WHAT ARE THE DIFFERENT TREATMENT OPTIONS AVAILABLE TO REPLACE THE MISSING TEETH?

Individuals may lose their teeth due to gum infections, cavities, physical trauma, or other medical conditions. Replacement of the missing teeth restores the function and improves aesthetics. If not replaced, a lost tooth may cause drifting of adjacent teeth into the space. This impacts the bite between upper and lower teeth and increases the risk of decay and gum infections. 

Currently, there are three key treatment options available to replace missing teeth: removable dentures, fixed dentures, and dental implants. Each treatment option has its benefits and shortcomings.

In this article, we discuss the pros and cons of different treatment options to ensure that an affected individual can make an informed decision. 

What are different treatment options to replace the missing teeth?

A. Removable partial denture

A removable partial denture comprises a plastic base resembling the color of gums and artificial teeth that are attached to the plastic base. An individual can easily remove the denture set at will. Partial dentures may also have a metal framework and clasps (hook-like structures made of stainless steel) attached to the plastic base. These clasps and frameworks are attached around the natural teeth and help stabilize and retain the partial dentures in the mouth.

A dentist may teach the individual how to remove and place the denture back. Individuals may require some practice to get used to the removable dentures. In the follow-up appointments, the dentist will look for the soreness due to dentures and make necessary adjustments. Dentures should be worn during the day and removed at night. They become loose or crack over the years and may need to be replaced.

How is a removable partial denture fabricated?

Fabrication of a denture typically requires three visits to the dentist.

In the first visit, the dentist will take the impressions of the jaws and record the bite of the upper and lower teeth. He/she will send the impressions along with the bite to the dental laboratory. In the next visit, the dentist will evaluate the trial denture in the individual’s mouth and recommend necessary changes to the laboratory. In the final visit, final dentures are delivered.

Advantages of removable partial denture:

• Easy to replace multiple missing teeth at multiple sites.
• Extensive preparation of natural teeth is not required to support the denture.
• Less expensive than fixed dentures and implants.
• Future loss of a tooth can be accommodated by modifying the existing denture.
• Easy to repair.

Disadvantages of removable partial dentures:

• Breaks easily if the denture drops on the floor.
• May cause discomfort due to irritation from the sharp ends of denture or clasp
• Requires frequent repairs or replacements.
• Individuals with subpar oral hygiene may develop decay or gum infections around natural teeth that support the denture

B. Fixed partial denture or bridge

A fixed partial denture is ideal in cases with multiple missing teeth situated next to each other. To replace a single missing tooth, an artificial tooth is placed at the missing tooth’s site and connected with the two adjacent natural teeth using crowns (caps), creating a three-unit bridge. In a traditional bridge, natural teeth (also known as abutments) are prepared (trimmed or reshaped) to receive the crowns (caps). The crowns on the natural teeth are connected with the artificial tooth (known as pontic).

How is fixed partial denture prepared?

Fabrication of a fixed partial denture typically requires three visits to the dentist.

In the first appointment, the dentist will prepare (trim) the natural teeth on either side of the missing tooth space. Then, an impression of the teeth along with the space will be taken and sent to a dental laboratory. A bridge comprising crowns and pontics will be prepared. This bridge can be made up of metal, ceramic, or a combination of both. In the next visit, the dentist will fix the bridge permanently using dental cement. A dentist may also give a temporary bridge until the permanent one is prepared.

Besides commonly-used “traditional bridges”, cantilever bridges and Maryland bridges are also widely used. A cantilever bridge attaches to a single abutment tooth only. Meanwhile, a Maryland bridge uses metal wings instead of crowns. This type of bridge is mainly used to restore front teeth. Failure rates are higher with cantilever and Maryland bridges compared to traditional types.

Advantages of fixed partial denture:

• Resemble natural teeth both in appearance and function.
• Less expensive than dental implants.
• Hassle-free as frequent removal of the denture is not required for cleaning.
• Faster process than implants.

Disadvantages of fixed partial denture:

• Involves the trimming of healthy natural teeth. Sometimes, over-trimming of the tooth may expose the pulp (the innermost layer of the tooth). This may require individuals to undergo root canal treatment before bridge placement. 
• The average life span of a bridge is 5-10 years. Teeth underneath the bridge may develop decay and cause discomfort. Additional treatment may be required after removing the bridge. 
• If the bridge is not prepared or fixed well, the individual may complain of frequent dislodgements. 
• Extra effort may be required to clean underneath the pontic.

C. Dental Implant

A dental implant is a screw-shaped structure that is drilled into the jaw bone at the missing tooth’s site. It replaces the tooth root and is present underneath the gums. After a few weeks, once the implant heals or attaches firmly to the underlying bone, a component is attached to the top of the implant. A crown is fixed to this component. A dental implant is made up of titanium and zirconium. They are highly biocompatible and harmless to the surrounding bone and soft tissues. Dental implants can be used to restore a single tooth, multiple teeth, or full set of teeth.

How is a dental implant placed?

Before the dental implant surgery, the general health of the individual is evaluated. The implant placement site is assessed both clinically and radiographically. On the day of surgery, gum at the missing tooth site is cut and opened, and the bone is exposed. An implant of the desired size is inserted deep into the bone with the help of drills. Following this, gums are stitched back using sutures. The dentist gives the post-surgery instructions along with the medications. After a few weeks (once the dental implant heals), a component is attached to the implant which supports the crown. 

Advantages of dental implant:

• Dental implant restoration closely mimics a natural tooth
• Unlike fixed partial dentures, the placement of dental implants does not require trimming or reshaping of adjacent healthy teeth.
• If placed and maintained well, implants can last for life.
• Compared to other restorations, dental implants have a higher success rate (of over 95%).
• Individuals are more comfortable chewing all types of food with dental implants.
• Dental implants constantly stimulate and stress the underlying jaw bone. This prevents bone loss and keeps the jaw bone healthy.

Disadvantages of dental implant:

• Dental implant surgery is preferred in healthy individuals to achieve a higher success rate. Individuals with ailments such as uncontrolled diabetes, bleeding disorders, recent heart attack, stroke, cancer, and psychiatric disorders are contraindicated from the surgery as they impact the healing. It is also contraindicated in chronic smokers or the ones with poor oral hygiene to reduce the risk of implant failure. 
• The placement of dental implants is a technique-sensitive, time taking procedure and requires multiple appointments.
• The cost of dental implants is higher than the other restorations. For instance, the cost of a single dental implant in the US may vary from 1,500-6,000 USD. Removable partial dentures cost 500-1,500 USD and traditional 3-unit fixed bridge costs 500 -1,500 USD
• Individuals may experience discomfort and swelling post-implant surgery which subsides in 3-5 days. However, some individuals are at risk of complications such as infection, injury to nerves, blood vessels present around teeth, and implant fracture.

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References:

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• https://www.mouthhealthy.org/~/media/ADA/Publications/Files/ADA Patient Smart_Tooth_Replacement.pdf?la=en
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