Missing Teeth

Missing Teeth

One of the most distressing thing for anybody is too lose a natural tooth due to various reasons. It can adversely hamper the quality of life of the patient in many ways. It affects both the aesthetics and function of the patient. A missing tooth or teeth alters the mastication or chewing ability, speech. Also over time if a missing tooth is not replaced it causes bone loss in the jaws and loosening of the overlying soft tissue.Significant bone loss leads to loss of vertical height in the patient which is the distance between the nose tip and the chin. this can severely affect the oral functionality and the facial aesthetics or appearance. This also makes replacement very difficult over time.A loss in vertical height put excessive strain on the temper mandibular joint (TMJ) over time. This results in a common complaint of pain and tenderness in patients on mouth opening and chewing. It also causes Trismus or restricted mouth opening due to the discomfort in the joint.

Also over time the gap or space left by a missing tooth can lead to movement or tilting of the adjacent teeth to fill the gap naturally as nature desired. Also the teeth in the opposing jaw which lies opposite the missing tooth holds it in place. Now when this tooth goes missing there is supraeruption of the opposing tooth in which the tooth moves out of the socket above the occlusal plane. This leads to loosening and loss of the opposing tooth.In addition to the above problems loss of an anterior or front missing tooth severely affects the aesthetics. In such a case the patient is very conscious when smiling or speaking. This also hampers the speech thereby gravely undermining the confidence of the patient. All the above problems can be avoided by timely and accurate replacement of missing teeth.Since replacement teeth should last for at least several years, it is very important to choose the correct option depending on various factors like: Patient’s concern, oral health, time frame available, cost effectiveness.

There are three main options available to replace missing teeth. These include the following:

  1. Removable dentures : These can be either complete or partial dentures. As the name suggests these can be removed and cleaned out and placed back into the mouth. This is one of the oldest technologies available.The advantage of this system is that the centre and the surrounding area can be easily cleanedBut over time this system has become outdated as there are several problems associated with
    This like : Fitting and adjustment of a removable denture takes a lot time and effort on both the patient and dentist’s part. One of the biggest disadvantage is the significant amount of bone loss associated with removable dentures. Also in many cases it causes a lot of discomfort for the patient as the base plate rests directly on the gums. Speech of the patient can also be altered and it takes time to to speak effortlessly while using the denture.A complete denture in the upper and lower jaws replace the complete set of missing teeth in an edentulous patient. A partial denture replace few or several missing teeth in a partially edentulous patient. This generally consist of a metal framework covered in acrylic with good quality acrylic teeth.
  2. Fixed bridges : In this system a bridge or a fixed restoration is used to replace missing tooth or teeth. In this system the adjacent teeth next to the edentulous area are reduced or ground to act as support or abutment for the bridge. These abutments hold the bridge in place.There are certain advantages of this system like it is fixed to the adjacent teeth and does not need to be removed and placed again and again by the patient. This significantly reduces the patient hassle. Also a fixed bridge is much more comfortable as there is no baseplate resting on the soft tissues so it is much less irritating to the gums. This is also much more aesthetic in which the prosthesis lies on the soft tissue, also if the shade matching is done well it gives a very good result. Ceramic or porcelain bridge can be matched very well to the adjacent teeth. Also the forces of mastication or chewing are not transmitted.The disadvantage of a fixed bridge is that it is more difficult to maintain the gingival or gum health. It is imperative to keep the soft tissues surrounding the abutment teeth clean and the gums healthy. Also it compromises the adjacent or abutment teeth by grinding them it can cause sensitivity and pain over time. In some cases over time these teeth need pulp therapy or root canal treatment. This is the main disadvantage as compared to an implant supported crown.
  3. Dental Implants : Dental implants are considered the golden standard of care for prosthetic replacement of missing teeth. There are certain things which need to be considered before planning an implant replacement like:
    • Area or space available for replacement of missing teeth.
    • Condition of the bone in edentulous area including structure and hardness.
    • Medical condition or health of the patient
    • Habits like smoking, tobacco chewing etc
    • Cost of treatment
    • Patient preference.

    Dental implants have a good success rate if the above factors are taken into consideration. In a healthy patient with adequate bone height and width implants are well accepted. Good and regular oral hygiene habits are of utmost importance. Also, certain conditions like uncontrolled high blood pressure and diabetes are another deterring factor.

    The steps involved in straightforward placement of dental implants are:

    1. Formation of a customised treatment plan for individual patient after a thorough clinical and radiographic examination.
    2. After surgical planning first the extractions are completed following which implant placement is performed. In this the actual implant made of titanium is placed in the bone after local anaesthesia at the surgical site and adequate osteotomy.
    3. After completion of the surgical step the site is closed, and the body is given time to heal which is about 6 to 12 weeks.
    4. After the completion of the surgical step and adequate healing time, the prosthetic step is initiated in which the implant head is once again exposed.
    5. Following this the final impression is made and the bite of the patient is recorded for the final prosthetic replacement that is either a crown or a bridge.

    Like every surgical or dental procedures implants have certain pros and cons, the advantages are:

    • Dental implants are fixed in the bone and not removable.
    • Implants have the best aesthetics and appear almost like natural teeth.
    • They maintain the integrity of the jawbone and soft tissues.
    • They are very comfortable for the patient for chewing and mastication.

    The disadvantages are:

    • Regular cleaning and maintenance of the implant and surrounding tissues is very important or else it can result in implant failure due to infection in the gums.
    • Implant rejection: In some cases, the body does not accept the implant as a foreign body reaction. This results in implant loosening and loss.
    • In rare cases, if the implant is placed too close or impinging on vital structures or nerves it can lead to pain and partial parasthesia or loss of sensation in the surrounding soft tissues.

    In certain cases, implant surgery is not straightforward and requires certain surgical manipulations like:

    - Ridge augmentation or enhancement where there is deficient bone height and width due to bone loss. Various techniques used are bone grafting or enhancement using bone graft material.
    - Sinus lift: In certain cases when the sinus margin is very close or is low, that is close to the ridge margin, in such cases first the sinus floor needs to be lifted or elevated to create space in the bone to place the implant.


Dr. Gargi Kandhari

Conservative Dentist and Endodontist, Aesthetic Dentist

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