Recently I conducted a survey of my general dentistry colleagues regarding wisdom teeth extractions. The results of the survey indicated that they tend to shy away from recommending removal of third molars if they are asymptomatic. One of the excuses they used was…let's just watch them. To that I say, watch them do what? Watch them develop pericoronitis, watch them damage adjacent teeth, watch them lose periodontal attachment, watch them form cysts or develop tumors. No!

Knowing that approximately 85% of all wisdom teeth will need to be extracted, and that the longer you wait to extract the more difficult it will be, I recommend prophy-lactic extraction of wisdom teeth between the ages of 14 and 25. Removing wisdom teeth before the full maturation of the roots will help minimize some of the more serious complications of wisdom teeth removal, such as numbness of the lower lip, chin, gum or tongue. The younger a person is, the faster the healing time; therefore, your typical teenagers will heal much faster than your middle-aged person with difficult impacted wisdom teeth.

I have chosen two case examples of wisdom teeth causing complications in adults. Case number one is a 42-year-old female with one single remaining impacted wisdom tooth, number 32. This patient presented with acute pericoronitis in the area of tooth number 32. An i-CAT was taken and revealed a full bony impacted tooth number 32 with the roots almost at the angle of the mandible with a large cystic lesion above. There was extensive periodontal bone destruction on the distal of tooth number 31. Risks, complications, benefits and alternatives of removing the impacted wisdom tooth were all explained to the patient. The proximity of the inferior alveolar nerve in relation to the roots of this impacted wisdom tooth was also explained to the patient and the CAT scan illustrated the position of the nerve for the patient. The tooth was removed in segments and the inferior alveolar nerve was seen deep and lingual to the roots. A thin-walled cystic lesion was peeled out of the bone and curetted to healthy bleeding bone. The biopsy report came back as a cyst of the mandible. This patient was extremely fortunate that she did not develop any complications from this extraction.

Case number two is that of a 62-year-old male referred to me by his dentist, to evaluate a radiolucency in the right mandible. The panoramic x-ray revealed a large radiolucency extending from the impacted tooth number 32, which is facing inferiorly and a quarter of the way up the ramus of the mandible and extending anteriorly, undermining teeth number 31, number 30, and number 29 respectively. There are only 4 mm of bone thickness to the inferior border of the mandible. Extensive consultation with the patient regarding the nature of the lesion was conducted and the proposed treatment plan was presented. Some of the differential diagnosis for this lesion would be an odontogenic keratocyst, ameloblastoma or a mixed tumor. The lesion was biopsied and a thick cystic lining was encountered and when perforated, a heavy mucoid, cheese-like material was found in the entire cavity. The biopsy results, again, showed a cyst of the mandible with inflammation. 

Due to the large size of the cyst, I decided to use decompression. Decompression is a technique used to remove all the pressure from the system, thereby enabling the lesion to shrink to more manageable size. This particular patient was not as lucky as the patient in the first case. Unfortunately, this patient developed numbness of his lip, chin and gum which slowly resolved over a one-year period.

These are just two cases that I selected out of a large file of difficult impacted wisdom teeth, in mature individuals. I would strongly suggest that most wisdom teeth be evaluated by an oral surgeon for possible extraction. Oral and maxillofacial surgeons are best equipped to make the proper determination of when and how to remove impacted wisdom teeth. ■