Wisdom Teeth Surgery

Wisdom teeth are also known as third molars and are the last teeth to develop in your jaws. They generally erupt between the ages of 17 to 21, when we supposedly acquire wisdom, hence their name. Most people have four wisdom teeth – two at the top and two at the bottom.

What is an impacted wisdom tooth?

Wisdom teeth become impacted if they have inadequate space to erupt normally. They are either going to surface in the wrong position or not erupt at all.

In some cases, fully buried wisdom teeth remain problem-free. However, most impacted wisdom teeth that are partially exposed tend to be difficult to clean, leading to tooth decay and gum disease. Impacted wisdom teeth are also commonly removed before symptoms occur to prevent future problems.

When do I consider removing my wisdom teeth?

Impacted wisdom teeth can cause a host of problems:

• Gum pain or swelling which may limit your mouth opening
• Facial swelling when the infection is severe
• Decay of the wisdom tooth, the neighbouring molar or both
• Formation of cysts or tumours
• Cheek biting and ulcers
• Food trap and bad breath

If you experience any of the above, visit a dentist or oral surgeon for an examination. Radiographs (X-rays) are usually done to view the condition of the wisdom teeth and other neighboring structures.

Wisdom teeth are easier to remove when patients are younger, since the bone is softer and healing is generally faster. The decision to remove wisdom teeth is not always straightforward, hence, it is always better to be clinically assessed.

How are wisdom teeth removed?

Wisdom teeth can be removed under local anaesthesia (when you are awake) or general anaesthesia (when you are ‘asleep’). The choice of anaesthesia depends on your general health condition, anxiety associated with the procedure, as well as the anticipated level of surgical difficulty.

Local Anaesthesia

Part of your jaw and the surrounding tissues will be numbed and you remain fully conscious. The tooth will be exposed and removed as a whole or in multiple fragments. Stitching of the surgical sites may be done and gauze will be placed over the surgical wound to stop bleeding.

Most people are worried about feeling the pain during the procedure. Actually, once the area is numb, the sensations you feel are mostly pressure and vibrations.

General Anaesthesia

For surgeries performed under general anaesthesia, you will be in a medically induced state of sleep. A combination of drugs will be administered by injection into a vein and/or breathed in as gases into your lungs. You’re likely to be admitted for 6 to 8 hours and discharged home on the same day.

What are the complications and risks involved?

All surgeries carry risks, with wisdom teeth removal being no exception. Having said that, wisdom teeth removal is a relatively safe procedure with low risks. The main risks include but are not limited to:

Root tips that fracture off which may be left behind

Curved, slender roots of wisdom teeth tend to fracture off during removal. Most times, these root tips are retrieved. However, they may be intentionally left behind if the nerve is close by, to mitigate the risk of nerve injury. Healing tends to be uneventful as bone grows over to bury the root tips.

Infection of the surgical wound

Infection can occur, sometimes even after a month after surgery. If you notice fever, persistent swelling, pain or pus oozing from the wound, please arrange for a clinical review.

Dry socket

This is a painful condition that may occur two to four days after the procedure. Normally, a blood clot forms in the tooth socket after a tooth is removed. However, when the blood clot fails to develop or dislodges from the socket, the underlying bone is exposed, leading to intense, throbbing pain that may radiate to the same side of the jaw or face.

Conditions that may predispose to dry socket are:

• Smoking
• Poor oral hygiene
• Difficult surgeries
• Use of birth control pills
• History of dry socket
• Vigorous rinsing or spitting and use of straws for drinking shortly after the procedure

Damage to the adjacent teeth

The adjacent tooth with decay or fillings may fracture or the filling dislodged. It may sometimes be loosened if the pre-existing bone condition is poor. As such, a new filling or root canal treatment and crown may be required if the tooth is structurally weakened. In rare instances, the tooth may be extracted.

Temporary or permanent numbness to the lips, chin and tongue

The lower wisdom teeth/roots lie close to nerves that provide sensation to your lower lip, chin, gums, teeth and tongue on the same side. The nerves may be bruised or injured during removal of the tooth, resulting in numbness or altered sensation in your lips, chin or tongue. Fortunately, taste is rarely affected.

Oro-antral communication

The upper wisdom tooth/roots commonly lie close to the maxillary sinus or antrum, which are empty air spaces behind your cheek bones. The roots may sometimes extend beyond the jawbone into the antrum.

The removal of the tooth may result in a socket or hole that connects your mouth with the antrum, called an oro-antral communication. If this happens, you may experience the escape of fluids from the mouth to the antrum and nose.

Some communications heal spontaneously over time. Larger communications may require a second surgery to close it.

Pain at the jaw joints

Following an extended period of mouth opening during the surgery, the jaw joints may ache. For those with pre-existing temporomandibular joint disorders, the surgery may exacerbate painful symptoms.

What can I expect after wisdom teeth surgery?

A small amount of bleeding for a few hours after surgery is expected. Avoid rinsing your mouth rigorously during this time as this disrupts the blood clot and provoke bleeding. Oral bleeding usually consists of blood mixed with saliva.

Biting a piece of gauze placed over the surgical wound generally stops the bleeding within 30 minutes. Despite this, if fresh blood wells up from within the wisdom tooth socket, please proceed to the dental clinic or the Accident and Emergency department for after-hours care.

Don’t be surprised if your face swells up over the next two to three days. Facial swelling is a normal response to all surgical procedures.

There may be bruising or skin discolouration around the cheeks and jaws, sometimes extending all the way to the neck. Bruising generally appears bluish-black initially before turning greenish-yellow, and fades after two to three weeks.

You may also experience some pain, jaw stiffness and restricted mouth opening for a few days. The corners of your lips may also be sore and cracked but will heal with time.

For a quick recovery, good oral hygiene is important. Continue brushing your teeth gently and take the prescribed medications, as they are effective in alleviating most of these discomforts.

If you smoke, now would be a good time to quit as this has been shown to delay wound healing and increases the incidence of dry socket. Try to stop smoking 2 to 3 days before and after surgery.

What can I eat after surgery?

Soft and cool food (like porridge, mashed potatoes, yoghurt and even ice-cream) are best for the first day. You can upgrade your diet gradually.

Gently rinsing your mouth with water after meals helps to remove food particles lodged in the empty tooth socket. You will be issued a syringe and taught care techniques.

Post Operative / Extraction Advice

• Local anaesthetic has been administered on you. Please do not suck or chew on your numbed lip/cheek, thereby causing bruising
• Remove gauze in your mouth after 30 minutes. If bleeding continues, replace gauze over wound and bite firmly on it for a timed 15 minutes. Repeat if necessary
• Do not leave gauze in the mouth unattended in children, the elderly or mentally handicapped
• Do not eat, drink or sleep with gauze in the mouth
• Do not exercise, do heavy work, smoke or drink alcohol for a week as it may cause bleeding and delay the healing process
• Expect gradual onset of swelling which is worst on the 2nd or 3rd day. Do not put warm compress as this may worsen the swelling
• Some bruising in the skin may occur. This should resolve over the next 2–3 weeks
• Go on a soft diet initially and keep your mouth clean by brushing and rinsing gently after meals
• Complete your course of antibiotics if they have been prescribed
• If you have been issued a syringe, use it from the 4th postoperative day to flush out food debris trapped in the tooth socket. Do this daily for about 2 weeks

Should you encounter severe and persistent bleeding:

• During working hours (Monday – Friday 8:30 AM to 5:30 PM), return to the Dental Clinic
• After working hours, proceed to the Acute & Emergency Care Centre, Khoo Teck Puat Hospital

SMS 91139895 if you have any issues or concerns. We will contact you within the working day.

For video instructions on post-operative/extraction advice, scan the QR code or view "https://youtu.be/ce_WNF_FOwE".

Orthognathic Surgery

What is it?

Orthognathic surgery, otherwise known as corrective jaw surgery, is performed to correct misaligned jaws and teeth. The disproportionate jaws can be due to abnormal development or the result of a traumatic injury. Orthognathic surgery is usually done in conjunction with orthodontic treatment to harmonise the jaw relationship and improve the bite (occlusion).

You may want to consult an oral surgeon if you experience:
 

• Difficulty chewing when the upper and lower teeth do not meet – open bite, underbite, overbite, crossbite
• Unclear speech
• Asymmetry of the face
• Inability to make lips meet without effort
• Excessive show of upper teeth especially when smiling
• Facial defects
• Obstructive sleep apnoea and snoring

• Prognathic jaw occurs when the lower jaw is overdeveloped and protrudes beyond the upper jaw
• Retrognathic jaw is a receding lower jaw, sometimes called a weak chin
• An 'open bite' leaves space between the upper and lower teeth when the mouth is closed

Does the whole treatment take a long time? What are the stages involved?

After investigations comprising x-rays, photos and impressions of your teeth are done, the oral surgeon and orthodontist will formulate a treatment plan. Treatment usually starts with braces for about 12 to 18 months to level and align your teeth in preparation for surgery. You may look worse during the pre-surgical phase! After surgery, braces will be resumed to fine tune the bite. It generally takes approximately 2 years to complete the whole treatment and retainers will have to be worn after to maintain stability of the bite. The treatment plan and total time required differs on a case by case basis.

How is orthognathic surgery done?

Orthognathic surgery is performed by oral maxillofacial surgeons and carried out under general anaesthesia.

The incisions are made inside your mouth to avoid scars on your face. However, small external incisions may sometimes be required. The jaw bones are then cut, moved and placed into their planned positions. Titanium plates and screws are inserted to fix the jaw bones in their “ideal” positions.

The surgery could involve the upper jaw, lower jaw or chin, depending on the problem. Upper jaw surgery is also known as maxillary osteotomy whereby bone above your teeth around the maxillary sinus and nasal cavity is cut, allowing the upper jaw to be mobilised. Lower jaw surgery, otherwise known as mandibular osteotomy, is performed by splitting bone posterior to the molars bilaterally so that the teeth bearing segment can be mobilised. Chin surgery or genioplasty is done by separating the chin from the lower jaw. These mobile segments are stabilised with mini plates and screws to allow bony healing.

Is the surgery safe? What are the complications and risks?

Orthognathic surgery is generally a safe procedure. However, all surgeries are associated with some degree of risk and long-term complications. Sometimes the outcome may not meet your expectations. The following are some possible complications and may not be exhaustive:

Bleeding. If blood loss is significant, a blood transfusion is sometimes required.

Wound infection. This may appear 1 to 2 weeks after the surgery with symptoms of fever, increasing pain, swelling and foul-smelling discharge from the wound. Contact and return to see your surgeon as soon as possible.

Nerve injury. The nerves may be moved or stretched, resulting in numbness at the lips, chin, tongue or palate, which can be temporary or permanent. Rarely, there may be facial palsy which takes several months to recover.

Relapse of the jaw position. This can occur soon after the surgery or some months later. If the bite is mildly affected, orthodontics can resolve the problem. Larger changes in jaw positions may sometimes require another surgery.

Damage to teeth. The bone cuts may be very close to the roots of teeth. The blood supply to the teeth may be disrupted, resulting in the need for root canal therapy. In extremely rare occasions, the affected tooth/teeth may have to be extracted.

Pain at the jaw joint. Prolonged jaw opening at the time of surgery may exacerbate pre-existing temporomandibular joint disorders and pain.

Loosening of titanium plates and screws. Infection may sometimes cause loosening or exposure of the hardware. A second surgery may be required to remove these plates and screws.

Do the titanium plates and screws need to be removed?

Fixation plates and screws are not routinely removed after bone healing and generally do not cause any long-term issues if left attached to the jaw. They also are deeply buried and will not be felt through the skin. Some of you may wonder if the plates and screws will set off alarms at security checkpoint metal detectors. Since titanium is a non-ferrous metal with extremely low magnetic field, the metal detectors will not be set off, so you can travel in peace!

Is orthognathic surgery worth going through?

The improvements in bite, speech, appearance and quality of sleep outweigh the downsides of the surgery. At the end of the day, the decision to proceed with the surgery lies with you and what you want. It is best to have a frank discussion with your orthodontist, surgeon and even with people who have undergone this surgery before making up your mind.