That is one of the most often asked questions I help people answer in what I do. What’s the best way to replace a missing tooth? The answer seems simple at first but it’s actually complex. Stick with me & see where this leads you. There are five avenues you can take with a missing tooth (or one that will be missing soon). Quite simply, they are: 1. Nothing (don’t replace it), 2. A removable device, 3. A bridge, 4. An implant or, 5. Move another tooth into its place with orthodontics. Which one is the best one varies wildly from person to person. And as you read, keep this phrase in mind: once you lose what God gave you at birth, everything else is a compromise. Here we go:
Nothing
Did I just say nothing is an option? As in pull the tooth and then leave it missing?! Yes. In some cases that is the best course of action. Usually not in the case of a front tooth. For example, suppose the missing tooth is a second molar (presuming the wisdom teeth are missing – that would be the last tooth in line). An also suppose the patient has restricted maximal jaw opening from TMD (commonly called TMJ). In that case it is often preferrable not to place an implant in the 2nd molar position because surgical access is difficult and it can make the TMD worse. Even in the case of normal TM joints I often don’t love 2nd molar implants. They’re the most difficult to access for daily home care, they often have less attached gingiva around them on the cheek side (a high determiner of long-term implant success), etc. Now suppose it’s not the only missing tooth in the mouth and in fact there are already other missing teeth in the same arch. In this case I often encourage patients to consider the leave it missing option with the intent to simply replace it in a partial denture (a prosthetic replacement for teeth that can often work quite well). One problem with not replacing a tooth is that the adjacent teeth can move (and the opposing tooth will come up or down into the space where the tooth used to be – it’s a thing & it’s called super-eruption). Teeth generally move forward toward the midline and also toward the opposing teeth. So the upper teeth move slowly toward the lower teeth and vice versa. This slow tendency toward tooth movement in these two directions is part of our design and it’s purpose is to compensate for wear on the chewing surfaces of the teeth and also in between the teeth. Teeth generally don’t move away from the midline although I have seen it happen and it remains unpredictable.
A removable device
This is usually a partial denture – so called because it replaces only some of the teeth in the arch. This is different from a full denture where all the teeth in one arch are missing. A partial denture is often considered when the span of missing teeth would be too long for a bridge and/or there are simply so many missing teeth that replacing them all with individual implants is simply too expensive. Additionally, when teeth are missing for a very long time the body resorbs (dissolves) the bone that used to support the roots of the teeth. Often this means there is not enough bone in which to place implants with a reasonable long-term prognosis.
A bridge
A bridge is not a removable appliance. That is one thing that people love about bridges. Let’s look at the pros & cons. Not removable, that’s a pro unless you consider that you now have a piece of hardware in your mouth that is different than the rest of the teeth and you’ll have to modify your home care routine to suit (but hey, all of these options require home care modification). You can’t floss a bridge like you normally floss your teeth. You can floss between the bridge and the adjacent teeth but not the fake tooth – the one you used the bridge to replace. We call that the pontic. For that one you have to thread floss underneath the bridge. Once you get the hang of it it’s no big deal. If you’ve ever flossed around braces you’ve already done this a ton. A bridge is limited in the number of teeth that can be replaced. Two missing teeth in a row? Maybe a bridge can be done. Three? Nope. Too long a span (unless it’s in the front of the mouth and then only if the A-P spread will allow it but that gets really nerdy). How about this scenario: tooth-missing-tooth-missing-tooth. Two missing teeth but there’s a good tooth in between them. Can you do a bridge then? Technically yes but this phrase applies: you tie the fate of bridge teeth together. Let’s say the center tooth fails, what then? Usually you carefully cut the bridge and then remove the center tooth. Now you’re back to a three-missing-teeth scenario and another bridge isn’t an option. And usually by that time there’s no longer enough bone to revert to implants without extensive bone grafting. Back to the simple scenario with the single missing tooth and an otherwise completely unrestored dentition (no fillings or crowns on any other teeth). In this case, a bridge would require removing all of the enamel from two teeth (that’s very invasive to the tooth) and can result in one or both of those teeth needing a root canal. I’m not a fan of that. So that’s where I say an implant is better (but not in every case). Keep reading.
An implant
Let’s go back to the simplest scenario: you have all 28 of your teeth (32 less the wisdom teeth for adults), this is the only missing tooth that you have (or will have), and none of your other teeth have ever been restored (no fillings, crowns, root canals, etc). In that case the best solution is almost always an implant because it spares the adjacent teeth (unlike a bridge which requires that the neighboring teeth be prepared [grind the enamel off the teeth] for crowns). But there are exceptions in this case too. Would this be the second, third, or fourth attempt at getting an implant to work in this same spot? Do you have serious metabolic or health challenges that would elevate the risk of implant failure even if this is the first attempt? Is there something else unique about your situation that would be a contraindication? In medical-speak that means you should not do _____ procedure. If none of those apply then an implant is virtually always the best way to go in this scenario. Here’s a silly scenario: if you have all 32 adult teeth and the one missing tooth in question happens to be a wisdom tooth then, no: don’t replace it at all. Leave it missing. In fact you should probably have the opposing wisdom tooth removed at the same time. If you skipped the Nothing section above go back and read the part about second molar implants. A final note about implants: sometimes people come to me with an unspoken presumption that goes something like this: “if only I had enough money for an implant then that would solve my problem.” I don’t think that is a helpful thought to carry around with you. I have seen plenty of very wealthy people spend a lot of money on implants only to see them fail. That’s because implants are not a direct replacement for your natural tooth. They have their limitations and they are known to fail at a far higher rate than natural human teeth do.
Orthodontics
OK this scenario is exceedingly rare, so by all means give this a read but most likely this isn’t your case. The most likely scenario to see this is in an adolescent or young adult who loses a first or second molar and the wisdom tooth is still in place and the wisdom tooth is angulated correctly and the patient has the ability and disposition to keep the teeth clean from here on out. I can tell you that is a super rare “planetary alignment” indeed. As we get older our bones are less pliable and therefore it becomes difficult if not impossible to bodily move teeth through the bone after adolescence to the degree necessary to wholesale reposition molars like that. Hence it really only works when we’re young. Yes there are additional measures that periodontists and orthodontists can use together (see decortication) to make that repositioning more likely but it gets very costly and we lose predictability.
So the question of what’s the best way to replace a missing tooth isn’t simple. But it can be. A so-called “cookie-cutter” approach is not adequate to take all of this into account. And what I have just described is just the tip of a very large iceberg. My descriptions of the above five options are woefully incomplete (that’s not the point of this writing). You need an approach that is well thought out, follows a formula, and, most importantly, presented to you thoroughly and completely and allows time for questions and “what-ifs” and in language that you can understand. It’s a big decision that requires careful consideration. Don’t make it on a whim unless you really love buyers-remorse. This is why I always insist that we make the final decision only after a complete exam that takes all parameters into account. That can help make the decision process so much easier.