Complicated wisdom tooth problem

[gradym]

I’m in my late sixties. Upper right wisdom tooth was extracted approximately 27 years ago. The lower right wisdom tooth has migrated upwards about 4 millimeters because of lack of an opposing tooth.

That lower right wisdom tooth has had a series of big fillings, and they always fall out after six months to 1 year. The last time the filling fell out, I had pain and the dentist suggested extraction, but I am nervous about extraction and the possibility of permanent nerve damage, so I asked her to just fill it again. She did so, although she warned that the filling probably would not last long.

That filling has now fallen out, but there’s no pain. Maybe the nerve has died?

The dentist suggested that, if I didn’t want to extract it, the next best thing was to crown it, and also crown the tooth next to it, and then attach the crowns together. She said this attachment would prevent the 3rd molar from migrating further.

I don’t really like the idea of crowning both teeth if it’s not necessary, and a few questions occur to me:

At my age, is this lower wisdom tooth really going to keep migrating if it only migrated a few millimeters in 27 years?

Is it possible the wisdom tooth will migrate to the point that it self-extracts itself safely? Is it migrating away from the root, or just growing longer?

What if I asked her to just crown the wisdom tooth and not its neighbor?

What if I do nothing?

For the record, the 2nd molar also has a fair amount of decay.

I haven’t had panoramic x-rays, but a regular x-ray did show that the 3rd molar roots are pretty close to the nerve and I don’t want to risk having permanent nerve damage even if it’s unlikely. The x-ray also showed that the wisdom tooth is not straight, it’s angled away from the second molar.

I would like to be able to chew hard food on that side again, instead of always chewing on the left side (I did that to avoid disturbing the fragile filling on the right side). Now that the filling has fallen out, I’m chewing soft foods on the right side with no pain.

I’d greatly appreciate some opinions so I can make a decision.

Thank you.

 

[MattKW]

1. The risk of nerve damage from that extraction is about as likely as getting hit by lightning on a clear day. Any competent dentist or oral surgeon would not have a problem with that.
2. The idea of crowning it and joining to the adjacent tooth is absolutely bonkers, and is much more high-risk than the extraction.
   There's the risk of damaging the nerve in either tooth (5-10%) then needing an RCT.
   There's bad angulation that would increase that risk dramatically.
   There would be a big problem trying to keep the gap between your teeth clean.
3. I would have the wisdom removed, and THEN crown the 2nd molar. No other sensible option.

 

[gradym]

Thanks for the reply, MattKW.

I have read that the risk of having nerve damage that affects the lip, chin and gum is not insignificant. The following is from Coronectomy – oral surgery's answer to modern day conservative dentistry (https://www.nature.com/articles/sj.bdj.2010.673):

"Mandibular third molar surgery
Oral surgery procedures commonly involve the removal of MTMs. A significant risk associated with this procedure is temporary or permanent altered sensation to the lower lip, skin of the chin, teeth and gingivae on the operated side caused by iatrogenic injury to the IDN. The incidence of injury to the IDN when removing MTMs varies from 0.41% to 8.1% for temporary lack of sensation and 0.014% to 3.6% for prolonged signs and symptoms.1 In 'high risk' teeth this may reach 20%."

Also see "Inferior Alveolar Nerve Injury after Mandibular Third Molar Extraction: a Literature Review" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306319/

0.014% to 20% (in high risk teeth) does not seem to me to be comparable to the odds of getting struck by lightning on a sunny day. Did you look at my x-ray? The dentist did say that my roots were curved and long, and that made it more risky.

You think my x-ray does not look risky for damage to the inferior alveolar nerve?

When I was searching for a dentist in the Asian city where I am retired, I settled on two finalists. Then I googled these dentists and found Google Reviews for each of them.

BOTH dentists had one review in which the person said he had suffered altered sensation to the lip, chin, gums after a wisdom tooth extraction, which appeared to be permanent. One person said they have pain and involuntary drooling from the corner of their mouth, almost a year later. They were full of regret for having extracted the wisdom tooth.

These were reviews of the clinic, so not necessarily of the dentist that I see at that clinic.

Based on what I’ve read about coronectomy (a procedure that seems to avoid the nerve damage), it’s contraindicated in teeth with a lot of decay, which my tooth has. (Although I found another article that said maybe it can be done on a decayed tooth.) Anyway, it’s quite difficult to find any oral surgeon here who is experienced in coronectomy.

I also googled my dentist’s suggestion of placing two adjacent crowns and connecting them to prevent any further lengthening of the wisdom tooth due to lack of an opposing tooth. I could find no reference to that procedure. I wonder if that’s a standard procedure or an original idea of my dentist with no precedent.

I guess I have to go to another dentist and get another opinion. Maybe more than one other dentist.

Thanks again for your reply.

 

[gradym]

I just want to add: my dentist isn’t 3rd World trained -- she graduated from a highly regarded dental school in the US and was recommended by local expats.

I do appreciate your opinion. You might be correct. I am very risk-averse on matters like this, and just want to find the best solution.

Placing two crowns on the 2nd and 3rd molars and joining them seems dubious to me, too.

I still wonder what would happen if I just did nothing. The filling has fallen out and there is no pain. Is it possible the wisdom tooth can eventually come out safely by itself?

 

[MattKW]

1. The literature you cite covers all cases of wisdom surgery and all skill levels. I certainly wouldn't let an inexperienced person attempt this extraction. So a good surgeon would have very little risk.
2. The biggest hurdle to removing that tooth is not the root shape or proximity to the IAN. It is the way that the tooth points slightly backwards (disto-angular). Like removing a tree, the direction of the roots determine the direction to apply the forces, so this tooth will come out in a backwards direction, into the bone behind it. This makes it the most difficult factor in your case.
3. The roots of wisdom teeth usually lie to the inner side of the IAN. You are looking at a 2D image so it can look like overlap. In the "old" days, we only had 2D images, and this is where a lot of those unfavourable statistics in the reports were developed. Nowadays, a prudent oral surgeon will arrange a 3D image and make plans accordingly.
4. If you wait for pain, then you will have less opportunity to have a well-planned extraction done carefully. And you are not getting younger, so older patients have more medical issues, more medications, and heal more slowly. You don't want to have an emergency at 85 years old when you're in a nursing home.

 

[gradym]

Thanks Matt for the reply. Sorry it took so long for me to respond.

Well, I went to another dentist and he had different ideas.

First of all, I was wrong -- the filling in the 3rd molar did not come out. What came out when I was flossing must have been a piece of the filling from the 2nd molar.

He said that the 3rd molar did not look like a risky extraction. When I said I was still reluctant to extract it, he suggested I could leave it alone as long as the filling was intact. And he said I could either crown the 2nd molar, or put an overlay on it.

Then I went back to the original dentist and she said an overlay is not strong enough for the biting forces that I would get on the 2nd molar. She also said that if the big filling on the 3rd molar eventually comes out, the filling could still be replaced.

Her suggestion of placing 2 crowns on 3nd and 2nd molars and connecting them -- I think she means “splinting” them.

She said if I crown both 2nd and 3rd molars and don’t splint them, it will be impossible to prevent food from getting between them, and I won’t be able to keep it clean even with daily flossing. And this will lead to decay and loss of both teeth eventually.

I’m a good flosser so I am skeptical about this. Unless there is something about the angle of the proposed (unsplinted) crowns that will make it impossible to get the floss between them completely.

I see from the x-ray that the 2nd molar’s roots are partially exposed above the gumline. I guess this means it really should be crowned?

The main thing to me is that I want to be able to bite hard foods on that side, instead of always biting on the other side for fear of dislodging the big filling on the 3rd molar.

I also read somewhere that lower 3rd molars do not generally get longer due to lack of an opposing tooth, this problem is mostly with upper molars. Also, even if the 3rd molar HAS lengthened, it is not getting in the way of my bite on that side. I can still close the bite fully.

 

[gradym]

Matt, you are talking about getting a CT scan on the wisdom tooth, right? But my risk aversion also applies to radiation -- and isn’t a CT scan a LOT of radiation?

 

[MattKW]

Where do I begin???

1. Splinting is the same as connecting or joining them. Still a stupid idea and highly risky, but what would I know? Me and honestdoc probably have 60-70 years of experience clocked up between us.
2. Get rid of the wisdom tooth, repeat ad nauseam.
3. All radiation carries risk. You are exposed to background radiation minute of every day. That Xray you have put up above is equivalent to about 8 hours background radiation. A cone beam CT is about 8X that of background, a transatlantic airflight is about 16X that of background. Think about what the crew are exposed to during their working career.

 

[gradym]

Thanks Matt. I appreciate your opinion and will seek out a really good oral surgeon.