False Teeth FAQ.

Or: Be true to your teeth...

O.K., so you tried, but you just couldn't prevent the loss of a few teeth. Fixed bridges, partial dentures, full dentures, implants...
what now? What's right for you?

Q: I lost a front tooth and the gap is equal to nearly 1½ teeth. (My teeth started spacing after I gave birth to my son 31 years ago. Doctors informed me that I probably had juvenille onset peridontitis which was not detected.) I do have peridontitis which has been treated but there has been damage. I've been advised that one other front tooth needs to be removed, although it's not very loose. One dentist advised a bridge and crowns from canine to canine, while another advised against it and suggested that I need lots of surgical work done before anything can be done to restore my smile. A flipper (small removable denture) would not work for me because of the very large gap. I was wondering if there is a method whereby a removable denture could be constructed that works much like a bridge capping my other teeth from canine to canine. My bottom front teeth are also splayed and need correction. What I need to know is what would be the best and least expensive corrective procedure to restore my smile? I've been practically a hermit since it happened and in a severe depression which is worsening. Anyway, any advice would be appreciated.

A: There is almost always a removable denture prosthesis that can be made in lieu of a fixed bridge (the converse is not nearly as certain).

The logistics and sequence of the treatment must be determined. If (as most patients) you are not fond of walking around with the missing tooth in front, you will want to consider making a provisional denture prior to other treatment. There is nothing inherently different in the construction of a provisional denture from a "permanent" denture, but its intent is different: it is intended to serve its function until the other preparatory work (extractions, periodontal, and restorative) is completed, and a "permanent" prosthesis is constructed.

Given your periodontal status, attention to this gum problem is indicated. However, there are those who, due to failure of a previous periodontal course of therapy or poor periodontal prognosis, will refuse further periodontal treatment. In any case, if the prognosis of the remaining teeth is guarded, provision should be made for future tooth loss. This will usually mean construction of an acrylic base partial denture, which is well suited to the possible future addition of denture teeth as their natural counterparts are lost. We would advise extraction of those teeth that are most in danger of near-term loss prior to denture construction, in order to minimize the inconvenience of frequently parting company with your denture as it travels back and forth between your mouth and the dental laboratory as new denture teeth need to be added.

Q: I just finished the 3rd stage of dental implants. I have had many failures over the past three years. I finally have 5 stable implants.

My oral surgeon and my general dentist (the one who will be make the teeth) are at odds on what type of teeth should be made for me. My oral surgeon wants a fixed, permanent bridge, and my general dentist thinks this is a mistake and wants to make a snap on removable bridge. My oral surgeon claims that there has been much research on this that indicates I will have a better chance of success with a fixed bridge.

Can you provide me with the pros and cons of both types?

A: Firstly: This is a decision that should have been made before implant placement. Admittedly, one must be willing to change the proposed treatment mid-stream if implant failures necessitate treatment re-evaluation.

Secondly: An oral surgeon by choice limits his practice to the narrow focus of oral surgery. We may get some flak from our specialist colleagues on this, but it makes about as much sense getting restorative recommendations from an oral surgeon as having your appendix removed by a dermatologist. Your general dentist has access to the same journal articles as the surgeon. He also has (presumably) years of clinical experience in restorative and prosthetic dentistry, which the surgeon does not. General practice is also fundamentally different from most specialty areas in that it encompasses a long view of patient care, where a doctor-patient relationship develops over many years. This not only works to the benefit of quality of service, but enables the general dentist to develop a sense of continued responsibility for the outcome of treatment. A specialist is, of course, conscious of the quality of his care, but is seldom threatened by the prospect of viewing his less than perfect treatment again and again over the years. In other words, the general dentist's opinion, all other things being equal, has more validity.

Five implants may be more than are necessary to retain a removable implant-retained overdenture, and fewer than are necessary to retain a full arch fixed bridge. The relative advantages and disadvantages of implant-retained removable versus fixed bridgework are essentially the same as those of conventional tooth-borne removable and fixed bridgework. Subjectively, most patients would prefer fixed bridgework, since it more closely simulates the function of natural teeth. However, removable dentures derive much of their support from the denture bases against the gum tissue. Consequently, the magnitude of potentially destructive forces directed against the supporting abutments are reduced with removable dentures. Additionally, many overdenture attachments transmit chewing forces to the fixtures at a location further beneath the gum line than do fixed bridge abutments, further reducing stress on the implant.

To sum up: for full arch prostheses, removable dentures are more versatile, more retrievable in the event of implant failure, and potentially less likely to result in implant failure than fixed bridgework; they are somewhat less pleasing to wear due to their being perceived as a foreign body in the mouth and their slight movement during chewing.

If you have further questions about restorative dentistry, you'd do well to ask your general dentist. After all, he and you will both be living with the results for a long time.

Q: I am 42 years old and having dental problems. I have been given the option of a full upper denture or two implants with multiple root canals, posts and crowns costing approximately $13,000 with no guarantee of success. I suffer from frequent abscesses and systemic lupus. What is the best way to go?

A: We would make the case for favoring the root canal/posts/crowns/implant alternative more strongly if we were talking about the lower jaw. A full lower denture is a wretched thing to wear. A full upper denture is not nearly as much of a challenge, unless you have an overactive gagging reflex.

The statistics for maxillary (upper jaw) implants are not as favorable as those for the lower jaw. The quality of the bone and the presence of anatomical structures such as the sinuses in the upper jaw introduce complicating factors not encountered in the lower. Recent surgical advances have mitigated these disparities, but have not eliminated them. Additionally, there is controversy regarding the simultaneous use of natural teeth and implants in supporting a prosthesis. Finally, systemic disease such as lupus, combined with the medications used to treat it (e.g., corticosteroids) will depress your ability to combat infection, and will make you a less than perfect subject for surgery.

To sum up, we would give the edge to the extractions with full denture prosthesis. In the interest of being fully candid, we'll tell you that we are not the biggest boosters of implants in general. We would suggest discussing the pros and cons with your dentist, who will have a more intimate knowledge of your dental status and medical background. Certainly the prospect of getting a $13,000 case (not to mention his desire to act in your best interests) should justify his spending time with you talking about this. We would suggest you get a second opinion with another dentist if there's any doubt in your mind; you'll have to live with the consequences of your decision for a long time!

Q: My son, age 24, has had one tooth pulled. Is it better to have an implant, or a bridge? What are the pros and cons? He has had two different opinions from professionals on this. Is there something called a Maryland bridge? Thank you.

A: The use of dental implants is not as new as some would have you believe; the concept is an obvious one to any dentist who has ever needed to replace a missing tooth. Dental implants have been placed sporadically since the beginning of the last century (we're talking 1900's here...). Recent developments since 1954 in Sweden have brought about the modern endosseous implant. It has been an evolutionary (not a revolutionary) development that has increased the number of options that a dentist can offer the (non-indigent) patient, though not dramatically altering the practice of those of us practicing down in the trenches. The disproportionate attention paid to implants is a reflection of the power of economics. There is publicity everywhere about dental implants-- in the lay press, in professional journals, and in educational seminars given to dentists. Implants constitute only a very minor part of our practice.

It is true that if the teeth to either side of the missing tooth are over-filled or in bad repair, placement of a conventional fixed bridge (where the surrounding teeth are capped in order to support a false tooth) will not only replace the missing tooth but also strengthen its neighbors. But what of the situation where the neighboring teeth to be used as bridge abutments are in perfect physical condition and need no repair?

Some dentists point out that this is a terribly aggressive and invasive way to support a bridge. They will offer that by placing an implant rather than such a bridge, they have offered a more conservative approach. What we can't understand is why cutting down these neighboring teeth, even if they are in "perfect" condition, is any less conservative than slicing open the gums and pulling out a plug of bone (not to mention all the waiting for healing). We know most of our patients would rather not have surgery. The placement of a conventional fixed bridge is not sexy new technology, but it works, and has a track record that stretches back further than implants. Insurance plans also seldom pay for implants, which makes a difference in our practice, anyway...

A Maryland Bridge (so called because it was developed at the University of Maryland) was popular in the late '70's and early 80's as a conservative (there's that word again!) alternative to fixed bridges utilizing crowns or inlays as abutment attachments. It uses an etched metal wing on the lingual (inside) surface of the teeth surrounding the missing tooth, which is attached to these teeth by bonding with plastic resin. When used in appropriate areas of the mouth, they are durable, but they frequently don't look as pleasing to the eye as more conventional designs (the metal attachments sometimes do not escape notice), and they frequently loosen if they are used in unsuitable situations...

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