FREQUENTLY ASKED QUESTIONS

CROWNS, BRIDGES AND IMPLANTS

I am 53 years old and just had a back tooth removed in my lower left jaw. My dentist has suggested that I replace it with a bridge. From what I understand he will be cutting down the teeth next to the place where the tooth was removed in order to replace the missing tooth. I am not sure that I want to have this procedure done. Can you tell me if I have any other options?

Replacing a tooth such as the one you had removed can be done in a number of ways. The way you replace it depends on the specific circumstance you present with. I will review a few of the common scenarios and hope that one of them fits you.

  1. If the teeth next to the missing tooth have no decay or restorations, the way to replace the missing tooth is straightforward. The treatment of choice is to use an implant that will support a crown as a permanent replacement. An implant can be placed in the jaw bone and a post will be attached to it once the implant becomes integrated. This is the treatment of choice because you would rather not shave down the adjacent healthy teeth to place a permanent bridge. I addition, the cost differential between these two options is not enough to sway you either way.
  2. If the teeth next to the space have significant amounts of decay or have large restorations that will lead your dentist to believe that the tooth itself is unsupported, and in all likelihood could fracture when under stress, the treatment of choice would be a bridge. The reason for this is that the teeth next to the space need crowns anyway, so why not make a bridge by connecting the two teeth with a fake one. This type of restoration is also permanent and only takes 3 to 4 weeks once started. An important thing to note here is that you need to allow enough healing time from the time of extraction so that all the shrinkage that is going to take place does so. If you do not wait for this to occur you will end up having the shrinkage take place once the permanent bridge is placed and consequently, catch a lot of food under your bridge. In order to keep the teeth next to the space from drifting towards the space, your dentist may want to have a temporary bridge made during the healing phase.
  3. If you have teeth missing on the opposite side of your mouth you may want to consider having a partial denture made. This would be a good option because, typically, a balanced partial (a partial denture replacing teeth on both sides of the dental arch) will be very comfortable, especially if it is totally tooth-supported instead of partially tissue supported. This would also make sense if the overall investment that you make in your teeth is limited by your financial situation. I have seen many cases where a partial denture could replace all of the missing teeth in an arch for the same investment of replacing a single tooth with either a bridge or implant as discussed earlier. Please understand that both the bridge and the implant most closely mimic a natural tooth whereas a removable partial denture is recognized by most patients as foreign.
  4. In the past, a dentist would suggest replacing the missing tooth with a very small partial denture that attached to the teeth in front of and behind it with metal clasps. Though this does work I am very apprehensive restoring a patient in this manner. My concern is that the partial is easily dislodged. If this does happen it can be swallowed because of its small size. Worse than that would be if it were aspirated into the lungs.
I am a 62 years old and have a very loose tooth on the bottom in the front. In the past it had a root canal and then surgery to remove some infection. I have been to the dentist and he told me that the tooth is not able to be saved. When I asked him how to replace it he told me to remove the other three front teeth and make a bridge from one eye tooth to the other. I am not sure that I want to remove those three teeth to replace the one giving me a problem now. Can you shed some light on this for me. I would really appreciate it and I enjoy reading your column.

Thank you for your thorough description. I feel as though I know exactly what you are talking about and will address some of your concerns. Incidentally, your concerns in this matter are very similar to everyone's concerns with the same circumstances. As you have mentioned, it seems clear that the loose tooth needs to come out. The three teeth beside this one are your lower incisors. These teeth have very small roots that are not very supportive. What your dentist may not have discussed with you is that there may be decay in these teeth or they may be periodontally compromised (that is they do not have a lot of bone support around them). Such a situation would not be surprising to me. If this were the case and you were going to make a bridge from one eye tooth to the other eye tooth it wouldn't make sense to include the compromised incisors. In all likelihood, the incisors would fail and need extraction before the eye teeth needed treatment. In fact, a bridge made from eye tooth to eye tooth should last a very long time if done properly.

To recap - I feel as though your dentist is right on target with extracting the four incisors and making a bridge from eye tooth to eye tooth. This is a very common and predictable restoration that should last you many years. Please don't forget that your responsibility in this is good home care to include brushing and flossing as well as regular visits to your dentist. The one place this can fail is at the junction of the bridge and the tooth. If not kept clean it could decay and require repair, replacement or be lost in the future.

I have a one tooth partial replacing my upper front tooth. I would like to get rid of it with something that is more permanent.

There are a few ways that you can replace your missing tooth with a permanent tooth. The most straight forward way to do it is with a fixed bridge. This entails shaving down the adjacent teeth, placing caps on them and suspending a fake tooth between the two of them. This would be cemented in permanently. It will take about two visits and is very predictable. The biggest drawback is that you may be shaving down teeth that otherwise wouldn't need to be shaved down. This brings me to the next option which would be to replace it with an implant. Through the use of an implant, you wouldn't need to shave down the adjacent teeth and still get a permanent replacement tooth. An implant will require two surgeries and the fabrication of the cap that goes on top of it. It will take approximately 8 months from start to finish and can be very predictable if done by someone experienced with implants. In some cases, a one day implant and crown can be done. This requires that certain parameters are met. Another way to replace your tooth is through the use of a different type of bridge. Your dentist will need to shave down only the back of the adjacent teeth and make a bridge with two wings that key into the adjacent teeth. It is cemented in permanently and can be done in two visits. I am not a big fan of this type of bridge because they can be unpredictable and become loose. If made out of metal it can discolor the adjacent teeth once cemented in. We are now seeing this type of restoration made out of plastic materials. If these prove to be predicable they may be a very nice alternative. I hope this info helps you make a decision.

I am 82 years old and have had three of my front teeth capped for years. Two of those caps came off about 2 years ago and I have been that way since then. The other one seems to be loose. I am wearing a partial that I am comfortable with and was wondering if I could put two new caps on the teeth that no longer have caps and match them to my partial. Could you also tell me what you think is the problem with the other cap that is loose. You should also know that the two teeth that the caps came off of are almost broken off down to the gums.

I am going to answer your question the best way that I can without seeing you. I will be assuming some things as I go along - if they are the wrong assumptions please go to a dentist for an answer that can be specific to your situation.

The assumptions that I am going to make are as follows:

  1. All of the rest of your teeth are okay and the partial denture you are wearing fits properly.
  2. The teeth that do not have the crowns are not broken so far down that they will require surgery to restore them.
  3. None of the teeth have had root canals
  4. You would rather have these teeth repaired than extracted and added to the denture.

Since the two teeth that have no crowns on are broken off near the gums you will need to have root canals done. This will allow you to place posts in them that will support a build-up material. This build-up material, along with the post, will take the place of your natural tooth structure. Once you have the post and build up in place the dentist can make crowns or caps to fit over them. By doing this you will not only have teeth that look nice but also support the remaining tooth, as well as the post and build-up.

You had mentioned that you thought that the other crown that you have in your mouth is loose. When a crown feels loose there is either decay under it that caused it to get loose or the cement that was used has washed out. If you are certain that there is no decay you can sometimes remove the crown and recement it. A very important consideration when doing this is - there is a risk of breaking the tooth that the crown is cemented onto. If this is the case I would suggest that the crown be cut off rather than tapped off. If the crown is cut off you would need to remake it rather than recement it. Let's assume that we had to cut it off and remake it. In this case, it would be ideal to combine the crowns on the two teeth with the root canals, posts, and crowns to the tooth that we cut the existing crown off of. This type of restoration is called a splint because you are joining all 3 teeth together as one piece. The two teeth with the root canals will be getting additional support from the other one.

You had questioned whether or not the crowns that are made can be made to fit to your partial. The answer to this is yes, however, it is something that is very difficult to do. The procedures that are done in the office need to be very precise. In addition, it is very important to use a laboratory that has high attention to detail. If any one part is missed you will not end up with a result that is satisfactory.

I had a partial denture made 2 years ago and recently had a crown made that fits under the partial. Ever since the crown was made the partial hasn't fit properly. The dentist made all sorts of adjustments to the crown when he put it in and it still isn't right. Do you have any idea what this is all about and what I can do about it?

When you make a crown precision is very important. The proper amount of reduction of the tooth is imperative so there is enough room for the restorative material. A good impression allows the lab to make a crown with margins that meet the tooth smooth and closed. This is important so you do not get decay under the crown at a later time. When you make a crown under a partial not only do you have to do all the things that you do to make a crown but now you have to make it match the existing partial. As you probably know, a partial denture is retained with clasps around a tooth and should have a rest seat or little dimple in the tooth that the partial sets into to avoid seating of the partial into the gums. It may be the case that your crown was made in such a way that it never fit the partial and the adjustments that you mentioned were an attempt to make it fit. This is in no way an easy thing to accomplish but there are times it is the only way to restore things. It takes a lot of detail on the dentist's part, as well as the lab that he or she uses. In response to what to do - you probably need to get to a dentist for evaluation. With a few more adjustments things may be okay or you may need to have a new crown made.

I am a 54 year old woman and I am in search of a second opinion. I have recently lost all of my back teeth on the bottom right side in the back. I have my own teeth in the front and a permanent bridge on the lower left side. I am told by my dentist that all of my teeth are okay, including my top ones, and that all I have to do is replace the missing teeth on the bottom. He is recommending using implants that will eventually get crowns on them. He says that it would be the most natural and overall be the best way to do it. He said that a partial denture would be uncomfortable at best. My biggest concern is not the money and time involved; it isn't even the pain, it is the fact that I have to be put to sleep to do the implants?

Let me first congratulate you on even writing to me with this question. It is a good question and should be answered before you proceed with treatment. All too often a patient will either not go ahead with treatment or do treatment with questions in their mind when all they have to do is talk it over with their dentist or, as you are doing get a second opinion.

If I can picture your scenario, and I think I do, it seems as though you and your dentist are right on target. Implants would certainly be the nicest way to restore your mouth under the circumstances. They would, in fact, be the most comfortable, as well as the most natural. If you were to make a partial denture you would, in all likelihood, not be happy with it since it would be one-sided (replacing the teeth on only one side) and therefore not be balanced. I find that patients with a denture such as this keep it out of their mouth more often than in their mouth.

To address your concern about being put to sleep, the way the oral surgeon will put you to sleep is different than if you were put to sleep for major surgery in a hospital. I am quite certain that your surgeon will be using conscious sedation rather than general anesthesia. If this is the case many of the risks associated with general anesthesia are not there. I would suggest you discuss this with the oral surgeon before the procedure - I am sure he or she will be able to put you at ease. Once again, it sounds as though you have been well cared for so far. I have no reason to believe that this will change either. Please discuss your concerns with your doctors - I bet everything will be cleared up for you and you can enjoy the benefit of dental implants and good restorative care for the rest of your life. You won't regret it!

I am 53 years old and have just moved to Citrus county. A friend of mine in New Jersey just had implants put in to hold her dentures in. She was very pleased with the end result and could eat anything she wanted. Could you tell me what some of my options are. Thank you.

Congratulations to your friend. She has joined so many former denture wearers and is now experiencing the benefits of dental implants. To follow is a list of some of those benefits:

  1. Confidence that your teeth will not move upon speaking or chewing.
  2. Very little or nothing covering the top of your mouth thereby letting you taste foods better.
  3. The ability to eat foods that a denture wearer usually can not - corn on the cob, spare ribs, etc.

Since most people are comfortable with their upper denture and unhappy with their lower, let me start by talking about the lower denture. The most common method of using implants in the lower jaw is to place 5 implants in the jaw. These implants will resemble either a bullet or a screw and are placed in the jaw after it has been prepared. These implants would stay in the jaw for approximately 4 months during which time you are wearing your own dentures. At no time during this procedure will you be left without the ability to wear your teeth. After the 4 months are up your dentist will place posts into these implants and build a bar that connects them. It is to that bar that your teeth are fastened. When your teeth are in your mouth they are very secure. The beauty of this type of system is you have the ability to remove the teeth and clean the implants and bar extremely thoroughly, thereby avoiding any problems. You can expect the entire procedure to take approximately 6 months from the time the implants are placed to the time that they are restored. Another method to restore the implants involves much of the same procedures, however, the final teeth can be placed so that only your dentist can remove them, if necessary.

Let's discuss the top jaw. The same basic procedures apply to the top except that you would typically use 8 implants instead of 5. In the event that your sinuses are large and there is little bone, we would normally build up the bone before placing the implants. Depending on whether or not the bone was built up, it could take between 10 and 18 months from start to finish.

If you are having difficulty with your dentures and think that you could benefit from dental implants you should seek the advice of your dentist. He or she will either be trained to do both the surgery and make your teeth or they will work in conjunction with a surgeon who will place the implants. It is best to bring a list of your desires and questions to that appointment. In doing so you will be sure to be well informed and your dentist will be able to tell you if your goals are reachable through the use of dental implants.

I have a root canal on my tooth. My dentist tells me I need a crown now. Why do I need a crown if the tooth is dead.

You are among the great majority of the population that thinks that because a tooth has had a root canal the tooth is now "dead". Though the main blood and nerve supply to the tooth is removed in the process of doing a root canal, the tooth still has nourishment going to it. Let us talk about the reasons why you may need a crown on a tooth that has had a root canal. If the reason for the root canal was a large amount of decay that went to the nerve of the tooth, there is a good chance that you also had a filling in place already and therefore there is very little supportive tooth left. If this is the case, the reason for the crown is to protect the tooth from the forces of chewing and thereby avoiding its breakage beyond the point that it can be repaired. Your dentist will probably suggest that he or she either place a post in the tooth and build it up or simply build the tooth up without a post. Both of these procedures are used to reestablish the contours of the tooth so that a crown can be made.

I have every tooth in my mouth except for my wisdom teeth and my bottom first molar. Can you help me decide how to replace this tooth. I've been told different things by different people and can't seem to make up my mind.

First off, let me congratulate you on having all of your teeth except for the ones mentioned in your question. Your situation is not a unique one and there are some very specific thought processes that I go through when presented with this dilemma. If the teeth next to the space have no decay or very small restorations, the treatment of choice is the placement of an implant or two on which we would cement a crown. If the teeth next to the space are in the need of a crown themselves, either due to a fracture, large restoration or broken piece of tooth, then the treatment of choice is a cemented bridge. The other option that one might think of is a removable denture. I would discourage you from this because the denture would be too small and could be swallowed if dislodged. The fee for the above recommendations is so similar that money is rarely a deciding factor in this. What is most important, as always, is what is best for the patient. I would encourage you to see your dentist and he or she can help lead you in the right direction.

About 5 years ago I had a root canal, post and crown done on my front, top, center tooth. It has since come loose 2 times after being cemented by my dentist. I am frustrated with this and wonder what you think.

Since you had a root canal and a post done there is a good chance that there is very little tooth left above the gums. If this is the case we are relying on the post for much of the retention of the crown. In addition, it is in the front of the mouth where you are probably generating significant forces upon eating. The scenario that you are talking about is not too uncommon. There are a few things that can be done to minimize it coming loose, however, in many cases, it is simply a difficult situation. I will list some ideas that come to mind though none may apply to you specifically:

  1. Consider the type of post used and its design.
  2. Be sure that the occlusion (or the way your teeth come together) is correct and not high.
  3. Consider the type of cement used for the post as well as the crown. Do the post and crown fit the tooth properly or is there an opening where cement can wash out?
I just had my front top tooth extracted because a root canal went bad. The root canal was done years ago and I had some sort of surgery done to the tooth about 7 years ago . My dentist told me there was nothing else to do to save it. Now that it is out I want to replace it. My dentist gave me a few options to include a bridge or an implant. These options are simply too costly for me right now. Do you have any other ideas? Thank you.

Your scenario brings to mind two options. They are as follows:

  1. You could make a flipper to replace the tooth. This restoration would replace the tooth for now and allow you the same options your dentist recommended when you are ready. It is a removable appliance that is primarily cosmetic, though it can be reasonably functional.
  2. If you know that the option of an implant is out of the question you could prepare the teeth adjacent to the missing tooth and make a temporary bridge. This would not be as costly as a permanent bridge, however, it needs to be followed by a permanent bridge in the near future. The nice thing about this scenario is the restoration is cemented in and is not removable. Because it will be followed by the permanent restoration your dentist will use temporary cement. If the temporary cement washes out you may need to have it re-cemented until you are prepared for the final restoration.

I hope this information helps you make a decision on what to do to restore your smile.

I have a bridge on the upper right that was done about 7 years ago. I am now getting a bad odor and a funny taste from around the back tooth. I do not have any pain or sensitivity. What do you think this is and what should I do about it?

Your bridge has probably lost its cement seal on the tooth that is giving off the odor. When you lose this seal food and bacteria get under the bridge, decay, and give off a nasty odor. If the rest of the bridge is loose your dentist can tap it off and evaluate the situation. If there is no decay all he or she has to do is recement the bridge after cleaning and disinfecting the teeth that support the bridge. If the rest of the bridge is firm I would recommend that the bridge be cut off, evaluated and treated as mentioned above. In the event that the rest of the bridge is firmly cemented and you attempt to tap it off, there is a great likelihood that a tooth is broken and you end up with more problems than when you started. The reason you have no sensitivity is either this was discovered early enough and there is no decay or the tooth has had a root canal and thereby will have no sensation even in the presence of a lot of decay. I would suggest you get to a dentist as soon as possible to have this evaluated. Like many things - the sooner the better.

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