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Sometimes Dental Implants Are Not The Best Option

Sometimes dental implants are not the best option!  I know this sounds strange coming from a dental implant specialist but for the last 20 years of my career, there are some cases that are best off not having implants.  There are disadvantages to dental implants.  There are also disadvantages to bridges as well.

Elongated dental implant teeth with exposed  abutment and non-cosmetic result

Sometimes the best advice given to you by a dental implant specialist is not to have implants but rather to have a bridge made over natural teeth.  There are times where the dental implants will look worse than having a bridge!

There are many factors that go into my judgment… In no particular order:

  1. Some people genetically have a poor “bio type. ” This means that there gums and bone are genetically thin.  They are prone to losing bone and gum around the implants over time.
  2. Front teeth with vertical bone loss with a high smile. This can lead to a very aesthetic appearance of the implants with open black triangles and long horse like teeth.
  3. Previous failed implants
  4. Missing bone on the interproximal (side) of a critical tooth in the front of the mouth
  5. Cases where bone grafting would not yield a cosmetic result and in fact may worsen an already bad situation
  6. Medical conditions or lifestyle choices such as heavy smoking, severe osteoporosis, that would make bone grafting high risk or unpredictable.
  7. Type of temporary teeth patient could have during bone grafting healing. Sometimes people need removable temporaries and they do not want to take them out at night   to that the gums rest.
  8. Periodontal (gum) condition of the other teeth in the mouth
  9. Unstable bite especially lack of back teeth.
  10. Are you (the patient) willing to go through what it takes to do it right?

Here is an example of a patient that had two existing implants for his front teeth. (picture above) When I first met this patient he came to me for a second opinion while in the midst of having treatment done.  I did not place these implants.  

The front teeth look very long like piano keys.  The lack shape and character.  The two center teeth are implants while the two side teeth are crowns.  One of the side natural teeth has bone loss a cavity on the interproximal side of it.  This causes vertical bone loss and a very exaggerated elongated smile. One of the implants is losing bone via peri-implantitis.  The abutment is also showing.

It is ‘possible’ to correct this type of deficiency with a block graft, GBR and or titanium mesh bone graft but this patient did not want to go through this again and was unhappy with the final result.  He came back to me a few years later to see what could be done.

In his situation you cannot graft bone and gum onto the existing implants.  You have to remove the implants and start all over or go with a bridge option.

In his case, I removed the implants and we decided that it would be best for him to have a bridge.  I sedated him under IV sedation, removed both implants, did some basic socket preservation bone grafts, extracted one of the bad natural teeth and made a 6 unit bridge going from tooth 6 through 11.

 

I agree that these teeth are not perfect!  But I do think he looks much better than before!

They are not supposed to be perfect.  He wanted to have teeth that looked more natural.  In order to accomplish this I purposely made the teeth kind of crooked, added some yellow/brown stain near the neck and a little bit of pink just in case he smiles really high.

This treatment was completed in 2-3 visits.  In reality if this patient came to see me the first time I would have steered him in the direction of having a bridge if he did not want to go through complex vertical bone grafting that may take 1-2 years to complete.

I have no doubt that this bridge will last 20 years as long as the patient takes care of it (diet and lifestyle are a huge part of bridge longevity) .  The big disadvantage here was that I had to grind down to more teeth.  The canine teeth numbers 6 and 11 are the largest roots in the mouth.  Because there was no root canals on these teeth , they are very strong even when ground down

I hope this post allows you to appreciate the complexity of diagnosis and treatment planning in implant dentistry.  Please keep in mind that dental bridges last much longer in the front of the mouth than they do in the back of the mouth.

My goal is always to have patients have treatment done right the first time.  Complications can and do happen. Proper planning  and experience can reduce the chance significantly.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

13 thoughts on “Sometimes Dental Implants Are Not The Best Option

  1. Dr. Amin,

    A few years ago I had my #18 molar pulled and planned to leave it vacant. A few weeks ago, I needed to have my #19 pulled and will get an implant for it. I am wondering whether I should go ahead and get an implant for #18 as well? 1) Is this possible since no bone grafting was done at the time #18 was pulled? 2) Are there any other possible complications to having two implants right next to each other? 3) Would you recommend I replace #18 since I was doing fine without it prior to losing #19? Thanks for your response!

    1. This post about replacing second molars may help you make a decision. Your second molar is tooth #18. it is very possible to still have it done despite no bone grafting and it is quite common to have both teeth replaced as long as you have both upper molars to chew against them. I do this all the time!

  2. Good morning doc.
    I had a full mouth of crowns at 16. (Tetracyclene disorder) I’m now 65. I’m on fixed income and my teeth were in bad shape. I couldnt afford the $65,000.00 for a full mouth of crowns. So I researched and went to top skilled guy in Costa Rica for $12,000. They did a beautiful job. During the middle of procedure I needed root canal and the specialist actually prepped me with dental dam. I havent seen one of those ever! Anyway, trying to keep this in sequence. Almost 4 years in now.
    A couple of my teeth (all bridges & crowns) began to feel loose and I could feel food collecting in spaces.

    Meanwhile, I began breaking ribs for no good reason. 4 within 1 yr. Just turning basically. My doc put me on mega dose vitamin D. My question is:

    If I have serious bone malnutrition and everything is soft. My teeth are all beginning to move in a big way. Afraid to have nightguard made because I’m afraid it will pull out teeth.

    I don’t know what to do. When I go to a dentist they get unwrapped because I went to CR and begin lecturing I get what I paid for. . . Not fair, not true they are state of the art and he taught at U of P.
    Anyway, I’m afraid they all will just have to come out and do a
    4 X 4 or something like that. Im terribly vain, retired showbiz and dentures makes me sick that they come out. With severe bone loss would I be able to have 4 attachment points IF the bones are indeed that soft AND that is the problem?

    I know doc, a lot of “if’s” I’m struggling, with little finances and angry my options of good oral health can only go as far as I can financially go. Not far!

    Thanks for helping me choose a starting place. Dont know what to do. I dont want to travel to CR to find out I have no options? Where shall I begin? Thanks doc for a reply.

    Warmly
    SheelahKaye

    1. This is a tough spot to be in. Your bone metabolism seems really off with the Vit D issue.

      Have to seen an endocrinologist?

  3. Hi Dr. Amin–I saw you in 2014 to evaluate a back tooth that had been recommended for extraction by my dentist and an oral surgeon. Thanks to you I avoided this procedure–you said the tooth was fine and the pain I was experiencing in that tooth would go away in a few weeks. I am very grateful for your evaluation! At the same time I asked you to evaluate an extraction that had been done 11 months prior and had formed a small passage into the maxillary sinus. The oral surgeon who performed the extraction was quite confident that the passage would heal and close. After 11 months on antibiotics it became clear that the passage had epithelialized. The oral surgeon then performed a very simple flap procedure that healed quickly. But during the 11 month interval a fair amount of bone loss had occurred. I was schedule for a bone graft and implant with you, but could not face taking any more antibiotics. Four years later I am still feeling averse to facing a bone graft. My teeth and gums and general health are very good. I know an implant is the wisest choice because this particular tooth that has a significant structural function. But I am wondering if there is anything else that could be done instead. The tooth just proximal to the extraction site has an old crown. I would be happy to have the crown removed to become part of the bridge. The tooth on the other side is the last one (the one you saved) and I would prefer to keep it as whole as possible. So, bottom line, is there any chance that I could have the crown-bridge on one side and some sort of strengthening of the connection on the other side that does not require shaving? Thank you for your thoughts.

      1. Thank you very much for your reply, Dr. Amin. It gives me hope that there is a solution that will work for me. If you don’t mind, can you give me an idea of how much “shaving” has to be done on the adjacent teeth? Any amount of shaving is fine with me on the proximal tooth that is already compromised by an old crown. As far as the back tooth, I realize that every case is different and this will be just a guess, but if you could give me a general idea, perhaps a range of the percentage of the tooth–minimum and maximum, and an average percentage, it would be helpful to me. Also, would you be willing to do this bridge for me? I would prefer that you do it if possible.

  4. Hi Dr. Amin,
    I’m sure you get frustrated answering questions from people like me that are across the country and not able to use your practice. However from reading your articles, responses, etc. your expertise and knowledge may assist in my decision whether or not to get implants for a bottom denture. I also apologize in advance if this comment is way too long.
    I have been to both an oral surgeon and a general dentist in the past couple of weeks to inquire about having my few remaining really bad bottom teeth extracted and the possibility of implant to hold a bottom denture in. I had to have my top teeth out about twenty years ago and got an upper denture so I want to replace that one as well for a “newer model”.
    The oral surgeon did the orbital x-ray and said he could remove the remaining few teeth and the remaining roots. He said he could also do the implants provided my bones are ok. I had also provided him a list of my current medications.
    The general dentist I went to also did an orbital x-ray and said due to two medications that implants are probably a good choice for me. She asked how many years I’ve been on antidepressants, which is twenty years (have been on all SSRI and SSNI ones available through the years, currently Cymbalta). On my list also was Fosamax which she explained would probably be the main reason that implants wouldn’t work on me due to something that may hinder the bone healing. I am also have insulin resistance and am on Metformin. She also said due to all of my factors that I should definitely let the oral surgeon do the extractions and implants if possible and she would gladly do the dentures after healing.
    I also have a genetic disorder that affects collagen and connective tissue. My joints dislocate and my ligaments, etc. are all very elastic, thin skin, etc. It also makes Novocaine type injections disperse almost as soon as they are given, thus the oral surgeon that can use alternate drugs and/or sedate me.
    Your opinion Dr. Amin? Thank You

    1. Your dental procedure is likely pretty easy but it is complicated by your health and medications. I would strongly suggest that you are treated by an expert in the field of dental implants. Medications such as SSRIs and Fosamax of course can cause some healing issues but most of the time things are okay. Be sure to read this article about Fosamax and bisphosphonate medications in general. It really depends on how long your on it and when you stop. The oral versions of Fosamax are much less risky than the intravenous forms such as Zometa. I place implants on diabetics all the time.

      Because you have risk factors you want to consider procedures that are very predictable such as bone leveling versus rebuilding and grafting bone.

      I hope this helps you… Ramsey Amin DDS

  5. Dr. Amin, next week my current dentist is taking out tooth number 7 as she says my root canal has failed (had to get it due to internal resorption from my son kicking me by accident when he was 2). Therefore, I have no time to see you–you are booked out a while– and get your opinion/prices on if my mouth can handle an implant (or if I should just do a bridge). My question is, do you know of a cosmetic implant specialist that is as good as you near the Glendora, CA area???

    1. With all due respect…what is the rush? Unless you have pain there is no reason to move this along so quickly. These are body parts to be taken very seriously especially front teeth. I’m sorry that sometimes it might be a bit before you can schedule with me but I focus on quality not on quantity.

  6. My son (mid 50s) plans to get implants, missing 2-4 upper front teeth more than 4 years.
    My question, his dentist wants him to extract ALL his top teeth… The teeth are healthy.
    I don’t understand the reason for asking him to extract the rest of his teeth at the top… that seems unnecessary!

    Were not sure if his body will reject the implants and if so, he’ll be without any natural teeth at the top.

    Hope you can you help me with this!
    Thank you,
    Grace

    1. GREAT QUESTION!! There are times that replacing the entire upper jaw is more beneficial, cost effective, better long-term and more cosmetic than replacing just a few. I would highly doubt that the other teeth are healthy. That would be very odd for a dentist to suggested extraction of healthy teeth. Perhaps they are in a bad position in relationship to the bite. Don’t get me wrong, keeping your natural teeth is by far the best but there are times that this option is better. Statistically the chance that the implants will work for your son is 95% or greater. Every practitioner has their own success rate and of course the more experienced the dentist, the better the chance that this is closer to 100%. Perhaps a second opinion is in order?

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About Ramsey A. Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.