Maryland Bridge (Bonded Resin Retainer)

The Maryland bridge, or bonded resin retainer, is an alternative to implants and conventional crowns to replace missing teeth. This type of replacement procedure can be considered when the space to be restored is next to teeth in good alignment that are not heavily restored with filling materials. Because this type of bridge is adhesively bonded to the enamel on the abutment teeth, having adequate enamel is important. A Maryland bridge is fixed into place and is not meant to be removed at night.

Maryland Bridge vs. Fixed Bridge

One advantage of this process over a conventional bridge is that a missing tooth can usually be replaced with a minimum amount of preparation (drilling) of the remaining teeth. It is not necessary to prepare the tooth to the same extreme degree as with full tooth coverage restorations (crowns or caps). This method is an extremely conservative procedure. It is also less expensive (about one quarter less) than a conventional bridge. Tissue health around the abutment teeth is usually excellent because little or no preparation of the tooth structure near the gingival (gum) tissues is needed. Unlike conventional full coverage restorations, teeth prepared for a Maryland bridge retainer will not need endodontic treatment (root canal therapy) at a later date.

If the patient has abusive eating or bruxing (grinding) habits, this type of restoration is contraindicated. Although we do consider it more of a restoration for posterior (back) teeth rather than anterior teeth, it does display metal more so than a conventional bridge. The biggest disadvantage of a Maryland bridge is that the expected life may not be as long as that of a conventional bridge made of full coverage crowns. This technique was only introduced in the early 1980s and therefore does not have the extensive successful history of full coverage bridges. While breaking of a Maryland bridge is not likely, debonding can occur, requiring a re-cementation. In some rare instances, it might have to be redone. In either case, you may be charged a fee for the procedure. A Maryland bridge is a fixed replacement for a missing tooth, but one that will need to be redone in the future. The success rate at 5 years of Maryland bridges in our practice is approximately 80%. However, this is a much better result than the national average, which shows a success rate of about 33% at 4 years. Maryland bridges are most appropriate for single-tooth replacement. 

If dental implants are not an option for you for tooth replacement and you do not want the teeth on either side of the space to be radically prepared (cut down or drilled), then you should consider the Maryland bridge technique. For many patients, the advantages of less drilling of the teeth and the reduced cost make it a desirable alternative.

If you have any questions about the Maryland bridge technique, please feel free to ask us.

What Are Implants?

Have you lost your teeth due to: severe tooth decay, gum disease, trauma, or even a failed root canal? You may qualify for implant treatment. Dental implants are used to replace one or more missing teeth in your mouth. Implants are made of titanium or similar materials that are well suited to the human body. Implants are artificial replacements for teeth roots that support a restoration or a dental appliance. 

Twenty-five years ago, if someone described how missing teeth could be replaced with implants, it might have been called a miracle. Ten years ago, the use of dental implants to replace missing teeth might have been called astounding. Today, implant procedures are called routine. We would like you to have a basic understanding of what implants are, what can be expected from them, and what limitations they might have in your specific area of need.

A dental implant is a synthetic metallic root substitute that is placed or implanted in the jaw bone. It can be used to replace a single missing tooth, provide an abutment (anchor or retainer), replace several missing teeth, or provide added retention to a removable dental appliance such as a full denture. In fact, if you are missing all of your natural teeth, it is possible to have maxillary (upper) and mandibular (lower) fixed replacements. The replacements do not come out and you cannot remove them yourself.

Two separate events are needed when replacing a missing tooth with an implant. First is the surgical phase in which the implant is placed. In the second phase, the replacement teeth are constructed and fixed into proper position.

The implant placement procedure involves making a small incision in the gum area where the implant is to be placed, preparing a site in the underlying bone, inserting the implant into the prepared site, and closing the tissue over the implant with several sutures. This area is left undisturbed, usually for 4 to 6 months. More healing time may vary due to the density of your bone. The lower jaw is composed of bone that is more dense than that of the upper jaw. This healing time allows for the slow integration of the implant within your jaw. The implant is held in place by the bone.

 
After the healing and integration of the implant, the placement site is exposed by reopening the gum. A post will then be fastened to the implant by cement or with internal threads. The crown, bridge, or other type of replacement will be attached to this post. Some dentists prefer to do all phases of the implant procedure themselves, but many choose to perform either the surgical or prosthetic (the actual construction of the replacement device) only. If this is the case, a periodontist or oral surgeon will perform the surgical portion of the implant placement.

Implants are very successful. Maxillary and mandibular implants are more than 90% successful. Lower implants have a somewhat higher success rate than upper implants. Occasionally, implants fail, but it is not common. Chances of an implant failure, many times, can be determined during or after the surgical phase before the replacement tooth or teeth are constructed.

Smokers take note: There is a heightened risk of dental implant failure among smokers - as much as a 20% greater failure rate!

We will discuss with you the requirements and options for your particular situation. There are usually several possibilities for effectively replacing missing teeth. It is important to decide on the design of the implant-retained replacement prior to the actual implant surgical procedure. Position and alignment of the replacement teeth need to be carefully considered before determining the location of the implant.

If you have any questions about implants, please feel free to ask us. 

Partial Dentures

A partial denture is designed to replace one or several missing teeth. You may consider a removable partial denture to replace the missing teeth, if:

· you have missing teeth

· the remaining teeth cannot accept a fixed bridge

· there is not sufficient bone for implants

· finances are limited

Removable partial dentures have been made by dentists and worn by patients for many years.  Partial dentures are composed of three different materials. A cast metal base with clasping arms holds a pink plastic gum tissue and plastic or porcelain teeth. The metal clasps are silver in color and, depending on the individual circumstances, may or may not be visible when you talk or smile. These clasps are absolutely necessary to hold the partial in place. Their location and design are dictated by the shape and position of your remaining teeth and which missing teeth will be replaced. We will show you where the clasps are to be located in your mouth. Most of the time, the amount of preparation (drilling) of your natural teeth needed to ensure successful clasp design is minimal. Often there is no need for a local anesthetic injection. This is unlike fixed bridgework, which always requires significant tooth reduction for proper design and fit.

If you find that the appearance of the clasps will be objectionable, then you might consider different possibilities. It is common to place crowns on the teeth that are clasped by the metal arms, and then place the clasps inside the crowns. This will give you a more natural appearance, but it will add to the ultimate cost of treatment. It involves significant preparation of the natural tooth and you might also want to rethink about fixed bridges or implants.

The base of the partial denture will rest lightly on your gum tissue. At some time in the future it is expected that you will need adjustments to the base. Usually this means an addition of more pink material to the denture base. Clasp arms will loosen and need to be tightened at various times. Weight loss or gain will also affect the fit of the base of the partial.

Although a partial is less expensive than a fixed bridge, which is metal and porcelain cemented into place, there are several possible drawbacks. It is much more bulky than a bridge and is more difficult to wear initially. You may have to adjust the way you speak to accommodate the extra bulk. After awhile, this will not be much of a problem. And depending on the position of the retaining clasps, they may be visible when you talk or smile.

Do not sleep with the partial dentures in place.  The partial dentures absolutely must be removed during sleep time to be cleaned and give the clasped teeth a chance to rest. The gum tissue under the denture needs a chance to breathe and reestablish proper blood circulation. The partial denture can compress the tissue and reduce blood flow in the area. Plaque can accumulate on your denture and your gum tissue.  Use a very soft toothbrush to gently brush your gums.  Also brush your partial denture daily with a denture brush and denture cleanser.  Always store your partial denture in water when you are not wearing it.

Porcelain and Resin Veneers

When people speak of “bonding” their teeth to make them look better, they are usually referring to either porcelain or resin veneers. Veneers cover only the outside portion of the tooth, the part that shows when you smile or talk. In fact, all tooth-colored dental restorative materials are bonded, whether the restoration is in a front tooth or a back tooth. Strictly speaking, in dentistry, bonding refers only to adhesive joining of two dissimilar materials. Silver fillings can be bonded, as can crowns (caps).

Porcelain and resin veneers are placed in order to correct slight or severe defects in tooth alignment, shape, or color. They are also placed when teeth have been moderately restored and the teeth have been weakened. This is done when there is still enough enamel left for the bonding to be successful. If the teeth are in very poor alignment or there is insufficient enamel remaining, bonding to improve the appearance is not possible. At that point orthodontics or full-coverage crowns must be considered. The most common use for bonding veneers, either porcelain or resin, is to improve the cosmetic appearance of the patient.

Without question, porcelain veneers look the best and last the longest. They are indicated when the teeth are in fair to good alignment or when a more pleasing tooth color is desired. They are not usually placed in a patient under 16 years of age. The procedure usually requires some slight to moderate tooth preparation (drilling). Local anesthesia is usually necessary. The procedure requires two separate appointments, approximately 10 days apart to complete. This is because the veneers are constructed in an offsite laboratory. Once bonded into place, the porcelain veneers become very strong. The success rate is high, and they can last up to 12 or more years. Anything that will break your natural teeth can break the porcelain veneers, for example, hard candy or frozen candy bars. Veneers are highly stain resistant. They are a good treatment choice when all the front teeth are being restored. They are more expensive than resin veneers, but they last longer and look better than resin. Porcelain biting surfaces can cause more rapid wear of opposing natural teeth.

Resin veneers are also available. They are placed by the dentist in one office visit. Resin veneers are used in similar situations to porcelain veneers. However, they last only half as long before requiring repair or replacement. They are advised for patients who are still growing. They look very good but are not as good as porcelain. While repairs to the resin veneers are not too difficult, they have a tendency to chip more than porcelain veneers.

Basically, porcelain looks better, lasts longer, is stronger, more expensive, and requires two dental appointments to complete. Resin veneers are less expensive, easier to repair, and better for children, or if there are financial considerations.

It is very important to come in for regular recare appointments for cleaning and examination if either type of veneer is placed. This way, we will be better able to quickly correct any problems that develop. A 3- to 4-month interval between appointments is customary.

Early Childhood Caries

What is early childhood caries?                     

Early childhood caries, which used to be called “baby bottle tooth decay” and “nursing caries,” is a severe form of dental decay found in very young children who presumably are put to sleep with any liquid other than water in a bottle. Children who have experienced prolonged breastfeeding will have the same type of tooth decay patterns. Many times, the decay is very advanced before the parent notices the problem. This is another reason that we want to see your child for his or her first dental visit while those new teeth are still in the eruption phase.

How does early childhood caries develop?

The teeth most affected by early childhood caries are the upper front teeth. As the child falls asleep with a bottle containing any liquid other than water (or at the breast), pools of the sugared liquid collect against the tooth surfaces. These sugars feed the bacteria found in bacterial plaque to produce an acid, which starts the decay process. When the demineralization process is not stopped through proper prevention, the crowns of the teeth can be destroyed to the gum line; abscesses can develop, and the child can experience severe pain and discomfort.

What is the best prevention?

When oral bacteria are fed liquid sugar for a prolonged period of time, the resulting acid can be very damaging to tooth structure. Similarly, when oral bacteria are fed little bits of sugared liquid, nonstop, over a day’s time, the results can be quite damaging to tooth structure.

We believe the best prevention for this type of problem begins with an understanding of the decay process, and how you can stop it before it even starts. We recommend that you bring your children to the dentist when they are in the infant stage so that we can perform an infant oral examination and discuss with the child’s oral self-care, including:

·         Children should not be put to sleep with a sugared liquid in a bottle. No milk. No juice. No soda. Plain water only.

·         Children, including infants, require daily oral cleansing. If no teeth are present, the gums should be gently wiped with a wet cloth.

·         When teeth are present they should be brushed with fluoridated toothpaste, but only with a very small amount about the size of a pea, or less.

·         Liquid sugars and other easily fermentable carbohydrates such as white bread, cakes, cookies, or crackers should be given with meals and not as “snacks.”

·         The proper level of systemic fluoride should be in place by the time your child is 6 months of age.        

In-Office Power Whitening Technique without Light Activation

Front teeth, the 6 to 10 teeth most easily seen when you talk or smile, are the teeth that can benefit most from an in-office “power” tooth whitening. Just as with back teeth, if there are medium- to large-sized fillings in the teeth, it is probably better if these teeth were  protected with crowns. The in-office power whitening procedure is one of the most conservative and least expensive methods to attempt to lighten tooth color back to a more acceptable appearance.

The procedure involves isolating the teeth to be whitened and protecting the gum tissues and lips. A whitening solution is then mixed and applied to the teeth. The type of application and number of appointments depends on the type of whitening system we believe will be best in your situation.

 

Most patients show great improvement after only one treatment. Since the protective biofilm that normally covers the tooth enamel is removed during the whitening procedure, you should avoid smoking and drinking pigmented liquids (coffee, tea, red wine) for about 24 hours after the whitening is completed. After 24 hours, the biofilm is usually back in place. The final color will usually regress one shade in the first 1 to 3 months, with most of the change coming in the first week. Some teeth may need a second appointment (or a combination of in-office and at-home tray system whitening) to achieve the desired result. The degree of whitening for any tooth is variable and impossible to predict. However, recent studies show that 97% of all patients who whiten their teeth are happy with the result. The color change should be satisfactory for 3 to 7 years.

If you have dental restorations (crowns, bonding), the plastics and porcelain will not change color. You may need to have some of those fillings redone once your teeth are lightened. We will let you know whether you can expect to have some fillings replaced due to the color change. If you are going to have fillings replaced, you should wait at least 2 weeks after the whitening is completed for the tooth color to stabilize before new restorations are placed. Some postoperative sensitivity is possible, but it usually disappears quickly. The tooth enamel or dentin is not damaged by the whitening process.

Tissue Recontouring

When you smile or talk, your teeth are framed by your lips and the visible gum tissue. People looking at you notice your teeth. People notice missing teeth, tooth alignment, gum color, discolored fillings, tooth color, and how much of your teeth actually show. If everything is integrated well and looks natural, people say you have a nice smile! If something does not look natural, it may be easy to define such as crooked, stained, or yellow teeth; periodontal disease shown by red-colored gum tissue; or discolored fillings. Something does not look quite right.

That "something" may be related to the teeth and gum architecture. The position of the gums where they meet the teeth is esthetically important. If teeth look too short, there may be more gum tissue covering them that is considered attractive. You may show too much gum tissue when you smile. There may be a difference in the height of the gum of one tooth versus another tooth. This could be caused by recession from brushing too hard, gum disease, or just an issue with the way the tooth erupted into place. All of these things can take away from your appearance.

There are several, simple periodontal procedures that can correct most of these routine problems. Some involve removal of unwanted tissue while others involve grafting of tissue. Orthodontics might be helpful in some situations. The most extensive procedures will require referral to a specialist.

One type of cosmetic periodontal plastic surgery, involves the gum tissue being reshaped and re-contoured without the use of stitches. This procedure is done in a dental office. One or multiple teeth can benefit from treatment. Post-operative discomfort is usually minimal. However, if tissue is removed then there may be sensitivity.  The improvement generated by this kind of procedure can be startling!