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Loss of teeth – The Sequelae and Solution, Implant Prosthodontics

28 Sep 16 

The damage that loss of tooth can bring about in one’s life is well recognized. While early detection of problems and timely intervention to prevent tooth loss is the best solution it is usually very late by the time we recognize it. It usually begins with the loss of one or few teeth. The usual thought that “only one tooth is lost, I have the rest to manage” is the culprit.

      Every tooth remains in its position as a result of balance of many forces. Say for example, the force of the cheek is compensated by the force of the tongue. If the cheek had to be removed for some reason the teeth would flare out because of the force of the tongue. Similarly every tooth exerts force on its adjacent teeth and on its opposing counterpart. The moment a tooth is removed there is an imbalance of force in that area. There is a loss of equilibrium which results in a sequelae of events.

After loss of a tooth the adjacent teeth slant towards the vacant space. The opposing tooth moves into this space. This will result in food impaction, dental caries and gum disease. This could even lead to temporomandibular joint disorders. Usually the teeth in front when lost are immediately attended to as esthetics is compromised. Seldom do we realize that the posterior teeth (premolars and molars) are important for chewing.

      When a tooth is lost on one side say left side, one tends to avoid that side for chewing. As a result of drifting of adjacent teeth, food impaction becomes a persistent problem. Food impaction can cause foul smell, dental caries and gum disease. This results in habitual use of the right side for chewing. The right side becomes overloaded over a period. The difference may be compared to walking with two legs and hopping on one leg! It won’t be long before one will feel tired walking with one leg. With a prosthetic leg or crutches one can walk much longer.

       Slowly but surely teeth are lost one after the other. It will take few years to realize this. By then one is rendered partially or completely edentulous. Quite often a dentist is approached when a tooth in the esthetic zone is lost or when chewing becomes impossible due to loss of posterior teeth. There are various methods of and missing tooth or teeth. Teeth can be replaced with a fixed or removable prosthesis. The fixed prosthesis may take support from healthy adjacent teeth or implants. This denture cannot be removed by the patient.

        A loose removable denture which pops out every time one has a hearty laugh, or when one sneezes or coughs is any denture wearer’s nightmare. The patient prefers not to smile in public!! A dentate individual does not understand the psychological impact this has on the individual's personality. The edentulous patient who has a loose denture loses his confidence. The patient finds it difficult to face his family, relatives, friends and comrades. This becomes a big handicap. It has a telling effect on one’s performance as an individual at home, at work and in the society. Some individuals prefer to remain at home and avoid family unions and social functions. The response to this handicap ranges from ‘taking it in the stride’ to depression requiring psychological counseling.

        Did you know that denture adhesive is a million dollar industry in the United States of America!!??

         

        Now what is this issue of loose dentures? Can’t the dentures be tightened? Can’t we make dentures that are better fitting? Do the good fitting dentures become loose after a period of time? Is there any method by which we can stop this? Are loose dentures a result of incompetent dentists? My old dentures used to be retentive when it was made – it became loose after few years! The new denture is loose from day one, why!? These are many of the questions we face from our patients.

         To understand this common problem one should understand the anatomic changes that are associated with the loss of teeth. Our teeth are anchored into the alveolar process – a type of bone that is tailor made to support teeth. It may be compared to the foundation of a building. The stronger the foundation, the stronger the building will be. When this foundation is lost, the teeth become loose and fall – seen as a sequelae to gum disease. This alveolar process exists only as long as the teeth are present. From the moment the teeth are removed this bone starts resorbing – in simple words this progressively reduces in size till the basal bone is reached. Though this takes few years it is an irreversible process. 

         When an edentulous patient approaches a dentist it is more often with reasonably good amount of remnant alveolar bone. This means that there is a good foundation available. One should recognize that this foundation is undergoing irreversible progressive resorption! In other words it is shrinking in size. The denture made at this point of time is definitely going to be retentive. Over a period of time the denture becomes loose as the bone is shrinking in size – the denture is not. After few years of use, the denture becomes too big for the ridge. It may be compared to a little boy’s foot in his dad’s shoes. The denture has to be redone! Now the foundation is smaller and the denture is bigger – a challenge to any dentist. The retentive quality of this denture will definitely less when compared to the original one.

           Is this the end of the road? With so much of advancement in science isn’t there a solution? Is there anyway we can stop the loss of this bone? Is denture adhesive a solution?

           Denture adhesive is a solution and it helps people to manage the prosthetic denture for some time. But this does not address the issue of loss of bone!!

           Few decades back an astounding discovery was made that commercially pure titanium integrates with bone. It was found to be biocompatible with absolutely no allergic response! What more, now it has been established that they are perfect substitutes to natural teeth. They are called dental implants. These dental implants are buried into the bone and act as an artificial tooth root! Once they integrate with the bone a crown is placed on top similar to natural crown! One can chew as with natural teeth. It brings back the smile and confidence – A goodbye to loose dentures. It brings back the youth in you! It Changes your personality and your attitude towards life. No more shying away from social functions. No more eating alone! Laugh to glory and sneeze confidently!! Yes it is all history! To top it all it stops the resorption of alveolar bone!!

           Who should be approached to place implants? Is it a painful procedure? Are there any contraindications? How many implants are required if all the teeth are lost? Is it very expensive? Is age a barrier?         

            The branch of dentistry that deals with the replacement of teeth and associated structures is called Prosthodontics. A dentist who specializes in this science is called Prosthodontist. The science of implantology is essentially a prosthetic driven science – in other words implants are placed to replace lost teeth. Implantology is essentially a Prosthodontic discipline with a surgical phase. An Implant Prosthodontist or any dentist who has undergone a recognized training program in implantology may be approached. 

Placement of implant in the bone is probably the simplest affair in implantology. It is a painless and comfortable procedure for the patient. The procedure is a more pleasant experience than a simple extraction! Usually the anesthesia that is required is less than that is required for extraction. The thrust is on diagnosis and treatment planning.

            The status of general health is of significance. Implant is contraindicated in some conditions such as, uncontrolled diabetes, severe osteoporosis and irradiated bone. The health of the bone and its reparative capacity is of immense importance in the success of the implants and this is compromised in the above mentioned conditions. A healthy person may have an implant placed even at the age of 100. This means that while a 30 year old uncontrolled diabetic may not be an ideal candidate for implant, a healthy 90 year old lady, may be a good candidate. A controlled diabetic can have implants with good prognosis!

            The main limiting factor is the available quantity and quality of bone! This may be compared to soil testing before the construction of a building. If there is sufficient bone of good quality, implant placement is a simple procedure. If bone is not sufficient bone grafts may be used and an extra appointment may be required. Bone grafting is a routinely done procedure to save natural teeth. If sufficient bone is present, ideally one implant supports one crown. If many teeth are missing, fewer implants may be used to support all the missing teeth. The implants will act like the pillars of a bridge bearing the load of all the missing teeth.

 The number of implants that may be used to support the missing teeth is decided by the amount of bone available and the economic factor. If all the teeth are missing a removable complete denture, retained using 2 implants may be used to replace all the 14 missing teeth of an arch. There is an option of a fixed denture using 6 implants, replacing 14 missing teeth. If there is sufficient bone and the patient demands the best he could have individual implants replacing the missing teeth, in other words he could have up to 14 implants in one arch alone replacing 14 missing teeth! So there is a range of treatment options which may be tailor made for the patient!

Implants are made of titanium. Implants of different shapes and designs and are made with high precision. The sterilization protocol followed is also of very high order as it is permanently placed in the bone. Precision tools are used during the surgical and prosthetic phases. These factors influence the price of an implant. One should be careful about the implant being used. Implants that are ADA and CE accredited are of dependable quality. Quality has a price! Dental implants are becoming affordable for the common man now.

Loss of teeth was a sign of the aging process in the past. With the tremendous progress that the field of medicine has seen in the last century man is able to live a longer life. Man is blessed if his long life is a healthy one and the first step is to have healthy teeth. Without natural teeth or stable and retentive artificial teeth, food is always compromised. Digestion is impaired.  Soft food is preferred. Malnutrition is the result. It is in old age that food has to be broken down well in the mouth. It is important to have stable teeth for the same – natural or implant supported!

“I should rather have lost an arm, as long as it is not the one that wields my sword. For I must tell you, Sancho, that a mouth without molars is like a mill without a millstone, and dentation is to be valued much more than diamonds.” 

Miguel de Cervantes, Don Quixote

-Dr. Vinod Krishnan