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On using a Maryland Bridge as a temporary restoration before dental implants

Posted on March 7, 2016 by David A. Hall.

Greetings Dr. Hall,

My 12-year-old daughter is genetically missing #10, the maxillary left permanent lateral incisor. We had orthodontic treatment done to move the teeth far enough apart to put in a replacement tooth with an implant. That was completed in December. She now has a permanent wire bonded to the backs of the top 3 center teeth.

Since she is too young for a dental implant right now, we opted to go for a Maryland bridge at the recommendation of her Orthodonist because we did not want to have her deal with an upper Hawley through her teen years. Two weeks ago (after taking impressions and slightly preparing teeth #9 & #11 about a month ago), our family dentist put in her Maryland Bridge. There was no metal on it and she cemented the two non-metal wings to the adjacent teeth. The next day we got new impressions for a new retainer and then the next morning, the Maryland Bridge fell out. She ordered a different type of cement and yesterday evening the same bridge was replaced; this morning while eating a waffle the bridge fell out again.

Now, the Orthodontist and Dentist want to make her a new Maryland Bridge with metal wings instead. Here are my concerns/ questions in which I am looking for an expert second opinion:
1. Will the metal wings on the bridge allow it to affix better to her teeth, lasting at least 5-6 years until we can get the implant?
2. Will there be damage to her permanent teeth (#9 & #11) when the Maryland Bridge is put on AND later taken off? I would like to avoid her needing unnecessary dental work on #9 & #11.
3. Cosmetically, will the metal wings make more of a difference than when they were porcelain? Since this is in the very front of her smile, it is so important that the blend is as close to perfect as can be. I am concerned that irreparable damage could occur on #9 & #11 (not to mention the self esteem of a tween girl at risk here due to this cosmetic, yet genetic flub.) Any advice and opinions are appreciated.

We are going back to the dentist next week for new impressions and for a new Maryland bridge with metal wings to be made (which I am not paying any additional money for.) Also, is there a price difference generally in the bridge that is all porcelain versus one with metal wings? Just curious.

Thank you for taking the time to read this, it is TRULY appreciated. I just want to do what is best for now and especially for her future dental needs.
– Makisha from Arizona

(see Dr. Hall’s response below)

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Makisha,
I’m sure your dentist is well-intentioned, but she does not appear to be an expert in cosmetic dental bonding. And I would not let her do a metal-backed Maryland bridge, because I believe the same thing will happen, and I will explain why. There is a much easier, less invasive way to handle this.

Maryland bridges can work well, but it’s not just a simple matter of making space for the wings and then bonding it on. There has to be some preparation done, and in that preparation there has to be what is called resistance form created in the teeth to which the bridge is bonded. There have to be some grooves or something placed to keep the bridge locked onto the teeth – you can’t rely on just the bonding to do it. So when you made reference to “slightly preparing” the adjacent teeth, that spelled trouble. The number one reason that Maryland bridges come off is inadequate preparation.

Here’s a picture of a Maryland bridge preparation front tooth with a groove similar to the type of groove that would help this Maryland bridge stay in place. This is deeper than would probably be required here, but you get the idea.

So your dentist did this “slight preparation,” and the bridge came off. She theorizes it must be the cement – let’s try a stronger cement. Nope, comes off again. Now she theorizes it must be the zirconia – if we switch to metal, it will stay on. No, it won’t work, because the problem isn’t in the materials, it’s in the design.

Now she could go back and do the proper grooves or whatever is required to get the bridge to stay on, but then it makes no sense to do a dental implant later. The main reason for doing a dental implant is to avoid having to prepare the adjacent teeth. Once they’re prepared, you may as well stick with the bridge.

A flipper partial replacing a single lateral incisor

The easy solution here is to do what we call a flipper partial. It’s just a false tooth affixed to a small plastic plate that fits behind her teeth and snaps on with metal clips in the back. In some cases the clips aren’t even necessary. But even when clips are used, people can’t see them. I’ve seen these hold up for many years and look extremely natural on very attractive women. A Maryland bridge isn’t an appropriate temporary restoration because the teeth have to be prepared. And if the preparation is adequate enough to hold the bridge in, it will later need to be filled in. It’s against my sensibilities to permanently prepare teeth for a temporary restoration.

So, to answer your questions:
1. Will the metal wings allow the bridge to affix better to her teeth?
No – no way. In fact, I wouldn’t be surprised to hear that the dentist has more trouble bonding the metal on than the zirconia metal-free version. Metal is harder for most dentists to bond.
2. Will there be damage to the teeth?
Yes. There already has been some damage by the “slight preparation” and there will be more damage if your dentist keeps at this, especially if she finally gets it right and prepares the teeth enough so that the bridge will stay on.
3. Is the metal in the bridge a cosmetic problem?
Yes. The metal will darken the adjacent teeth. This is why dentists are moving toward metal-free Maryland bridges.

I’m guessing that your current dentist should have no problem making a flipper partial that will work for your daughter. If you run into any trouble, get back with me and I’ll refer you to someone who can do this right.

– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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Can you bond a Maryland Bridge to porcelain crowns?

Posted on January 18, 2016 by David A. Hall.

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Dr. Hall,
Can you place a Maryland bridge between 2 teeth that are porcelain crowns on implants?
On my upper right, I’ve been missing my first molar and my first premolar. There was another tooth between them, but that’s going to have to be extracted. Can my dentist just put a Maryland bridge in there and attach it to the teeth on implants on either side?
Thanks

Ed G

Ed,
The simple answer is that yes, you can attach a Maryland bridge to existing porcelain crowns, but it’s very tricky and questionable whether it would hold up over time.

Diagram of a Maryland bridge

Many dentists have problems with Maryland bridges, resulting in a short lifespan for the bridge. They seem really simple to place—grind the adjacent teeth a little to make space for the metal framework, and then just bond it on. But it’s not quite that simple. There should be certain grooves placed in the preparation to resist the forces that will occur. Otherwise it is very easy to dislodge a Maryland bridge.

And you have the added complication of having porcelain crowns on the adjacent teeth. The ideal is to bond the metal wings of the Maryland bridge to enamel. That gives the strongest bond. Bonding the bridge to porcelain is inherently weaker, even if it’s done right. And very few dentists know how to bond to porcelain.

Then there is the additional complication of having to prepare the teeth with the porcelain crowns so that they have the proper grooves, with retention and resistance form that will help keep the bridge from coming loose. Placing proper grooves could cause the groove preparations to go through the porcelain entirely and reach the underlying metal. Now, instead of bonding to porcelain, the dentist needs to bond to metal, which is more difficult still.

So yes, it can be done. But it’s a high-risk, difficult procedure.

The ideal would be if the dentist would anticipate this possibility back when the original implants were placed. Knowing there is one natural tooth left between the implants, the dentist should be anticipating that at some point in the future the patient could lose that tooth. Then the implants for the missing teeth should be placed so that the abutments end up parallel and then use a screw-retained crown. When the tooth in between is lost, the dentist would simply unscrew the adjacent crowns and replace them with a bridge.

Another solution would be to place a third implant in the missing space, assuming there is enough space in the bone to accommodate a third implant.
– Dr. Hall

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Three keys for patients to avoid dental implant failure

Posted on November 12, 2015 by David A. Hall.

Dr. Hall,
In your opinion is a CT scan necessary to have before placing a dental implant?
The tooth in question is a front upper tooth. My preference is not to have this scan because I have had many x-rays in the past both dental and non-dental.
Maybe you might have an opinion on my second question.
One of the dentists I have shortlisted uses implants from a company called Southern Venturi. My concern is that they are not widely used which could be problem in the future if a part was needed or if another dentist had to make some adjustment.
Thanks and regards,
Tim from Ireland
(See Dr. Hall’s answer below.)

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Tim,
You have some good questions, and have touched on two of the subjects that are critical to avoiding dental implant failure. I will answer those, and add a third criterion you didn’t address.

On the first subject, I would do the CT scan. I will tell you that a lot of dentists will place an implant without a CT scan, and it isn’t hard to find them. But there are a lot of implants placed to replace front teeth where the root form pokes through to the nasal sinus. Or the dentist will try to avoid that by using a short implant, which isn’t sturdy enough to hold up long term. So I would do the CT scan. There are some x-rays you could cut out, but I wouldn’t cut out this one. Placing an implant is a 3-dimensional activity and the dentist needs that 3-dimensional CT scan in order to assess if there is enough bone, in both depth and thickness, to accommodate the implant without poking through somewhere it’s not supposed to.

On the second matter, as far as the brand of implant fixture, the problem you want to be concerned about isn’t so much finding a replacement part or making an adjustment later–you should be most concerned about the quality control of the manufacture. I’m not sure about the quality of Southern Venturi implants. I interview many top dentists about their dental implants treatment and I’ve never interviewed a dentist who has used that brand, so I’m leery. These fixtures need to be made to very exacting standards, which is required to avoid dental implant failure. This is a big issue with implant dentists. A dentist can save a lot of money by going to cheaper manufacturers, of which there are many, but they sacrifice that precise fit that is required for long-term success.

Excellent implant dentists are very fussy about the brand of implant fixtures they use. The top two manufacturers are Straumann and Nobel Biocare. Also excellent would be 3i, BioHorizons, Zimmer, and Astrotech. Some dentists add Bicon to this list, but that company is controversial with some top implant dentists who question their long-term success rate. I would not go to an implant dentist who uses a cheaper implant fixture.

You have to be very careful with implants. This is the number one field for dental malpractice lawyers in the United States, and I have no reason to believe that the situation is any better in Europe. Since dental implantology is not an officially recognized specialty, a dentist can get into it here in the states without any specialized training. If you want to be really certain of your dentist, look for some credential (fellowship, diplomate status, or accreditation) from either the International Congress of Oral Implantologists or the American Board of Oral Implantology. (While these organizations don’t have many members in Ireland, both of them have some.) This is a third key to avoiding dental implant failure. Otherwise, you can walk out of the office very happy with your dental implant but then five years later be looking for a dentist who can put you back together because the implant came loose and the surgical site needs to be rebuilt with bone grafting. Or you could have any of a host of other problems with them. I should add that many quality implant dentists do not have one of these credentials, but if they do have one, it is a reassurance that you are in good hands.

I hope this is helpful.
Dr. Hall

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Is diabetes a contra-indication for dental implants?

Posted on September 23, 2013 by David A. Hall.

Is Type 1 diabetes a contra-indication for dental implants? If not, what special procedures should be taken when implanting in a diabetic?
– Mel from Maryland

Mel,
Type 1 diabetes is not a contra-indication for dental implants, but it is a significant risk factor.

With diabetes, it’s not so much special procedures that are needed as much as careful diagnostic work, assessing other possible risk factors, and an extra level of care throughout the placement and restoration of the implants. If I had type 1 diabetes, I would be sure to go to a dentist with well-documented expertise in dental implants. I would go to the website of the International Congress of Oral Implantologists and look for someone in your area with diplomate status, or the same status from the American Board of Oral Implantology, which is the credentialing arm of the American Academy of Implant Dentistry.

With this caveat: If that refers you to a surgeon, I would make sure that no implants are placed unless there is close coordination with the restorative dentist. Some surgeons will place the implants, collect the fee, and then you see the restorative dentist and discover that they aren’t in the location that the restorative dentist needs for the restorative treatment plan and end up with a dental implant horror story.
– Dr. Hall

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A case of implant dentistry incompetence from the U.K.

Posted on March 25, 2013 by David A. Hall.

Dr. Hall,
I had implants fitted and the crown came loose. I went back to the dentist and he x-rayed my mouth and reassured me that the implants looked fine and that it was just a case of cementing the crown back in place. When he tried to remove the loose crown it would not come away and he had to use a special tool, when it came away the implant came with it ! is it possible that he pulled it out accidentally or would an implant not succumb to force?
– Ann Marie from the U.K.

Ann Marie,
Clearly your crown was not loose – it was the implant that was loose all the time. A loose crown is so easy to remove that it usually falls off of its own accord – it would never require any kind of special tool. And I’m sitting here trying to imagine the gross incompetence of the dentist not being able to figure out that the crown was not loose, when he was not able to remove it. Now I realize that standards of health care in the UK are not very high, but even with that, I’m having trouble reconciling this that happened to you with incompetence. It kind of seems like the dentist wanted to go through the motions of recementing the crown to cover up that the implant was loose. A loose dental implant is serious. A loose crown is easy to fix.

A loose dental implant can happen for several reasons. You didn’t tell me the time frame of when this came loose, but if it is right after the crown is placed on it could be an indication that the crown was placed prematurely – before osseointegration was complete. Or it could be that the stress on the crown was too much for the situation, that the implant was not substantial enough to take the stress, or that the quality or amount of bone support of the implant was inadequate.

It’s also possible that the implant became infected. However, that would probably have been associated with pain, so I’m going to put that further down on the list of possibilities.

Fixing this is not a simple matter. It’s more complicated than just replacing the implant. The bone will have to be filled in again – the bone that was removed before the implant was placed. It’s possible that more bone will have to be grafted in because what was there may not have been adequate in the first place, and with what has happened in the loss of the implant, there is likely to be some shrinkage. And then, of course, you need to find someone that will do this right. I wouldn’t go back to the original dentist – no way.

If you were in the United States, I would advise you to demand that this dentist pay whatever it costs you to fix this right. You would have excellent legal leverage. In the UK, however, you have different standards of care and a different system, so I don’t know what to advise you about that.

– Dr. Hall

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Should I change dentists in the middle of my dental implant procedure?

Posted on October 3, 2012 by David A. Hall.

Good Morning Dr. Hall,
I recently visited my local Dentist to have a price quoted to repair a cracked #5 tooth (upper right first premolar), while at the same time, have the #7 tooth in front redone (upper right lateral incisor), which had been ground down and “capped” back in 1978. For the #5 tooth I was quoted a cost to me, the patient, of $4,736.00 which includes the extraction of the #5 tooth, the bone graft, to provide me with a Lava Crown and one custom implant abutment. This cost also covers the Implant Specialist and absorbs additional misc costs passed onto me, the patient as well.

For the #7 tooth I was quoted a cost to me of $4,736.00 also, which includes the same breakdown as above. I agreed to the price and the procedure began with the extraction of both my #5 and #7 teeth, including bone grafts completed on both teeth, immediately following with the installation of a Maryland Bridge to stay in place for a period of 3 months while both surgery sights heal. Once they have both healed properly,the Lava Crowns and Implants will be installed which will complete the procedure.

However, since I’ve had the Maryland Bridge installed 3 weeks ago, I’ve had to have it replaced 3 times and wonder if that’s unusual. If not, I would appreciate knowing if the reason is due to the fact that a neighborhood Dental Office, practicing General Dentistry did the work instead of a Cosmetic Dentist? If so, at this point, would you recommend that I find a Cosmetic Dentist to complete the procedure on both teeth, picking up where the General Dentist’s Office left off? Or would you recommend that I stick with the General Dentist and trust that aside from their not being able to perfect the Marilyn Bridge on the #5 and 7# teeth and keep one in my mouth for more than just a few days at a time without it breaking apart, that they are capable of completing the work and providing me with the professional results that a price tag totaling $9,472.00 should buy? I appreciate and thank you in advance for the time and effort(s) you put into providing me with accurate answers to the questions I’ve asked herein. My email address is: Hollywoodnights@cox.net and I look forward to hearing from you soon Dr. Hall.

– Holly from Arizona

Holly,

Yes, I would agree that the inability of your dentist to keep this Maryland bridge in place is troubling. And it would tend to indicate a lack of training or experience in dealing with esthetic dentistry technology. If I were in your shoes, I would switch dentists.

A Maryland bridge is made of a false tooth or teeth suspended between two metal wings. The wings are etched, and the backs of the adjacent teeth are etched, and then a bonding composite is sandwiched between the wings and the backs of the teeth. If it comes off prematurely, there is a flaw either in the design or the technique or both. The flaw needs to be fixed and then the metal needs to be re-etched by the laboratory for it to re-adhere. I’m guessing that your dentist doesn’t know that, and also may be clueless about the flaw that caused the de-bonding in the first place.

And not only are the esthetics of your case very important, but implant dentistry is not for beginners either. If your dentist had much experience replacing anterior teeth with dental implants, he or she would have settled on a reliable temporary technique. But no, it appears that he or she is in unfamiliar territory – a second troubling aspect to your case.

It is an ethical obligation of all dentists to cooperate any time you want to change dentists. So when you tell your dentist you want to switch, he or she should provide the new dentist with any information needed to properly complete the procedure. And since you are at a good stopping place in the procedure. there shouldn’t be any extra costs for anything having to be re-done. Except possibly for the cost of the temporary tooth. If the Maryland Bridge technique isn’t one that appeals to your new dentist, he or she may want to create a new temporary. Most implant dentists would probably lean toward a dental flipper as a temporary tooth replacement in this situation.

Dr. Hall

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Should I go to Clear Choice or Costa Rica for my dental implants?

Posted on April 12, 2012 by David A. Hall.

Your website only discusses Clear Choice as a provider of the all-on-4 implant procedures. I went in for a 3d x-ray and initial eval at both Clear Choice (CC) and EON. My experience with CC was consistent with the experiences of others reflected on your website. EON seemed much better. In particular, the head of the EON clinic spoke with me. Apparently he used to be associated or partnered with CC. He stated that he left CC because he did not like the practice of abandoning the patients once they had the procedure done. Also according the the “evaluation done at CC and reported to me by the sales rep, I was a fine candidate for the procedure. The dentist from EON referred to the x-ray and mentioned several consideration that needed to be evaluated. Ultimately he stated that they could make the necessary modifications to allow insertion of the implants without bone grafting. If any of this seems odd or false, please let me know. I figured you might benefit from my description of the initial meetings with the 2 local competitors in Chicago area. Thank you. Mike Burke My next step, in addition to scouring the internet for justification and knowledge is to consider going out of the country to have the implants put in. Costa Rica?

Mike from Chicago

Mike,
I don’t understand. You are unhappy with the idea that you would go to Clear Choice and get dental implants and they wouldn’t have any follow-up. And for THAT you are going to Costa Rica? What kind of follow-up do you think they have in Costa Rica? Do you think THEY will call you for a checkup and a cleaning?

Having dental implants placed, even in the United States, is a risky procedure. We are seeing so much malpractice in this area. Dentists are getting into it without adequate training, and the standards of care are not well established because it isn’t a recognized specialty and is fairly unregulated.

But take the worst dentists you have in the United States, and remove ALL quality control standards that even they have, and that’s what you’ll have when you go to Costa Rica. If you are a brave soul, you could try getting crowns or bridgework done in Costa Rica, because you could always have those re-done if something goes wrong. But when something goes wrong with implant dentistry, you could end up a dental cripple, maybe with practically no jawbone. They could accidentally place implants in your nerve canal, in your nasal sinuses, they could perforate the bone. Infection could set in. The implants could be too short or too thin. They could be placed under load prematurely. They could come loose. If they place cheap fixtures, they could lack precise tolerances, which would leave openings for infection and coming loose. The fixtures could corrode. You could get peri-implantitis. There are so many things that could go wrong with dental implants. At least in the United States you might have some legal recourse if things go bad.

I am not a fan of Clear Choice. As you were told, they do not have any follow-up contact with you. We have numerous reports of high-pressure sales tactics. And the all-on-4 procedure has some risks – if anything goes wrong later with any one of the four implants they place, the entire case will have to be re-done. But you are far better off having this done by Clear Choice than going down to Costa Rica. If you want the best care, my recommendation would be to find a solo practitioner with expertise in dental implants. Look for credentials from either the International Congress of Oral Implantologists or from the American Academy of Implant Dentistry.

There are other dentists who do the all-on-4 procedure in the Chicago area. Dr. Anthony LaVacca in Naperville is one. He is a board-certified prosthodontist and is also implant surgery trained. Another option could be to get a second opinion from Dr. William Cohen in Glenview, who used to be my dentist when I lived in Iowa.

But please, please, don’t go down to Costa Rica for dental implants, not if your quality of life is important to you.

Dr. Hall

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A dentist is ethically obligated to give you all your options

Posted on April 10, 2012 by David A. Hall.

When I was a child I was hit in the mouth twice, once from falling out of a wooden school swing and the other time from throwing a croquet ball up in the air and catching it with my front tooth. Needless to say the older I’ve gotten the more yellow brown it has become. My dentist told me I would have to get an implant because there was no root but yet I still have the VERY UGLY BROWN TOOTH.

I also have several back teeth that need filings and at least 2 that need to be capped. I don’t have a lot of money to be putting into just one tooth when I have several others that need to be fixed, although the one that gives me an UGLY SMILE is the one everyone can see. PLEASE HELP ME.

Thank You so very much for your time.
Sincerely, THE GIRL WITH THE UGLY BROWN TOOTH
Danielle in Tennessee

Danielle,
I would switch dentists, and I will explain why.

One of these two traumatic incidents with your front tooth jarred it enough to sever the nerve and blood supply that go to the tooth. This would cause the tissue inside it to die, which would then cause it to become infected. It’s possible that if this tooth had received a root canal treatment at that time, it could have prevented the root of the tooth from being eaten away, but it’s also possible that would have happened anyway, as a side effect of the traumatic injury. The process is called root resorption, and it can happen because of an untreated infected tooth, or because of traumatic injury to the tooth.

But now that the tooth has no root left, you can’t save it.

There are three basic ways, however, to replace a missing tooth, and your dentist is negligent in only presenting one of them to you. He or she has an ethical obligation to give you all the options that would work. And while the implant option is probably the best choice for you, it is also the most expensive. Did you tell your dentist that this was too expensive for you? If you did, and you still didn’t get any options given to you, then it shows not only negligence but a lack of character on the part of your dentist.

A dental bridge is the traditional way to replace a single missing tooth. A bridge requires that the two adjacent teeth be covered with crowns (you may know them as caps), and then a false tooth is suspended between them. This is a little less expensive than an implant.

Another option is to use a removable partial denture that clips onto your other teeth and has a false tooth on it. While less comfortable than either a bridge or an implant, it is a fraction of the cost of a bridge. A flipper partial is the simplest way to do this, and it can cost as little as a couple of hundred dollars.

Find a dentist who is willing to give you all your options and who will work with you to keep the costs down. I don’t know everything that went on in your visit with your dentist, but just from the information that I have it doesn’t appear that you should trust this dentist.
– Dr. Hall

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