Monday, February 15, 2010

What are My Options to Replace a Single Missing Tooth?

A Common Situation

     One of the most common treatments in dentistry is the replacement of a single missing tooth. It's something we do so often because recent studies estimate that more than 70% of Americans are missing at least one tooth (not including wisdom teeth) whether that tooth was lost to disease, a traumatic accident, or even because it never formed in the first place. 

While there are several treatment options to solve this common problem, they can vary widely in terms of durability, initial and long-term maintenance costs, number of appointments needed and total length of treatment time. Ultimately the choice is yours but your dentist can help you to understand the pros and cons of each option in your specific case. It's also important to keep in mind that in some cases if your situation seems stable and not likely to worsen with time, simply doing nothing and leaving the space can be an appropriate option. In most cases, though, some kind of treatment would improve the situation.


     Removable appliances are usually the most economical way to replace a single tooth, but they often have more disadvantages. The most obvious is that the device comes in and out of the mouth and often moves around while chewing and speaking. To prevent it from being a choking hazard it must often be bulky. Where a removable device usually becomes a more attractive option is for the replacement of several missing teeth. In this kind of situation the price difference between a removable partial denture and teeth that stay in all the time and look and function naturally can be much larger, so the disadvantages become less of an issue. There's definitely something to be said though for the psychological advantage of teeth that look and feel like a part of your own body. A removable device can speed up bone loss in the missing space though, making the upgrade to a fixed or cemented-in solution more costly or time-consuming to achieve in the future.

Fixed Option #1: Bridging the Gap

     Once the decision is made to go with a 'fixed' or cemented-in option, the most common choice is between a bridge or an implant. A bridge is essentially a chain of crowns made of metal and porcelain (or just porcelain) that uses the teeth on either side of the space for support while placing a natural looking tooth in the space itself. This option almost always requires removing some of the top and sides of the support teeth to produce a bridge that will stay cemented in place predictably. Some advantages include the time of treatment (usually just 2-4 weeks), the number of appointments needed (2-3) and the fact that most dental insurances provide coverage for the procedure. Disadvantages include that they are harder to keep clean (they require special brushing and flossing methods), higher replacement costs if something breaks or fails down the road, and the fact that you have to involve the teeth on either side (which increases the small chance that  they may need additional treatment, like a root canal, in the long-term). That final consideration (the teeth on either side) can often make the choice between a bridge or an implant easier. If the teeth on either side of the space have large fillings or some other condition that would have require putting a crown on them sometime in the future anyways, then a bridge may ''kill two birds with one stone'' by filling the space and improving the teeth next door at the same time. If those teeth wouldn't have needed crowns or have never had any work done to them, then the option that really shines is the dental implant.

Fixed Option #2: Implants Can Mimic Nature

     With over forty years of solid research behind them, dental implants have really changed the way dentists treat missing teeth. They represent a way to replace what has been lost  
by adding back rather than taking away from the surrounding teeth. A titanium implant is placed in the bone in the area of the missing tooth. After a healing period a post called an abutment can be added and a crown is made over this piece. The advantages include little to no drilling on the teeth next door and the fact that implants do not decay and never need root canals. If they fail to heal in the bone in the short term, the procedure can often be repeated. If the replacement tooth breaks in the long term, replacing the crown and/or abutment could be all that is needed (at a cost of about a third of replacing a failed bridge). The disadvantages are mostly related to the additional time that is involved to allow the implant to heal in the jawbone. These times vary depending on the area of the mouth involved and the quality of the bone there. Current guidelines suggest waiting no less than 3 months but possibly up to 6 months for the most predictable results (although in some cases a temporary crown can be inserted on the same day as the placement of the implant). Additionally, to achieve the best results it is often necessary to improve the site of the missing tooth by grafting bone or soft (gum) tissue before a properly-sized implant can be placed there. These additional procedures, while adding time and expense to an overall treatment plan, can make the difference between a ''just O.K.'' result and a solid, long-term result that really mimics nature. The pictures shown here represent an almost ideal situation where we planned from the start to place the implant just a few months after the loss of the tooth. We were able to put a bone graft into the area at the same time the tooth was removed. Afterward, healing went well (a little bit of gum recession resulted in the exposure of a some of the metal collar under the crown but this wasn't a concern for this patient). Many times, however, the tooth has been missing for awhile and more gum and bone has been lost; in this case a choice has to be made between undergoing additional procedures or settling for a less than optimal result.

      Another factor to be aware of is that not all dental insurances cover dental implants, but this is improving. While it's understandable to want to choose the option that takes less time or has a lower cost up front, it's important to remember that treatment doesn't end the day the space is filled--we hope to provide you a solution that will serve you for a long time. However, nothing we do in dentistry lasts forever- a dental implant can result in lower costs and less time in the chair in the long run. 

     As always, your dentist can help to guide you through the pros and cons in your particular situation. Fortunately, there is rarely a 'wrong' option--your dentist's goal is to empower you to choose the option that makes you feel the most comfortable while improving your chewing and self confidence by replacing your missing tooth.