All I want for Christmas; The options for a missing front tooth Photo

Albeit the cause for tooth loss can vary, the consequences are typically the same. The absence of a tooth, or teeth, can have several implications aside from the obvious cosmetic flaws. Functional hindrances and compromised mastication result from a poor occlusion [1], leading to a potential spiral of pathophysiological problems. One of the barriers to restoring an edentulous space may be the supra-eruption of an unopposed tooth to occupy some or all of the space needed for prosthetic replacement [2]. It may also cause a decline in alveolar bone and even deficiencies in TMJ function [3]. Causes can include congenital hypodontia to more commonly occurring trauma. Depending on the cause, treatment may be more accessible (i.e. accidental trauma may in rare, particular cases entitle the patient to more extravagant prosthesis on the NHS).

There are several means of treating tooth loss often dependent on various factors. Patients may prefer implants; the cost may deter them however, making bridges a more attractive option [4]. This poster will seek to cover potential treatment plans and relevant benefits/flaws.

Ultimately, treatment is dependent upon various factors. The cause of the missing tooth, surrounding oral health, compliance and even budget can influence the patient’s decision and to an extent, the dentist’s capacity to carry out the treatment. For example, an individual with very poor compliance and oral health may desire an implant - however surrounding tissue may be in such a condition, implants aren't physically plausible nor possible. Wholly, dental implants prove the most desirable treatment given their ‘permanent' residence, practical similarities to real teeth and reduced risk of associated disease/implications. They have an incredibly high success rate of ~97%, making them an incredible feat in dentistry. Trauma-patients usually opt for implants as their tooth loss is very localised and obviously, sudden. Hypodontia patients may also be inclined towards implants as they’re very much like human teeth. Patients with periodontitis are however recommended dentures due to already-poor oral hygiene decreasing the success rate and likelihood of implants even being possible. Children who have lost their deciduous incisors are usually not treated at all unless trauma caused the event - in which they may require a more extensive follow-up to ensure proper eruption of permanent dentition.

Leaving a gap is very rare. Not only is it aesthetically unpleasant, it can have a ‘knock-on’ effect on surrounding dentition and tissues. The absence of a tooth can introduce a cycle of problems, especially an incisor given its unique function and vitality in adult dentition.

Introduction Method

Discussion and Conclusions

Results

SCHOOL OF DENTISTRYLiverpool, L69 3GN, UK. email: kazam97@icloud.com

[1] https://sites.google.com/site/oralhealthin/articles/missing-teeth-and-their-problems

[2] Youngson, CC - Occlusal changes following posterior tooth loss in adults. https://www.ncbi.nlm.nih.gov/pubmed/17559530

[3] Alanen, P - Association between tooth loss and TMJ dysfunction. https://www.ncbi.nlm.nih.gov/pubmed/3859625

[4] Freeman, R - The psychology of dental patient care: Barriers to accessing dental care: patient factor http://www.nature.com/bdj/journal/v187/n3/full/4800224a.html

[5] Agrawal, S - Self-mutilation of teeth due to peer pressure: an aspect of child psychology. http://casereports.bmj.com/content/2014/bcr-2014-203624.full.pdf

[6] WebMD - Dental Implants http://www.webmd.com/oral-health/guide/dental-implants#1

[7] Sahoo, S - Biological aspects of dental implant; knowledge and perspectives in oral implantology http://www.dentalhypotheses.com/article.asp?issn=2155-8213;year=2013;volume=4;issue=3;spage=87;epage=91;aulast=Sahoo

[8] http://www.deddingtondental.co.uk/general-dentistry/dental-implants/

[9] Cruegers, N.H - Resin-bonded fixed partial dentures. http://www.deddingtondental.co.uk/general-dentistry/dental-implants/

[10] http://hodsollhousedental.co.uk/wp-content/uploads/2014/01/Dent_Update_2012_39_78-84.pdf

[11] https://www.speareducation.com/spear-review/wp-content/uploads/2014/09/pic2.png

[12] WebMD - Dental Health and Dentures http://www.webmd.com/oral-health/dental-health-dentures#1

[13] Bamigboye, S.A - Knowledge of missing teeth in patients https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4201933/

Incisors are often a focal aesthetic concern for many patients given their prominence in the mouth. Even children are recorded to have self-mutilated their own incisors due to peer pressure [5]. Treatment is often considered with this in mind. For missing teeth, there are four options - each of which intend to; A) restore function B) look ‘real’ C) prevent damage to surrounding structures

IMPLANTS - replacement tooth roots, provide strong foundation for prosthesis [6]

The utilising of dental implants has become an increasingly accepted treatment modality for the rehabilitation of fully and partially edentulous patients [7]. They offer a number of unique benefits such as preventing alveolar bone loss, receding of neighbouring teeth and allow for natural occlusion. A generic implant consists of a titanium rod to which a prosthesis such as crown, attaches to it superficially. The physical treatment process involves localised surgery, usually in ‘stages’. The titanium rod is placed into the alveolar bone, then left to heal naturally (bone cells grow around the transplant). This stage permits the implant to ‘lock in’, mimicking the root of a tooth. The incision is remade and a ‘healing cap’ is placed in to the gingiva creating a shape to support the prosthesis. Implants are quite possibly one of the biggest advancements in dentistry at present; they provide the most natural alternative to a real tooth.

Figure 1 - ‘Implant procedure’ adapted from [8]

The alternative treatment options are known collectively as ‘dentures’. The process to make dentures is generally consistent for both derivatives, with varying final refinements. 1. Initially, a series of impressions are taken of the entire

jaw. Appropriate measurements of how teeth occlude are also taken

2. Models (often made out of wax/plastic) are created. It allows for better insight into how the denture should fit and whether any changes are necessary; it too includes a test for ‘colour’, i.e. of the gingivae to ensure an ideal shade

3. Any appropriate adjustments are made and a cast is created

4. Adjustments will be made as necessary; usually minor sanding down of surfaces in contact with gingivae to ensure a comfortable fit

FIXED DENTURES - also known as ‘implant bridges’; crowns are attached to abutments created by either an implant or neighbouring teeth (post-preparation)

A resin-bonded fixed partial denture is a prosthetic construction able to replace 1 or more teeth within an occlusal system. It comprises a pontic element, adhesively attached to one or more abutment teeth/implants [9]. Whilst a viable option for missing dentition, its also proven that resin-bonded bridges may be most prone to failure if replacing an incisor [10].

REMOVABLE DENTURES - removable alternatives to the fixed denture. Often require more maintenance and ‘responsibility’ from the patient given the increased susceptibility to trapping food, to even losing the denture!

Removable dentures are probably the most common treatment option given their price and minimally-invasive nature. Whilst they may be incredibly tough to use to replace maxillary incisors [10], they’re fairly easy to make and can be sufficient in replacing mandibular incisors. Removable dentures can also come in various forms, clasp/‘snap-in’ dentures being the most common. This type of denture can result in localised bone loss, however.

Figure 3 - ‘Lateral incisor denture’ adapted from [12]

LEAVE A GAP - a less common option is simply leaving the gap. This poses a threat to local tissues, albeit is popular amongst those with poor oral health…

Leaving the gap is never recommended, nor often considered for missing incisors. It appeals to very few, yet still exists as a somewhat plausible option for those who have little to no concern over their oral health/appearance. Studies show a correlation between missing teeth and consequential implications of associated tissues [13]. As aforementioned, implications include supra-eruption of neighbouring teeth into edentulous spaces, loss of alveolar bone and even drifting of adjacent teeth amongst more.

References

I started my poster by creating a brief plan; this provided me with the means to outline and create an appropriate structure. I then began to pick apart my title, exploring relevant aspects so I could gain an insight into the intricacies of such a topic. To do so, I used generic search engines - refining my initial search down to isolated topics such as ‘hypodontia’. This provided me with greater depth and detail, allowing me to further my research and find relative resources.

I too spoke to a dentist who has encountered patients with this problem. This allowed me to not only gauge the clinical appropriateness of a treatment plan and autonomy, but also the significance of thoroughly informing patients of their choices. It gave me an idea as to how factors such as cost and oral health influence patients’ decisions. This made me think about whether or not wealth can and should dictate quality of treatment. Wholly, it may depend on the actual cause of the missing tooth.

To create the poster itself, I used Keynote and MS Word.

Kazam Hassan Mahmood

Figure 2 - ‘Maxillary incisor denture’ taken from [11]