Sharing the news with our patient that a tooth is no longer able to be restored can be met by a variety of reactions that range from apathy to an emotional sense of urgency as far as what can be done to replace this tooth. I’m curious how you handle the discussion related to a lower second molar (radiograph of Thomas #18 Perio).

PA #18

How much treatment is required to prepare this site for a dental implant-supported restoration ? Dental implants have improved the options available to our patients for solutions related to missing teeth. There are many advantages to preserving adjacent teeth and maintaining alveolar bone and it can become automatic to recommend a dental implant supported restoration for our patients making a decision on how to proceed. Super eruption of the opposing tooth (maxillary second molar) is a possibility; however, according to Shugars et. al. [1], bound edentulous spaces over a median follow up period of 6.9 years did not, as a general rule, demonstrate adverse consequences when deciding against the replacement of the missing tooth.

It would be unlikely that super eruption of the maxillary second molar into the space of a missing mandibular second molar could create an interference in protrusive movements. Anatomically, in terms of supporting bone, concerns arise as to the natural “undercut” of the mandible at the beginning of the retromylohyoid fossa, as well as the relatively superior position of the inferior alveolar nerve.

A recent study by Ham, et. al. [2] set out to gain insight as to the justification of a second molar implant-supported restoration. They found both a measurable increase in masticatory efficiency as well as a subjective increase in patient satisfaction following insertion of the definitive restoration.

For a patient that had premolars removed to facilitate orthodontic tooth movement, maintaining the chewing surface of a mandibular second molar can intuitively provide a functional benefit. The discussion can be a little more interesting when the patient has maintained all of their teeth (premolars) providing functional contact for first molar occlusion.

At the least, it is an opportunity to discuss treatment with our patient while increasing awareness as to the importance of maintaining their dentition.

References:

1. Shugars DA, Bader JD, Phillips SW, White BA, Brantley CF. The consequences of not replacing a missing posterior tooth. Journal of the American Dental Association 2000;131:1317-1323.

2. Ham D, Lee D, Chung C, Kim K, Park K, Moon I. Change in masticatory ability with the implant restoration of second molars. Journal of Prosthetic Denstistry 2014; 111(4):286-292. Douglas G. Benting, DDS, MS, FACP, Spear Visiting Faculty and Contributing Author. [ www.drbenting.com ]  


Comments

Commenter's Profile Image Andrew Soulimiotis
May 16th, 2014
I see patient lots of time with similar situations. I feel strongly that when a second molar needs to be extracted, especially when there is active infection or periodontal bone loss, that a bone graft of some sort needs to be placed. This would benefit the implant whether it is done soon after or even a few years later down the road. The other benefit I see in grafting is the effect taken on the first molar. I see many times when the buccal bone has collapsed over a short period of extraction and patients tend to get food trapped in this area, or even causes irritation of their throat from accumulation of debris or food packing in the crevice here. If no replacement was done, as long as they have at least one molar in occlusion on both sides, I am ok with observing any super eruption, as long as patient understands that if it happens very quickly without being addressed, that orthodontics may need to be used or extraction of the opposing tooth. So, in summary, I would extract, bone graft and offer the option of implant.
Commenter's Profile Image Douglas Benting
May 19th, 2014
Thank you for your comment Andrew. I agree with you particularly based on the information (radiograph) provided. Grafting the site preserves the patient's opportunity for a choice if initially an implant is not how they would like to proceed AND helps to avoid bone loss on the distal of the mandibular first molar.
Commenter's Profile Image Kenneth Goldberg
May 19th, 2014
As an oral surgeon I see these cases every day. My experience has been the majority of people choose to replace with an implant. If they're unsure I recommend grafting and allowing the normal 3-6 month healing period. This way they get to function without the tooth without the risk of super eruption. The majority of patients feel as if they lost chewing surface and choose to restore the area.