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Saving your tooth looks like a no-brainer to me

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Dr. Hall
I have to have either a root canal or implant in the first molar on the left side, bottom. There is no molar behind it, and I am wondering if there is a “snap on” smile version that would be less expensive, invasive and will allow me to cover the empty space, should I decide to have the tooth pulled?
– Beth from Washington

Beth,
Having the tooth pulled and replaced with a Snap-On Smile would be the worst of several options for treating your infected tooth.

Let me go through your options and their pros and cons.

You’re telling me that there is no molar behind your first molar. So you’ve already lost your second molar. Losing your first molar would leave you with no molars on your left side. I guess if you’re planning on going on a soft or liquid diet you won’t need to chew, but you really need something there. A Snap-On Smile is a temporary tooth replacement solution designed to help you, say, get through a job interview or a social function and look like you have teeth. It isn’t a functional replacement for molars. It isn’t very durable and isn’t all that cheap, either. The least expensive functional tooth replacement would be a removable partial denture.

But any type of appliance you put in your mouth that is removable and designed to be a functional tooth replacement is going to be much more stable if you have teeth in the back to anchor it. Imagine having a table that has legs only in the middle and on one of the ends, as I have pictured below. This is called a cantilever and isn’t very stable.
An unstable table with legs in the middle and on one end
This is like the situation you are creating in your mouth when you lose these back teeth. When you try to attach a tooth appliance onto the front teeth and expect it to replace back teeth, it’s not very stable. In addition, it creates a twisting force on the teeth that are supporting it, which can lead to the early loss of those teeth. There are partial dentures that are designed to absorb the stress with the soft tissue on your ridge, but they would require clasping other teeth, too, probably going on to the other side of your mouth.

The root canal treatment makes the most sense because that saves your own natural tooth. Being a molar, the tooth would likely need a crown also. But there are people who argue that a dental implant is a very predictable solution also. The root canal and the crown would be less expensive, though. To me, it’s a no-brainer to save your tooth.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

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.

Can I trust Comfort Dental?

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Dr. Hall,
I’ve had a bridge across my upper front, replacing all my front incisor teeth and anchored by the two canine teeth. About a year ago, the anchor teeth were so loose that they were extracted. I was going to Comfort Dental and after they did the extractions they suggested that I get a partial to replace those teeth plus one upper molar that is also missing. So I did that last year, but I’m finding the partial to be extremely uncomfortable and I need something different.

I asked Comfort Dental what I should do. They said they could replace my upper teeth using implants. They would use mini implants to keep the expense down for me, and they have told me it would last for ten years. I’m also missing three teeth on the lower left, and they would replace those with a flexible partial.

Because of my unhappiness with the partial they made, I became unsure that I could trust them, so I decided to get a second opinion from another local dentist. They came up with a completely different plan, which has left me a little confused, so I was wondering if you could help me. This other dentist said he wanted to do a bridge replacing the missing upper molar, since the teeth on either side of the missing one are broken down and would need crowns anyway. Then he wants to replace the two canine teeth with implants and put a bridge on them replacing all my front teeth. He said they’d be regular implants, so more expensive than what Comfort Dental was going to do for me. He said that as an option he could put a third implant in the middle of the bridge. The whole plan is considerably more expensive

I don’t have a lot of money, so I’m tempted to do with the cheaper option that Comfort Dental gave me. But after the experience with the partial, I’m not sure I can trust them.

Any advice?
Jim B.

Jim,
Yes, I can help you out with this.
First, a comment about Comfort Dental. Comfort Dental is a corporate dental clinic with about 150 locations throughout the Midwest, Southwest, and Northwest. It isn’t the type of place I would go for quality care. The corporate model of dental practice is designed to maximize profit. While many patients find them convenient and inexpensive, they tend to be attractive to dentists just out of school who are trying to get some experience before launching out on their own, so they have a lot of turnover. You are more likely to get quality care from a dentist/owner practice where the dentist is trying to establish long-term relationships with patients.

Now about the treatment plan. Mini implants are not designed to support individual teeth–they are too weak. They are cheap to place, but they are indicated primarily to help stabilize a complete denture. Giving your implants a lifespan of ten years may be generous, but even if they last the full ten years before failing, the failure of a dental implant is a serious event. What do you do after it fails? You can’t just place another mini implant because the reason the implant becomes loose is that it looses its bone support. So you have to have new bone grafted in before replacing the implant. No, you need something more solid.

The other dentist is suggesting a bridge for your missing molar. This makes sense because it sounds like you need crowns on the teeth adjacent to the missing tooth anyway. Adding a false tooth suspended between those crowns would add only about $1000 to the cost, much more practical than placing an implant with a crown on it, which could easily cost three times that.

Then about your front teeth.

Replacing four missing front teeth is a tricky proposition. You said you had a bridge replacing these teeth, but didn’t say how long that bridge had been present. I would be surprised to learn that it had lasted very many years, because of the high stress that would be on the anchor teeth (dentists would call these the abutment teeth). Let me share with you some dental bridge engineering principles. Here is a diagram of a dental arch.

dental bridge

Let’s imagine that the first premolar on the left side of the diagram is missing and we’re going to replace it with a dental bridge. I’ve drawn a line between the proposed abutment teeth. You’ll notice that the replacement tooth is going to be suspended directly between the abutment teeth. This is a favorable stress situation. There aren’t going to be serious twisting forces on these abutment teeth.

Here is another diagram of the same dental arch, but we’re going to imagine that we need to replace all four incisors.

cantilever dental bridge

Imagine now when we put stress on the incisal edges of the very front teeth. That will produce a twisting force on the abutment teeth.

This is what you had with the bridge that you lost. It’s not surprising that you ended up losing both abutment teeth–fairly predictable, in fact.

Now implants placed in the positions of these canine teeth could be more sturdy than the original natural teeth, still, trying to support all those teeth with the two implants in the positions of the canines is risky, in my opinion. Placing a third implant somewhere close to the middle of the bridge would completely eliminate any twisting effect and would greatly increase the stability of the restoration. It could well last you for the rest of your life.

My opinion. I hope this is helpful.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

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.

Some dental bridge engineering principles, and why this planned bridge will fail

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Dr. Hall,
I had my upper 6 front teeth pulled due to periodontal disease. I was going to have 4 implants with two pontics, but asked for something less expensive. So we are talking about doing a permanent bridge. I have read about the Maryland Bridge and feel now that maybe the separate implants with two pontics would be better? They have charged me the same price so my question is …would 4 implants and two pontics be better?
– Jill from Pennsylvania
(Note from Dr. Hall – a pontic is the false tooth part of a dental bridge.)

Jill,
I can’t really prescribe anything specific for your case without seeing you, but I can be some help here by giving you some guidance from basic principles of bridges and restorative dentistry.

If you are accurately telling me what your dentist is telling you, then something is very wrong here. A permanent dental bridge replacing six missing upper front teeth on any patient with significant gum disease would be a disaster waiting to happen. It’s not going to last, and in the end will be by far the most expensive option. Other options would be far better in multiple ways. And I’ll explain why. I’m going to explain this in some detail here for you and then use this explanation as a blog post that will hopefully help others with similar questions.

Here is a diagram of your upper arch:

upper-arch

So you are saying that you have had the front teeth extracted, which would be teeth numbers 6 through 11.

Here are a couple of principles of doing bridgework that every dentist is taught in dental school.

First, any bridge needs to be supported by teeth that collectively have the same amount of support as the missing teeth. In other words, if the bridge is replacing two medium-sized teeth, it needs to be anchored by at least two medium-sized teeth. If four small teeth are missing, they could maybe be supported by two large teeth, if those supporting teeth are twice as large as the missing teeth. So, you are missing four medium-sized teeth (6, 8, 9, and 11) and two small teeth (7 and 10). To support that adequately, you need four medium-sized teeth (4, 5, 12, and 13) and probably one large tooth (3 or 14). So you are ending up with an extremely complicated 11-unit bridge, consisting of six false teeth supported by five existing teeth. Now I suspect that your dentist, especially if you are pressing to save money, may be planning something less than this. But breaking this rule would severely limit the lifespan of the bridge.

Second, when you start adding supporting teeth, you increase the likelihood of failure for two reasons. One is that each supporting tooth has to be prepared to be perfectly parallel to all the other teeth. Getting five prepared teeth to be all parallel to each other (or even four) so that the bridge fits perfectly is extremely demanding, and I would not ask a regular family dentist to do that. When you add to that complication the problem of having teeth on opposite sides of your mouth, making those parallel is a very tricky proposition. Another reason is that if you have any kind of trouble down the road with any of the supporting teeth – decay or gum disease or any other significant problem – the entire bridge will have to be re-done. How expensive is that going to be? Way more than implants.

Third, with six missing front teeth you have what is called a cantilever effect. Look at the diagram and imagine that tooth #4 is missing. This tooth could be replaced with a simple three-unit bridge – the missing tooth #4 supported by teeth #s 3 and 5. Notice that these teeth are pretty much in a straight line. There would be no tipping forces at all when chewing stress is borne by tooth #4. This is the type of stress these supporting teeth are designed to take. But now compare this with teeth #s 6 through 11. These are on a curve. The strongest bridge between teeth #s 5 and 12 would be on a straight line between the two teeth. But that kind of a bridge would go across the roof of your mouth and wouldn’t make any sense. So we have to loop the bridge out around the curve. Have you ever seen a highway bridge that curves out like that? Of course not. They always form a straight line between the supports. The reason for that is that when you’re out on that curve, you create tipping forces which put a large amount of stress on not only the supporting structures but the entire bridge. This force becomes a force that wants to twist and push the two closest anchors (#s 5 and 12) and actually pull the remaining anchors out of their sockets. These are stresses that these teeth are not designed to take, and the life expectancy of such a bridge would be pretty short. You would probably end up losing all of the anchor teeth, in addition to the six you are already missing. To compensate for that added stress factor, your dentist could try anchoring with six teeth instead of five. But then you increase the risk also and may end up losing all six of them.

The conclusion of all this is that a permanent bridge replacing six front teeth would be a bad idea for someone with healthy gums in the hands of some of the most expert dentists in the country. When you add the complicating factor that you have significant gum disease, and add that to the possibility that your dentist may be an average family dentist, you are courting disaster.

So what should you do?

Anything other than the fixed bridge. Don’t end up in our collection of cosmetic dentistry horror stories.

The most economical solution would be a removable partial denture. With today’s acrylics, this could be made to be very esthetic and could have clear acrylic clasps that would be virtually invisible to anyone else. There are some inconveniences to having a removable partial denture, but the cost would be a small fraction of the cost of any other option.

The most comfortable and highest quality solution would be using dental implants. Now whether or not you could support the false teeth with two or four implants would depend on how much bone support you have and the stress of your bite.

My advice? Get a second opinion from an excellent dentist. (See my posts about how to ask for a second opinion.) There is an excellent dentist near you with a national reputation. I’ll send you his name as well as another who is quite a bit further for you but whose fees would be considerably lower. Some dentists will give second opinions for free. But even if you pay $100 for it, that would be much more sensible rather than throwing $10,000 or more at a solution that may only last a few months, even if you don’t end up having the second dentist do the work.

Dr. Hall

We thank our advertisers who help fund this site.

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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