How should I manage this hopeless tooth?
I have a patient of record who comes in each year for a recall examination and oral prophylaxis and is otherwise healthy. Â She presented recently with an abscess around #2 [maxillary right second molar;17]. Â She also has an impacted adjacent #1 [maxillary right third molar;18]. Â #17 has significant intraoral swelling of the gingiva and deep pockets. Â #2 is has a full gold crown which is splinted to #3 [maxillary right first molar;16] which is healthy. Â I am planning on extracting #2 because this tooth is hopeless. Â Should I attempt a bone graft with membrane at the time of extraction? Â I am assuming the bone around the socket will be infected. Â Would it be better to extract #2 and wait until the area heals and infection resolves and then place a bone graft and membrane? Â If the buccal wall remains intact should I not do a graft? Â What do you recommend?
Tooth 17 five years ago, healthy and no pocket
![]Tooth 17 five years ago, healthy and no pocket](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/MS-KIM-359-003.jpg)
Tooth 17 with deep pocket and swollen.
![]Tooth 17 with deep pocket and swollen.](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/X12-08-12-1.jpg)
Put GP cone to measure pocket depth
![]Put GP cone to measure pocket depth](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/X12-08-12-2.jpg)
In the Mouth
![]In the mouth](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/08/P12-08-12-2.jpg)
19 Comments on How should I manage this hopeless tooth?
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Dr. Alex Zavyalov
8/17/2012
Good diagnostic images. Separate and remove distal crown. Revise the tooth mobility. If it’s really weak, extract it; clean the socket and wait for at least three months to know adjacent tooth prognosis. Grafting with further implant insertion is rather questionable now.
smileartist
8/20/2012
no graft in infected site. agree with extraction asap, must remove #1 conjointly to prevent future complications. also agree to get prognosis on #3 after 2-3 months before planning implants. case is straighforward after that.
CRS
8/21/2012
Send this is an oral surgeon after you separate the crowns to remove #1,2.
CRS
8/21/2012
The second molar root will get hung up on the impacted tooth which is under the sinus so lay a surgical flap to prevent a tuberosity fracture.
John Manuel, DDS
8/21/2012
I'd kind of suspect that second molar was weak at the time the fused crowns were placed - cone shaped root with a lot of contact against the impacted third molar. For certain a poor prognosis there.
The first molar Endo seal does not look smoothly done - maybe some problem there. Good idea to separate and let some time pass. Maybe have an endodontist evaluate the first molar before any nearby implants. Between the chronic perio and the rough Endo, you have two possible area where infection may invade your new implant site.
John
steve m
8/21/2012
I agree #2 is hopeless and should be removed. Tooth #1 which is impacted in direct proximity will also need to be removed at the same time or it would likely have a negative influence on the treatment outcome. I would definitely augment the socket at the time of extraction. The concept of not placing a bone graft because of "infected bone" is not valid as long as the tooth is completely removed, the socket is thoroughly curetted free of all soft tissue, an antiseptic is used to irrigate the socket and a systemic antibiotic is used post operatively.
However the upper second molar site seems to the least predictable as a good implant site even after all normal prepratory steps.
Jennifer Watters, DDS
8/21/2012
First, section the crowns. Then make crestal incisions around #17 and gently retract the flaps for visability. Elevate the tooth, remove it, debride the socket gently, but thoroughly. I like to use a tetracycline capsule dissolved in an ounce or two of sterile water to gently irrigate the area prior to grafting and I also mix some of the tetracycline powder into the bone graft material. Also check the distal of #16 and clean it. Then I would place a bone graft with a collagen membrane or plug and try to get the best closure possible, even if the buccal wall is gone as you mentioned (I don't think that would be the case). I would leave #18 alone unless further infection presents itself. I would wait 6 months to observe healing before considering an implant. I would cover the patient with antibiotics (Amox or Clinda) for 10 days and start them a day or two beforehand. If the person is high-risk for infection (i.e., diabetic or immune compromised, or smoker) I would wait and graft later.
Uli Friess
8/22/2012
I would extract 18,17 plus 16(1).
No augmentation,after three months implants in regio 16 and 17 with or without sinus lift.
dr bo0b
8/22/2012
Good post! I have been removing graft infected material post op. after docs have grafted after removing infected teeth and doing graft the same day. Not happy patients. I have to explain why the graft failed when they ask. Not a good feeling.
Uli Friess
8/24/2012
That`s exactly the way I see it.
Uli
Nguyen La Tri Dung
8/24/2012
Dear all Dr.,
Thank you very much for your comments.
I have some cases with socket preservation right after tooth extraction. I clean the socket carefully and graft inside. I don't see any infection, but also I don't see a good result,too. So from now, I rarely repeat this treatment, especially, in infected socket.
How about your experience?
Best regards,
Dr.Tri Dung.
Uli Frieß
8/24/2012
It is my strong oppinion ,that the use of any graft material
always leads to a retired growth of natural bone.So, I would
always avoid it, unless I had nö other possibility and enough
Time (One Year or more) to wait.
Uli
Jennifer Watters, DDS
8/28/2012
Periodontists are always extracting teeth that are hopeless periodontally with a lot of bone loss and simultaneously grafting the socket successfully. The only difference here is the impacted 18 adjacently. Even if the decision was to remove the 18 and the 17 simultaneously, I would imagine my oral surgeon friends would still graft it at the time of extraction unless this was a severe "space" infection which required significant drainage. Was there a fistula, facial swelling or swollen marginal gingiva?
franco
9/17/2012
The question ,is it a good idea to place implant fixture @ #2 at all?. Probably need to consider shortened arch ! the other question, how come you have missed the localised periodontal deterioration while seeing the patient regularly?
Nguyen La Tri Dung
9/17/2012
Dear Dr. Franco,
Thank you for your suggestion. Shortened the arch is one of treatment option for my patient. However, I've met her few days ago and she said that she felt uncomfortable with missing tooth. So she needs implant.
Patient come to my clinic regularly, however, just for teeth cleaning. I didn't directly check for her. Just my hygienist took care her. It's my mistake. Furthermore, because of the gold crown, it's difficult to see the big caries inside the crown and because 2 crowns connect 2 molars, patient didn't feel any pain or tooth loosing until she had the periodontal absces.
Best regards,
Dr.Tri Dung.
franco
9/17/2012
Dr Dung, thank you for the clarification. we probably need to consider the prognosis of implant fixture at this part of the mouth, at given bone quality, quantity, occlusal forces and oral hygiene feasibilty. I understand patient's need but, IMHO, patients may have high expectation of a treatment option but the reality can be different. I'm not discouraging you to place implant. I'm just giving my opinion.
Regards
Franco
CRS
9/23/2012
I suspect that the second molar was splinted due to perio. The wisdom tooth should have been removed prior to crown placement since it contributed to the periodontal issue. That said you've got an endo treated first molar you'd like to keep, so I would lay a full thickness flap with release between #2-3 and remove #1 and #2 protecting the buccal plate which is key to the success of the graft. Remove any chronic granulation tissue and place a teflon membrane or resorbable membrane depending on the condition of the buccal plate and tuberosity. That way you will have a reconstructed alveolus regardless of placing an implant. This protects the first molar and leaves the patient with good bone and tuberosity for future implant or a partial as they age, thinking longterm.
CRS
9/23/2012
Also primary closure is very simple to obtain here. What makes a bone graft work is the condition of the buccal plate, stability, support, blood supply and primary closure. The area has chronic perio imflammation not gross infection which would be treated with systemic antibiotics prior to surgery. I feel it's best for the patient to restore the bone. The graft is a spacer during healing.
Richard Hughes, DDS, FAAI
9/24/2012
Section, extract # 2 and revisit later, if the patient is interested in any further treatment.
