"Impacted Wisdom Teeth": What is the recommended treatment?

Impacted "Wisdom Teeth"

by: Abhishek Mogre DMD, Board Certified Oral & Maxillofacial Surgeon

      Shoreline Oral Facial Surgery & Dental Implants

"Wisdom teeth" or Third Molars are the last teeth to develop and erupt in our jaws. Since these teeth usually erupt around the age of 16-20, commonly known as the "Age of Wisdom", these teeth are called "Wisdom teeth". In majority of patients, Wisdom teeth fail to erupt completely, which is also commonly known as an "Impacted Wisdom Tooth". 

Wisdom teeth are developing and the Jaw Bone has lack of room.

The common reason for Wisdom Teeth to become "Impacted" or fail to erupt, is lack of room in the jaw to accommodate them in a normal position. As a result of this, Impacted Wisdom teeth can become tilted in position, and encroach on the surrounding important structures such as neighboring teeth, nerves (in lower jaw) or sinuses (in upper jaw).

Wisdom Teeth are seen growing sideways.

When Impacted Wisdom teeth grow against the second molars, they may cause deep pocketing in the gums of the second molar, known as a Periodontal Pocket. A deep periodontal pocket on a functional second molar can compromise the health of the molar. 

Impacted Wisdom teeth can also lead to development of benign Cysts or Tumors, later in life. Such Cysts and Tumors grow from the "Follicle" or the nourishment sac around these Impacted Wisdom teeth. 

Wisdom teeth may also need to be removed, prior to braces or "Orthodontic Treatment" to create more room in the jaw to correct crowding of teeth. 

If the Wisdom Teeth are erupted in a normal functional position, they do not need routine extraction. Patients do have to make a conscious effort to brush and floss around those erupted wisdom teeth, as they do in all their other teeth. Failure to maintain adequate oral care, results in Dental Caries or Decay on these Wisdom teeth. 

Wisdom teeth location in the mouth, can sometimes make it difficult to reach with a toothbrush or floss, and in such a scenario, Dentists may recommend their removal to prevent an infection or pain developing from a carious or decayed wisdom tooth. 

Wisdom Teeth Surgery, if necessary, is performed by an Oral and Maxillofacial Surgeon. The Oral Surgeon would perform a thorough clinical exam, including reviewing patients health history, check periodontal pocketing around these teeth, and evaluate X rays during a Consultation visit. Oral Surgeon will then recommend and discuss the Anesthesia options such as Local Anesthesia vs In Office General Anesthesia or "Sedation" for the surgery. 

Impacted Wisdom teeth surgery, being a difficult surgical procedure, is usually performed under IV anesthesia/Sedation by an Oral and Maxillofacial Surgeon. Oral and Maxillofacial Surgeons, undergo extensive Anesthesia, Medicine and General Surgery training in their residency, and participate in Anesthesia training along side Anesthesia Residents with direct supervision by a Staff Anesthesiologist. This extensive training, provides the Oral Surgeon with an expertise to perform simultaneous Surgery and administer Anesthesia for in office Oral Surgery procedures. 

Extraction of wisdom teeth are performed in one surgical appointment, unless otherwise recommended and approved by your Oral Surgeon. This prevents, multiple times of recovery period and multiple administrations of anesthesia. 

Patients usually will leave the office with an Ice pack. Recovery is typically 48-72 hours. Patients are instructed to be on a soft diet for comfort reasons, and are also advised to keep good oral hygiene.

Patient return for a follow up visit as deemed appropriate by the Oral Surgeon.

For more information, visit our website www.shorelineoralsurgery.com 

Step by Step guide in preparation of "PRF".

How is "PRF" prepared?

by Abhishek Mogre DMD, Board Certified Oral and Maxillofacial Surgeon

"PRF" or Platelet rich fibrin is used in Oral Surgery for assisting in mucosal healing and faster angiogenesis and maturation of bone grafts. It is also used in third molar surgeries or "Wisdom Tooth" surgeries to reduce post surgical pain, and reduce the dependance on post surgical narcotic medications. 

Following steps are involved in the preparation of PRF.

• Collection of Venous "Autologous" (patient's own blood): In the picture below, Dr Abhishek Mogre is seen collecting patients own blood in a test tube (without any anticoagulant) using a 21g Vacutainer. The crucial step here is locate an appropriate peripheral vein, and the amount of blood required for the particular surgery has to be collected in less than 2 minutes. If the blood collection time increases, it will affect the quality of the PRF that is generated. 

• Transporting the collected blood and running the Centrifuge: As explained in the previous step, the tubes with collected blood have to placed in the centrifuge within 2 minutes of the start of the blood draw, and the centrifuge has to be run in a very specific setting. Dr Abhishek Mogre has chosen to use the original "Dr Choukran" concept and his centrifuge setting to generate the optimum quality of PRF product. It is very important to understand that the final product will vary if the centrifuge protocol is not followed. See the picture below of the centrifuge used by Dr Mogre in Shoreline Oral Facial Surgery & Dental Implants office.

• Opening the caps of the test tubes and allow the PRF to self coagulate: Once the centrifuge has completed its appropriate cycle, remove the tubes, open the caps and let them stand in the test tube holder until the final product of PRF coagulates or "clots". It is important to understand that we are allowing "Physiologic" clotting process without any additives while preparing the PRF. The time for this step could vary between 5-15minutes. 

• Remove the 'PRF" from the test tube and place it in the PRF container for compression: The PRF is the middle layer in the test tube, and is gel like in consistency. It is carefully removed from the tube and placed in a PRF container and then compressed into flat membranes. During this process, the exudate rich in Fibronectin, Vitronectin, Stem cells and growth factors is collected in the bottom of the container. This exudate is used to hydrate any Allograft or "Cadaver Bone Graft" or Xenograft or "Bovine or Equine bone graft". See the pictures below, where Dr Mogre carefully removes the gel like PRF and then places in the container. The final product after compression looks like flat membranes.

• Using the Final compressed PRF for surgical use: The final PRF membranes can now be used for variety of oral surgery procedures. Commonly they can be mixed with the bone graft materials, used in extraction sites/lower third molar or wisdom teeth sites etc. In the picture below Dr Mogre is mixing the PRF membrane with the bone graft material to improve the success of the grafted site. 

Introduction of PRF

Platelet Rich Fibrin: Introduction

by Dr Abhishek Mogre, Board Certified Oral & Maxillofacial Surgeon

Platelet Rich Fibrin commonly known as PRF is a second generation Platelet Growth Factor.
It is developed conveniently by using an appropriate Centrifuge to spin patients blood and divide it in 3 layers. The bottom layer after the spin, is composed primarily of Red Blood cells. The middle layer or PRF is composed of Platelets, Stem Cells and White Blood Cells held together in Fibrin network. The top layer is acellular plasma.

PRF is then separated and is prepared in variety of different ways as appropriate for the surgery.

PRF is different from the previous generation Platelet growth factors in the following ways:

1. It contains no additives such as Bovine Thrombin.
2. The PRF Gel which comprises of Fibrin, Platelets, White Blood Cells & Stem Cells is much more stable than all previous generation Platelet Growth Factors.
3. The Cytokines and Growth factors from PRF are released and available for 1-2 weeks compared to few hours or a day in previous generation Platelet Growth Factors.
4. The process of generating PRF is very simple, and requires a good peripheral IV access.

Shoreline Oral Facial Surgery & Dental Implants.

What are the options if my child's Canine or "Eye" teeth don't come through the gums?

Impacted Canine or "Eye" teeth

~ Dr Abhishek Mogre DMD, Board Certified Oral & Maxillofacial Surgeon

Are canines or “Eye Teeth” commonly impacted? 

- Maxillary canine tooth is the second most common tooth to become impacted. An Impacted       tooth simply means that its “Stuck” or not able to erupt in proper functional position. 

Is it a better choice to bring Impacted Canine in proper position or just to extract it? 

- Canines play a critical role in occlusion or “Bite”. Canines have the longest and strongest roots and their position in the arch helps them to guide the rest of the teeth into proper bite. If a canine is impacted, every effort should be made to assist its eruption in proper functional position, with the help of an Orthodontist. Extraction or removal of impacted canines should not be a first choice. 

- An impacted canine is seen to be positioned on the palatal aspect in relation to the other teeth, 60% of the time. 

CBCT or "3D scan" image of Dr Mogre's patient shows a lower left permanent canine tooth
failing to erupt in normal jaw position.

What is the best time to treat a potential problem involving impacted canines? 

- Early recognition of the problem remains the key. Usually, patients General Dentist/Pediatric Dentist or Hygienist will identify the problem and make a referral to an Orthodontist. The orthodontist will then evaluate and make appropriate referral to an Oral Surgeon for removal of baby teeth or extra/supernumerary teeth to allow space for normal eruption of canines. 

- Many times, just removal of baby teeth or extra teeth may not be sufficient to solve the issue, and an Oral Surgeon will need to surgically expose the canines and attach special brackets and chain to those impacted canines. The orthodontist then uses special elastic bands to bring the canines in proper position. 

Dr Mogre performed
Surgical Exposure of impacted canine.

Attaching a gold bracket with chain to the canine

Panoramic X ray of Dr Mogre's patient, shows the attached bracket and chain to the impacted canine tooth.

What is a normal recovery time after such an “Expose and Bond” procedure for Impacted Canines? 

- Surgical recovery involves 24-48 hrs of mild discomfort. Pain is well controlled with tylenol or Advil. Patient should start a soft and bland diet for 24-48 hours and then advance towards regular diet as tolerated. Patients should care for their oral wound by rinsing and gently brushing to avoid any food retention.

Are there any other concerns? 

- Surgical exposure and bond of Impacted canine teeth is a common procedure with low risks/complications. Sometimes the special bracket can de-bond, during the assisted orthodontic treatment, and may need to be reattached. Usually, the impacted canine is exposed in the oral cavity and the reattachment can be easily performed in the orthodontist’s office. If the soft tissue is covering the canine, then the Oral Surgeon may need to re expose the canine, and attach the bracket in his office.

What are the choices for Anesthesia for this procedure?

- A typical surgery of Expose and Bonding of Impacted canines is performed under IV sedation and local anesthesia. Patients are instructed to remain empty stomach for 8 hours prior to their surgery under IV Sedation. Please refer to our Anesthesia section of the website for details about IV sedation. 

Simply call Shoreline Oral Facial Surgery & Dental Implants at 650-965-2222 if you have any questions.