areas.These are: the relationship of the lower third molars(nos. 17 and 32) to the mandibular nerve, and theproximity of upper molars (nos. 1 and 16) to themaxillary sinuses. The maxillary sinus is a cavitywhich is lined by a thin epithelial (skin-like) tissue.If the sinus is perforated, it could create a directopening between the sinus and the oral cavity. Thiswill be discussed in detail later.

The mandibular nerve (sometimes referred to asthe inferior alveolar nerve) is actually the third divi-sion of the trigeminal ("three-headed") nerve whichprovides sensory information to the mandible (lowerjaw), the lower teeth, the posterior one-third ofthetongue, and the lips and face. There are two mandi-bular nerves, one on each side of the face extendingto the midline. Therefore, if damage were to occur tothe right mandibular nerve, this would affect thelower right jaw to the midline of the face, includingthe lower right teeth, the right posterior one-third ofthe tongue, and the lower right lip to the midline.The resulting numbness is called paresthesia (anes-thesia due to physical trauma to a nerve, as opposedto anesthesia induced by medication). To a trumpetplayer it is obvious how important the proximitybetween root structures and the mandibular nervebecomes when evaluating the risks of extraction. Ifthe roots of a third molar closely approximate themandibular nerve, then extraction of the tooth couldimpinge on the nerve even to the point of completelysevering the nerve. If paresthesia results it can lastfor several weeks, several months, or in extremecases, indefinitely. The extent (i.e., the amount oftissue involved) and longevity of paresthesia aredirectly related to the degree of trauma inflicted onthe nerve. Ifthis unfortunate circumstance is severe

General Information

Removal of wisdom teeth, referred to as thirdmolars, is one ofthe most frequently performed oralsurgery procedures. Trumpet players dread thethought of having any teeth extracted, but wisdomteeth seem to be particularly notorious because oftheir reputation for causing pain and complications.This article is designed to present, as clearly andconciselyas possible, what brass players should knowregarding the procedures and risks associated withthe extraction of third molars.

Wisdom teeth usually come in between the agesof seventeen and twenty-three. As such they are thelast adult teeth to erupt, and come in at an agewhen we are older and presumably "wiser." Dentistsnumber our teeth beginning with the upper rightgoing across to the upper left, from one to sixteen,and then from seventeen to thirty-two on the lowerleft going across to the lower right. Therefore, thefour wisdom teeth are properly numbered as fol-lows:

I. Upper right third molar = tooth #1II. Upper left third molar = tooth #16

III. Lower left third molar = tooth #17N. Lower right third molar = tooth #32

The best way to see how third molars are devel-oping, and whether or not they may have to beextracted, is to have an X-ray taken of the jaw in thethird molar area. This is the point at which a regu-lar dentist may recommend an oral surgeon. The X-rays taken for regular check-ups by a general den-tist (bitewings and periapical X-rays) are taken onsmall X-ray films. These are excellent for detectingcavities and for viewing the depth of decay in vari-ous teeth. They are not always advantageous, how-ever, in detailing third molar development, sincethird molars often form farther back in the mouththan the standard X-ray films can comfortably reach.This is especially true if the patient has an active"gag" reflex to the placement ofbitewing X-rays. Forthis reason oral surgeons typically take panoramicX-rays.

Panoramic films give doctors a more completeview of the entire jaw and root structure for both

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enough, it can potentially be a career ending injuryto a brass player.

The keys to minimizing the possibility of pares-thesia appear to be early detection and extraction ofthird molars before root structures are fully formed.A recent clinical study of more than 9,500 patientsby Drs. Osborn, Frederickson, Small, and Torgerson(four Detroit-area oral and maxillofacial surgeons)found that the optimum time for third molar extrac-tion is between the ages of twelve and twenty-four.These doctors concluded that paresthesia was fourtimes more prevalent among twenty-five to thirty-five year-olds than in twelve to twenty-four year-olds, and was an even greater risk after thirty-five.They further observed that the cause of this in-creased risk was directly related to the completionof root formation and the proximity of the teeth tothe inferior alveolar nerve (mandibular nerve). For-tunately, the study found that when paresthesia didoccur, 55.3 percent ofthe patients who suffered fromthis condition had normal sensation within twomonths, and 78 percent recovered within threemonths. However twelve percent still had nervedysfunction six months after surgery. Of the 16,127mandibular third molar extractions done in thisstudy, 16 percent were erupted, while 84 percentwere impacted (not erupted). The findings weresummarized at the conclusion of an American Asso-ciation of Oral and Maxillofacial Surgeons SurgicalUpdate:

... as patients become older there existsan increased chance of surgical morbid-ity with reference to nerve paresthesiasand alveolar osteitis. Also indicated - aspatient's age and teeth continue to de-velop and remain unerupted, the inci-dence ofpostoperative complications riseand become more significant and pro-longed. The oral surgeons thus concludedthat, if indicated, removal of third mo-lars should be completed in the teenageyears to decrease both operative andpostoperative morbidity.Functional third molars should be re-tained and restored. Because this studyindicated significantly fewer complica-tions among younger age groups, oneshould evaluate patients for removal bythe time skeletal growth is complete (16-18 years of age).A recent review of the literature showsthat most paresthesias will resolve in

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one to two years if left alone.'It should also be noted that removal of teeth at

an early age results in more rapid healing, and thatthis in turn avoids long delays in the resumption ofnormal practice routines for musicians.

Example Cases

Example I reveals how critical the proximity offully formed root structures to the mandibular nervecan be. In this panoramic X-ray, the lower left thirdmolar (#17) is fully impacted (not erupted). Theclose proximity of #17 to the second molar (#18)would make the eruption of #17 virtually impos-sible. The roots of #17 are directly on top of themandibular nerve. If this impacted third molarpresses against the second molar (#18) as #17 triesto erupt, it could cause extensive pressure and sub-sequent pain. Infection and decay could result if anopening in the gum tissue developed between #17and #18 which could allow saliva to "leak" along thelength of #18's root surfaces. Pressure created fromimpacted teeth can cause overcrowding and irregu-larity of other teeth. Because of the relationship ofroot to nerve, however, extraction here could causeparesthesia. Had the third molar in Example I beenremoved before the root structure was fully formed,an easier and safer extraction with less chance ofnerve damage would have been possible. This is anexcellent argument for early detection of impactionand subsequent early extraction.

Example II reveals a different set of concerns.This X-ray views the upper left third molar (#16)and the lower left third molar (#17). Both of thesewisdom teeth are partially erupted, both are comingin straight, and both have room to erupt further. Ifit became necessary for an oral surgeon to extractthese teeth at the time of this X-ray, the problemscould be as follows: (Upper left #16) The roots ofthisexample are in close proximity to the maxillary si-nus. Removal could possibly cause sinus perfora-tion. If the maxillary sinus is ruptured, several un-desirable consequences can result. These includeoral-antral (sinus) infection due to the direct contactbetween oral and sinus tissue fluids, chronic drain-age, and subsequent sinus inflammation.

When a rupture does occur it is treated in thefollowing manner:

1) The socket is "packed" with resorb-able sterile gel-foam to close the wound.2) The surgeon employs multiple tightsutures(stitches).

3) The patient is advised to avoid "blow-ing his nose" for ten to fourteen days, orlonger if necessary. 2

4) For trumpet players, practicing shouldbe discouraged for at least two to fourweeks."

The lower left third molar (#17) in Example II isin close proximity to the mandibular nerve. Eventhough the potential for problems here is much lessthan in Example I, the patient should be aware ofthe relationship of tooth to nerve and of possiblecomplications. This patient could very likely be ad-vised to wait one to one-and-a-halfyears to allow forany additional eruption to occur and then to have#16 and #17 extracted.

Example III illustrates a different type of thirdmolar impaction known as mesioangular impaction.Here the lower right third molar (#32) is impactedat a right angle towards the adjacent teeth. Failureto extract this tooth could cause pressure againstother teeth in the vicinity, creating swelling. Thepain this creates can be severe and often radiatestowards the ear. This can cause the entire side ofthe face to ache. Eventually this condition couldendanger the alignment of the teeth on that side ofthe jaw. Possible paresthesia from nerve damagehere is less likely than in Examples I and II becausethe roots are not near the mandibular nerve. How-ever, the incision necessary to remove this thirdmolar will be longer than in the other examples.This may create more post-operative soreness andcarry a greater risk of infection. If #32 had beenextracted when the root structure was less devel-oped, or even non-existent, the incision would havebeen shorter, therefore healing time would havealso been shorter.

As we have seen, spatial relationships betweenteeth, bone, nerves, and oral and nasal cavities,often necessitate the extraction of wisdom teeth.Another condition called pericoronitis involves thegumline and can also indicate necessary extraction.Pericoronitis usually occurs when a lower third mo-lar does not erupt entirely through the gumlinewhile simultaneously, the upper third molar iserupted. This results in the "sandwiching" of gumtissue between opposing third molars and subse-quent swelling of the gumline to the extent that itinterferes with occlusion (biting). As a result of thisswelling, every time the patient occludes he bitesdown on the gum, causing pain and further inflam-mation. Resultant pain can be severe and is furthercomplicated by the possibility of infection.

Example I: Fully impacted left third molar (#17,large arrow). Smaller arrows follow the path of themandibular nerve revealing the close proximity ofthe nerve to the root structure of #17.

Example II: Upper left third molar (#16). Arrowshows the close proximity of #16's root structure tothe maxillary sinus.

Example III: Lower right third molar (#32) is im-pacted at a right angle towards the adjacent teet.This is classified as a mesioangular impaction.

February, 1990 / ITG Jo

Decisions Before Surgery

When it is decided that a patient would benefitfrom the removal of third molars, decisions mustalso be made on how many to extract and what kindof anesthesia to use. General anesthesia, which ren-ders a patient totally unconscious, is normally rec-ommended if teeth are impacted because the proce-dure is often too traumatic for the patient to experi-ence. It is also used for multiple extractions - againfor trauma related reasons. Whenever general anes-thetic is used, it is almost universally recommendedthat all planned extractions be done at one time inorder to minimize the number of exposures to theanesthetic. Most patients find that there is not muchadditional postoperative discomfort from multipleextractions as opposed to single extractions, espe-cially if the teeth were impacted. Also, the practical-ity of going through one surgical ordeal and onepost-operative period makes good sense to a work-ing brass player. If a local anesthetic such as Novo-caine is used, patients often elect to have only rightor left side third molars extracted at one time inorder to lessen the anxiety level of consciously sit-ting through four extractions.

If only one third molar on a given side is re-moved, and the opposing molar is retained, the pa-tient runs the risk of the remaining molar su-praerupting (continuing to erupt beyond its normalrange of occlusion). This takes place because theretained third molar has no antagonist during nor-malocclusion, and is consequently free to continueerupting. Failure to extract this antagonist oftenresults in supraeruption to the point that teeth canocclude into opposing gum tissue, a situation simi-lar to pericoronitis. For this reason dentists almostuniversally recommend extracting third molar an-tagonists.

Breakage

Another area of concern, and one which maydetermine whether or not nerve or sinus membranedamage takes place, is the possibility offracturing athird molar during surgery. Approximately one outof every three third molars breaks during extrac-tion. This can be caused by abnormally hard bone,brittle teeth, or badly decayed teeth. If this occurs,the surgical digging that takes place in order toremove the remaining root structure can increasethe risk of nerve damage and maxillary sinus mem-brane perforation, and can increase overall tissue

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trauma. The earlier in the development ofroot struc-tures that third molars are removed, the less likelybreakage will occur. A clean extraction, with nobreakage, rarely causes nerve or sinus complications.

After Surgery

Once a nonimpacted extraction is completed,the patient will be asked to bite down on sterilegauze for thirty to sixty minutes to help create a clotand stop the bleeding. Additional gauze is oftenprovided should bleeding continue later in the day.Normal amounts of food can be eaten, but spicyfoods, alcoholic beverages, and sharp-edged foodssuch as pretzels or potato chips should be avoided.

Several methods exist for keeping the woundclean and free of food particles. Some doctors givepatients water syringes. This is not the method ofchoice because of the potential a jet-spray of waterhas to dislodge the clot, creating a "dry socket". Abetter method is a solution of hydrogen peroxideused as a rinse three times a day after meals. Thiskills bacteria around the wound and dislodges foodparticles from the area without risking clot damage.

Dry socket, known medically as localized acuteosteitis occurs when the blood clot that forms in awound socket breaks down and is dislodged, or whena poor blood supply to the wound exists, thus hin-dering the formation of a clot. These situations cre-ate a "dry socket" where raw bone and nerve end-ings are exposed. This condition is very painful.Treatment is palliative (pain reducing) but does notnormally require an anesthetic. Dry socket pastecontaining eugenol (cloveoil extract), camphor, ben-zocaine, and other ingredients is placed onto sterilegauze. The gauze is then positioned into the socketwith tweezers and left in place. This is repeateddaily for five to ten days, or until the conditionresolves itself.

For many extractions, sutures (stitches) are usedto close the wound. Sutures are utilized in instancesinvolving a "wide" socket, and are needed for surgi-cal extractions where an incision is necessary alongthe gumline in order to gain access to the molar,such as is seen in a mesioangular extraction (Ex-ample III). Suturing promotes quicker healing, lesschance of infection, and less bleeding.

Planning for SurgerylRecovery

It is unrealistic to plan on playing trumpetimmediately after having oral surgery. Certainly

•performances and "pressure situations" should beavoided entirely for several weeks after surgery. Itis best to plan on having oral surgery done over anextended vacation so that recovery can occur with-out worry about a deadline or playing commitment.Should the patient suffer from paresthesia due tonerve damage, it may be impossible to play. In mostcases this condition, should it appear, will resolveitself in a short period of time.

The decision to resume playing should be deter-mined by consulting with the oral surgeon and byusing common sense. The doctor can give you arealistic appraisal ofhow difficult the procedure willbe, and an estimate of how long it will take to facili-tate proper healing. When practicing resumes, theplayer would be wise to stop playing immediately ifacute pain or bleeding affects the area of extraction.Physically demanding playing - i.e. high-registerwork, extremely loud dynamic levels, or long etudesrequiring maximum effort, should be avoided in fa-vor of a more fundamental approach to musical aswell as physical recovery. Warm-up exercises in-cluding long tones, scales, lip slurs, moderate to softdynamic levels and tonguing exercises will help at-tain a quicker return to form. After not playing foran extended period, these types of activities seem tomake good sense and will help areas of lip sensitiv-ity and endurance at the same time. Trumpeterscan select solos and etudes which are less demand-ing physically but satisfy the need to begin workingagain."

If patients rush the recovery process in favor ofa quick return to playing, they risk a much higherprobability of bleeding, infection, and additional dis-comfort. This in turn will needlessly delay the heal-ing process and be much more costly in the long run.A musician's best ally during the recovery period ishis doctor. If questions arise that the patient can notanswer, the oral surgeon should be notified. Doctorsare generally very understanding when they realizethe concerns trumpet players have regarding theseprocedures. If a doctor will not take the time toanswer questions to your satisfaction, find anotherwho will.

Conclusion

This article stresses the need for early detectionand treatment of third molar problems. It is oftendifficult to face dental care and easier to put offfacing these decisions to some nebulous date in thefuture. We justify our negligence by rationalizing

that we are simply too busy to deal with this condi-tion now. As careers progress, however, they gener-ally tend to get busier, and the stakes become evenhigher should serious problems arise. It is in a youngmusician's best interest to have panoramic X-raystaken between the ages of sixteen and eighteen byan oral surgeon and, if necessary, have third molarsremoved. This can alleviate the increased potentialfor complications that exists if third molars are leftto be dealt with later in life.

Notes

1 American Association of Oral and MaxillofacialSurgeons Surgical Update. Volume two, issuetwo, Summer 1986, p 3.

2 Penicillin is often prescribed as the antibiotic ofchoice to prevent oral-antral infections. If apatient is allergic to penicillin the dentist willprobably substitute a drug like erythromycin.The reason for this precaution is that a sud-den sneeze (if the patient catches a cold) canre-rupture the healing membrane.

3 This is recommended because of the pressure cre-ated between the nasal and oral cavities whenplaying trumpet, and the likelihood that prac-ticing would delay the healing process, aggra-vate the wound, or rupture the sutures, open-ing the cavity once again.

4 Excellent examples of this type of therapeuticrecovery material could include Arban's TheArt of Phrasing found in his Complete Conser-vatory Method (pp.191-245) or the ReinhardtSelection of Concone Studies.

Panoramic X-rays were provided by Dr. WayneF. Wagner, an oral surgeon from Park Ridge, Illi-nois.

This article is a revised version of "Understand-ing the Procedures and Risks Involved in the Ex-traction of Third Molars," which was first publishedby Mortenson and Kolar in Medical Problems ofPerforming Artists, Vol. 3, September, 1988.

Dr. Gary C. Mortenson is assistant professor oftrumpet and director of brass ensembles at KansasState University.

Dr. Lawrence W. Kolar, D.D.S. is a Dentist inprivate practice in Norridge, Illinois. He also servesas a part-time faculty member at The UniversityIllinois College of Dentistry.

February, 1990 I ITG Jo.