What's the best way to replace a missing tooth or teeth?
OK, so you've lost a tooth. Whether it was lost due to gum disease, severe decay, or trauma, you're still stuck with the same problem...a missing tooth. Your dentist may have spent a couple of minutes explaining your options and now a staff member is standing over you asking you to decide how you want the tooth replaced. Obviously if there were an easy answer to the question I wouldn't feel the need to write this article.
The method you choose to replace a missing tooth depends on a number of different factors, all of which are nearly equal in importance. The factors to consider include cost, time, longevity, comfort, esthetics, convenience, and the effects of the treatment on the adjacent teeth and the rest of the mouth. You have the four basic options below, and remember we are speaking about replacing a single missing tooth here.
- Do not replace the tooth
- Removable partial denture
- Fixed bridge
- Dental implant
These options are listed in order of increasing desirability and not surprisingly also in order of increasing cost. Let's examine each choice in more detail.
Not Replacing a Tooth
Is it OK to not replace a single lost tooth? Yes! (Well the real answer is "It depends....") It is not the end of the world to lose a tooth, although there are consequences depending on the location of the lost tooth. If it is a wisdom tooth (what we refer to as the third molar) I would definitely say do not replace it. In fact, for wisdom teeth, I would say take the other three out as well! Few people have room in their jaws for the wisdom teeth and they are usually impacted or crowded. If your wisdom teeth did erupt properly and you do have space for them and lost one I would still say do not replace it. They are too far back in the mouth for accessibility to perform restorative procedures well. You will not percieve a loss of chewing ability, you will not see a defect in your smile, and you will not see any effect on your facial structure (like "sunken in" cheeks). If the tooth you have lost is the second molar, that is, the last tooth in the back (assuming there is no tooth behind it, i.e. the wisdom tooth), you could seriously consider not replacing it as well. Clinical studies indicate that even with all four of your second molars missing, you ability to chew food properly is not significanly altered. A lost second molar rarely effects your smile or facial structure and appearance. However you must be aware that the tooth that opposes the lost tooth may supererupt. That is, an upper tooth that does not have a lower tooth to chew against will migrate down until it finds something to stop it, and vice versa. This does not always happen, but your dentist can monitor for it at your semiannual check-ups. A supererupted tooth may not necessarily cause problems. Problems can be prevented or dealt with simply by your dentist. Like a lot of things, early detection leads to simple solutions. Any other lost tooth should be replaced as a loss of chewing abiltity will be noticed as well as a change in your appearance. If there are one or more teeth behind a lost tooth, drifting and tilting of these teeth usually occurs. This can lead to a number of serious complications that include developing bite problems and even loss of additional teeth. So if you have lost an important tooth, get it replaced! One of the three tooth replacement options below should suit you. All three of these options will provide the benefit of preventing tooth movement and maintaining your appearance.
The Removable Partial Denture
The most inexpensive tooth replacement option is the acrylic removable partial denture, AKA "the Flipper." One study in the Journal of Dental Research (J Dent Res.1996 Feb;75 Spec No:714-25) reported that one in five people aged 18 - 74 wear a removable partial denture of one sort or another. There are many varieties of removable partial dentures and they are made to replace from one to many missing teeth. The "Flipper" is most inexpensive type. However for replacing just one tooth, it is a lot of "hardware" in your mouth. That is, along with the artificial denture tooth that fills the gap in your smile, there is a plastic framework that covers all or a part of the roof of you mouth. This is necesary to keep the denture tooth in position and provide retention to keep the partial denture in your mouth. Additionally, flexible wire clasps are sometimes present to grab onto key teeth for additional retention of the partial denture. All of this material in your mouth is one of the drawbacks of this technique for tooth replacement. Because the denture tooth is not rigidly fixed in your mouth, the partial denture will always have some movement when chewing. Patient's often find this movement unsatisfactory. Sixty-five percent of partial denture wearers have some problem or complaint with it (J Dent Res. 1996 Feb;75 Spec No:714-2). Despite it's drawbacks, because of the much greater costs of the other tooth replacement options, the "Flipper" is a popular choice.
The Fixed Bridge
The fixed bridge, or what we refer to as a fixed partial denture, is the next tooth replacement option we'll discuss. A fixed bridge requires preparing, that is cutting down, the teeth on either side of the missing tooth. This is not terribly conservative treatment. Tooth preparation of the adjacent teeth is irreversible and involves the removal of quite a bit of tooth structure. See the photo on right. I know it may seem a bit barbaric, but for the longest time it was the only way to provide a fixed, non-removable replacement tooth. Providing this service well is technically demanding and will require all of your dentist's skill. A well made fixed bridge can look natural, function well, and potentially last a lifetime. However, 75% of fixed bridges fail within 7 years. The fixed bridge is at least three teeth connected together with the false tooth (the replacement tooth) in the middle. Because the teeth are connected, you cannot pop dental floss between them. Instead you must thread the floss through underneath where the teeth are connected or use a special small brush to get under the connectors. People tend to neglect to perform this inconvenient extra step in their oral hygiene routine. This contributes to the relative high rate of failure. Also, the extra stress on the teeth supporting the fixed bridge can lead to mechanical breakdown and thus adds to the failure rate. The fixed bridge is still the treatment of choice for many patients.
The Dental Implant
The dental implant can be the best method for replacing a missing tooth in most cases. It involves surgically placing a titanium artificial root (the implant) into the space that the root of the lost tooth occupied. A crown is then connected to the implant. See diagram to the right. One benefit of this tooth replacement method is that the adjacent teeth are left unaltered. The dental implant and its crown are a free-standing self-supporting total tooth replacement. That is, the root of the tooth as well as the crown of the tooth are replaced and the new tooth does not rely on the adjacent teeth for support. Clinical studies show that unaltered teeth adjacent to an implant have a much better long-term prognosis than teeth supporting a fixed bridge. Because the dental implant is not connected to the adjacent teeth it can be flossed and maintained exactly as you would your natural teeth. Modern dental implants have been in use since the late 1950s and research & development have improved the technology to now be one of the most successul forms of treatment in dentistry today. The cost of the single tooth dental implant can be nearly the same as that of the fixed bridge depending on the circumstances. Finally, the dental implant has the same chance to last a lifetime as one of your natural teeth. Look for my next article explaining using dental implants for replacing single missing teeth in more detail.