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    Crown versus Extraction
    jonmar2 posted:
    I need practical advice.

    I was recently advised I have a broken Wisdom Tooth. My dentist gave me the option of a gold crown or referral to a surgeon for extraction. My tooth is not impacted in any way, but does have a filling.

    Cost is not a factor in my decision - my insurance covers either at the same rate and both procedures cost about the same.

    What are the pros and cons to both procedures? I worry about infection after extraction, broken crowns, moving teeth etc.

    Please help. I'm a bit time constrained and need to make a decision.


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    _swank_ responded:
    Personally, I'd be more worried about infection from leaving the tooth in my mouth. Wisdom teeth are hard to take care of and often get cavities which is why they're often removed. So you could end up paying for a crown and then losing the tooth anyway. That's my opinion. I only ever got one wisdom tooth and it had to be removed because there was no more room.
    Zev Kaufman, DDS responded:
    Dear jonmar2:

    I am all for cost effectiveness. However, my guidelines are as follows:

    If the wisdom tooth is easily restorable (simple filling, or an easily accessible crown) and it has an antagonist (an opposing tooth), one might consider spending the effort and money and keep the tooth.

    If the wisdom tooth does not have an antagonist and/or requires extensive work (root canal, post/core, and crown), the cost is not justifiable, and it should be removed.

    The question of leaving wisdom teeth in is usually decided based on your ability to keep it clean. Most people do have difficulties in cleaning teeth that far back. Many "old timer dentists" still recommend keeping wisdom teeth just in case one looses the second molars and a bridge restration is planned. However, for the past 30 years, with the advent of implants, this has become a moot point. Implant restorations are far superior and more cost effective compared to a bridge.

    By the way... the cost of a quality crown is about 3-4 times the cost of an extraction. If you are placing a very low quality crown on the tooth, you might as well have it removed. You will have to make the same decision only a couple of years down the line if the crown is of poor quality. The better the quality of the crown and the dentist making it, the easier it is to clean and the longer it will last.

    Best of luck,
    Dr. Zev Kaufman
    jonmar2 replied to Zev Kaufman, DDS's response:
    Dr. Z,

    Thanks for the advice. After reading your post and extensive consultation with my personal dentist, a maxillofacial surgeon and my insurance company (four phone calls rendering three different answers regarding coverage!), I've decided to keep the tooth and have it crowned.

    If by chance you read this reply, my crown will be gold. I chose metal over porcelain based on malleability and what I perceive to be long term success of the crown. Is this a good idea? And, by the way, my insurance actuall covers gold at a higher rate than porcelain. I was surprised by that revelation.

    Thanks for your reply.

    markmhb replied to jonmar2's response:
    I think if you read Dr. Kaufman's response (Zev, forgive me for putting words in your mouth), you'll see that he is not a strong advocate for crowning your tooth. I'm sure your dentist is happy, because (going back to your original question of the advantage of placing a crown), the advantage is predominantly his.

    In point of fact, the retention of a wisdom tooth as a contingency for a fixed bridge to replace a second molar is an "iffy" proposition, because few wisdom teeth have the root morphology to serve well as fixed bridge abutments.

    Wisdom teeth contribute very little to the functioning of the mouth. That is not to say that they should be profligately removed (a policy position held by many oral surgeons), but it means that time, effort, and money spent on the salvage of a badly damaged wisdom tooth could be put to much better use elsewhere-- if only by your preferred charity organization.

    If you do decide to move forward with your plan to crown your wisdom tooth, you would not want a "metal over porcelain" crown, which does not exist. Perhaps you might select a "porcelain over metal" crown, which does exist, but the addition of porcelain would be wasted on a wisdom tooth, which would be invisible to all except your dentist, who will nonetheless enjoy looking at it. However, porcelain only serves to make an invisible tooth look nicer, while introducing unnecessary fragility, and requiring your dentist to reduce the height of an already short tooth, which may impact on the strength of the bond between the crown and the tooth. If you must place a crown, you may as well place a full cast metal crown. It will be sturdier.

    Hope this helps...

    Mark Bornfeld
    Brooklyn, NY
    Zev Kaufman, DDS replied to jonmar2's response:
    Dear jonmar2:

    Mark is right, I am not a big advocate of saving wisdom teeth. However, as I said before, if you can keep it clean and there is an opposing, intact tooth, you might want to consider placing a crown on the wisdom tooth. A full gold crown will be my choice in this situation.

    Best of luck,
    Dr. Zev Kaufman
    jonmar2 replied to Zev Kaufman, DDS's response:
    Thank you both for your comments; they were very helpful in helping me make my decision. I chose to have a full gold crown placed on the tooth for a couple reasons, most of which you addressed in your discussion.
    Generally, I have very good oral hygiene and have few problems with my teeth. In the case of this cracked tooth, it is still, apparently, 100% intact except for the crack. I do still have the opposing tooth and it's in good shape.
    My surgeon was willing to remove a single tooth, though he advised me against it, probably for many of the same reasons you've addressed. Here's the kicker that pushed me over to the crown. My insurance would only cover the anesthesia necessary for a removal if I had both the cracked tooth and its antagonist (I think that's the term Dr. Z used) removed. In doing so, the cost WAS NOT close to the same and the crown became a more affordable solution. I hate to admit cost as a deciding factor, but it was.
    Again, thanks for your practical advice. It's exactly what I asked for, needed and received.
    Zev Kaufman, DDS replied to jonmar2's response:
    You are very welcome!
    Glad I could help.

    Best wishes,
    Dr. Zev Kaufman
    sterlinm replied to Zev Kaufman, DDS's response:
    Hi Dr. Kaufman,

    I'm not sure if you are still active here, but I'm in a very similar situation and I thought I'd see if you had some advice. I just went in for a checkup after a couple of years as a delinquent and my new dentist said that it looks like one of my upper wisdom teeth will either need a crown or extraction. I have room for all of my wisdom teeth and it sounds like the other three are in okay shape for now. It sounds to me like if I were to have the one extracted it would involve having all 4 wisdom teeth extracted. In that scenario would you still advise against trying to save the tooth? Are there any important disadvantages to having them extracted, particularly if your mouth has room for them?

    Thanks very much,
    markmhb replied to sterlinm's response:
    Hi Michael,

    This may be an old thread, but common sense is timeless. The guidance provided above still very much applies.

    "It sounds to me like if I were to have the one extracted it would involve having all 4 wisdom teeth extracted."

    Why would it sound like that to you? Each tooth must be considered on its own circumstances. Granted, because the removal of a lower tooth often causes the corresponding upper tooth to "hyper-erupt", an upper tooth may need to be removed if the lower is extracted. However, because the lower teeth are often positioned a ?-tooth position forward of the corresponding tooth in the upper jaw, the reverse is often untrue. In other words, because the lower wisdom tooth occludes partially against the upper second molar, its removal would not be necessary simply because the upper wisdom tooth is being extracted. The removal of your other wisdom teeth may be beneficial for other reasons that cannot be assessed here, but they certainly would not need to be removed solely because one upper wisdom tooth was being extracted.

    As I see it, the only reason why extraction should be avoided would be if local or systemic health conditions made such a procedure risky. For example, if there was no access to a skilled oral surgeon in your community and the extraction was deemed to be technically beyond the skill set of your general dentist, or if you had some health problem that exposed you to systemic risk from a surgical intervention.

    I hope your characterization of yourself as a "delinquent" was not something that was offered as a critique by your dentist. Some dentists are guilty of labeling patients with pejorative terms when the doctors' and patients' respective life priorities are not aligned, and the term even sounds like something I could have heard from another dentist as a casual, off the cuff remark at one of our professional dinner meetings. I would have used a different word, so let's leave it at this: if you're not as dentally conscientious as you should be, that would actually favor the removal of the tooth rather than restoring it. A practical and pragmatic case selection would require that the doctor select a course of treatment that is most in keeping with his patient's state of self care. There is little doubt that the removal of the tooth would put your mouth into a condition that would be easier to maintain at your accustomed level of professional oversight.

    Hope this helps...

    Mark Bornfeld
    Brookyn, NY
    VictorRyoo replied to markmhb's response:
    I think, dental crowns are a better option in place of implants. These days, such crowns are available, with the help of which you will not look ugly and live your normal life without hesitation.

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