Dental Q - Root canal and root amputation

[seaotters]

Hi, Dr. Stein,

Thank you so much for the very prompt and informative reply! Your timely reply really helped because I was able to read your comments before meeting with a periodontist today (recommended by my new dentist). The periodontist had the same opinion as you that the tooth had to be extracted and I needed an implant with bone graft (though he hardly bothered to look into my mouth, only looked at the same X-ray photo I showed you here; guess the photo says enough? ) He said the extraction and implant will be done in his office (hopefully a periodontist is also good in implant?). The abutment procedure, he said, may be by either my dentist or him. Here is my little concern: how important is the abutment skill for the success and safety of the implant? The reason I ask is my new dentist is a young newbie with only 2 yrs practice, and I don't want the implant to have any problem, present or future, due to improperly done abutment. I've heard that despite the high success rate of implant, some were screwed badly.

Since it's the lower molar, does it mean it will not affect sinus in case something done wrong (no need to move the sinus membrane, etc.)?

Another curiosity: is regular X-ray sufficient for implant, or a panoramic X-ray is necessary?

Basically I am more convinced now that extraction is the only way and implant is the best solution for me in the long term. This was suggested to me months ago when the abscess first appeared, but I have been indecisive because I'm kind of "conservative" and oral surgery is a big thing for me. I thought of bridge. Your explanations really helped me understand what's going on in my teeth and I'm more comfortable in the extraction/implant decision.

Re the #18 tooth, what kind of problem do you think might happen to it if nothing done? Infection or fracture? I think I can be careful to prevent fracture, but I can't help if it's going to have infection. I didn't have a chance to ask the dr. today about that tooth.

Thanks again for your time and help!

[Jax]

Chiming in, for no other reason, than to say "Thank you, Dr Stein!"

[seaotters]

Jax, thank you for thanking Dr. Stein

Dr. Stein, I just thought of another question: in addition to implant and bridge, is a removable denture also a solution (if I don't mind the hassles of taking it off and putting it on)?

If yes...

a) Would that still need bone grafting?
b) With a removable denture, will there be infection issues or bone loss in the future?
c) Will it affect future option of eventually having an implant, say many years later?

I know I may be sounding very conservative here , but it seems to be the least invasive and least prone to complications or any future repairs and more X-rays for check-ups...

Thanks again and sorry for so many questions.

[Laurence Stein DDS]

Seaotters... (Are there more than one of you? Forget I asked)

The abutment is the device that connects the implant to the crown. You can kind of divide them up into: 1) stock abutment... which come out of the package and screws directly into the implant, 2) Modified abutment... a stock abutment which is modified or prepared by either the dentist or lab to improve the support and contours of the soft tissues surrounding the final crown and 3) Custom abutment... which can be a cast or milled abutment that more closely mimics the shape and contours of the original tooth.

Since you will be replacing a molar which has a "diameter" greater than the teeth in front of it, your surgeon may want to place an implant with a wider diameter. This allows an easier transition from the implant diameter to the tooth diameter where it emerges from the gum into the mouth. This can minimize the space between teeth that could become a trap for food. Discuss this with him. Abutments used for the wider diameter implants are different than the standard abutments but are handled the same way by the restoring dentist.

The stock abutment is a no brainer. The other abutments require both time and expense to help create a final restoration that looks and functions like a real tooth. This is where experience comes in. Personally, I prefer to determine the shape and contours of the abutment because I will ultimately be responsible for the appearance and function of the final restoration. Your periodontist is likely not going to take the time to place anything other than a stock abutment. That being said, for some teeth, a stock abutment is all that is necessary for a great result.

For lower implants it is important to visualize the height of the bone and the position of the mandibular canal. This contains the nerve that supplies the feeling to the teeth and lower lip. YOU DON"T WANT TO HIT THIS. Additionally, if the bone width is narrow or angled, then you might want to visualize this. A simple x-ray might suffice. A panoramic x-ray would be better and if there are any questions about anatomic structure position, bone thickness or angulation then a cone CT is best. The last two techniques also allow the dentist to evaluate the entire jaw for additional problems that might not be visible on the simple x-ray.

As far as #18: Nothing on the x-ray you displayed showed any pathology. It must be evaluated clinically. If there is mobility (looseness) or caries then you might want to add an additional implant. Thinking out to the future, the prognosis for the implant will be better (in most cases) than for tooth #18. With this in mind, and because splinting is often recommended for lower molar implants, the philosophical question becomes "Is it better to do this now and splint rather than in the future and place individual non-splinted crowns?"

You must discuss this with your periodontist and dentist.

Laurence Stein, DDS

[Laurence Stein DDS]

Seaotters,

Man, you have a lot of questions!

You would probably hate a removable denture. Especially if it replaces only one tooth.

You could get away without bone grafting in most cases. Infections are not a problem but decay in teeth covered by the clasps might be a problem. You could use a removable denture as a temporary or long term temporary prior to future implants. If you are still thinking implants, then you should bone graft even if you make a denture now.

My advice is skip the denture and do the implant(s). It's simpler, less costly over the long run and you establish normal function like natural teeth.

If you plan to use implants from the get-go, don't even bother to place a "temporary" partial denture. No one will see the space and it will be gone in about 3-4 months when the implants are ready to restore. A temporary will simply be an additional cost with little benefit. The adjacent teeth won't even drift much in the short term.

Laurence Stein, DDS

[seaotters]

Hi, Dr. Stein,

Seaotters is just one. Apparently 'seaotter' had been taken by another member of fellow species. I'm flattered by your curiosity.

Thank you very much for the detailed explanations about abutment, so I've got some idea what's important in the process.

Dr. Stein, the reason I thought about denture is not so much about the cost as the small chance of failure (I know the success rate is high, but still not 100%). Also drilling a hole in the jaw bone still sounds something big to me. My guess is nowadays maybe only old people losing a lot of teeth use removable dentures? Otherwise, in what cases is a removable denture recommend over bridge and implants? I was told that implants prevent bone loss, but bridges don't. What about removable dentures? (what's the "science"/mechanism about bone loss anyway?)

OK this is the end of my inquiry . Dr. Stein, since I don't know how to thank you for your time, patience and great help, let me just say that I hope you are enjoying diving!

[Laurence Stein DDS]

Seaotters,OK, last free answer

There is no dental procedure with 100% success. Implant success is at least as good as a first time, well done root canal. Drilling the hole takes less than a minute and usually has minimal post op discomfort... less than most simple extractions.

The only reason the jaw bone exists is to hold teeth in. Remove the tooth or the tooth's function and the supporting bone begins to disappear. An implant transmits biting load to the supporting bone and thus mimics the function of a tooth. The rate of bone loss around an implant is approximately 1/10th that of an empty space.

Removable dentures do not maintain bone levels. Fixed bridges seem to have less bone loss and implants the least.

There are also other negatives to both removable devices and fixed bridges. That being said, the fixed bridge is still a good method of tooth replacement. Of course you must sacrifice some tooth structure on adjacent teeth. If these teeth were already restored, then it's not such a big deal. If the teeth are virgin, then you have subjected them to a procedure which may be a problem for the nerves within those teeth, for maintaining good hygiene and the possibility of future decay at the interface between the bridge support and the prepared tooth.

Removable dentures would be prone to many more problems down the line.

That's it! I'm done! Nada! No more!

Seriously, you must discuss any treatment and outcomes with your doctor. He is the only one in the appropriate position to make a final treatment recommendation.

Regards,
Laurence Stein, DDS

[seaotters]

Dr. Stein, many thanks for the comprehensive info and advice!

Have fun in the water!

Now ...... oops, sorry, not until maybe next year (if I survive in the dentist's chair)...

Have a wonderful year!