Front teeth missing

Posted: 22 Jan 2013 10:53 AM PST
In an earlier article, I discussed the possible scenarios that patients with multiple missing anterior teeth
may present with. It’s also important to be aware of the multiple ways
you can prosthetically replace a patient’s multiple missing anterior
teeth successfully.
Tooth supported fixed partial denture.
For many patients, a tooth supported fixed bridge is a very predictable
and esthetic option for replacing multiple missing anterior teeth. The
predictability of the result is highly dependent upon the length of span
and the quality of the abutments, as well as the patient’s
parafunctional activity. Research reports a three-unit anterior bridge
on vital abutments as having an estimated 20-year survival rate of 83
percent, while the same bridge if one abutment has endodontic therapy,
drops to a 60 percent survival rate.
For a four or more unit tooth
supported FPD on vital abutments the 20 year survival drops to 77
percent, and if that bridge has an endodontically treated abutment the
survival drops to 56 percent. In spite of these numbers, tooth supported
FPDs can be excellent options for replacing multiple missing anterior
teeth.
Implant supported fixed partial denture.
For many patients who are missing three or more anterior teeth, an
implant supported FPD may be the best choice, especially if the
remaining teeth would not make good abutments because of their
structural condition. In fact for a patient missing both maxillary
centrals but who has poor bone in the missing central incisor locations
for implants, but also very poor lateral incisors from a structural
perspective, it may be beneficial to consider sacrificing the lateral
incisors and placing two implants in their location to create a
four-unit implant supported FPD rather then consider extending a tooth
supported FPD to the canines.
The one challenge we still have
with replacing multiple missing anterior teeth with implants is placing
an implant for every missing anterior tooth, to date it’s very difficult
to manage the gingival esthetic outcome when an implant is used for
every missing anterior tooth. Typically separating implants with a
pontic, except for adjacent central incisor implants, generally produces
a more predictable esthetic result.
Tooth supported removable partial denture.
An excellent tooth supported removable partial denture is still a
highly viable alternative for patients with multiple missing anterior
teeth, especially those with a significant ridge defect in an isolated
area of a few teeth, but good adjacent abutment teeth for the RPD. Using
a removable appliance also has the side benefit of being able to ridge
lap prosthetic soft tissue over the facial of the ridge and up under the
lip, moving the junction of the acrylic and patients tissue out of
sight in a high smile. The use of a similar ridge lap is possible for
pontics, but is usually contraindicated over implant abutments in any
fixed restoration as it makes oral hygiene for the implants nearly
impossible.
Implant supported removable partial denture.
One of the areas that implants are very effective is as abutments for
removable partial dentures. No matter how significant the ridge defect,
if there is enough bone to anchor the implant, an implant supported RPD
can be excellent esthetically. In addition the adjacent natural teeth
don’t have to be involved in the prosthesis in any way. Two different
approaches are typically used to retain the RPD to the implants, bars,
or locator type attachments, both work well, but the design has to
stabilize the prosthesis to the torsional rotation that occurs when
incising on the missing anterior teeth.
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