Replacing Missing Lateral Incisors

miss_feminem

Hello all,

I have been missing my two laterals incisors since I was a child. When the baby teeth fell out I had no replacement adult teeth. This caused by two front teeth to move apart causing a large gap.

I have recently (in the past 5 months) gotten braces to move the front teeth back in to their correct positions and we're (myself and the dentist) both surprised at how fast the teeth are closing (as it was a pretty big gap).

So now that the teeth are nearing their final destination, I am thinking about my options for replacing the missing lateral incisors. My main concern is keeping my natural teeth in the best condition I can. Therefore, I would be completely against getting a conventional bridge.

I have researched implants and these look like the best option for me. However, my dentist also recommended a Maryland Bridge and explained how this works and I've done my own research.

So, my question is, has anyone had implants or a Maryland Bridge and are you happy with the results? Can you bite and chew food as though you had your own natural teeth, etc?

Or has anyone any other suggestions for replacement teeth?

vishal

A Maryland is a temporary solution. Implants would be best. Be sure to visit your restorative dentist before the braces come off to make sure that you have the correct amount of space and the proper positioning of the roots. Don't wait too long to make your choice after the braces come off as the roots of teeth will relapse very quicly even with a removable retainer with false teeth

BryanL

It's not a simple question and doesn't have a simple answer.
To get a perfect result in a case like this takes a lot of training and planning and usually time, it may involve more than one specialist.
I couldn't say which is the best option for you but both can give stunning or less than satisfactory results, depending on the case.
Bryan

georgieporgy

Vishal and Bryan's comments are good. I think I'm older (57) than both of them, so speaking from experience I would say it's a very difficult call to make. The patient has to be fully informed and then make the decision.

I've fixed this situation with implants, 3 unit fixed bridges, 2 unit cantilevers, 3 unit marylands, 2 unit marylands, and partial dentures. I have never been totally happy with any restoration. And I think that is because I have been working on virgin teeth in perfect mouths. It seems a shame to be drilling perfectly good teeth but at the same time you can't have a young person walking around with great big gaps. (American tourists would think we were backward)

The choice of treatment depends on the person and the mouth. The patient is usually aged between 16-30. A bit young for implants I think. If you insert an implant in a front tooth for a 20 year old can you be sure it will last till age 85?. I honestly don't know. (Fitzgeme where are you?)
My choice at this stage in life (and I mean my life, not the patient) is a 2 unit maryland bridge cantilevered off the canine. It does depend a bit on the Bite, but if the patient's bite is 'lite' then this can last a long time and is minimally invasive.
I would never ever again do a 3 unit maryland. (it's possible some of them might work out ok??)
can you eat normally on a maryland bridge? depends on your bite. it works well with some and not with others. You have to ask your dentist about this.
An implant really would feel normal and strong etc, but you would have to be prepared to have further work done 20/30 years later.

miss_feminem

Thanks for the replies everyone

I'm slightly confused now as one of you say a Maryland Bridge is a temporary fix and then another says that an implant will need to be revisited in 20/30 years time? Why would the implant need to be revisited?

I thought an implant would be similar to a real tooth? In that, as long as I cared for it like my real teeth, it wouldn't cause me problems?

My dentist has said that I am a very good candidate for a Maryland Bridge, but I'm not quite sure myself if that's the route I want to take.

I was wondering if I got the bridge and then decided I wasn't happy with it, would it be possible to then get impants further down the line? (No, I'm not rich, lol). But then I read vishal's post about the roots relapsing and then implants may no longer be an option.

Ah, such a tough decision, I'm not sure what to do

miss_feminem

Oh and just a side note: I'm 24 in case that makes any difference.

vishal

many dentist believe marylands are a temporary solution as they may debond frequently and you will have to have them re-cemented.
i was thought, the best way to retain space for a lateral incisor where the space has been managed with orthodontics is with a maryland bridge, with retainers on both canines and central incisors. this will prevent the roots of the central incisors moving into where the potential implant will go. the only problem with having retainers on both canines and central incisors is that the bridge may debond more frequently due to differential tooth movement between the two teeth.
if the bridge debonds off one tooth, you may not notice this and this is a site for decay or for potential relapse.

btkm8unsl0w5r4

My two cents.

Post ortho defo go 3 unit. Cantillevers are fine except where you require ortho retention. Cantillevers after a while tend to rotate the canine and tip the canine root into the lateral space. The debonding arguement and caries arguement against 3 units pales in the light of having to put brackets back on at a later date.

Marylands are a medium term solution not a temporary solution. Last about 7 + years if designed correctly and bonded well to good enamel.

The implant is the best option, no doubt however costs are higher. Next is the maryland bridge, aesthetics not so good at gum level, lower cost, less lifespan. Then a partial denture as a last option.

miss_feminem

Thank you everyone for your replies. I'm going to make an appointment to get assessed for implants. Assuming I have enough space and my bone is sufficient, I think that's the route I will take. Here's hoping I win the lotto in the mean time :P

ballsymchugh

Harvey Fluffy Foot wrote: »

My two cents.

Post ortho defo go 3 unit. Cantillevers are fine except where you require ortho retention. Cantillevers after a while tend to rotate the canine and tip the canine root into the lateral space. The debonding arguement and caries arguement against 3 units pales in the light of having to put brackets back on at a later date.

Marylands are a medium term solution not a temporary solution. Last about 7 + years if designed correctly and bonded well to good enamel.

The implant is the best option, no doubt however costs are higher. Next is the maryland bridge, aesthetics not so good at gum level, lower cost, less lifespan. Then a partial denture as a last option.

there are times i wonder what was i doing when i missed this stuff in college!! i would've suggested marylands (a decent wing shouldn't debond so easily if designed correctly) but anyway, fitz is the expert here.

btkm8unsl0w5r4

Dont get me wrong ballsmchugh I love resin bonded bridges and do loads myself (including muli-pontic posterior ones . I think however that a lot of poeple saw a study by Dunne and Miller and another by Nico Creugers showing that cantillevers had as good a success rate as double abuted bridges. This may be true but it does not mean you always choose a cantillever where possible. I double abutt post ortho, Perio cases, where large restorations or little enamel remains, most posterior cases. The only time I use cantillevers are for laterals where some say the optical charastics of the central is altered by the resin wing. With cantillevers you need a very definate contact with the pontic and the tooth without a wing.

ballsymchugh

i would've jumped at cantilever bridges here to be honest. on a hunch (given patient's age and just finishing ortho) i'd presume that the 3's and 1's are in perfect nick, the spacing is just right, and i wouldn't want to do too much damage to either. but that's also because i haven't done anything close to an implant at all yet!!
time to think about specialising i think!!

georgieporgy

Are you guys familiar with Ray Bertolotti? aka the father of adhesion dentistry. He favours a cantilever off the canine for best long term retention and minimum invasion of healthy teeth in a young person. The jury is out on when one stops being young.

I hate cantilevers and never do them except in a case like this, which is rare. I charge 2000 euro for such a cantilever and they look great. I find them more difficult to do than a 3 unit fixed bridge.

In 35 years I have only seen one instance of a rotated canine where the pontic rotated labially. That was in 1976 in an old lady who had had a cantilever placed about 30 years earlier. I fixed it by replacing with another cantilever.

I agree that an implant is really the best option but I have seen the occasional failure and some that were not very aesthetic (placed by a non cosmetic dentist perhaps?:D)

btkm8unsl0w5r4

I think the key here is that its just post ortho, retention is key (of the arch not the bridge). Retention of the root position of the central is important if implants are the next step, if the central has been moved a good bit orthodontically it can tip its root into the lateral space without much change in the coronal position. I have to say I have seen quite a few (including my own - Doh) cantillevers off canines rotate out of contact (google geller wing for a solution - the contact is made concave to encase the distal of the central, causes a little flossing trouble but prevents rotation) but only in post ortho cases and cases with poor posterior support and a very anterior bite forces.

Yes cantillevers last just a well (on laterals), I dont prep for resin bonded (Dahl in prior to impression) so I dont see any conservation issues with two wings. However I hate cantillevers most of the time unless there is a controlled implant or removable occlusion with no contact on the pontic, huge thick connectors, really good abutment teeth and no other option.

Lateral implants are tricky, the position in 3 dimensions espically mesio distally (need to be as close to the canine as possible) and apico-coronally (too superficial is a total disaster). Often grafting is needed and narrow neck implants which have their own intricies. I agree georgie that sometimes suboptimal results are achieved with implants.