Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

February 19, 2018

Another Sinus Perforation – Did My Dentist Treat it Right?


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Hello Dr Hall,

First off I would like to thank you for sharing your time and knowledge. Today I had 12 teeth extracted. Upon removal of an upper molar, my sinus was perforated. The dentist put a compound in to increase blood clotting. Immediately I was able to breath quite easily through the perforation. Will a perforation allowing air through easily heal properly? I was prescribed a 10-day antibiotic to help prevent infection. I am also not currently experiencing any real pain or discomfort. Kinda strange while normal at rest breathing I feel the air in my mouth. I am currently using gauze to apply pressure although I have no bleeding. Any information you can offer will be greatly appreciated. Thank you for your time.

– Robert L.

Robert,
I don’t want to paint myself as the country’s greatest expert on sinus perforations, though I’m getting a lot of questions on this. I had only had this happen to my patients a couple as I was practicing, and I followed the procedure I was taught. I packed the socket with gelfoam – a resorbable sponge that assisted in the retention of the blood clot and its conversion into replacement bone, and then I pulled some of the tissue around the tooth I had extracted – this tissue becomes loose when the tooth is gone and it was easy to pull that over the extraction site to close it over. Then I advised each patient not to blow their noses for a few days. Both cases healed in a few days and without complications. Bone grafting materials are now readily accessible to oral surgeons, and they can be used to accelerate the healing of bone – which is the goal here – to re-create a layer of bone between the teeth socket and the sinus.

What I was taught was to eliminate that air passageway between the mouth and the nose so that the perforation would heal. Now you’re telling me that you have a hole in that perforation that hasn’t really been closed. Will it heal? I’m guessing that eventually it will, but I’m not entirely sure, and it could take quite a long time. But meanwhile you have a situation susceptible to infection and every time air goes through the hole it’s going to want to open that hole a little more–not how I was taught and it seems to me a recipe for very slow healing. Plus what do you do when you’re eating peas and they get up into your nose? :-). I know some kids who would love that, but that can’t be how this is supposed to work.

What to do? I would ask for a referral to an oral surgeon to close this. The future health of your mouth including the ability to plant implants to replace the teeth requires a good thick foundation of bone to work with here and that will be enhanced by proper healing of this sinus perforation.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

January 10, 2017

Putting my teeth back in with crazy glue


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“Bout 3 months ago my teeth just starting falling out root and all the whole tooth. I been using crazy glue but it is starting to mess up the inside of my mouth and it hurts all the time the crazy glue is killing me cause when I’m inhaling it but I have to leave the house and I want let people see me with out teeth but I only go out when I have to I have no life I stay home out the times I don’t date I want go out with friends please help me.”
– (we’re not posting a name with this question)

This was actually not a MyNewSmile question but was a question we found submitted to another website that we manage.

Unfortunately, I don’t think I have a good answer for this poor woman. There is an answer, but I don’t think she’s going to like it. I’m writing this blog post because I think it’s interesting what she has tried to do.

First I want to comment on the severity of her gum disease and the hopelessness of trying to get these teeth to stay in, even with crazy glue or superglue. I have seen gum disease so bad that the teeth fall out spontaneously, and to be that bad the teeth already have to be dangling somewhat from the root. Here is a photograph of the teeth of a patient with advanced periodontal disease. As bad as this is, it’s not nearly the stage of periodontitis that this woman is experiencing.

Photograph courtesy of Dr. David Mastro, Roswell, GA

Photograph courtesy of Dr. David Mastro, Roswell, GA

This patient’s lower four incisors are getting close to being loose enough to fall out, but they’re not that bad yet. Imagine a little more of the root showing–this is what this woman had.

Putting them back in with crazy glue or superglue? These glues have cyanoacryate, which is is an excellent soft tissue adhesive, but it would only hold for a day or two, maximum, I’m imagining from my experience with it. And the teeth would still flop around.

My guess is that it’s been a number of years since this woman visited a dentist.

She needs a dentist badly now, and my guess is that none of the teeth are saveable at this point. She needs removable dentures or dental implants.

– Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

August 4, 2016

A couple of teeth just fell out!


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Dr. Hall,
My mother is 85 years old. Just last week she had two teeth filled. She recently lost a tooth and has a partial for that area. Then a few days ago, another tooth fell out. Both missing teeth are from the lower jaw. Fortunately they are in different areas of the mouth. She is very self-consious. At her age, her remaining teeth and gums are probably not in the best of health. We are considering a bridge(s) but are not sure as we don’t know how healthy the rest of her teeth are. Do you have any affordable recommendations on what we can do for the area that is missing teeth?
– Diane from Colorado

Diane,
If I am understanding you correctly, these two teeth just fell out. If that is the case, your mother has advanced periodontal disease (gum disease). It doesn’t get more advanced than that, for teeth to be so loose that they just fall out.

Continuing on with that assumption, it is likely that she has no really solid teeth left, so bridges would be out of the question. A bridge anchors replacement teeth to the remaining teeth, but in doing so it puts additional stress on those remaining teeth. In your mother’s case, that would hasten their demise.

The ideal replacement for missing teeth is dental implants. However, you asked for something affordable. Your mother would likely need full-mouth restoration, and the price for doing that with dental implants could easily get to be $20,000 to $40,000.

Given the condition of advanced periodontitis, all of her teeth are likely loose and would be candidates for extraction. I would seriously look at complete removable dentures. The main disadvantage of removable dentures is that it begins a long-term process of bone resorption. But at the age of 85, that would not be likely to be a significant problem for her.

Cu-Sil partial denture

A Cu-Sil partial
(image courtesy of Dental Arts Laboratory, Peoria, IL)

Another solution would be a type of partial denture called a Cu-Sil partial that is built like a complete denture, but has holes in it to allow the existing teeth to poke through, and there is a silicone ring in each hole that snugly holds each tooth. This is a little more stable than a complete denture, and as additional teeth are lost, it is a simple matter to then close each hole and put in a new artificial tooth.

A conventional removable partial denture also puts extra stress on the remaining teeth. It’s not as much stress as a bridge, but it’s still enough to weaken the teeth, so I wouldn’t recommend that either.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

June 25, 2016

Where should denture teeth be placed?


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Dr. Hall,
Should permanent dentures (all on four) be placed with the anterior teeth 2 to 3 mm from the gum line or should they follow the gum line? Is this a common procedure or the dentist’s choice? I have bulky lips as a result.
Thank you.
Luis from Florida

Dear Luis,

gumline

This is the gumline

I think we have a terminology problem. The word gumline refers to the edge of the gum where it meets the tooth. When the teeth are extracted, there is no more gumline. If the teeth are replaced with a complete denture, then the gumline would refer to the edge of the pink acrylic on the denture where it meets the false tooth. So where the teeth are placed defines the gumline, making it impossible to place the teeth anyplace else than right at the gumline.

I think what you are talking about is the placement of the teeth in relation to the ridge of the jawbone under the denture, so let me address that.

When you get a complete removable denture, the front lower teeth should be placed directly over the bony ridge. This is important for the lowers particularly because if they are too far forward, the denture will tip up in the back whenever you bite anything with your front teeth.

In your case, however, you are talking about an All-on-4 denture, which is implant-retained. An implant-retained denture isn’t going to tip when you bite. And then you are saying the teeth are only 2-3 millimeters from the ridge, which isn’t much. That is close enough to be within range even for a removable denture. So their placement sounds fine from the point of view of being able to chew. However, there are other considerations in the placement of the teeth, such as the appearance of your lips. What should be done, with quality dentures, is there should be a wax try-in of the denture before it is made in acrylic. When I made a set of dentures, I would always have the teeth set up in pink wax on a plastic plate made to fit the patient’s mouth. With this wax try-in, I would evaluate the appearance of the teeth, the patient’s speech, fullness of the lips, vertical dimension, and bite to make sure everything was correct before the denture was processed.

If your denture is already made, there may still be an easy remedy. If your implant-retained denture is made so that it is attached to the implants with screws, it can be removed and teeth re-set. It isn’t that difficult a procedure to have the front teeth drilled out and re-processed into the denture in a new position. Some dentists might even do this for free, but I suspect that many would charge some for this revision after the denture is made. But it shouldn’t be expensive.

– Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

May 16, 2016

She says she’s too young for partial dentures

Filed under: Extractions — Tags: , , , , — mesasmiles @ 2:52 pm

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Hi Dr. Hall,
I’ve had teeth problems my whole life. I have chipped missing and discolored teeth. It seems like no one wants to help me fix them. The only thing the dentist wants to do is partial dentures. I guess I could do that but I would really like something more permanent in the front. I’ve tried to talk to him about it and he doesn’t say anything. Finally he said the way your teeth are we can’t do anything else but take out the bad teeth and do partials. I thought with all the stuff dentists had they could fix anything. My question is if you have really bad teeth can they still get fixed? Plus why do dentists suggest partials instead of fixing your teeth? By the way I’m 35 feel like I’m to young for full partials.
– Theresa from New York

Theresa,
Dentists vary a lot in their interest in saving teeth. In my practice, I was passionate about that and rescued a number of teeth that other dentists said were hopeless teeth. Almost every tooth that has tooth decay or is broken can be fixed, but there are many dentists who don’t want to go to the trouble of saving them. And for missing teeth, if you’re willing to pay for dental implants, that is by far a better way to treat missing teeth than removable partials.

Also, when you have a mixture of missing teeth, chipped teeth, and discolored teeth, as you have explained, there are usually a number of different ways to fix them. But some of those ways require newer technologies such as dental implants or dental bonding and some dentists aren’t comfortable doing those.

You can be grateful, at least, that your dentist isn’t willing to go out of his comfort zone. Some dentists will do that, to please the patient or to avoid losing the patient, sometimes with disastrous results.

Just get a second opinion. Look for a dentist with a similar philosophy to yours. Again, don’t try to push any dentist out of his or her comfort zone. Listen to what they recommend, gently prod to see if they are giving you all the options, ask what they recommend, and then decide if that’s what you want to do. If you do want to save the teeth, you want a dentist who enjoys doing that, because they will have a passion and practice in doing that successfully. And for a dentist who is good at placing dental implants, that is the thing they will certainly prefer doing for you and will likely be the first thing they recommend.

Good luck,
Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

January 11, 2016

Maryland bridges keep coming off. Is there another solution?

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Dr. Hall,
I have a question about my daughter’s teeth… The two lateral incisors did not come in. The dentist put on braces and left a place to use a Maryland bridge. The wings are both broke and she has had them cemented several times. She is 21 now and has no dental insurance. Her dentist said that she could have implants but she will have to have a bone graft.. Would it be better for her to go back and have braces applied again to the top teeth only to pull them all close together and file them down… Then again I’m wondering about the price?
– Alaina from West Virginia

Alaina,
So your daughter is missing her two lateral incisors.

I would absolutely not bring the teeth together to close the space and then file down the canine teeth. I had a patient who had that done and later came to me as an adult to ask me to help make it look normal and there was no way to make the result of that look normal. The canines are thick, fat teeth that stick out in the front and that simply doesn’t work. Furthermore, the canines perform an important function in protecting the back teeth against sideways stresses and if you move them to the front, they can’t do that.

Here is a photo first showing the two missing laterals, which is probably the way your daughter looks now:
missing lateral incisors
And here is a photo showing what a smile looks like with the canines moved into the position of the lateral incisors:
missing lateral incisors after orthodonticsShaving the canines and even bonding to them or doing porcelain veneers would not look normal. Yes, it looks better than missing teeth, but as a cosmetic dentist, if a patient comes to me looking like this and wants the ideal solution, I would have them put in braces to move the canines back to their normal position and then use one of several methods to replace the lateral incisors.

The dental implants would be the best solution, no question. If there is money to do that, that’s what I would recommend.

However, the second best in my opinion would be a simple flipper partial. I had an office manager for my dental practice that used a flipper partial the entire time she worked for me. You would never know, meeting her, that her lateral incisors were not real. It’s a simple plastic plate with the twoflipper partial replacing lateral incisors teeth attached. It fits up on the palate and there are two wire clips, one on each side, that snap over the back teeth to hold it in. The cost should be pretty reasonable – maybe a couple hundred dollars, more or less. Here’s a photo of what that appliance would look like.

This isn’t the ideal solution. Some people have difficulty eating with these flipper partials and they have to remove them to eat. And over time, the jawbone shrinks where the missing teeth were. For a few hundred dollars more, you could get a more elaborate partial.

She could also get conventional porcelain bridges replacing these teeth, but that would require grinding down the healthy central incisors and canines. I would rather see her do the flipper and save up her money for implants later.

This monkeying with Maryland bridges, I would not do that. Not only do the wings of a Maryland bridge make the central incisors look darker, you can have problems with them staying in. I suspect that your daughter’s Maryland bridges were poorly designed, for all the trouble she has had with them. But even with a good design, they can be some trouble. I would prefer the flipper partial.

 

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

October 13, 2015

I have a split tooth – can it be saved?

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Dr. Hall,

I have a split tooth. It’s one of my upper teeth, near the front. A dentist in Ft. Myers, Florida, recommends extracting all of the tooth and then doing a bone graft and then a dental implant to replace it. The tooth is identified as tooth #4 on the dentist’s chart/treatment plan. The dentist stated that there is no possibility to save the tooth.

I want the tooth repaired, if possible. It is a tooth otherwise healthy, however, the tooth is completely split, right down into the root or gum. Causation is unknown to me.

I request any suggestions that you have about repairing the tooth, or about a dentist. l live in the Kissimmee, Florida area. I have the basic Humana dental PPO plan.
Thank you for your attention to this letter.
– James from Florida

 
James,

As you may have seen on the website, I was the one who did the research showing that it is possible to save a tooth with a vertical root fracture. I published that research in the Colorado Dental Journal in 2004, and a Portuguese version of what I wrote was published in Brazil. This is totally contrary to conventional thinking, as almost everywhere else in the dental literature you will read that these teeth are not savable.

One problem with research that goes directly against the grain of the consensus of thought in a profession is that it takes more than one researcher to change that consensus. The feeling is that the research needs to be corroborated by a second, independent party. So you are very unlikely to find another dentist who would try to save a tooth like this. However, just this July, 2015, a research team in India duplicated my research and was able to also save a tooth with a vertical root fracture. So I am hopeful that we’re on the way to getting my research accepted. If these publications will prompt an American researcher to corroborate what we have done, this could begin to become generally accepted.

Having said all of this, one of the things I discovered when I did my research was that in order to save a tooth with a vertical root fracture, it was necessary to get the parts of the tooth back together perfectly and then stabilize the tooth in that condition. If the fracture was several days old, it was impossible to get the two parts of the tooth back together perfectly, so the repair became impossible. I am assuming that with you writing to me and you have already had a dental visit, that this fracture isn’t something that happened today or yesterday. Unfortunately, that does make this tooth unrepairable and extraction would be necessary.

Luckily, dental implants have become a very predictable treatment option, and if that’s what your dentist recommends, that’s what I would do.

Dr. Hall

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

July 29, 2013

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

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

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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

October 3, 2012

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

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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About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

June 20, 2012

This complex appearance-related question won’t be solved by an unmotivated dentist

Dr. Hall,
I am a 67 year old woman who has had surgery for gum disease within the last six months. Also, because of the gum disease I have 6 missing upper teeth (3 on either side). I do have the front six and a back molar on each side. I suppose due to bone loss from the gum disease my front two upper teeth have a major gap between them. At the moment I contemplating either implants but due to the cost that may not happen. I have talked to my dentist about “partials”…currently I have a flipper. I have also been to an orthodontist to discuss braces to close the gap between the top 6 teeth, particularly the middle two. The problem with braces is that the flipper won’t fit and due to the amount of movement needed a partial would have to be remade multiple times. I am not sure if I just live with the gap and get the partial for the uppers and be done with it (even though I am 67, I still work, very active and I HATE that gap). My oral surgeon does do implants but he is talking well over $20,000 and that is a great deal of money. Any suggestions would be appreciated.
Janie in Texas

Janie,
If you’re going to get this aesthetic problem solved, you’re going to have to get out of this group of conventional-thinking dentists and find a dentist who is passionate about doing appearance-related dentistry.

I can think of a couple of possible solutions to your problem that might work, but each one would depend a lot on assumptions about your condition that I really shouldn’t make via e-mail. A specific solution would require a complete examination to let me know the bone levels on the existing teeth, the sizes of your front teeth, the size of the gap, the prognosis of the remaining teeth, and how everything fits together.

Now maybe there are no good solutions other than what your oral surgeon is suggesting, given everything the way it is in your mouth, but I can tell you that the prevailing thinking in established dentistry would be that this isn’t that big of a problem and it’s not worth trying very hard and certainly not worth taking any risks. The way we were taught in dental school is that patient concerns like you are expressing over this gap are relatively trivial, and to give them too much weight is pandering and unprofessional. They would not want to APPEAR to be thinking that, but in their professional circles as they talk behind the scenes among themselves, this is the thought pattern that we see all too often.

I would suggest getting a dentist who truly believes that appearance is important. Go to our list. There are actually several of our recommended dentist within 30-50 miles of you. They are all screened carefully by me personally to be highly sympathetic to appearance-related concerns like yours and to have excellent skills.

Dr. Hall

About David A. Hall

Dr. David 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 complete Internet marketing for dentists.

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