Impacted Premolar Below Implant Site: Best treatment approach?

When I look at this panorex I think the patient may have bigger problems than the impacted premolars. You've got to clean up a couple of things before you can put an implant in this guy. If the patient can't clean his own teeth do you think he'll be able clean around an implant?

These impacted premolars cause complications are extremely rare. I would installed implant, but the patient would have explained the problem and its possible consequences.

Other dental issues aside, if youre worried about hitting the impacted tooth, dont be- you might hit the mental/inf alveolar nerve first. Get a CBCT scan done to be sure.

OMS resident, I like your answer. I would leave the impacted premolars alone.

I agree with Dr L, the main problem isn't going to be the impacted premolar, its position should not affect implant placement directly. Following up on what OMS said, perhaps place a removable prosthesis and instruct correct hygiene with regular recall to evaluate patient habits before advancing.

It would be prudent to get a cone beam of the mandible. The impacted premolars should be evaluated for enlarged follicles and remove #30 root (active infection) scale and root plane. There is not enough bone height in the area of #19 so grafting is needed. The pathology needs to be addressed. The impacted teeth don't need to be removed since they are not near the implant and a buccal approach would be used anyway. I'd CYA about the rest of the oral cavity and the amount of bone @ 19. Good Luck!

Why even bother about the impacted premolar? A short implant would work perfectly well here. Agreed there are other issues in this patient's mouth but the premolar site/ It's a non-issue.

If it ain't broken don't fix it. Get a ct scan and plan the proper length of implant.

I agree there are other issues that need to be addressed before looking at implant placement in the LL. My concern with the impacted premolar is there seems to be a large radiolucency around the root of the impacted tooth. I would recommend a CBCT to better eval.

OMS made some important remarks......there are many issues to consider before placing an implant. The panorex film shows a mouth in disrepair with poor or little oral hygiene being practised. There is a serious issue on the lower right side where there is active destructive tissue destroying the bone around what appears to be the mesial root of a hemisected first molar; and there seems to be two premolars present plus the lower left and right impacted bicuspids...which of these teeth are supernumary teeth? Both impacted teeth are sitting in the regions of the mental foramina bilaterally, and surgery could cause problems if the dentist is inexperienced. A CBCT scan is of utmost necessity...do not look for trouble, refer to a qualified specialist. Dr. Gerald Rudick Montreal, Canada

leave it and put your implant with less length.

Good one Dr Rudick! Impacted bicuspids are supplemental supernumerary teeth and mostly are the end of a series i.e. extra lower second premolars. Other issues are periodontitis and the supra-eruption of #10 (upper left lateral incisor). There may be a retained root in the #19 site. The ring piercing on the nose looks good on the DPT !! but this is a non-issue too :)

I agree, the premolars are far from the site of the dental implants, and that there are some other things first, like hygiene. But what is your criteria to decide to leave the retained premolars? I would take them out and graft. The question is to all that advice to leave them.

This case goes through full perio eval and treat from my estemmed cadre of specialists. If it gets back to me, it will be to take impressions for final crowns on 19, 30 and maybe 10. Thanks to ryan or mark or Jason, you guys are great and I don't treat this case without you! If this guy doesn't make it back to me from them, he's headed for dentures....

Do what??? Bv

A CBCT would be most helpful. I did notice a radiolucency under #18 spreading mesially. Also, the crown/implant ratio would be >1 and, considering this guy's oral habits.. The bone loss is dangerously closing a vicious circle for this case. BTW, what's his age?

I agree with the first comment that this guy needs his perio controlled before any implant treatment is considered. That being said, the tooth should be removed and the site grafted and let to heal for about 6 months before attempting and implant. I think there is a lot of junk in the bone that needs to be cleaned up by the body before attempting an implant