The third molars, known simply as your wisdom teeth, are the last permanent teeth to erupt into your mouth some time between the ages of 17 and 21 years old. It is thought that the third molars were given the name "wisdom teeth" because they erupt at a time when a child becomes wiser -- as they enter adulthood.

The average person will develop four wisdom teeth, but that's not always the case for others. Many people develop supernumerary (extra) wisdom teeth or, if you're lucky, others fail to develop some or all of their wisdom teeth altogether.

The average mouth will only comfortably hold 28 of the 32 teeth we are predisposed to have. Since the wisdom teeth are the last teeth to erupt, there is often little room left to accommodate their size and anatomy, which often causes the wisdom teeth to either:

• Become impacted under the gum tissue and bone.
• Partially erupt into the mouth, resulting in only part of the tooth exposed above the gum line.
• Fully erupt into the mouth in an undesirable position -- usually tilting forward, pushing on the tooth in front of it.
• It is quite possible that each one of your wisdom teeth will erupt differently from one another, for example you could have only one impacted wisdom tooth, and the rest could fully erupt.

During your regular dental check-up, your dentist may take a OPG x-ray, also known as a panorex, to diagnose whether or not your wisdom teeth need to be removed. This x-ray gives the dentist a clear view of the area around the wisdom teeth, to determine the type of extraction necessary for each wisdom tooth. When the dentist discovers a reason for you to have your wisdom teeth removed he will access the position of the wisdom teeth and how each root is formed. Depending on his findings, your dentist will make the decision to preform the wisdom teeth extractions for you, or refer you to see an Oral and Maxillofacial Surgeon for your wisdom teeth extractions.

Wisdom teeth are usually the last teeth that erupt -- usually around the age of 17 or 18. Not everyone has their wisdom teeth: most people require wisdom tooth extractions, for a number of reasons. A common misconception about wisdom teeth is they must be removed. Realistically, this is not the case.

Wisdom teeth are generally removed because:

They are erupting in to an abnormal position -- tilted, sideways or twisted. They are trapped below the gum line, or impacted, due to lack of space in the dental arch. An infection, or pericoronitis, has developed from trapped food, plaque and bacteria. The way the patient's teeth bite together has changed, causing malocclusion of the teeth and misalignment of the jaws. The erupted wisdom tooth lacks proper hygiene because it is hard to reach, resulting in tooth decay. Oral and maxillofacial surgeons specialize in dental surgery. Your dentist may choose to refer you to see a surgeon for your wisdom tooth extractions, or he might perform the surgery in his dental office. The most common reason for a referral to an oral surgeon is because of where the wisdom teeth are positioned and the difficulty level of the extraction. If you request general anesthesia, or IV sedation, you will likely be referred to see an oral surgeon.

The thought of having your wisdom teeth removed can be intimidating. Keep in mind that this procedure is done in your best interest. Recovering from wisdom tooth removal is not as tough as you might think. When followed accurately, the instructions given to you before your oral surgery and after your oral surgery will ensure that your recovery is as smooth as possible.

If you developed wisdom teeth (and no, not everyone does), chances are you will require wisdom tooth removal at some point in your lifetime.

From personal experience, I have found that if I know what is happening during a procedure, I'm not as nervous or apprehensive during it. If you are curious to know how wisdom teeth are removed, keep reading.

After the elected method of sedation has taken effect, the oral surgeon or dentist starts the procedure by numbing the tooth and tissues in the area of the mouth where the wisdom teeth are located, with a local anesthetic. You've probably already had an x-ray, known as a panorex, taken of the wisdom teeth, but sometimes the dentist requires additional x-rays the day of the procedure. Any additional x-rays will be taken at this point in the procedure.

Once the patient is completely numb from the local anesthetic and the required x-rays have been taken, the dentist begins the surgical part of the procedure by removing the gum tissue that is covering the area where the wisdom tooth is located. If the wisdom tooth is impacted, an incision is made in the gum tissue, in order to access the tooth. The gum tissue is then pushed out of the way with a surgical instrument until the tooth is visible. There is a good chance that an impacted wisdom tooth could be fully or partially covered in bone. If there is bone covering the wisdom teeth, a high-speed hand piece is used to drill through, and remove the bone covering the tooth. If the wisdom tooth has already erupted into your mouth, the dentist will loosen the connective tissue from around the wisdom tooth.

Once the impacted wisdom teeth are visible to the dentist, various surgical instruments are used to gently loosen the wisdom tooth from any connective tissue in the tooth's socket. The use of the high-speed hand piece may be used on and off throughout the extraction. The same procedure applies for a wisdom tooth that was already erupted. It may be necessary for the dentist to cut the tooth into sections before it is removed. This is done because the tooth is at risk for breaking while it is being removed from the socket.

Once the wisdom tooth is loose, or it had been completely sectioned, it is ready to be removed. The dentist will remove the wisdom tooth with a selection of surgical instruments that are designed to remove the tooth from the tooth's socket.

Now that the wisdom teeth are gone, it may be necessary for the dentist to use stitches to close the area where the teeth were. This is done for surgically removed impacted wisdom teeth and in cases where the dentist feels the patient will heal better with stitches in place.

The dentist will give you some post-operative instructions to follow, along with a small amount of gauze for you to bite down on. Wisdom tooth removal, albeit a nerve-racking thought, is a very common dental procedure. Wisdom teeth may be removed in your dental office or in a surgical office.

The best advice I can offer someone undergoing wisdom teeth removal is to thoroughly follow the instructions your dentist gives you before your oral surgery and after your wisdom tooth removal surgery. If you have any questions or concerns regarding your wisdom tooth removal, speak to your dentist before the date of your surgery.

In the lower jaw, particularly, there may be a healing complication known as a dry socket. This ordinarily occurs in about 10 to 15% of patients, although we see it rarely in our office. With dry socket, healing progresses normally for about three days, and then there is a dramatic increase in pain in the socket and radiating to the ear. If this happens to you, call the office for treatment.

Sometimes sharp edges of bone may surface during the healing process. This does not necessarily need to be treated. They occur because of the body's work of reshaping the tissues in the area formerly occupied by the tooth. Unless the edges cause great discomfort, it would be best to let them alone, and the healing processes will smooth them out.

The roots of lower wisdom teeth may lie near the main nerve to the lower jaw, and the crowns may be near the nerve to the tongue. In about 1 to 2% of the cases, these nerves could be damaged during removal of the tooth. The result would be numbness in the lips, chin, and teeth on the side affected, or in the side of the tongue. Movement would not be affected--only sensation. If this happens, call the office immediately for a prescription of anti-inflammatory medication to ease the damage to the nerve. Expect some difficulty in using your mouth for several weeks, until it accommodates to the change. The nerve may take a month or several months to repair itself. It is not very common for this numbness, if present, to be permanent, but that is also possible.

It is also possible that the roots of upper wisdom teeth or other upper posterior teeth may lie so close to the wall of one of your nasal sinuses that the sinus wall would be perforated during the operation. This would result in some bleeding through the nose. If this should happen, Dr. Hall will advise you on how to care for it until it heals. Sometimes, in rare cases, the wall between the tooth and the sinus can be so delicate that attempts at extraction cause the tooth or a piece of the tooth to be displaced into the sinus. If this happens, an opening would have to be made into the sinus to remove the tooth.

The degree of risk of complications varies from patient to patient. If you are over age 25 or 30 when the impacted teeth are removed, you have a greater chance of complications, because of the increased density of the bone. The risks increase with increasing age. If you have the tooth extraction before their roots are completely formed, the risk of complications is usually minimal. The position of the teeth in the jaw and the difficulty of the surgery also affect the degree of risk.

Injury mechanisms such as falls, assaults, sports injuries, and vehicle crashes are common causes of facial trauma in children as well as adults. Blunt assaults, blows from fists or objects, are a common cause of facial injury. Facial trauma can also result from wartime injuries such as gunshots and blasts. Animal attacks and work-related injuries such as industrial accidents are other causes. Vehicular trauma is one of the leading causes of facial injuries. Trauma commonly occurs when the face strikes a part of the vehicle's interior, such as the steering wheel.

Bruising, a common symptom in facial trauma. Fractures of facial bones, like other fractures, may be associated with pain, bruising, and swelling of the surrounding tissues (such symptoms can occur in the absence of fractures as well). Fractures of the nose, base of the skull, or maxilla may be associated with profuse nosebleeds. Nasal fractures may be associated with deformity of the nose, as well as swelling and bruising. Deformity in the face, for example a sunken cheekbone or teeth which do not align properly, suggests the presence of fractures. Asymmetry can suggest facial fractures or damage to nerves. People with mandibular fractures often have pain and difficulty opening their mouths and may have numbness in the lip and chin. With Le Fort fractures, the midface may move relative to the rest of the face or skull.

Radiography, imaging of tissues using X-rays, is used to rule out facial fractures. Angiography (X-rays taken of the inside of blood vessels) can be used to locate the source of bleeding. However the complex bones and tissues of the face can make it difficult to interpret plain radiographs; CT scanning is better for detecting fractures and examining soft tissues, and is often needed to determine whether surgery is necessary, but it is more expensive and difficult to obtain. CT scanning is usually considered to be more definitive and better at detecting facial injuries than X-ray. CT scanning is especially likely to be used in people with multiple injuries who need CT scans to assess for other injuries anyway.

Initial management involves pain relief and assessment for possible airway problems. The jaw should not be bandaged as this may increase risk of obstruction - especially when bilateral fractures are present. Subsequent medical treatment plan includes fixation(either via external wires or internal plates and screws), reduction and immobilization of bony pieces. it also requires prevention of infection.

Measures to reduce facial trauma include laws enforcing seat belt use and public education to increase awareness about the importance of seat belts and motorcycle helmets. Efforts to reduce drunk driving are other preventative measures; changes to laws and their enforcement have been proposed, as well as changes to societal attitudes toward the activity. Information obtained from biomechanics studies can be used to design automobiles with a view toward preventing facial injuries. While seat belts reduce the number and severity of facial injuries that occur in crashes, airbags alone are not very effective at preventing the injuries. In sports, safety devices including helmets have been found to reduce the risk of severe facial injury. Additional attachments such as face guards may be added to sports helmets to prevent orofacial injury (injury to the mouth or face).

By itself, facial trauma rarely presents a threat to life; however it is often associated with dangerous injuries, and life-threatening complications such as blockage of the airway may occur. The airway can be blocked due to bleeding, swelling of surrounding tissues, or damage to structures. Burns to the face can cause swelling of tissues and thereby lead to airway blockage. Broken bones such as combinations of nasal, maxillary, and mandibular fractures can interfere with the airway. Blood from the face or mouth, if swallowed, can cause vomiting, which can itself present a threat to the airway because it has the potential to be aspirated. Since airway problems can occur late after the initial injury, it is necessary for healthcare providers to monitor the airway regularly.

Even when facial injuries are not life threatening, they have the potential to cause disfigurement and disability, with long-term physical and emotional results. Facial injuries can cause problems with eye, nose, or jaw function and can threaten eyesight. As early as 400 BC, Hippocrates is thought to have recorded a relationship between blunt facial trauma and blindness. Injuries involving the eye or eyelid, such as retrobulbar hemorrhage, can threaten eyesight; however, blindness following facial trauma is not common.

Nerves and muscles may be trapped by broken bones; in these cases the bones need to be put back into their proper places quickly. For example, fractures of the orbital floor or medial orbital wall of the eye can entrap the medial rectus or inferior rectus muscles. In facial wounds, tear ducts and nerves of the face may be damaged. Fractures of the frontal bone can interfere with the drainage of the frontal sinus and can cause sinusitis. Infection is another potential complication, for example when debris is ground into an abrasion and remains there. Injuries resulting from bites carry a high infection risk.

• Enlargement of the interdental papilla especially in the anterior or front of the mouth.
• As the tissue begins to enlarge, it may become more fibrotic, or dense.
• Inflammation in areas of enlarged tissue may begin to interrupt speech, eating, and esthetics.
• Painful areas in the mouth, bleeding gums, tooth movement, and changes in the occlusion or how the teeth bite together are common.
• Enlarged gingival tissue may begin to impose on the crown of the tooth. This causes the patient difficulty when trying to brush and floss the teeth thoroughly.
• Tooth decay and periodontal disease may become more prevalent due to the interference of the excessive gum tissue.

Patients who are experiencing drug-associated gingival enlargement are treated according to the extent of the overgrowth of tissue. Your dentist may recommend treatments such as:

• Regularly scheduled hygiene appointments as frequently as every three months, to ensure the thorough removal of plaque and calculus in area that are inaccessible with a toothbrush and floss.
• Mouth rinse consisting of .12% chlorhexidine may be prescribed as an aide in reducing the enlargement of tissue.
• The brushing technique used by the patient may be modified by the dentist to allow for the slight recession of the gum tissue from the toothbrush.
• Surgical removal of the excessive tissue known as a gingivectomy, may be preformed at the discretion of the dentist.
• Antifungal medication and certain antibiotics may be prescribed depending on the severity of the overgrowth.
• Changes in medication may be suggested by the doctor, although this may not be an option for all patients and will depend on the individual situation of each patient.
• Patients with gingival enlargement secondary to medications will most likely be referred to see a periodontist; a dentist that specializes in diagnosing, preventing and treating gum disease.