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Case Presentation #2
Patient with missing teeth and roots present with limited means
This middle aged patient comes to the office because she has two spaces on the upper left where the two premolars should be. The gap is not appealing, and she has gotten to the point where she doesn’t want it to be visible anymore. She has saved her money to the point where she has $500 cash, and is hoping there is something I can do for that price.
The roots of the two teeth are still intact, but end abruptly at the gumline – it is just the part of the teeth that are visible in the mouth that are missing. HOW this came about is hard to know for sure, but with some people addiction to methamphetamine can lead to this loss of crowns, while the roots remain. With her the two roots are healthy, the parts that are visible are solid and smooth. From the X-rays, the roots extend the normal distance into the bone, and are well supported by bone.
Other important information is that there are problems on the adjacent teeth. The first molar has a restoration on the side of the space that needs to be replaced. The canine has decay on the side toward the space and needs to be restored.
Treatment options:
First plan. Remove the roots and place implants. Build crowns on the implants. Restore the adjacent teeth at some point. Gap will remain visible while the implants are integrating into the bone – which will be for a few months minimum. Cost: per tooth from $2000 to $5000. Total cost of treatment approximately $7000.
Second plan. Save the roots, but remove the pulp by root canal therapy and use the canal space to build up the tooth to support crowns. Typical root canal $1500, buildup $500, Crown $1500 per tooth – cost $7000 without the adjacent teeth being restored.
Both of these treatment plans are very acceptable, except for the cost! The costs are totally out of her range, while they both represent good, sound and reliable treatments that, if done well, should last her many years.
But, what can be done that she can afford? I often ask my students to ponder this question and see what they come up with. Obviously, the patient will not go for either of the above options.
Third plan: removable appliance. A cast metal removable partial denture can replace the teeth, and sit on the roots, but be supported by other teeth, and retained by clasping to other teeth. It is a long-term solution, but for a patient not used to removable appliances, takes some getting used to. It covers part of the palate so the tongue can’t go where it normally does, and food items can get stuck under it. It must be removed at night, revealing that the gaps are still there. Cost: $1000 to $2000 – closer to her range.
Fourth plan: Flipper. This is a thin plastic removable appliance that includes a false tooth, or in this case teeth, and is clasped to other teeth. It is not made to last a long time, and is normally worn while a cast-metal framework partial denture, as priced above, is being made. It is breakable, and still takes up space in the mouth that is not comfortable for most people at the start, and compromises periodontal health if oral home hygiene is not the best. Cost: around $500. This would be a possibility, IF she is willing to deal with its insertion and removal, and the unfamiliarity, and the need for periodic replacement. The two adjacent restorations will add to this cost, maybe double it.
Fifth plan: Rebuilding the teeth using composite. For the dentist there is little cost – no laboratory procedures are required, so no lab fee that he has to pay. For this reason, pricing is much more flexible. He can restore the adjacent teeth at the same time. As the teeth are built up, they are connected to the roots using both adhesive techniques AND metal pins (like screws) that are placed in the roots at the corners. The two teeth that are built up will be connected together, so they will support each other under the load of biting forces, AND will be connected to the adjacent teeth, which are being restored, for additional support. FEW dentists have ever done anything like this, but it is certainly possible with our available technology. Longevity is a question, but one would encourage the patient to save their money over a few year period of time while this composite restoration is serving her purposes. Cost: whatever the dentist wants to charge, depending on the time required to do the work. If he values his time at $250 per hour and it takes two hours, then he can do it within the patient’s budget.
This was an actual case in Dr. Duggan’s office, and he did plan 5 for the $500 she had in hand and guaranteed the work for one year. The ultimate longevity of the restoration was never determined in that the patient was not a regular patient after that, but at least a few years or more would be expected with some caution on the patient’s part.