Overview of Oral Surgery, Extraction of Unerupted Teeth
Removing teeth that have not yet come through the gum is a usual dental procedure. This is done by many different types of dental professionals, from your regular dentist to an oral surgeon. A common issue with teeth is dental impaction, which can happen with all upper and lower teeth.
Contrary to what most people think, not all teeth that haven’t come through are impacted. Impaction happens when a tooth doesn’t fully come through when it’s supposed to. To correctly identify and treat impaction, the dental professional must understand when and how teeth usually come through the gums.
Anatomy and Physiology of Oral Surgery, Extraction of Unerupted Teeth
Tooth eruption is the process where a developing tooth moves from its initial location within the jawbone to its final, working position in the jaw. This process involves the removal of some bone and tissue that may be in the tooth’s path. The force required to move the tooth along this path is thought to be generated by the change in bone structure above and below the tooth.
While many theories exist to explain the workings of tooth eruption, the most commonly accepted one suggests that something called the ‘dental follicle’ manages this process. The dental follicle is like a little sac that surrounds the tooth when it’s just starting to form. If you remove this sac, the tooth won’t come through. In addition, this follicle develops into the ‘periodontal ligament’, which helps push the tooth from the gum’s surface to its final position. This ligament matures by getting shorter and stronger, which helps generate the force for the tooth to move.
Impacted teeth, or teeth that fail to erupt and become stuck within the jaw, can occur in anyone. Studies show the rate of occurrence varies, ranging from about 6-19%, and these issues seem to be more common in women than men. The main reasons for tooth impaction are typically lack of space or length in the dental arch, which is the curved shape formed by the alignment of the teeth in each jaw.
Tooth impaction is often seen in teeth that erupt later in the sequence of tooth development. If there isn’t enough space when they are ready to come in, they can become impacted. The wisdom tooth, or third molar, is the most frequently impacted tooth, followed by the upper third molar, upper canine, lower premolars, upper premolars, and second molar.
The least likely teeth to become impacted are the lower front teeth, first molars, and baby (primary) teeth. Impactions in these teeth are very rare and usually linked with specific conditions like having baby teeth still in place or abnormal growths in the mouth. Impaction can also happen with certain syndromes or hormonal disorders, and it can lead to other issues in the mouth, like cysts, tumors, tooth decay, root damage, and gum disease.
Why do People Need Oral Surgery, Extraction of Unerupted Teeth
Getting the right diagnosis and treatment requires checking your health and family history, and carrying out a complete check-up. When it comes to dental problems like tooth impaction (when a tooth can’t break through your gums because it’s blocked by other teeth), certain types of X-rays can be very important in identifying the issue. These include panoramic, periapical, occlusal x-ray, Computed Tomography (CT), or Cone Beam CT (CBCT).
The different types of X-rays can give us a picture of the position and angle of the impacted tooth, confirm if it’s really impacted, and show how it’s connected to the neighboring structures. CT or CBCT, in particular, can show the 3D position of the tooth, making it the best tool for understanding dental impactions. Before proceeding with surgery, your doctor needs to review your health history, perform an extensive check-up, and get a high-quality X-ray.
There are many reasons why a tooth that hasn’t erupted (come in or broke the gum surface) might need to be extracted. It might be because of tooth pain, decay, gum disease, issues originating in the tooth itself, an infection, damage to nearby teeth, the tooth hasn’t come in as it should, the tooth has come in the wrong place, or we’re planning to take the tooth out just in case it causes problems during a medical/surgical treatment. It might also be necessary if the tooth is in the fracture line of a broken bone, the tooth has been injured, there’s not enough room for it to come in properly, or in order to manage a trauma or perform oral surgery.
Often, these teeth don’t cause any pain or show any disease, so it’s common to extract them just as a preventive measure. However, there’s not much evidence to support the effectiveness of this practice. We need more studies to understand if taking out an unerupted tooth that doesn’t cause symptoms is actually beneficial.
It’s important to remember that we don’t have to do surgery for all impacted teeth. When considering extraction, the surgeon aims to minimize harm to the other teeth and the tissues that surround and support the teeth whenever they can. Repositioning impacted teeth within the jaw bone isn’t always possible. So in some cases, extraction might be the only good treatment option. Before an extraction is done, a number of factors have to be looked at like age, gender, tooth position, health of the impacted and nearby teeth, length of the dental arch (the curve created by the alignment of your teeth), and the relationship between the upper and lower teeth.
A study has found that impacted teeth might become more problematic if the patient is female, has retained primary lower canine teeth (baby teeth), if treatment is delayed, or if there are small, pointed teeth beside the two upper front teeth. These factors should be taken into account when evaluating a young patient and planning preventive or early treatments, as the severity of impaction can differ based on different factors.
Unerupted and impacted teeth that are left untreated can lead to problems. The most common issues associated with untreated unerupted teeth include the formation of tooth-related cysts, pain, infection, wear and tear of the top part of the tooth, root damage to nearby teeth, the tooth becoming permanently attached to the jaw bone, tooth displacement, and shortening of the dental arches.
When a Person Should Avoid Oral Surgery, Extraction of Unerupted Teeth
Before a surgeon can remove impacted or unerupted teeth (teeth that have not fully emerged from the gums), they need to make sure the patient is in the right health condition to undergo the operation. Each tooth must be examined individually to decide whether it should be removed, and surgery may not always be the best solution if there is no disease causing the impaction (tooth stuck below the gum line). Certain health conditions, medications, or issues with the tooth itself might make the extraction process more complicated.
People with uncontrolled epilepsy, a condition causing seizures, have a higher risk of choking or hurting themselves during tooth extraction. Similarly, those who have had strokes or mini-strokes are more likely to have another stroke during tooth extraction procedures. Therefore, these people need to have a detailed medical check-up and necessary precautions should be taken before the surgery.
Additionally, patients suffering from heart conditions such as heart disease, irregular heartbeats, heart infections, uncontrolled high blood pressure, or serious coronary artery disease need a thorough examination before any extraction can take place. Uncontrolled heart issues may lead to tissue death or a stroke. Patients who have had a heart infection, or are at high risk, may need antibiotics to prevent an infection.
Patients with severe kidney problems or liver disease can be difficult to manage because of a higher risk of bleeding and infection. Ideally, these patients should avoid surgical procedures. Kidney patients may need antibiotics to prevent infections due to a higher risk of getting sick.
People with weakened immune systems, like those who have had an organ transplant, are at a higher risk of getting sick after having a tooth removed. Antibiotics are not guaranteed to work in these patients, but they still require careful assessment and advice beforehand.
Patients with blood clotting disorders or taking anti-clotting medicines are more likely to bleed during a tooth extraction. Research suggests to continue taking the anti-clotting medication before the procedure, as the risk of stopping it is greater than the risk of bleeding. Doctors might monitor patients’ blood clotting speed to ensure it’s safe for them to undergo surgery.
People who have undergone radiation therapy are at a higher risk of developing a condition where the bone does not heal and is exposed to the oral cavity. A comprehensive dental check-up is needed before any radiation therapy is given. Also, patients taking certain medications for bone-related conditions can often develop a similar kind of complications after tooth removal. In these cases, elective extractions or other dental surgeries should be avoided if possible.
Moreover, the location of the tooth can add complexity to the extraction of unerupted teeth. For example, the lower wisdom teeth can be too close to a major nerve in the jaw, causing potential harm. In such cases, an alternative surgical method might be better to prevent nerve damage. Similarly, unerupted upper teeth can lead to opening between the oral cavity and the sinus if they are too close, thus requiring an assessment with radiographic images.
Preparing for Oral Surgery, Extraction of Unerupted Teeth
Before a surgeon performs a procedure to remove a part of the body, it’s important that they first perform a thorough check-up on the patient. This means that they need to learn about the patient’s medical history, do a physical check-up, and also use imaging technology (like X-rays) to look inside the body.
After they’ve done this, the surgeon needs to talk to the patient about what they plan to do during the surgery, why they’re doing it, what the benefits and risks might be, and any other possible treatment options. This helps the patient make informed decisions about their healthcare and whether or not they want to go forward with the surgery. It’s very important that they obtain the patient’s written consent before proceeding with the surgery.
Just before the surgery, the surgeon should reaffirm that the patient has given their consent for the surgery. They should also have up-to-date X-ray images showing the area where they’re operating, and any other important and nearby structures within the body. If necessary, they may need a CBCT (Cone Beam Computed Tomography) scan, which produces a more detailed image than an X-ray, to help them do the surgery more effectively.
How is Oral Surgery, Extraction of Unerupted Teeth performed
If you need to have an unerupted tooth (a tooth that hasn’t come through your gums yet) taken out, surgeons typically use a three-step process. First, the surgeon makes what’s called a flap. This is like a small door in your gums that lets them get to the tooth. The flap needs to be the right size so the surgeon can easily get to the tooth.
Next, the surgeon removes the bone that is around the stuck tooth. They use a tool called a surgical handpiece for this, which acts like a little power-drill for bones. It’s crucial that it releases air pressure away from where they’re working, like a tiny exhaust pipe. This is to prevent potential complications like an air embolism (air bubble in a blood vessel) or tissue emphysema (air bubbles in the tissue). If it’s a lower jaw tooth that’s impacted, the surgeon makes sure not to remove any bone on the inside (lingual side) of your jaw to avoid harming a nerve that runs there.
Once the surgeon can see the impacted tooth, they carefully cut it into pieces that are easier to remove. Using the surgical handpiece again, this time with a bur (a type of drill bit), they cut the tooth mostly in half, but from outside to inside. They then use a tool called an elevator to break off the remaining connection. When impacted molars (your back teeth) need to be removed, the surgeon angles the drill bit to be parallel with the outside groove of the tooth.
Now, let’s talk about flaps. The term ‘flap’ simply refers to the piece of gum tissue that the surgeon peels back to access the tooth. There are two main types that surgeons use in dental surgeries: full-thickness and split-thickness mucoperiosteal flaps. It’s vital that these flaps continue to get a good blood supply during surgery. To make sure this happens, the flaps are designed to have a wide base. Sometimes, the surgeon will include what’s called a releasing incision (a cut made to relax tension), but they have to be careful with these because they aren’t always needed and can sometimes interfere with healing.
There are a few places where releasing incisions are a no-go: the roof of your mouth; the inside surface of your lower jaw; around a specific point on your upper jaw called the canine eminence; and near a little hollow on the outside of your lower jaw known as the mental foramen. If the impacted tooth is a lower back tooth, the surgeon will often use an “envelope flap”. This kind of flap reaches from the first molar tooth to the back of the impacted tooth, and also extends sideways towards a ridge on the lower, outer part of your jaw.
Possible Complications of Oral Surgery, Extraction of Unerupted Teeth
There are always risks involved when a dentist removes unerupted teeth, or teeth that haven’t broken through the gum yet. These risks include complications during and after the procedure, such as alveolar osteitis, bleeding, nerve damage, displaced roots, and a link between the mouth and sinuses.
Alveolar osteitis, also known as dry socket, happens when the blood clot that forms after tooth extraction gets replaced by a different type of tissue, interrupting the normal healing process. This condition typically leads to a bad taste in the mouth, foul breath, and throbbing pain. It’s more common in women and can be influenced by things like smoking, using oral contraceptives, long procedures, the dentist’s experience, and rinsing mouth too early after surgery. It might be treated by cleaning the wound with saline or chlorhexidine, the application of a soothing dressing, painkillers, or even antibiotics in some cases.
Following tooth removal, postoperative bleeding is a common issue. If minor, applying direct pressure on the area with a gauze can often control it. However, if bleeding is more severe, the dentist may use products to help stop the blood flow, or even re-dress the surgical site with a healing enhancing device. In some cases, if the bleeding is from a nutrient vessel, the dentist may apply a certain type of wax.
Infrequently, the extraction of molars, particularly the third molars in the lower jaw, can damage the Inferior Alveolar Nerve (IAN) or the Lingual Nerve, causing numbness that can be temporary or permanent. As injury is quite rare, nerve damage more often leads to temporary numbness. Those with nerve injuries are usually monitored closely by the dentist, and full recovery can take up to two years.
If part of the tooth root is left behind after extraction, the dentist usually tries to remove it. However, in some cases where the remaining piece is too small, buried in bone, or not causing an infection, it may be left alone. Revisits and check-ups may be required if this happens. Be aware, while removing the root piece, it may accidentally get moved to other parts of the mouth.
Lastly, an unintended connection between the mouth and sinus, called oral-antral communication (OAC), can happen after the extraction of upper molars. To fix the small perforations, collagen plugs or resorbable collagen membranes are used. In the case of larger perforations, a surgical procedure is required. If the sinus gets infected, antibiotics and decongestant medication may be prescribed.
What Else Should I Know About Oral Surgery, Extraction of Unerupted Teeth?
Removing teeth that have not grown in completely or are stuck, known as unerupted or impacted teeth, is a regular part of dental surgery. This procedure is done by various types of dental specialists. Like other surgeries, once a tooth is removed, it can’t be put back, so the dentist needs to fully understand the structure of the mouth and how it works, and have the right skills to take out the tooth.
The dentist should also be ready to deal with any problems that might come up during the process. Before starting, they should check the patient’s health carefully and create a plan for the surgery that matches what the patient needs and wants. As part of this process, the dentist should explain the potential risks and benefits of the plan, and talk about any other options, to help the patient understand and agree to the treatment.
