I have a tooth (#19) which had a root canal done 10 years ago and then repeated last month. That didnt resolve the problem and Im told the next step is either to have an apicoectomy or an extraction and implant. Are there any diving considerations with either option?
Dental question: apico versus extraction
- Thread starter SeaGypsy
- Start date
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Laurence Stein DDS
Medical Moderator
Hi SeaGypsy,
I must emphasize that since I haven't examined you anything I say must be taken with a grain of salt and is for information only.
Your question is actually quite interesting. Until the common use of the current type of dental implants, my answer would have been a qualified, " Do the apicoectomy."
Two failed root canals on a molar tooth is already suspect. There is the possibility of hidden "accessory" canals, root fractures, periodontal problems that all compromise the tooth. If these exist, even an apico may fail.
Tooth #19 is the lower left first molar. It commonly has two roots and (usually) 3 canals. It can have even more roots and canals. If all canals cannot be reached surgically, you will still lose the tooth. The surgery is more complicated than apical surgery on teeth closer to the front of the mouth.
If there is no bony pathology at the ends of the tooth itself and no periodontal infection, the probability is that an implant will last longer than the tooth. You won't really know if the implant is successful for about a year however. Usually, if it is well integrated (healed to the bone) at 1 year, you will probably have the implant and the restoration supported by it much longer than an at best, questionable tooth--possibly for life. Implants haven't been around long enough to be certain but they are better than a questionable tooth.
A few years ago my advice would have been to do the surgery and try to save the tooth or if #19 was really questionable, extract #19, do a three tooth permanent bridge from #18-#20. (This assumes you have those teeth).
This may be a FIRST CHOICE IF, #18 and #20 both need crowns anyway (heavily filled teeth). It would only be a matter of time until you cap them. If these teeth are "virgin" or nearly so, then the implant makes more sense to me. Why prepare two perfect or nearly perfect teeth if an implant avoids this issue and results in a single tooth restoration?
For multi-rooted teeth like molars, it is my preference to allow at least 3 months of healing and if necessary a "socket preservation procedure" prior to re-entry for the implant surgery. The bone has greater osteoid potential when partially healed.
Immediate placement is possible but it is more difficult to place the implant in the bone between the roots of a multi-rooted tooth and a misdirected or misplaced implant is a real problem to restore.
For molars, you usually want to use the longest, widest implant possible as determined by the width of the pre-existing tooth, width and depth of bone and inter-arch clearance.
Remember, there is a main nerve within the lower jaw so there must be clearance for the length of the implant. You also usually need a minimum of about 5 mm between the surface of the gums and the opposite teeth. If you don't have this room, the implant may not be possible.
I personally hate using the "iffy" tooth and then having a failure. Many surgeons and restorative dentists will often replace a failed implant/restoration if it fails to integrate on the first try but will charge you another fee to replace a failed tooth.
The cost of an implant and restoration is greater--somewhat more than a 3 tooth fixed bridge. However, if implants do as we predict, you may have to replace a TOOTH supported bridge one time in your lifetime but the implant crown may last your entire lifetime. It is actually more cost effective in the long run. (See my qualifying statement earlier in this post)
If you do the apical surgery and then restore the tooth, should it fail over time, you will end up with the same implant you are currently contemplating now. Trying to maintain a failing tooth may also compromise the surrounding bone for the future.
It is a tough call. Ask all the questions you can.
Laurence Stein, DDS
:doctor:
Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)
I must emphasize that since I haven't examined you anything I say must be taken with a grain of salt and is for information only.
Your question is actually quite interesting. Until the common use of the current type of dental implants, my answer would have been a qualified, " Do the apicoectomy."
Two failed root canals on a molar tooth is already suspect. There is the possibility of hidden "accessory" canals, root fractures, periodontal problems that all compromise the tooth. If these exist, even an apico may fail.
Tooth #19 is the lower left first molar. It commonly has two roots and (usually) 3 canals. It can have even more roots and canals. If all canals cannot be reached surgically, you will still lose the tooth. The surgery is more complicated than apical surgery on teeth closer to the front of the mouth.
If there is no bony pathology at the ends of the tooth itself and no periodontal infection, the probability is that an implant will last longer than the tooth. You won't really know if the implant is successful for about a year however. Usually, if it is well integrated (healed to the bone) at 1 year, you will probably have the implant and the restoration supported by it much longer than an at best, questionable tooth--possibly for life. Implants haven't been around long enough to be certain but they are better than a questionable tooth.
A few years ago my advice would have been to do the surgery and try to save the tooth or if #19 was really questionable, extract #19, do a three tooth permanent bridge from #18-#20. (This assumes you have those teeth).
This may be a FIRST CHOICE IF, #18 and #20 both need crowns anyway (heavily filled teeth). It would only be a matter of time until you cap them. If these teeth are "virgin" or nearly so, then the implant makes more sense to me. Why prepare two perfect or nearly perfect teeth if an implant avoids this issue and results in a single tooth restoration?
For multi-rooted teeth like molars, it is my preference to allow at least 3 months of healing and if necessary a "socket preservation procedure" prior to re-entry for the implant surgery. The bone has greater osteoid potential when partially healed.
Immediate placement is possible but it is more difficult to place the implant in the bone between the roots of a multi-rooted tooth and a misdirected or misplaced implant is a real problem to restore.
For molars, you usually want to use the longest, widest implant possible as determined by the width of the pre-existing tooth, width and depth of bone and inter-arch clearance.
Remember, there is a main nerve within the lower jaw so there must be clearance for the length of the implant. You also usually need a minimum of about 5 mm between the surface of the gums and the opposite teeth. If you don't have this room, the implant may not be possible.
I personally hate using the "iffy" tooth and then having a failure. Many surgeons and restorative dentists will often replace a failed implant/restoration if it fails to integrate on the first try but will charge you another fee to replace a failed tooth.
The cost of an implant and restoration is greater--somewhat more than a 3 tooth fixed bridge. However, if implants do as we predict, you may have to replace a TOOTH supported bridge one time in your lifetime but the implant crown may last your entire lifetime. It is actually more cost effective in the long run. (See my qualifying statement earlier in this post)
If you do the apical surgery and then restore the tooth, should it fail over time, you will end up with the same implant you are currently contemplating now. Trying to maintain a failing tooth may also compromise the surrounding bone for the future.
It is a tough call. Ask all the questions you can.
Laurence Stein, DDS
:doctor:
Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)
Thank you very much for the information.
My dentist and endodontist both suggested the apicoectomy. When I went to the surgeon she said that it would be painful and difficult and has only a 50% success rate. Although I'm sure she meant well, it felt like she was trying to sell me on the idea of a $2200 implant. So your input is helpful. I'm going to get a second surgeon's opinion next week although at this point I'm ready to agree to anything that will make it stop hurting now.
It sounds like the apicoectomy involves removing some bone, do you think that will cause problems when diving until the bone fills in?
Thanks,
C
My dentist and endodontist both suggested the apicoectomy. When I went to the surgeon she said that it would be painful and difficult and has only a 50% success rate. Although I'm sure she meant well, it felt like she was trying to sell me on the idea of a $2200 implant. So your input is helpful. I'm going to get a second surgeon's opinion next week although at this point I'm ready to agree to anything that will make it stop hurting now.
It sounds like the apicoectomy involves removing some bone, do you think that will cause problems when diving until the bone fills in?
Thanks,
C
Laurence Stein DDS
Medical Moderator
Hi,
You have to be able to hold the regulator COMFORTABLY in your mouth.
If you do the apicoectomy, you probably won't be comfortable enough to dive for a week, maybe more. Baring complications, the bone surgery will already be filled with a clot and sutured. The sutures should be removed if not resorbable.
Eventhough it takes months for the bone to completely heal, you can go back to diving fairly quickly.
My guess is that it will take about 2-3 weeks for you to be able to hold the regulator. That should be long enough.
If you do the implant, the device actually plugs the hole and there is usually much less discomfort than an apico. Often you only need a dose or two of meds and that's it.
It's NOT a good idea to load an implant immediately unless it is inherently stable. Your regulator may transfer bite forces to the implant through indirect contact with either overlying gum tissue or through the healing abutment.
If the regulator puts no pressure on the implant, 3 weeks should be OK. There is no research about diving and implant healing.
Ask the surgeon about how stable the implant is immediately after surgery. Go with her recommendations.
Actually, I think the surgeon was more realistic for the same reasons I mentioned in the prior post. A second opinion is fine. Unfortunately, my opinion is not based on YOUR mouth but simply a hypothetical image I have of your description of your mouth. There are certainly times that apicoectomy is a reasonable procedure.
Apicoectomy for molars is complex surgery with variable results--often on teeth that have only have a questionable future. There is risk of mandibular nerve damage.
Make sure your dentist is able to restore the implant. There is some prepreparation that needs to be completed prior to surgery by the dentist (fabricate a stent for implant position during surgery, impression jig for first stage surgery impression taking for the purpose of anatomical temporaries, etc.). Make sure the surgeon and the restorative dentist are both consulted and are "synchronized".
Good luck. Let me know how the surgery goes. We'll splash it all over the internet!
Laurence Stein DDS
Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)
You have to be able to hold the regulator COMFORTABLY in your mouth.
If you do the apicoectomy, you probably won't be comfortable enough to dive for a week, maybe more. Baring complications, the bone surgery will already be filled with a clot and sutured. The sutures should be removed if not resorbable.
Eventhough it takes months for the bone to completely heal, you can go back to diving fairly quickly.
My guess is that it will take about 2-3 weeks for you to be able to hold the regulator. That should be long enough.
If you do the implant, the device actually plugs the hole and there is usually much less discomfort than an apico. Often you only need a dose or two of meds and that's it.
It's NOT a good idea to load an implant immediately unless it is inherently stable. Your regulator may transfer bite forces to the implant through indirect contact with either overlying gum tissue or through the healing abutment.
If the regulator puts no pressure on the implant, 3 weeks should be OK. There is no research about diving and implant healing.
Ask the surgeon about how stable the implant is immediately after surgery. Go with her recommendations.
Actually, I think the surgeon was more realistic for the same reasons I mentioned in the prior post. A second opinion is fine. Unfortunately, my opinion is not based on YOUR mouth but simply a hypothetical image I have of your description of your mouth. There are certainly times that apicoectomy is a reasonable procedure.
Apicoectomy for molars is complex surgery with variable results--often on teeth that have only have a questionable future. There is risk of mandibular nerve damage.
Make sure your dentist is able to restore the implant. There is some prepreparation that needs to be completed prior to surgery by the dentist (fabricate a stent for implant position during surgery, impression jig for first stage surgery impression taking for the purpose of anatomical temporaries, etc.). Make sure the surgeon and the restorative dentist are both consulted and are "synchronized".
Good luck. Let me know how the surgery goes. We'll splash it all over the internet!
Laurence Stein DDS
Disclaimer
(No representations are made that in any way offer a diagnosis, treatment or cure for any illness or condition, either discussed or implied. Answers to questions are offered as information only and should always be used in conjunction with advice from your personal diving physician/dentist. I take no responsibility for any conceivable consequence, which might be related to any visit to this site.)
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