Impacted Adult #18 - Nerve Damage

[mangobanana]

Hello,

I am F. 24 years old USA. I have an adult molar that is embedded in my jaw bone. The roots of #19 are wrapped are the lingual nerve.

I was not going to have surgery because of the risk of nerve damage, however I was recently made aware via 3d scan that #19 is starting to decay. I was told I would have to have #19 and #18 removed and two implants put in, in the future. I was also told that I am starting to lose bone in the area.

What are my options? Please help. Also if someone know anyone in the USA who has performed a surgery on this type of case please follow up with me. I am looking for a surgeon skilled with working around nerves.

I am attaching two x-rays one from 2013 and one from yesterday.

Thank you.

 

[MattKW]

Can't see decay from these xrays, but will take your word for it. I would strongly suggest extraction of 17 - it will never be any use for you, and is part of reason that 18 is tilting over. Having relieved the tilting, it may not be wise to risk a complete extraction of 19, but perhaps a coronectomy would be more suitable; might then straighten 18 back and upright again (braces). Here's a link with pictures: https://www.njcenteros.com/procedures/coronectomy/ This would also allow you to keep 18; then maybe later remove roots of 19 and consider implant at that stage. 16 would prob require extraction at some time following extraction of opposing 17

 

[mangobanana]

Can't see decay from these xrays, but will take your word for it. I would strongly suggest extraction of 17 - it will never be any use for you, and is part of reason that 18 is tilting over. Having relieved the tilting, it may not be wise to risk a complete extraction of 19, but perhaps a coronectomy would be more suitable; might then straighten 18 back and upright again (braces). Here's a link with pictures: https://www.njcenteros.com/procedures/coronectomy/ This would also allow you to keep 18; then maybe later remove roots of 19 and consider implant at that stage. 16 would prob require extraction at some time following extraction of opposing 17

Hello! thanks for the response. If you look at the 2018 xray for this week #17 is gone. I will look into a coronectomy. I was told I would need a surgery to straighten #18 because of the bone there to remove bone..

 

[MattKW]

Not sure about that. Maybe seek ortho opinion before doing any surgery for 19 and 17.

 

[Zuri Barniv]

Have they considered orthodontically extruding #19? We do this with impacted teeth all the time.

 

[Busybee]

Do dentists and neurosurgeons ever work together? It's crazy that such a risky procedure should be carried out by anyone but the top specialists. I do think that there should be more regulation of the profession when there are so many differing opinions and dental work is potentially life changing. An MDT approach to some situations is appropriate and I don't mean just in a dental hospital.

 

[MattKW]

Just wondering how you might achieve that with the wide crown and fully formed, complex roots on this tooth, and where the anchorage would come from? How sure would one be of success compared to simpler coronectomy, and later implant.

 

[Zuri Barniv]

The point of an extrusion is to dramatically reduce the risk you speak of. You don't need a neurosurgeon for that, but you might involve one if you were removing the tooth. In the end of the day, it is up to a skilled surgeon and no amount of consultations is going to change the outcome in a meaningful way.

 

[Zuri Barniv]

Just wondering how you might achieve that with the wide crown and fully formed, complex roots on this tooth, and where the anchorage would come from? How sure would one be of success compared to simpler coronectomy, and later implant.

As I understand it, #17 is gone, you would upright #18 and use a TAD for anchorage. Worst case scenario it doesn't move, so you move on to something more invasive. Best case it is extruded even a little which would reduce risk overall the more it came out. Coronectomy is great assuming you don't develop an infection there, which would really mess things up.

 

[MattKW]

If you wanted to simply remove the 19 surgically, then yes, it might be crazy and risky. But a coronectomy wouldn't be a problem for an oral surgeon or oral maxillo-facial surgeon (not sure what you have in USA). There is no need for a neurologist. I communicate regularly with all my specialist colleagues, and they work together on complex cases; they don't all have to be in the same institution.

 

[MattKW]

Coronectomy carries about 5% risk of infection. I don't know the stats for TADs but it's got its own risks of screw fractures (putting in and taking out) plus bone damage, and it might not even work, and there's the cost.

 

[Busybee]

The point of an extrusion is to dramatically reduce the risk you speak of. You don't need a neurosurgeon for that, but you might involve one if you were removing the tooth. In the end of the day, it is up to a skilled surgeon and no amount of consultations is going to change the outcome in a meaningful way.

A skilled surgeon and the right plan. But what is the right plan if dentists have so many different approaches? It's the same as any other complex clinical procedure - a multidisciplinary approach gives move chance of a positive long term outcome. Dissent leads to creativity, but as an individual you're not likely to disagree with yourself!

 

[MattKW]

There can be a number of different approaches to all clinical matters. It doesn't mean they're all wrong, but that they carry different risks - that's what Zuri and I are discussing here. The same thing applies to a MDT, and different MDTs can have different suggestions too. For a patient, they may worry about costs, pain, success rates, aesthetics, ... if mangobanana gets some opinions from specialists, then I'm sure he/she will work it out.

 

[Zuri Barniv]

I will tell you what I tell all my patients in these situations: start with the least risky option that has the greatest chance of success and go towards riskier options if the former ones don't work.

 

[Zuri Barniv]

Coronectomy carries about 5% risk of infection. I don't know the stats for TADs but it's got its own risks of screw fractures (putting in and taking out) plus bone damage, and it might not even work, and there's the cost.

I agree it should be considered, but even a 5% risk is not trivial. Can you image if that thing gets infected and now you HAVE to extract it? I wouldn't want my hand forced like that. And the risk of nerve damage when there is an active infection there is even higher. TADs have risk, but the risk is much lower. And if something goes wrong, it will be around the TAD...very far from that nerve. The biggest risk is cost, as you say. But with a highly complex and risky situation like this, I think cost should not even be a factor. You should do the least risky thing first, even if it might not work.

 

[MattKW]

Good philosphy in general. What is the least risky option with best chance of success here? I think it's coronectomy overall.

 

[Zuri Barniv]

Good philosphy in general. What is the least risky option with best chance of success here? I think it's coronectomy overall.

You might be right, I would still explore extrusion as a first option, but that's me.