By Dr Parsa Zadeh, DDS
Early on in history, human adult teeth would last a lifetime – which was only a handful of decades. Thanks to advances in medical technology, hygiene, and sublimation of nature, this “lifetime” has been extended to the better part of a century and the masticatory “demands” of human beings have changed tremendously as well.
There are many reasons one would lose permanent teeth. Now that we live longer and eat cooked, refined and soft food, we have to take measures to prevent premature destruction and loss of our teeth. Most permanent teeth are lost due to neglect, some are lost due to wear and tear, and a small percentage are lost due to accidents. As I will explain later, sometimes for medical and /or financial reasons we decide to remove teeth that are otherwise serviceable or salvageable.
Patient neglect: Most commonly, and especially in the developing world, it is the patient’s neglect of proper oral hygiene that results in uncontrolled periodontal disease and tooth loss.
In more advanced societies, an abundance of refined sugars, unfluoridated water supply (usually by drinking filtered water) and lack of early detection and treatment of cavities result in infection and loss of teeth.
Dentist neglect: Good dental work costs money. Unfortunately, the market demands for inexpensive dental work often results in dentistry that shortens the life of the teeth it is supposed to protect because it improperly cares for the teeth and care is often cursory.
Excessive wear and tear: No matter how good our hygiene is and how good the dentistry we receive is, certain habits like chewing gum and night time grinding and clenching can breakdown the teeth to the point that they are not salvageable.
Intentional Extraction: Sometimes, due to financial and other considerations, we may choose to remove a tooth that may otherwise be repairable. There are situations that it takes several thousand dollars and weeks of waiting for tissues to heal up to save a tooth, while removing it and adding it to the bridge or partial may cost a fraction of that in time and money.
More frequently, we may choose to replace an infected or broken tooth with an implant rather than saving that tooth for a more predictable and longer lasting outcome.
In our culture, a healthy and happy lifestyle includes a complete set of good looking teeth. So no matter how and why we end up losing teeth, we need them replaced by natural-looking and functional prosthetic teeth. If you find yourself in this situation, you may feel helpless and want help to make the best decision for yourself moving forward
The following are important factors in helping you make a decision:
- Condition and configuration of remaining teeth in each arch (if any).
- Your level of tolerance for any removable appliance.
- Your medical well being and willingness to have oral surgery.
- Condition of your jaw bone.
- Your dentist’s training and ability for specific procedures.
- Your expected time frame to have the procedure completed.
- And of course, cost.
Condition and configuration of your remaining teeth
NO TEETH: Classically, if you are completely edentulous (lacking teeth), you are in market for a complete denture. A complete denture, also known as a plate, is made up of an acrylic base that sits on the gums and has a set of teeth that are processed onto it.
Even though making a full denture is one of the oldest skills taught in dental schools, it is one of the most difficult skills to master and to do well. The reason for this is that all the possible variables in terms of color, size, position and shape of teeth come into play in fabrication of a full denture. Making a good full denture is much more closer to an art than a science.
In addition, the factors responsible for retention of this device have to be taken into account. It is not surprising to find many fast paced practicing dentists shying away from this procedure due to its complicated nature and the amount of labor required to do it properly.
Advantages of a full denture:
- Relatively inexpensive
- Universally available
- Can be esthetically pleasing
- Acceptable in medically compromised patients
- Can be easily secured by implants
Disadvantages of a full denture:
- Patient must “accept” and “learn” to use it
- Not as retentive as many patients want
- Can be disfiguring when poorly done
- Covers the roof of mouth
- Does not slow resorbtion of jaw bone
Cost of Full Dentures: $1000-$3000
The good news about a bad denture is that it can easily be replaced! It is never too late to get a good denture made and most of its disadvantages may be overcome by taking advantage of the variety of implant systems.
Of course, if you are totally edentulous, with today’s advances in implant dentistry, you can have a complete set of teeth implanted in your jaw bone, There are many other options between a traditional denture and complete implant set that you may find more suitable for your situation based on several factors that will be explained shortly.
SOME TEETH: There are two scenarios to consider here. The first scenario is when you have some missing teeth and remaining teeth are in healthy, working condition. In the second scenario, you have some missing teeth and some teeth that may be salvaged with some dental work like root canals, periodontal surgeries and crowns.
This brings us to an important topic of “At what point do you decide NOT to save your own teeth?”
There is absolutely no doubt that the teeth you are born with are by far the best set you can have. That is true for every part of our body, heart, kidneys, liver, etc. However, unfortunately for us, our body parts don’t always work as long as we would like and eventually need to be removed or replaced. Unlike many of our organs and other body parts, the outcome, cost and procedure of replacing our teeth has become acceptable, practical and within reach of the masses. And for the optimistic part and futurists in all of us, other artificial and biologically compatible replacement organs are rapidly becoming a reality at the time of this writing. Still, I would highly recommend doing everything in your power to make sure that you keep what you were born with. Nothing can ever replace that.
As dentists we are trained and ingrained for trying to “save” each and every tooth possible. In a perfect world that people have unlimited resources and enjoy an otherwise a perfectly healthy body and a perfect smile. But in the “real world”, we sometimes have to make decisions based on practicality and necessity.
It cannot be understated, regardless of the final outcome, the decision to remove a tooth is a very personal decision and you must thoroughly consider the consequences:
These consequences are:
- Will you miss that tooth? In my opinion, it is not worth trying to save an infected wisdom tooth. Take it out and don’t replace it.
- What is the long term prognosis of the tooth you are saving? A general rule of thumb is to consider if the tooth has at least another five years of good functionality after it is saved.
- Can you live and function happily without it?
- If you are going to replace it, how will you do it? Get a clear idea of the method and cost of replacing a needed tooth before you decide to remove it.
As with removing or altering any body part, tooth extraction is a very personal decision. However, you want the expert opinion of your dentist to help guide you through this process. We cannot make the decision for you, but we can tell you how we would have made that decision if that exact condition existed in our own mouths!
So, if you want to know what your dentist is really thinking, ask: “Doctor, What would you do if you had this exact situation in your mouth?”. Or: “Doctor, what would have suggested if this was your (mother, sister, daughter etc)?”
2 to 10 Missing Teeth
In the above scenarios that there are number of missing teeth and number of functional teeth, traditionally a Removable Partial Denture (RPD) is used. A removable partial denture is a prosthesis replacing the missing teeth in the arch by anchoring to the remaining teeth. Traditionally, the base is made up of an alloy of Chromium and Cobalt and covered by acrylic. The anchors (clasps) are extensions of this metal base. Chromium and cobalt are used as they are highly biocompatible metals, are resistant to wear and corrosion and are extremely durable. However, the metallic bases can sometimes have an unnatural appearance that some patients find off-putting.
In recent years, other materials like Valplast have become commercially available that although it is not as rigid as the metal base; are much more esthetically acceptable.
A very inexpensive and fast version of the denture appliance can be made from acrylic base and wire clasps. This variety is often called a “flipper” due to its poor retention.
We use this flipper variety as a temporary tooth replacement, when waiting for healing of dental implants. Generally flippers are despised by patients and they cannot wait until they stop using them.
Advantages of RPDs:
- Relatively inexpensive to replace 2 to 12 teeth in an arch
- Can be made for the medically compromised patient
- Can be remade easily without much regrets
Disadvantages of RPDs:
- Can be esthetically challenging
- It is removable and therefore objectionable by many patients.
- If the fit is not maintained, the appliance can damage the anchor teeth.
Cost of flippers: $150 to $1000.
Cost of metal based partial dentures: $1200 to $3000
1 to 4 Missing Teeth If missing teeth are few and there are neighboring teeth that are very sound, in the past, the treatment of choice was a Fixed Partial Denture or a “bridge”. A bridge is an appliance that replaces missing teeth by suspending the artificial teeth between crowns on the teeth adjacent to the empty space.
Advantages of a bridge:
- Can be done in two appointments and a few days
- Permanently cemented to adjacent teeth
- Every fast paced clinic dentist loves to do them
Disadvantages of bridge:
- Involves and mandates the preparation of adjacent teeth even if they are healthy Places extra load on the abutment teeth
- Costlier than a removable prosthesis
Cost of a 3 unit bridge : $1500-$3500
With the predictability and reliability of dental implants, bridges have become by far a second choice for fixed replacement of missing teeth. There are however limited situations that implants are contraindicated and then bridges are used as an alternative.
Your level of tolerance for any removable appliance
It is not surprising that more people object to wearing a removable appliance as a mean of replacing their missing teeth than ever before. The reasons are threefold:
- We are continuously improving our standards of living by increasingly adapting our surroundings to our needs and comfort. In the process we are becoming less willing and able to adapt to the older surroundings. Driving a stick shift and cranking the window open by hand was totally acceptable 30 years ago, but many find it unnecessary and annoying these days. Many do not even know how to drive a stick shift! Similarly 30 years ago when I attended dental school, wearing removable appliances was the norm for people with multiple missing teeth, but now, these same people find it annoying and unacceptable. This is often due to the increasing comfort and general superiority of fixed appliances and the prevalence implants.
- There is a viable and predictable alternative to wearing a removable appliance that did not exist before
- There is a social stigma attached to removable teeth. Most relate the “dentures in a cup” scene to the very old and destitute. We often see this done for comedic value now in television and movies like The Simpsons.
Although most people prefer not to have a removable appliance, sometimes it is the only practical option. The majority of patients should be willing to able to adapt, especially if there are issues or compromises that may prevent them from receiving a ‘fixed’ appliance.
Your medical well being and willingness to have oral surgery
This is an issue when you are deciding whether to use dental implants to replace your missing teeth or to secure your dentures.
There are hardly any true contraindications for dental implants and we have reached a level of advancement where bio-compatibility and allergies are of minimal concern. Certain conditions; however, make their long term success risky and they are worth taking into consideration.
Generally, if you are fit enough to have an extraction, you are fit enough to get an implant placed in your mouth. Any and all the precautions we take for extraction of teeth, we must take in placing dental implants.
- Smoking slows the healing in the mouth. Depending on how much one smokes, you may consider cutting down or stopping the habit. Non-smokers have a greater and “easier” success with dental implants.
- Uncontrolled Diabetes increases the chance of infection in the mouth. I personally believe, if you have a systemic problem like uncontrolled diabetes, it is more important that you see a physician to take care of the systemic issues and then consider getting dental implants.
- Dry Mouth usually result in older people and is enhanced by many medications that are in routine use by this population. This reduced salivary flow changes the bacterial balance of the mouth and allows the predominance of the type of bacteria that cause cavities on the root surfaces (root caries).
- Root caries may appear in numbers over a short period of time, usually in less than a year in a mouth that they did not exist before. Their detection presents a very frustrating situation for both the dentist and the patient. The source of this frustration is the recurrence of these cavities right next to any fillings that are placed to fix them. They redevelop very rapidly soon after they are fixed. You should seriously discuss the merits of trying to save these teeth in these situations with your dentist before making any decisions.
Condition of your jaw bone
In the past this was the limiting factor in our ability to place implants. This is the area that has seen tremendous progress in the past few years and sets the boys apart from men in this field.
The jaw bone maintains its shape by the demand that is placed on it thru the roots of existing teeth. As soon as this demand is eliminated by extraction of the tooth, the bone starts to resorb (diminish in mass). As a rule, the longer the tooth has been missing from an area, the less bone would remain for an implant to be placed in it.
The best opportunity to prevent this loss of bone is at the time of extraction. So if you are going to extract a tooth that you know you will have an implant in its place later, make sure you get the site grafted.
Bone graft is indicated for the following reasons:
- At the time of extraction to prevent the bone mass from diminishing.
- At a stage before implant placement to develop new bone where there were not sufficient mass for implant placement.
- To create a sufficient bone mass under the maxillary sinuses for implant placement.
- At the time of implant placement to enhance the quality and quantity of bone around the implant.
Types of bone graft I have found this procedure to cause considerable angst in the patient’s mind. People are concerned about the source of this bone and possible disease transmission. There is no reason for anxiety.
- Autograft: This is the bone that is harvested from patient’s own body, usually from a different area of the mouth. Usually we take the bone from the chin or back of the jaw. After harvesting the bone, I will fix the bone with bone screws that I will remove later after the bone has healed. Autografts heal the fastest but are limited in supply.
- Allografts: This is the bone from other human beings, usually donors. All the bones we use are from acellular tissue. The bone tissue from the donor is processed so that all the cells are washed out of it and only a scaffold of bone tissue remains. Because there are no cells, there is no need for tissue typing and there is no chance of any disease transmission. You can look up the process of preparing the bone we use in the office by going to www.lifecell.com
- Xenografts: Acellular bone from other species, usually cow. We use it mostly in combination with other grafts.
- Tricalcium phosphate: This is similar to “plaster” and has no organic origin. For this to work as a bone graft, it has to be mixed with blood cells or better, the stem cells from the hip bone. I do this frequently when patients are uneasy about the use of allografts or xenografts.
Bone graft adjuncts are needed when the recipient site cannot hold the graft material by itself for the healing period. They are also called GBR for Guided Bone Regeneration. There are many different types of GBR, each having its own indication.
- Non-resorbable soft GBR: Usually made up Teflon. Needs to be removed later.
- Resorbable GBR: Usually from bovine collagen. Gets absorbed into the body.
- Titanium mesh: Used for more complex situations. They need to be fixed by bone screws and need to be retrieved later.
- A Combination of the above.
The important point to remember for the bone graft and its adjuncts is that the more deficient your jaw bone is, the more complex the grafting procedure is. This means it needs longer healing period and it will cost more. Rest assured that the materials used in dentistry have an immaculate record of safety in terms of disease transmission.
Your dentist’s training and ability for specific procedures
This is probably the most important factor in considering any dental procedure, especially for those regarding in tooth extraction and replacement of missing teeth. Many dentists are not qualified to do implants or replacement teeth, which may cause undesirable results, or may try to convince you to take treatments that you either do not need or are generally unqualified to perform.
A good dentist will always try to save the remaining teeth you have and walk you through the advantages and disadvantages of your potential treatment plan. As I stated before, all of this work is a very personal decision. Many dentists will also refer you for outside treatment, which may increase wait times and cost. It is best to find a dentist who is both highly qualified and can perform all procedures in house, without the need to visit a different number of specialists. Of course, this is again, a personal decision and one you need to make for yourself.
I hope this guide was helpful in clearing up any misconceptions or questions you had about replacing missing teeth and the process of replacement appliances and implants. There are many more things that could be said, but it is better to discuss any questions and concerns you have with your dentist.