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Dental Case

Short summary

60-year-old male was informed by the dentist that his 44th tooth would have to be removed. He would prefer to avoid the avulsion. The expert advises him to lose the tooth for the success of comprehensive prosthetic rehabilitation.


Patient's questions

The patient hereby requests advice with regards to the general plan of treatment to be carried out, and specifically whether or not that tooth can remain.

Medical opinion

See Expert's Answer

Patient's History
Sex: M, Age: 60 years
Case history:
The patient stated that about three years ago, a carbon fibre pin was placed into his 44th element (4th lower from the right).
The pin had recently come out, and been replaced by the dentist. Who, at that time, informed him that, the tooth would have to be removed due to the current state of his gums. The dentist, also advised working on the upper right and left dental arch, but has not yet provided details of the treatment to be carried out.
The patient agrees to do the work on his bite, but would prefer to avoid the avulsion of the 44th element, which he would rather attempt to save.
From the x-ray tooth 44 (first lower right pre-molar) has not only a carbon fibre post (pin) which is properly prepared and of the right depth and diameter but it is also restored with a crown. From the patient statement it is unclear whether the crown is a new crown which was fitted after the new Post (pin) was performed, or if the old crown came out together with the Post (which is the more likely case), and re-cemented in place. These posts usually come out due to over-load on the crown which causes the post to fail or more likely due to a vertical crack of the root which often does not show on x-ray's limitation (a 2 dimensional depiction of a 3-D object- the Tooth). Unfortunately, the quality of the copy of the periapical and the low contrast of the panoramic x-ray, does not allow me to determine if such a crack is indeed present.
If the tooth is cracked there is no remedy and the tooth will have to be extracted!
A local Endodontis (root canal specialist) and Periondontist (gum specialist) should assist in the final judgement of the necessity to extract the tooth and should be able to come out with a good assessment of the prognosis of tooth 44.
If the patient agree to a comprehensive prosthetic rehabilitation (do the works on his bite in his words), tooth 44 may be a weak link, being the tooth in the worst condition in the lower jaw and therefore, the extraction of tooth 44 may eventually increase the lifespan of the whole treatment and increase the success of the treatment. As much as I sympathize with the patient's wish to save the tooth I would advise him to lose the tooth for the success of the whole treatment rather than "fight" for the tooth and affect the prognosis of the comprehensive work he requires.
It is clear that he lost teeth in the past (teeth 45 and possibly 46 on the lower right side, as well as teeth 35 and 36 on the lower left many years ago) and chose not to restore their absence on time which caused the lower molars (the back teeth on either side) to lean forward towards the gap formed by the loss of the lower second premolar teeth 35 and 45 and the lower first molar teeth 36 and possibly 46, leading to what is called posterior bite collapse, and often the formation of 2-3 bony pockets leading to the Periodontal state of the patient, gum disease which will diminish the amount of bone supporting the teeth and the increased mobility of the teeth. (Although the bone level of the tooth is not clear from the quality of the supplied x-rays).
Since no plaster cast of his mouth (mounted on an articular) were provided and no intra-oral photos are provided it is difficult to know the "work on the bite" but in principle extensive work on the lower jaw without providing antagonist teeth on the upper jaw is fairly useless. It will indeed stabilize the teeth in the lower jaw and re-establish the continuity of the arch of the Mandibular teeth (lower jaw). This can be achieved by constructing 2 bridges in the lower jaw after the need for extraction or treatment of tooth 44 is established:
1.    Either a 4 Unit bridge on the lower right side: 43 XX 46 (X depicting a missing tooth) or a 5 unit bridge: 43 XX 46 47 if the position on the vertical height of tooth 47 causes interference with proper occlusal level.
2.    Either a four unit bridge on the lower left side: 34 XX 37, or again, if the last tooth on the lower left side is interfering with the occlusal level it might have to be included in a 5 unit bridge 34 XX 37 38. Since tooth 37 is leaning forward (almost in 45 degrees to its original position, and needs to be "straightened up" considerably to achieve occlusal level, and due to the fact that it has a very deep filling in the distant aspect of the tooth it may require a root canal filling before the final restoration is performed).   
I must point out that if the patient's "gum condition" is deteriorated, Periodontal treatment will have to be carried out, preferably after the construction of the lower temporary bridges and before the starting the construction of the permanent porcelain bridges, this treatment will have to be carried out by a Periodontist (gum specialist) and the prognosis of the Abutmen teeth (the teeth that hold the bridges) is assessed by the Periodontist including the prognosis of tooth 44.
Furthermore, if no reconstruction of the missing upper teeth, especially on the upper right side, is planned reconstruction of the bite will not be complete. The patient has 7 lower teeth and only 5 opposing upper teeth on this side (the 5th tooth –tooth 15- is a cantilever of the old upper right 4 unit bride). The construction of the missing posterior (back) teeth of the upper right side will require either 2-3 implants and the construction of teeth 15, 16, 17 on them, or an upper removable partial denture which may be a "dated" solution, but still viable.
With all work required for complete "reconstruction of the bite," if implants have a good prognosis in this case, this will be the more elegant solution to this case. (Again with the quality of the supplied x-rays, it is very difficult for me to comment upon), but a local implant specialist will be able to give a good idea of the prognosis and success of such a procedure.
If you require further assistance I shall require the original:
Full mouth periapical status x-ray
A new panoramic x-ray
The patient's impression cast mounted on articular
Intaroral photos of the patient's bite front and both sides