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Dentistry/should i get bridge redone or go for implant

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QUESTION: I'm in my mid-40's. I had a gold onlay bridge that recently broke. Span covered #18-20. Abutment #18 separated and the gold onlay in it popped out. Abutment #20 is holding up and is keeping pontic #19 in place. My dentist (not the one who did this bridge) said the gold was probably too soft, and the bridge needed a higher percentage of palladium. He gave me two choices. A new, stronger gold onlay bridge, with more palladium. Or, an implant in #19, composite to be filled in #18, and keep the gold onlay already in #20. He thinks the implant route is more conservative.
I'm leaning towards having another onlay bridge. I feel that #18 and #20 were prepped for the onlay bridge ten yrs. ago, and so we're not dealing with untouched teeth. By the way, what is the life expectancy of a gold onlay bridge similar to what I had?  The reason I didn't have the implant 10 yrs. ago was that I thought implants were a big ordeal.
Can my dentist just clean out the area in #18 and 20 without doing additional prepping (drilling) in order to make a new onlay bridge.
If I go for the implant, what are the chances that I'll need a bone graft?
It is worth noting that #16 was extracted and #15 will likely be too, due to a severe furcation. I don't think an implant will be possible in #15.
Will my left face look distorted because of these three extractions? And in order to maintain a better facial appearance, should I strongly consider having an implant in #19? Does a pontic as part of a bridge provide the same facial appearance as an implant? What do you recommend?

ANSWER: Dear Michael,

I don't know how long your bridge lasted before it began to come loose.  If it lasted a long time, then the more practical, and usually less expensive way, would be to replace the bridge.  The more ideal AND more expensive way would be to make an implant to replace the loose bridge, salvage what you can of the onlays and recement them, if possible.  If not possible to recement, then make an new onlay or onlays.

When I say "more ideal", I mean that with a new implanted root to hold a new crown in place, you won't be chewing on a tooth that is unsupported, except by the two onlays, which have already come loose.  I can't answer you about bone grafting without seeing your xrays and looking at your jaw.  I will say that most implant placements involve placement of bone graft.

My statements stand even if you lose 15.  Patients who lose upper second molars rarely show changes in their face after healing is complete.  On rare occasions, the cheek on the side of the lost tooth may sink in slightly, giving the cheek on that side a more slender appearance and causing the cheekbone to look slightly more prominent.  The more molars that are lost, the more pronounced will be this effect, should it occur.  Facial appearance with and without molars is a subjective issue.  Some people like the appearance.  Some do not.  Each individual is different.  The other thing that an implant does is retain the bone height and width in the area of the missing tooth.  If this is an issue for you, definitely get the implant.  A pontic will not prevent this bone loss.  The effect of this on your facial appearance is minimal, if any.

My recommendations on issues this complex must be based on a thorough examination of your xrays and your mouth.  So I cannot help you make your decision, other that your use of my information above.

---------- FOLLOW-UP ----------

QUESTION: Thanks very much doctor for your well-discussed analysis! By the way, the bridge lasted 10 yrs. How long should a bridge similar to mine last? It was last week while eating, that #18 loosened and snapped off.
The oral surgeon I consulted said there is plenty of bone so that convinced me to go for the implant. At the time of implant surgery, my oral surgeon said he will saw off the pontic and keep the #20 gold onlay intact.
Should I have the hole in #18 filled by my prosthodontist prior to implant or after? Does it make a difference? He thinks composite is most conservative treatment to fill this hole.
 Prior to the oral surgeon's placement of the implant, do I also have my prosthodontist take an impression for dimensions of the pontic so that it would help him with the size of the restoration?
Are impressions taken prior and after, or only after? And what choice of material-crown for #19 would be the best for this restoration?
Your advice is greatly appreciated.

ANSWER: Dear Michael,

I'm finding it interesting that you have been to your dentist, a prosthodontist, and an oral surgeon, all of whom have provided you with their best advice.  And you still have questions for me.  You're employing a lot of dentists to answer your questions.  All of whom have met you, examined you, and seen your xrays.  These are the people from whom you should be seeking more information.  Without the information they have about you, I can't give you more than general answers to your questions.  So here goes:

Taking into consideration that you have now decided to go for an implant to replace #19 (good choice), and considering that you will be using the services of an oral surgeon, a prosthodontist and your dentist, for whose advice you have been and will be paying, my answers are these:

A bridge similar to yours will usually last from 10-20 years.

You should be aware that during the cutting of 19 away from 20, there is 10-30% chance that #20 will be loosened enough to permit leakage under that onlay. So be sure you see your dentist at least every 6 months to have this area checked.

The hole in 18 may be filled by either your dentist or your prosthodontist.  But since it was an onlay, and since it has come loose and likely has decay under it, I would recommend that another onlay or crown be made using Lava Ultimate, which comes with a 10-year warranty from the manufacturer.

Prior to anything being done, I would have the area scanned, or an impression made, so that what you were comfortable with before before can be duplicated as nearly as possible.

For #19, I would again recommend a crown made from Lava Ultimate, again because the manufacturer provides a 10-year warranty against breakage.

I hope I helped.  If your dentists are not familiar with these techniques or products, please have them contact me.

---------- FOLLOW-UP ----------

QUESTION: I'm sorry about the confusion. I didn't consult 3 different dentists. My prosthodontist is my primary care dentist. He was the one who presented the bridge or implant option. He didn't charge for this consultation. From what he said and after I've already left the office, I think of questions.
My consultation with the oral surgeon was also free of charge. And again I think of questions after I've already left the office.  At this site (allexperts), I feel more at ease at asking questions. And feel that I may be getting a valuable second opinion, or even better, an unbiased opinion. For example, the 10-30% leakage possibility was never explained to me. I will look into the Lava Ultimate. I thank you very much for your patience and your answers!
I don't understand what is meant by area scanned, what device is doing the scanning?

Answer
Aha!  I do the same after I leave my Dr.'s office.  Now I get it.  

In selective use for 25 years, now becoming more popular among dentists, is the laser scanner, which looks like large dental drill, acts like an intraoral video camera, and with the use of a laser for accuracy, scans thousands of images of your teeth into a computer, which then creates a computer model of your teeth.  Using this device, I can obtain more accurate results with my crowns and bridges.  This technology is not yet in widespread use among dentists due to its high initial cost.  But over the next 20 or 30 years or so, most dentists will be using this technology.  No impressions.  Crowns and bridges completed in one visit, with more accurate fits, while you wait.  No multiple visits for fittings.  No wearing temporary crowns.  For my patients and me, this has been a gift.  Talk to your prosthodontist about this.  Or have him contact me.

I didn't mean to be short with you.  I was just curious why you weren't getting your answers from the docs who know your condition the best.  Never be afraid to ask.  

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Howard Finnk, D.D.S., P.A., CEO

Expertise

I am a Family, Implant and Cosmetic dentist. I will answer questions on any aspect of dentistry and matters relating to the smile, gums, jaws and lower face. Member American Dental Association, Florida Dental Association, Broward County Dental Association, and Atlantic Coast District Dental Association. I have served as District Council Member of Alpha Omega, as well as serving for one term as its President. I am also a member of The Vedder Honors Society, Broward Dental Research Clinic, and Mount Sinai Hospital Guild. I have served as a Volunteer for Project Dental Health and The Tri-County Dental Health Council.

Experience

Having attained over 30 years of clinical experience in private practice in Michigan, in 2001 I was re-certified by taking and passing the Florida State Dental Board Examination. After moving to Florida, I spent nearly 10 years re-honing my skills while working as an Associate Dentist for several large dental groups. In September, 2004, I was appointed Adjunct Clinical Professor at Nova University's College of Dental Medicine. I am certified in placement of Mini Dental Implants, and I am Director of The Florida Implant Center (floridaimplantcenter.com). On March 1, 2010, at the age of 62, I began all over again by buying a dental practice near my home in the Fort Lauderdale area. As sole owner and Chief Dental Officer of the new Nob Hill Dental Center (nobhilldentalcenter.com), I can now carefully provide dental care to patients who care, all within a caring, joyful environment. Over my career lifetime, I have provided thousands of diagnoses, fillings, crowns, bridges, root canals, periodontal treatments, TMJ therapies, partials, dentures and extractions, and dozens of implants for my patients. The only aspect of dentistry with which I have very little experience is orthodontics.

Organizations
American Dental Association, Florida Dental Association, Broward County Dental Association, Atlantic Coast District Dental Society, Vedder Honors Society, Broward Dental Research Clinic, Alpha Omega Alumni Association, and American Association of Dental Implantologists. Formerly, American Academy of General Dentistry, Michigan Dental Association, Macomb Dental Society, Detroit District Dental Society, Tri-County Dental Health Council (a charitable dental care organization)

Publications
"How To Save Money At The Dentist" Going to press soon.

Education/Credentials
Bachelor of Arts and Sciences in Psychology from Wayne State University Doctor of Dental Surgery from University of Detroit College of Dentistry Adjunct Clinical Professor, Special Needs Department, Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida

Awards and Honors
Membership in The Vedder Honors Society

Past/Present Clients
HIPAA rules do not allow me to post this information.

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