PREVENTING PERIODONTAL DEFECTS AFTER THE EXTRACTIONS OF THIRD MOLARS
The article in the September issue of JADA regarding Periodontal Therapy as a preventive measure for Third Molar sites was very interesting on several fronts. First and foremost is prevention. We can predict early on with a panoramic scan the expected arch length concerns and pathology concerns there may be with third molar (wisdom) teeth. Early treatment, if appropriate, essentially eliminates the pathological concerns — eliminating the cause preventatively before it occurs — and minimizes the risk with treatment. Prevention is the key!
Certainly, there are many patients who, for many different reasons, so not get treatment early and then present with third molar pathology including periodontal concerns on the second molar teeth. Over the years we have tried many different methods to address this including bone grafting, PRP, PRGF, comprehensive debridement, tissue revision, etc. For the most part, because of the nature of the tissue flap, the adjacent raphae, the need for healing of the third molar site (concerns with bone fill, etc), individual patient risks, and the obvious concerns with the presence of biofilms and microflora; trying to localize one or two factors in the success of a technique is not possible.
One telling sign, as we are familiar with generalized periodontal pathology, is the angulation of the defect on the second molar tooth. if the radiolucent bone loss on the second molar shows an angular defect extending down the root the prognosis for healing with a defect is reduced. Stated differently: if bone loss associated with the wisdom tooth shows on the radiograph angling coronally as it approaches a second molar root we might expect that there is some osseous remnant along the root which will guide bone fill. Conversely, if the bone loss angles apically on the distal of the second molar (angular defect) it is likely that there is an existing biofilm on the second molar root and that the bone adhesion and bone fill will be impeded resulting in a periodontal defect.
How we handle both of these cases surgically is important. Debridement of the follicular tissues and excising epithelial ingrowth is basic. Curettage and even root planing is considered when the clinical picture dictates. Oral and maxillofacial surgeons are very aware and concerned about these findings and there is an expectation that we would address these concerns at the time of extraction. What I have found is that the results with grafting, etching, use of regenerative materials, and use of blood products such as PRP and PRGF do not make a difference in healing for most patients compared to debridement and curettage alone. My approach is to clean and debride the sites thoroughly, close to give the best chance for bone fill for the extraction (third molar) site as well as the adjacent tooth, and allow for natural healing. We would then consider periodontal treatment after a period of healing. At that time we now have bone fill which is stable, not inflamed, and well vascularized. We would also expect to have healed soft tissues which can be otherwise revised for proper approach and coverage after treatment.
Again, each case has its unique issues, concerns, and challenges so a treatment plan has to consider all of the factors. I strongly urge early evaluation of third molar teeth — usually mid-teen years — and treatment if appropriate.
If you have questions, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 to learn more.
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