Summary
In complex cases, every person is very different and there are many options available (i.e., partial dentures, bridges or implants).
It is important to look at the structural health of the whole jaw system, rather than just one tooth.
The big picture
We like to compare a set of teeth to a football team. When the whole team is young and fit they can manage with one player sent off with injury. Perhaps there is a bit more stress on the team for a while, but they can manage. But what do you do if your team is closer to forty than eighteen, and you already have three players missing, and half of those on the field are carrying injuries. At the start of every match you are more worried about the next player who will collapse than you are with winning the game. And the idea of just bringing in one young player and expecting the whole situation to be fixed is not being realistic.
This is when you have to take a step back and look at the whole issue before you spend any great effort on any one tooth, or player. In the dental case, the big issues that should be addressed first are related to the structural health of the whole jaw system, and not just any one tooth. A classic example that we see is where someone has worn their teeth down to perhaps half of their initial height. The front teeth are very short, and the edges keep chipping. And then one tooth breaks in a major way. The simple answer might be to put a crown on that tooth. But then that crown has been built at a wrong length. It cannot be made longer than all of the other teeth, because it would hit before all of the other teeth and would look silly. So, it is made short. And then the next tooth along fractures and another short crown is placed. In the end all of the front teeth can be crowned, and all of them will be short. It would have been much better if BEFORE the first tooth was crowned, an assessment was made as to where the patient needed to be at the end of their treatment, and a plan made that allowed them to work towards that goal. The teeth can be built up with composite to a more correct height, and then slowly work towards any crown that needs doing. Composite is not a material that will last forever, but it allows us to create a more correct starting point, and also to modify this if any problems are experienced as the patient gets reacquainted with a more normal bite position.
We are seeing more and more of these situations, where patients have had a lot of large ‘white’ fillings placed on their back teeth for cosmetic reasons, and these are ground down by the everyday action of eating, and by the grinding of their teeth at night. As the back teeth wear down, the load goes onto the front teeth, and then these become short.
Obviously, this re-opening of the bite is not something that can be done one tooth at a time. That tooth would be the only tooth that touches in the mouth. As such, it would fail in short time. So, there is initially some long appointments that try and get the bite opened and stabilised in as short a time as is possible, and then the situation is refined over a longer period to ensure that the end result is balanced both statically and dynamically. Only when we are happy with the restored platform will we then work forward onto the final crowns. This allows us to ensure that you are happy with the appearance and the feel of the new bite level. The final stages may involve crowns, implants or bridges, but this can be spread over some years to ensure that every step is satisfactory before moving on to the next. This also allows for the claiming of treatment over a greater number of years which can help with health benefits from insurance.
Sometimes there just are not enough teeth left to take the expected load. Even if you ‘correct’ the bite, everything would fail due to the lack of support and lack of stability that is a result of there not being enough teeth to share the load. When this happens, we need to start to find other ways of sharing this load.
Working upwards on a price basis, the first option would be to make some form of partial denture that fills in some of the spaces. This can be very useful, especially where a lot of teeth are missing, or where the remaining teeth just don’t line up above each other, or on the same side of the mouth. It is not very useful having a full set of upper left teeth and a full set of lower right teeth!
This is not a common situation, but what is common is having some lower ‘back’ teeth and some upper ‘middle’ teeth. This leaves only the front teeth to take the load. A partial denture on the lower would then put some of the load onto the posterior teeth and help preserve the front teeth. But, and it is a big ‘but’, you have to wear a denture, and that is not something that anyone would do if they could avoid it. They must be removed every night, and they tend to trap food and damage the remaining teeth. They solve a lot of issues, but they bring their own issues to the table.
Bridges can be of use. Here, we put a crown on a tooth behind a gap, and a crown on another tooth forward of the gap. We then make a ‘bridge’ that covers both the teeth and also the gap. This is a wonderful idea if the gap is not too long, and if the teeth on either side need a crown anyway. But if the teeth on either side are perfect then we do not like to cut away healthy tooth if we can avoid it. Further, the bridge cannot be too long, or we overload the teeth at either end, and they can fail. And since the whole bridge is made in one piece, if one tooth fails then the whole bridge fails.
Implants involve placing a new, artificial tooth root into the bone and then building up some form of restoration on top of the implant or implants. The important thing with implants is that we need to have enough good quality bone to place the implants, and there are also health and smoking issues that can preclude us from taking this option. But, if it is available, then it is of amazing benefit in providing us with new areas of support. In these complex cases, every person is very different, and the options are myriad. A full consultation is required before we can further advise you as to what is possible.
