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What options are available to replace missing teeth?…we basically have four choices when we lose a tooth:
- Do nothing
- Replace the tooth/teeth with a denture
- Replace the tooth/teeth with a fixed bridge
- Replace the tooth/teeth with an implant(s)
1. Doing Nothing
Not replacing a missing tooth is usually not the best option in the long term. I have honestly told many of my patients that you can lose one, two or three or more teeth and still be able to chew reasonably well…we simply adapt and move the food to other areas of the mouth. However in the long term teeth shift, overerupt and it can affect the entire “bite”. Also the remaining teeth can get over stressed and then they either break, become loose or begin to shift. Additionally, the bone in the area of the missing tooth begins to shrink or atrophy due to lack of use and stimulation-much like our muscles shrink when we don’t exercise.
None of this happens overnight but after several years of missing we start to see many of these things happening. Unfortunately by the time people realize it or they are told what is happening it is often “too late’ and it becomes a much bigger and more expensive problem to fix.
Sometimes we don’t have a choice, often for financial reasons. And at other times the tooth is so badly broken, decayed or infected that truly, the best treatment is to take the tooth out. Just remember to ask your dentist what the long term implications are for losing that particular tooth, and what options you will have in the future for replacing the tooth.
2. Replace The Tooth/Teeth With A Denture
Dentures are removable replacements for your natural teeth and gums. Essentially there are two categories called partial and complete (full) dentures. Partial dentures are made when a person still has some teeth in the arch, and they can replace from one to several teeth. Complete or full dentures are made when the entire arch (either upper or lower jaw) is missing all of the teeth.
Both types of dentures are made from either dental acrylic (a type of plastic) or a combination of acrylic and metal (usually a chromium cobalt alloy). There are pros and cons with each but that is too lengthy a topic to cover here…I’ll leave that for a future blog post.
Dentures are generally the poorest quality of tooth replacement. I liken them to a false or prosthetic arm….it may look like an arm but does not function like one and is a poor substitute for the real thing. Dentures are not much different. No doubt a denture is usually better than nothing at all, but they are fraught with problems.
Some of the most common problems with dentures are that:
- They tend to move in the mouth, especially while eating and/or talking
- They collect and trap food which can lead to gums problems, decay and further tooth loss
- They affect ones’ sense of taste and texture of foods-many of my patients have said that they either can no longer taste their food or have lost the enjoyment of foods because the “taste has been altered”
- They can be uncomfortable to eat with especially as they move and/or get food caught underneath
- Some people cannot tolerate them at all because they find it causes them to gag
- The additional thickness and foreignness of the denture can make it difficult to speak clearly
- The bone underneath the denture continues to atrophy and shrink-this becomes a greater problem affecting the stability and looseness of the denture the longer the teeth ahve been missing
- As the bone atrophies the denture can begin to put pressure on critical structures in the mouth such as muscle attachments and nerves, making them very uncomfortable to eat with
- Many people with denture avoid certain foods because they are just too difficult or painful to eat, such as raw foods, chewy or sticky foods and anything hard
- A person’s bite force and ability to ‘cut through foods” is decreased. Studies have shown that people with denture just don’t chew their food properly and swallow larger bits of food. Not only does this diminish one’s enjoyment of food, it also puts a greater burden on the digestive system.
I have many anecdotal stories from my patients related to the problems of dentures, but this one was told to me just last month. Although everyones experience is a little different, I think it sums up the above problems very well. This gentleman had lost about one half of his teeth over several years and his few remaining molars were now loose, tipped over and ready to fall out as well. I have paraphrased his words:
“I finally decided to come in to see you about getting some teeth. I have not been able to wear a (partial) denture for years because they have never been comfortable and they have just been a waste of money.
I really like to eat corn and my favourite is corn on the cob. But lately I’ve realized I can’t digest it and need to do something to fix my teeth. For a long time I haven’t been able to eat corn on the cob with these teeth but I was able to overcome that problem because I always used a knife to cut the corn off the cob. But a few months ago I noticed that whenever I ate corn, after I had gone to the washroom the pieces were still there totally intact! It was like I hadn’t chewed it at all. I thought…I really like corn but if I’m not chewing it and it is simply passing through me I can’t be getting much nutrition out of it. There’s no point in buying it or eating it….what a waste. And if that is what is happening with corn, what else am I not chewing properly and just passing through my body. So that’s when I decided to come and see you to find out what can I do to replace my missing teeth.”
Replace The Tooth/Teeth With A Fixed Bridge
Bridges are methods to replace teeth whereby the teeth are non removable…they are permanent. Prior to implants, bridges were the very best method of replacing a missing tooth and depending on the particular circumstances a bridge may still be the best option for a particular patient.
In the past bridges were commonly made out of a combination of a gold alloy with porcelain placed on top of the alloy. The metal is used for strength while the porcelain is placed for aesthetic reasons. In the past 10-15 years there have been huge advances in the strength of different porcelains and under certain circumstances we can also make all ceramic bridges that do not have any metal whatsoever.
A bridge requires a solid and healthy tooth to attach on either side of the empty space. The most common bridge involves placing a crown on a tooth in front of the space and a crown on the tooth in behind the space. The false tooth (pontic) is attached to the crowns on either side. Although the teeth are all joined together they are made to look like individual teeth.
Some bridges can be made that do not require placing crowns on the adjacent teeth. In those cases the bridge is bonded (glued) into place or a small inlay (filling) preparation is placed instead of a crown, to hold the false tooth in place. Although these are much more conservative methods to place a bridge they are not as strong and therefore we have to be selective where they are used.
There are several advantages to bridges compared to dentures.
- They are permanent so you do not have to remove them
- You can chew very well and efficiently with a bridge compare to a denture
- It is similar in size and shape to our natural teeth so it does not feel big like a denture
- Those people who have a strong gag reflex and cannot tolerate dentures are able to tolerate bridges as they are essentially the same size and shape as natural teeth.
Replace The Tooth/Teeth With (An) Implant(s)
What Are Dental Implants?
Today the most common implants are essentially the equivalent of an artificial root made of either titanium or zirconium. In shape they look more like a cylinder or screw, but they are all placed into the bone where the original tooth used to be. The unique properties of these two materials is that if they are placed next to bone and allowed to heal “undisturbed” then bone will grow around and next to it. The implant then become attached (osseointegrated) to your jawbone and it is very solid…much more so than your natural teeth.
With this solid implant we can attach other “parts” to it such that they can hold a denture in place or even be used to cement or screw permanent teeth into place. Although implants are more solid than natural teeth, it is still critically important to treatment plan, design and engineer all the steps with dental implants. That includes determining if there is adequate bone volume, where and how many implants are needed and where and what type of teeth will be placed for proper function, health, esthetics and long term success.
Dental implants can be used to replace a single tooth, several teeth or an entire arch of teeth. Todays “modern day” implants have been around since the 1960’s, although there have been many changes, improvements and developments since they first became available. There is no doubt in my mind that, in most cases, a dental implant is the very best method of replacing missing teeth. Implants provide the next best thing compare to our natural teeth. The long term success rate of implants and the (much lower) rate of failure and complications of dental implants compared to traditional bridges and dentures is far greater especially in the long term.
However, the most important step for long term success is to begin with a proper diagnosis and treatment plan that will ensure long term success. I have been placing and restoring implants for 25 years as of today and I still see many of my first patients still functioning very well with their implants and teeth. I have also had other patients come to see me as their dentists have retired and some of those patients had implants place 30-37 years ago….also still functioning perfectly well.
Second is to find an implant dentist who can confidently provide you with the treatment both prosthetically and surgically. In some cases the same dentist may be able to provide both phases of treatment but it is also not uncommon for patients to see one dentist for the surgical phase and another dentist for the prosthetic (teeth) phase.
Dental implants can be a big decision for many people. I tell my patients to take their time, consider their options, ask questions and certainly ask the dentist(s) to share similar cases they have done in the past.
One word of caution regarding dental implants.
Although dental implants have been around for many years the number of methods of approaching and treating a given situation is much greater for dental implants than traditional bridges or dentures. As the level of training and education among implant dentists improves this will likely become less, but even today I see a wide variation of professional opinions, experience levels and methods of approach. In some cases two different approaches can be equally good, but that is not always the case. I have been told by some patients that a previous dentist said they didn’t have enough bone when in my mind (and hands) there was more than enough bone to place an implant. I have been told by patients who do not have adequate bone that they have no other option besides a denture, yet there were several possibilities to build up and increase the volume of bone and to subsequently place implants. I have also had patients opt for a treatment involving fewer implants (probably because it was less expensive) only to find out that it was “under engineered” and the implants and teeth begin to fail in just a few years. I have also had patients come in who have spent a considerable amount of money, only to have things fail almost immediately and be told that “there is no guarantee.”
If you have any doubt as to what is being treatment planned, what the success is expected to be, what is or isn’t “guaranteed”….go for a second opinion. I tell my patients deciding to have dental implants is similar to making any big decision or purchase….we often check out a few options before making a final decision. I never feel “ruffled” if a patient tells me they want a second opinion before making a final decision…in fact I encourage it.