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Dentistry/Grafting and Implants

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QUESTION: Dear Dr. Teig,   I have a question concerning whether or not to go with crowns as this prosthodontit wishes to do. The teeth in question are the upper teeth, the large ones in the back. Now, the old amalgams are somewhat large and cracks are visible. Two teeth have had small pieces chip off. What I think is as time went by and dentists would work on these teeth, each time they would make their new fillings larger and larger. Personally, I am not looking for a Hollywood smile (nor the expense), but I do desire keeping as much natural tooth as possible.  A crown removes all the surrounding exterior of the tooth forever, leaving the internal parts of the tooth forever susceptible to whatever; even though now surrounded by a new, so called tough exterior (gold and crown cap). I already have one crown and I'm not happy with it all, never was. It hurt for 16 months after installed. And it looks horrible.  I know you haven't seen my teeth so it's hard for you to give your best opinion. I saw the photographs myself, the ones the prosthodontist took. To me it's a judgement call. Yes, the amalgams are old and large, and yes, there are visible cracks. But having done bodywork on automobiles myself, if I were a dentist, I'd take the challenge and try and rebuild the teeth with composite resin and see what happens. It's worth a try, isn't it?? But, he isn't a regular dentist, he's a prosthodontist and he wants to go with crowns, that's what he does. I went to him because other teeth desperately needed attention, gum recession with cavities. I had my teeth scaled also. Boy, are the gums much better. I saw him today and I have about six weeks before I see him again. I could go around for consultations from other dentists in the meantime. I don't want to put out $9,000 for 5 crowns when I might be able to get 5 new composite fillings for $1,000!! See my point? I just wanted to ask you to get your best "general" opinion. I have a lot going; two teeth just pulled, a scaling done, 10 cavities filled/bonded, a possible root canal, another cavity that's going to be difficult to access, two sockets taking forever to fill in, difficulty eating,etc.. I don't want to go through 5 crowns, especially since my one and only experience was horrible.  Could you possibly comment, Dr. Teig, on this question? Could you please try? Thank you so very much, sir!    Mark S.

ANSWER: Mark -  Any determination to replace existing fillings with other fillings, when there has been damage to fillings, is mostly made on the amount of underlying tooth structure decay or damage.  If the tooth structure remaining after the removal of the fillings leaves the remaining tooth structure to be unsupported (such as a house without a foundation).  When this has occurred, the remaining tooth structure will not be strong enough to support new fillings. If the fillings are placed, the tooth will fracture more and eventually the cracks will go into the nerve canal.  When this situation occurs, a crown is necessary to support the tooth from the outside.  

So not examining you, I think the prosthodontist probably evaluated the tooth structure and felt from a direct exam and from xrays that the only way to save the teeth was to support them from the outside.  Of course, I cannot be sure without examining you or viewing your xrays, but from what you have described, that's what it sounds like.

My suggestion is to ask the prosthodontist directly.  If you still doubt, see another dentist to get a second opinion.  If you have additional questions, feel free to contact me again.

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QUESTION: Dear Dr. Teig,  I have a question concerning grafting and implants. The two teeth that were recently pulled were severely infected. I won't bother going into the details of how the infection disrupted my state of health. Anyway, since they were so infected, and since I was repeatedly warned of the severity of the infection by different dentists, I chose not to have the grafting done just minutes after the teeth were extracted. I figured that if the teeth were that badly infected, there might be a good chance that there would be infection lingering in and around the jaw bone area. Even though the surgeon said he would clean the area, so what. Why did he have me on an antibiotic? But only 5 days worth at that. Sorry, but I read enough reviews on the computer from different people who had problems afterwards with infections of various sorts.      So, I just got back from the dentist a little while ago. I talked with the hygienist who cleaned my teeth today. I asked her about grafting, implants, etc.. She said that the grafting now would be much more difficult for it to take. Secondly, there would be a lot more time involved. Why so much time?? The surgeon said I had to wait 4 months now before grafting could be attempted. Hygienist said it would be an additional 4 months for the grafting to take. Then another 4 months just to implant the post. That's a year! And I need 2 implants. The teeth extracted, 19 & 30, still have holes from a month ago and I don't think they will ever close up. So I'm thinking why bother. And there's still the 5 crowns issue. Remember, I asked you about crowns versus new fillings? Dr. Teig, could you at least explain the length of time involved with all this grafting and implant stuff. What's this I've read about some dentists who do the whole thing at once; pull the teeth, place graft and post simultaneously, and then slap a crown right on it? All in an hour. There's a couple of dentists down in Washington D.C. that advertise this procedure. What's the deal?? Maybe I should just get the remaining 26 teeth pulled and get false teeth instead?     Could you explain a little, please?      Thanks!      Mark S.

Answer
Mark you are much smarter than the surgeon.  It is very important to wait at least 4-6 months after an infected tooth is extracted before a grafting to the socket is performed.  If the grafting is now done by a knowledgeable surgeon it is not more difficult, other than the surgeon needs to k.ow the "onlay graft" technique.  Periodontists use this all the time for bone loss.  So it does heal, but a protective material is placed over the gum tissue covering the implant to protect and stabilize it during healing.  So this procedure will take time to insure no infected tissue or bone remains.  It will take at least 3 months after the extractions of infected teeth before a grafting can be considered.  What can be done, depending on the healing of the infected bone, is to place the graft and implant at the same time.  Then waiting 4 -6 months for bone and graft healing is necessary. At that point a crown can be placed within a few weeks.

Those doctors who advertise the extraction, graft, implant and crown at the same time do not have a high success rate.  Sure some succeed, but their success rate is 50/50 at best.  There have so many features with this rushing.  Failure chance is much higher with this rush.  I know because I have been contacted so many times about this rush.  What they advertise would be similar to immediately repairing an infected fracture of a leg or arm and walking on the leg immediately or throwing a baseball with the just aligned bones.  Not good!!!!  For the same reason people with jaw fractures cannot chew for weeks.

So deal with an honest realistic surgeon and everything would be done properly.

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon and I am available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicine for over 20 years. Assistant Clincal Professor and State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA -University of Connecticut DMD - University of Pennsylvania School of Dental Medicine

Awards and Honors
National Honor Society (OKU), Philadelphia County Dental Society, Mosby Book Award, Oral Surgery Honors, Summa Cum Laude

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