Should I or shouldn't I?
 

Went to the OS for a consult today. Upper wisdom teeth are in and bottom wisdom teeth are impacted. Went for consult because #18 molar has an abscess with bone loss and regular dentist thought that there was infection around the wisdom tooth also. After OS did another set of xrays, he said no infection or cyst around wisdom tooth so it does not need to come out (thank goodness). His advice was to pull #18 molar, clean out infection, and do bone graft using cow bone ? or synthetic material. Am I understanding right, he pulls the tooth, cleans out the area and packs in this synthetic material and sews it together so there is no worry about dry socket? Also, what is the synthetic bone material made of and is it safe to have in your gums? He also suggested that since he saw a small cavity between an upper tooth and the wisdom tooth that I should probably pull both upper wisdom teeth also. Why would I do that if they've grown in straight and have no infection around them? That doesn't make sense to me. Also I don't want to be put out for the molar extraction and bone graft...is that a bad decision? Thanks for all your help and your knowledge.

Hi lin,

I can answer your questions....

Erupted upper wisdom teeth that are so far back that they are not being utilized for chewing purposes are prone to decay and periodontal disease because they are very difficult to keep clean. Removing them is usually simple and you would not miss them because you are not using them. Leaving them in predisposes the second molars to decay in between them and the second molar.... again, cleaning that area is difficult. Sometimes the decay on the second molar cannot be accessed until the wisdom tooth is removed because there is no room to angle the drill or even see what you're doing to place the filling.

If #18 is abscessed, it is imperative to have it removed because it can infect that entire area of the jaw and beyond.

As for placing bone graft material in that socket.... that is done to help encourage new bone growth to help preserve some of the bone height meaning when a tooth is removed, there is a minimum of 50% bone loss that is basically non restorable without the bone graft. The loss of bone can have a negative affect on the side of the first molar that is next to tooth #18. The difference in bone graft material varies on the manufacturer... some are derived from pig, cow or cadaver... synthetics are derived from calcium phosphate or hydroxy apatite. The big difference is the way the body utilizes the grafting material... the Alloplasts (synthetic) take a bit longer to work as opposed to the Allografts (cadaver) or Xenografts (animal). The bone is placed directly into the bony socket... a collagen membrane is placed over the graft and the gum is sutured closed. It is not irritating to the gum.

Regarding the choice of anesthesia for the extraction and grafting.... if you chose to be asleep, it is a twilight sedation of which you feel and remember nothing. You also wake up fairly easily afterwards. A local anesthetic is also used with this sedation and you would be very numb for a few hours. If you chose not to sedated, you would be profoundly numb for the procedure and for several hours after wards. You could also consider oral sedation with some valium or xanax taken the night before and the morning of the surgery which helps to take the edge off. A local anesthetic would still be used and again you would be very numb.

I hope this information is helpful to you... all the best!
Bryanna

Bryanna,
Thanks so much for your quick reply. Since I have been reading these Q&A's and so many of your answers, I was wondering about the issue of doing a bone graft at the same time of the extraction seeing that I have bone loss and infection around #18. The OS said that the extraction would leave a large hole, he would clean out the infection and do a bone graft to help support the molar next to #18. My concern is that I have read that you do not suggest getting a bone graft right then if the area around the tooth has infection because the gum should heal first. He never mentioned that to me and the last thing I want to do is have a bone graft, it doesn't heal because the area had infection in it, the bone graft fails, and I have to do it all over again. Wouldn't a responsible OS know this and not suggest having a bone graft done right away? I'm confused about this. Thanks in advance for your response. Maybe I need to get a second opinion from another OS.

Hi lin,

You are correct! It is not ideal to place bone graft material in a surgical site that is infected. The risk of graft rejection and further infection is elevated under those circumstances.

The oral surgeon can only determine the health of the bone when he removes the tooth and debrides the bone. If he sees that he has achieved an adequate debridement with a healthy blood flow and can feel adequate solid bone, he may chose to place the graft at that time. If those conditions are not evident, he may chose to close it up, let it heal for a few weeks and then reopen the area to place the graft.

The idea is to place bone graft material inside of healthy bone. My suggestion is to make it perfectly clear to the surgeon that you do not want any grafting done at the time of the extraction if there is any doubt about the health of the bone. You would prefer to wait and have a second surgery for the grafting. Just so you know, the second surgery is a minimal procedure if done a few weeks post op extraction. It basically goes like this.... Anesthetic is given... a small incision is made over the surgical site... the bone is scraped to remove any residual debris and to encourage a healthy blood flow... copious amounts of saline are used to irrigate the site..... the graft material is packed inside the socket.... a collagen membrane is placed over the graft... and the gum tissue is closed over the site. The recovery is usually not that bad, just a little sore for a few days.

If you feel more comfortable getting a second opinion, then by all means do that. I cannot stress enough that it is the patient who will direct the course of treatment in most cases..... meaning, if you say you want it all done at one time because you are not going to have a second surgery... that is what will be done. If you say you are most concerned about the health of the bone and want the healthiest outcome, the surgeon will take that into consideration.

I hope this helps.... :)
Bryanna