Bridge vs implant pros and cons – Questions to guide your decision

1. What are your expectations?

   Time and initial complications are longer and higher with implants than bridges, therefore you must be financially and emotionally prepared for things like failure of bone graft and failure of the dental implant.  The fact is that placing an implant is a surgery with known and unknown complications.

2. What are the financials of the situation and what is the insurance coverage?  

   The cost for either is almost the same, if everything goes right.  In the short run, a bridge is just slightly cheaper than an implant and usually more predictable; ie less unexpected costs.  Some insurance plans will not pay for one or the other, so if utilizing insurance that may be the deciding factor in choosing.

3. Do you need a bone graft and if so to what extent?

   Deficient bone favors a bridge as bone grafting is more expensive, time consuming, and as with any surgery has known complications (most significant being infection causing graft failure).  The location and volume of the deficiency is important.

4. What condition are the teeth next to the space in?  Do they have root canals, bone loss, or existing crowns?

   If teeth adjacent to the space need a crown or are likely to need one in the future AND have good bone support – a bridge is favored.  Bone loss on the surrounding teeth favor an implant.  Virgin teeth may favor an implant but depending on patient age may be a great indicator that that person does not get decay or bone loss and that a bridge will likely hold up VERY well.  Heavily restored teeth with little physical structure left to support a bridge or teeth that have existing root canals favor an implant.  A root canal on a tooth next to the gap does lower the success rate of bridges.

5. Dry mouth?  Caries risk?  Oral hygiene?

   Dry mouth, caries (cavity) risk, and someone with a history of not doing a very good job of flossing and brushing all strongly favor an implant.  Don’t want to do a bridge on someone who is likely to lose one of the supporting teeth to decay.

6. What is the experience and knowledge of the doctor?
   

   A dentist is much more likely to be proficient at a bridge than placing and restoring implants.  It takes more skill and experience to place and restore excellent looking implants.  I am biased, but I feel a dentist who places their own implants is more equipped to help you make the decision of implant or bridge.  For one thing they known more of the complications, issues, and requirements of both.  If your doctor does both then the financial interest of steering you one way or the other is gone and/or the issue of “if all you have is a hammer everything looks like a nail” is also gone.

7. Where is the space?
   

   Survival rate of back teeth bridges and implants is very similar but in the front implants survive better.  Upper jaw bone is weaker and implant survival rates drop a little.

8. What is the age and health of the patient?

   If older the decision is less important because statistically whatever is done does not need to last as long.  Youth leads more towards implant route.  Poor health in an older individual favors a bridge (unless that poor health includes dry mouth).

9. Patients experience and/or perception of either bridge or implant.

   If the patient has had a negative or positive experience with one or the other it is often wise to just stick with that.  Many times, as you can see from the meta-analysis below, the long term success rates are the same.  Basically this comes down to a personal decision and although it seems like a “big” decision, it often doesn’t matter which you choose.

10. Smoker?

    Everything fails at a higher rate with a smoker.  Heavy smoking might favor a bridge, but #3 is and #5 are often worse for smokers too.

11. Attached tissue in area?  Need tissue graft?

    Without attached mucosa the area favors a bridge.  Research says this does not impact the long term survivability of implants but many in the field, including myself, do not feel that is accurate.  Also, without attached tissue some pain may occur around the implant as movable tissue rubs against the implant.

12. Future of other teeth in the mouth.

    The more teeth someone is missing the more that favors an implant because once an implant is placed it can be used for different things in the future.  For example if a 35 y.o. gets an implant to replace a single tooth and 40 years later is missing many more teeth, the implant can be used to attach a bridge or denture to.

Interesting systemic review (Levin JADA 2013 Oct) favoring the preservation of natural teeth over extraction and implant placement.

This website is attempting the same as I am with this page, to make the decision process a series of questions based on literature. I think it is an excellent platform to build off of when deciding implant v bridge.

Below this is all the implant or bridge pros and cons research.  Primarily it is on longevity and complications of the two options.

A dental bridge was used to fill the space AFTER a dental implant had failed.  This failed dental implant case can be seen on the link.

3 unit dental bridge

Failure rates of 3 unit bridges are difficult to pin-point because different studies use different criteria for determining what a “failure” is.  If the bridge abutment gets an amalgam patch, is it a failure?  If the porcelain fractures off of one cusp, is it a failure?  What about when an abutment requires endodontics? In these cases the bridge typically lives on but many studies define it as a failure.  I believe because of these 3 issues, and a few other less important ones, these numbers tend to be lower than what one should expect.

I believe only situations in which the lay person would consider a bridge a failure should studies consider it a failure.  Those would include loss of abutment tooth or massive unrepairable decay on abutment tooth (the last one is determined to some degree by the skill of the operative dentist).  The rest of the problems should be reported separately as “complications” and given it’s own percentage.

Research on dental bridges – Greater than 10 years

Reitemeier study private practice 94% at 11 years; ‘metal ceramic defect’ 82% at 11 years  VITAL only

DeBacker study basically RCT hurts long term survival=help decide bridge or implant

• year 20 was 83.2% for the vital group and 60.5% for the RCT group

Debacker 2008 IJ Pros RCT really bad for 4 unit bridge especially maxilla

• Maxilla RCT only 25% and Mandible RCT 67% Vital 74%

Creugers 1994 meta-analysis shows survival rate of bridge (replacement for any reason)

7. 7. • 90% at 10 years and 74% at 15 years

Napankangas study dental student bridges

7. 7. • 18 year survival rate of the FPDs was 78%

Reitemeier private practice

7. 7. • 94% 11 years survival and 82% w/o problems at 11 years

Scurria 1998 meta analysis  This study is excellent!!!  I believe this is the most accurate data available because their definition of failure is removal of bridge.

7. 7. • 93% at 10 years and 75% at 15 years

With a broader definition of failure that include bridge removal and/or technical failure requiring replacement.

7. 7. • 87% at 10 years and 69% at 15 years

Bart, Dobler, et al. Survival rates

7. 7. • 90% at 10 years 80% completely complication free
      • 81% at 15 years 35% completely complication free

British study British dentistry, especially the free government stuff, is of much poorer quality than just about anywhere else in the world.

7. 7. •  Survival of conventional bridge abutments is 72% at 10 years

Research on dental bridges – 10 years or less

Pjetursson 2007 meta-analysis

7. 7. • 10 years of function 89.2% for conventional FDPs, which is almost the exact same as an implant
      • 10 years of function 80.3% for cantilever FDPs (not sure is single or double abut)
      • The incidence of technical complications is significantly higher for implant-supported reconstructions than dental bridges.  I think he is referring to implant bridges and not implant SCs though.

Sailer meta-analysis 2007

7. 7. • 5 year metal ceramic 94% and 5 year all ceramic 89%

This photo shows our patient who had a tooth in a day placed.  First picture shows how he left the day the tooth was removed and an implant placed.  The second shows healing at 4 months.  The last picture shows the final crown in place.

Single tooth dental implant

Survival rate of an implant is not necessarily easy to determine because different studies use different criteria for their definition of “failing” implant.  I prefer survival to mean present, but often significant bone loss radiographically counts against survival.  The survival rate calculations may or may not include these “failing implants”.  The data appears to slightly favor an implant over a bridge but long term data is not present.

The design of implants is constantly improving and the implants today are often much better than the ones from older studies.  However, this research often uses implants placed in ideal sites which in the real world are not the norm (check the PEARL Network study).  Further complicating implant studies is that surgically placing implants is much more technique sensitive so an implant is not an implant is not an implant.  I have noticed over the last several years (2014 right now) that many implant doctors are becoming implant complication doctors and complications are becoming a significant part of any implant meeting that doctors attend.

Research on dental implants

Lindh 1998 meta analysis

7. 7. • 97.5% at 4-7 years and 94% for implant supported bridge

Creugers systematic review

7. 7. • 97% at 4 years

Pjetursson 2007 meta-analysis

7. 7. • 89.4% for implant-supported SCs at 10 years

Pjetursson 2008 meta-analysis

7. 7. • 97% for implant survival at 5 years
      • “However, biological and particularly technical complications are frequent.”

Pjetursson 2012