Why dentists don't recommend Maryland Bridges?

[joey87]

TLDR: I have a tooth fracture on my maxillary central incisor (#21) after failed RCT and the dentist recommended an implant, but I have an extreme phobia and risk factors (smoking, SSRI, PPI). Both dentists I talked to do NOT recommend getting any RBBs, but studies show a different picture.

I'm a science nerd so I have read over 30 clinical studies and meta-analyses on PubMed, and it turns out that the success rate of RBBs/Maryland Bridge is not so bad, despite being slightly inferior to implants (over 95% for implants)


Studies reference on RBBs

Key points:

• Higher success rate on maxillary anterior teeth, and when only 1 tooth is missing
• The most common complication is debonding in around 20% of cases, which is comparable to the 20% risk of developing peri-implantitis.
• Cantilever RBFDPs have a better survival rate for missing central maxillary incisors compared to other designs
• Counter-intuitively, the one-retainer design is better. The two-wing design is the most prone to failure compared to the cantilever design.
• In the past, the two-retainer design was the most commonly used, which is more prone to failure, so it could explain the negative perception by dentists. A lot of improvements have been made in recent years, with the optimization of cementation materials around 2013. That’s why the success rate is better in more recent studies.
• I have a deep bite and some sources are suggesting it could increase the debonding risk, but is also a risk for implants (I could not find any study on RBBs survival rate with deep-bite)
• Zirconia, Alumina, and Ceramic have great documented success rates, but many studies recommend going with Zircona framework material

2018 - Meta-analysis of 29 studies (2300 RBBs)
“Meta-analysis of these studies reporting on 2300 RBBs indicated an estimated survival of resin-bonded bridges of 91.4% after 5 years and 82.9% after 10 years. RBBs with zirconia framework and RBBs with one retainer tooth showed the highest survival rate. Moreover, the survival rate was higher for RBBs inserted in the anterior area of the oral cavity compared with posterior RBBs. The most frequent complications were de-bonding (loss of retention), which occurred in 15%”

2021 - Integrative review of 23 clinical publications on Anterior-Region RBBFDPs
“5-year survival rate at 86.2% for metal-framed prostheses, 87.9% for zirconia prostheses, 93.3% for alumina prostheses, 100% for glass or ceramic prostheses, and 81.7% for fiber-reinforced composite restorations. Failure rates did not significantly differ between the different material groups or between the single- and double-retainer groups.“

2007 - Meta-analysis of 17 studies
“Meta-analysis of these studies indicated an estimated survival of RBBs of 87.7% after 5 years. The most frequent complication was debonding (loss of retention), which occurred in 19.2% of RBBs over an observation period of 5 years. The annual debonding rate for RBBs placed on posterior teeth (5.03%) tended to be higher than that for anterior-placed RBBs (3.05%)”

2018 - Systematic review of studies from 1965 to 2017
"Success was defined as the RBFPDs remaining in situ and not having experienced debonding, biological failures, or mechanical failures at the examination visit. Meta analyses of the included studies showed an estimated 5-year success rate of 88.18% for the metal framework RBFPDs and 84.41% for the nonmetal framework RBFPDs. The estimated 5-year success rate for each nonmetal material category was 92.07% for zirconia, 94.26% for In-Ceram alumina, and 84.83% for fiber-reinforced composite. The failure rate was not statistically significant among the single, double, and multiple retainers RBFPDs. The 5-year clinical performance of RBFPDs is similar to the performance of conventional fixed partial dentures (FPDs) and implant-supported crowns."

2023 - Systematic Review of 11 articles after 8.2 years (687 patients, 783 RBFPDs)
"A total of 142 failures were reported for 783 prostheses, the most frequent being debonding" (success rate of 82% without debonding)

"Conclusion: RBFPDs are a viable clinical option for the rehabilitation of patients with single edentulous spaces, mainly when using a single retainer and a zirconia-ceramic prosthesis."

2013 - Meta-analysis of 49 studies on RBBs
"Estimated three-year survival rates were 82.8% for metal-framed, 88.5% for fibre-reinforced composite and 72.5% for all-ceramic resin-bonded bridges. (mean)"

2018 - Systematic Review of 8 studies
"The estimated 5-year survival rate of all-ceramic RBFDPs was 91.2%. Debonding and framework fracture were the two most frequent technical complications, and the estimated 5-year debonding rate and fracture rate were 12.2% and 4.8%, respectively. Additionally, cantilevered all-ceramic RBFDPs had a higher survival rate, lower debonding rate, and fracture rate compared with two-retainer all-ceramic RBFDPs. Zirconia ceramic RBFDPs had a lower incidence of failure but a higher debonding rate compared with glass-ceramic RBFDPs"

2017 - Clinical study on 87 RBFDPs in central incisors (108 zirconia RBFDPs / 75 maxillary incisors)
“Zirconia ceramic RBFDPs yielded a 10-year survival rate of 98.2% and a success rate of 92.0%” … “all-ceramic cantilever RBFDPs provide an excellent minimally invasive treatment alternative to implants and conventional prosthetic methods when single missing anterior teeth need to be replaced”

2018 - Study on 206 RBBs (anterior region)
“Overall survival rate of anterior region RBBs was 98% at 5 years, 97.2% at 10 years, and 95.1% from 12 years till 21 years”

2011- Study on 84 RBFPDs
“Overall survival rate has been computed as being 77% after 10 years of service, 88% after 10 years”

2004 - Study on 74 RBFPDs (64 in anterior region)
“A mean survival rate better than 69% after a 13-year observation period was calculated. Including the rebonded restorations, a mean functional survival rate of 83% was estimated. A total of 18 failures (24.3%) of all restorations were observed, the main cause being loss of retention.”

2018 - Meta-Analysis of 19 studies
“After evaluation of the selected articles, it is likely that cantilever design all-ceramic RBFDPs are more successful than two retainer design in the anterior region”

2018 - Review of 12 studies
"Conclusions: The use of cantilever RBFDPs showed promising results and high survival rates."

2014 - Study on 42 RBFDPs (cantilevered ceramic zircona in anterior region, single-retainer design)
“During a mean observation time of 61.8 months two debondings occurred. Both RBFDPs were rebonded using Panavia 21 TC and are still in function. The overall six-year failure-free rate according to Kaplan-Meier was 91.1%. If only debonding was defined as failure the survival rate increased to 95.2%.”

2022 - Follow-up clinical article on 3 patients over 26 years
"Conclusions: Cantilevered single-retainer all-ceramic RBFDPs today made from veneered zirconia ceramic can be considered a standard treatment for the replacement of incisors and provide an excellent esthetic outcome with a long-term preservation of soft tissues in the pontic area."

2011 - Study on 38 anterior RBFDPs
"The 10-year survival rate was 94.4% in the single-retainer group. "

---

So what am I missing? I don't want to sound like a smart ass who pretends to know better than professionals, but the dentists I have talked to never did any RBBs so they don't have first-hand experience and I'm not sure they have read the recent studies. Obviously, my phobia makes me susceptible to confirmation bias, that's why I came here to have other opinions. I tried not to cherry-pick the studies and included some with less favorable outcomes, but I ignored older studies published more than 20 years ago after reading how much of a difference the recent technological improvements made.

 

[joey87]

Is my thread ever going to be approved? If not, why?

 

[MattKW]

I read a couple of your helpful citations and also give you my personal experience.

1. Your first 5 points are quite valid. As you say, originally Marylands bridges were made to be retained on the 2 adjacent teeth. They would almost always debond off one tooth - the patient didn't care but decay would develop under the loose bonding and patients would come in facing potential loss of another tooth. So, cantilevered is the way to go - several of your citations are only looking at that difference, or they are looking at different cements.
2. Meta-analyses can be misleading unless you read them carefully and sometimes go back to the original full-length articles. There is a lot of conflicting discussion over the different teeth restored, the different tooth preparations used, the different adhesives,.... that simply isn't being compared very clearly.
3. I have downloaded 2 of the citations, annotated them, and attached for you to read. The 2013 meta-analysis gives a broad history and overview of the evolution of these techniques. The 2017 article has a pic (Fig 2) of the ideal case for Marylands, i.e. missing lateral incisors (small teeth) attached to central incisors (large teeth).
4. In my experience, the major issues to watch out for are:
   1. Not enough space between the upper and lower teeth. Your deep bite suggests this will be an issue.
   2. Heavy occlusion - again, your deep bite is not ideal.
   3. Insufficient grip from adjacent teeth - in your case you are hanging a large central incisor off another large central incisor. Ideally it would be a small tooth held by a larger tooth.
5. And yes, a deep bite may make an implant difficult.

So, you need your dentist to be really sure of assessing your risks, and preferably have some experience in at least a simple composite resin bridge - that is your most cost-effective and least damaging choice, but success rate will be so-so. Otherwise, go to a specialist prosthodontist who will have more experience in difficult cases and at least get a better opinion.

 

[joey87]

Thank you for the response and for sharing the PDFs. I have read the full studies, and I agree meta-analyses can be confusing with so many variables involved. Finding data specific to central incisors is also very hard - the 2017 study is interesting but the sample is so small that I take it with a grain of salt.

I still found the other studies relevant because the consensus seems to be that the maxillary anterior teeth have a better RBB survival rate than other teeth (especially canines and posterior teeth). So my thought process was to use the average survival rate of all teeth as a base case and assume that I would probably get a better survival rate on incisors with a short-span bridge (only 1 tooth). That's why this 2017 systematic review is so interesting, not only it is the largest sample I found (2300 RBBs) but it also reported one of the best survival rates:

resulting in an overall number of included studies of 29. Meta-analysis of these studies reporting on 2300 RBBs indicated an estimated survival of resin-bonded bridges of 91.4% (95 percent confidence interval [95% CI]: 86.7–94.4%) after 5 years and 82.9% (95% CI: 73.2–89.3%) after 10 years. A significantly higher survival rate was reported for RBBs with zirconia framework compared with RBBs from other materials. RBBs with one retainer had a significantly higher survival rate (P < 0.0001) and a lower de-bonding rate (P = 0.001) compared with RBBs retained by two or more retainers. Moreover, the survival rate was higher for RBBs inserted in the anterior area of the oral cavity compared with posterior RBBs.

Just wondering if by chance you have access to the full-text PDF of this one? I'm curious to see if I can find more fragmented data in the full article with the survival rate for only central incisors.

Not enough space between the upper and lower teeth. Your deep bite suggests this will be an issue.

This is what I'm worried about, and I could not find any study specifically looking at bridges' success rates with a deep bite. This clinic says “Deep overbite would also contraindicate a Maryland Bridge” but other sources say there is often a workaround.

My deep bite never caused any problem and there seems to be enough place for the wings, but I'm not an expert. I don't feel any pressure on the incisors, so I would be surprised if I have heavy occlusion but again I'm just speculating. I assume one of the dentists would have noticed signs of wear.

To be honest, I did not even realize I had a deep bite before reading stuff about that recently, so it has never been diagnosed because it wasn't a problem (until now?). I have an appointment on Oct 12 with a dentist to check this out. They said that the two-wing design could be better for deep bite occlusion, but I'm skeptical about that.

the patient didn't care but decay would develop under the loose bonding and patients would come in facing potential loss of another tooth

I do care, this is definitely something I am worried about, as I am very prone to tooth decay. I had more than 25 fillings in my life following carries, despite brushing my teeth 2 times per day and regular dental floss, cutting sugar almost everywhere, and using products like Fluoride, Xylitol, Periogen, Arginine, Hydroxyapatite, ... Luckily, my adjacent incisor is healthy (#11), and even the #21 doesn't have any cavity (it just died randomly 20yrs after I fell from a ladder and chipped the corner of the tooth, then got a RCT which caused a longitudinal fracture 5yrs later)

Insufficient grip from adjacent teeth - in your case you are hanging a large central incisor off another large central incisor. Ideally it would be a small tooth held by a larger tooth.

Good point, multiple studies mentioned this. However, it seems that the other central incisor is still the best abutment according to this study:

"In the case of replacement of a central incisor, it is advisable to rest on the other central incisor,
not on the lateral one. Indeed the palatal surface is larger and, therefore, more conducive to
better bonding of the prosthesis. A light gingivectomy can be realized to optimize the bonding
area. The lateral maxillary incisor also has a higher translucency compared to the central, and
thus, for aesthetic reasons, it should not be chosen as an abutment. In the lower jaw, lateral
incisors might be considered as a support for RBBs."

The only study I found comparing RBBs survival rate in central vs lateral incisors is this one but again very small sample (25 RBBs) and short evaluation periods. Only one debonded (2-wings on #21 with abutments on #22 and #11)

Another study found that most instances (60%) of debonding involved bridges that had replaced the maxillary central incisor (186 cantilever bridges) presumably due to excessive occlusal contacts and pontic overload.

 

[MattKW]

Hello, happy to keep chatting to you. In future chats, would you mind numbering your paragraphs? It'll be easier to reply, thanks.

Para 2. Yes, I can access most articles. Attached is my annotated copy of the 2017 study you requested.
Para 3. Yes, a deep overbite would require a personal examination of your teeth and a good look at how much space you have, plus the action of your teeth during chewing movements. You're welcome to put up photos and I'll give it a go - I would need 1 taken front-on, 1 taken side-on, and one taken looking up from your lower front teeth (all with teeth closed and lips retracted).
Para 5. As you will read in the 2017 article (and in my experience), one-wing designs are much better.
Para 7. Yes, you would have to bond to the adjacent central incisor. Replacing a central incisor with an RBB is more likely to debond than the more desirable replacement of a smaller lateral incisor.

One of the issues we face in this discussion is that although you have presented many articles looking at survival rates and comparing materials, it would be equally important to see if you could find articles that addressed the most successful design considerations in more detail.
i.e. Exactly what criteria did the authors of the clinical trials use when selecting patients? What type of preparations did they use? That might take quite a bit more searching.

 

[joey87]

Para 3. Yes, a deep overbite would require a personal examination of your teeth and a good look at how much space you have, plus the action of your teeth during chewing movements. You're welcome to put up photos and I'll give it a go - I would need 1 taken front-on, 1 taken side-on, and one taken looking up from your lower front teeth (all with teeth closed and lips retracted).

1. Wow awesome, thank you so much for this, it is VERY appreciated! Would be great if I could stop worrying about that
Here are some pictures: https://photos.app.goo.gl/nAPdd4Z32zwfFteb9
and a video: https://photos.app.goo.gl/EfvfRMp8YKbTsmxS7

Closer view from an endoscope camera:

Record_20231005132033.mp4

drive.google.com

occlusion edited.mp4

drive.google.com

2. I just bought this pack of Articulating Paper with 1-day shipping, will post more pictures tomorrow. Not sure if I got the correct product, if I remember correctly the last time I saw a dentist doing this test, the strip texture and color looked like a blueish surgical mask.

3. I also tried to get Shimstock Strips but I couldn't find anything on Amazon Canada. The closest product I found is this but it is not for dental use and the thickness is different (0.005)

4. Maybe that's a dumb idea, but I did the test with a strip of aluminum foil between the 2 incisors. If I just close my mouth normally, I can pull the strip out (I can feel some resistance). If I close my mouth strongly and put pressure on the teeth, then the aluminum foil will not come out easily and sometimes tear into 2 pieces, but I have to apply constant pressure.

5. Could Enameloplasty be an option to reduce the length of the lower central incisors (without devitalizing the teeth) if there is not enough place for the wing of the bridge? It would also look better aesthetically, I think.

6. Not sure if relevant but here are some XRays of my upper incisors

in 2018 before the RCT on #21

After the RCT:

and here is another XRay taken 2 weeks ago after the longitudinal fracture diagnosis and after the abscess appeared:

 

[MattKW]

A great shame about the 21 despite a very nice RCT.
The photos and videos are very helpful, thank you.

1. You don't enough space between your upper and lower teeth to place an RBB without firstly cutting back the palatal surface of 11 to make sufficient space. It's an option, but a major intention of an RBB is to do minimal or zero tooth damage.
2. I see that you have quite a complex dentition. Have you ever considered total orthodontic treatment? That might resolve your limitations.
3. Even if you don't want to do full ortho treatment, perhaps consider simply moving the 11 forward with a simple ortho appliance in order to make space on the palatal side for the RBB. Then the 21 false tooth would be made to match the 11 at a slightly forward position. I wouldn't advise bringing them both forward as far as 12 and 22, just to make enough space on palatal of 11 for RBB.
4. To answer your point 2., that's fine to get articulating paper but your simple test of aluminium foil and the images has told me all I need to know.

 

[joey87]

Thanks so much once again for your help. Feel like we're making some progress, at least the occlusion thing is sorted out. And the good news is that you haven't mentioned anything about orthognathic jaw surgery which is really something that freaked me out.

1. I would still prefer cutting back the palatal surface compared to an implant, but dentists will probably think it's a bad idea because the tooth is healthy. I agree I should consider orthodontic options first.

2. Never considered total orthodontic treatment until today, because it didn't cause any problem besides not looking good. Now I am thinking of canceling my appointment next week and directly going to an orthodontist clinic instead, which is most likely where they will refer me after coming to the same conclusions as you. I'm definitely open to trying any minimally invasive procedure, but I just don't want to delay the bridge too long.

3. How long should it take approximately to bring the tooth forward? The endodontist who diagnosed the fracture said it would take around 6 months until I get complications with #21. Right now the abscess is very small and not really painful. I drain it every day and not much comes out of it. Do I have enough time for ortho treatment before extraction?

4. Any idea if my misplaced mandibular incisors can be fixed by full orthodontic treatment alone? When I was a kid a dentist said I had to get some teeth reduced in size, i thought it was too late now

5. Is Invisalign considered a full orthodontic treatment suitable for deep overbite or would I need braces/retainers/springs? I have not researched this as much as the bridge stuff

6. Assuming I get orthodontics to move #11 forward, then put a RBB without cutting back the palatal surface, do you think that my occlusion would still increase the risk of debonding or it would be comparable to a normal occlusion success rate? The way I imagine it, pressure on #21 and #11 would be reduced even more because there would be almost zero contact with the bottom teeth, which sounds even better than a normal occlusion with contact?

 

[MattKW]

In reply:
2. Orthodontics is more than just aesthetics. When you see the ortho, also mention concern and idea of losing 21 and replacing with RBB. Then he can work that into potential treatment plan. Copy and take our conversation. The 21 can be extracted and a fake tooth attached to braces while doing ortho if you go down this path, so also ask about this.
3. If just moving 11 forward, the should take <6 mos.
4. No, still possible. Have seen ortho treatment for 80yo done successfully.
5. An orthodontist can do either Invisalign or standard braces. I would advise braces as much better control and faster, more predictable results - ask the orthodontist.
6. I think it would make it comparable to normal occlusion, which is why I suggested it.

 

[joey87]

I tried to get an appointment with a specialized Orthodontist clinic, but the wait time for the first appointment is almost 2 years...

If just moving #11 forward to make things simpler, is this something that can be done by a generalist dentist clinic that is also doing basic orthodontic services, or do I really have to see a specialized orthodontist? I found a generalist clinic offering orthodontic services and their website advertises Invisalign, braces, and Orthodontic appliances, but it doesn't say much more. I called them and tried explaining my situation but I couldn't get a clear answer and they just told me to schedule an appointment to see if they could help.

 

[MattKW]

Should be doable by a general clinic with some ortho experience. Who knows, maybe they'll do the Marylands too?Again, take our conversation along to help. Better still, email everything (including Xrays) to them in advance of the appointment.
P.S. Whereabouts are you that it takes 2 years to get a specialist ortho appt?

 

[joey87]

Found a local clinic that could do extraction + cantilever bridge + maybe basic ortho, but...

1. They prefer the EMAX material instead of Zirconia (2 other clinics also said the same thing) or metal/ceramic. I don't have a strong preference for this and I am not so confident about which material is the best, so it's not a dealbreaker.

2. They recommend the 2-wings design but they will let me take the final decision and make a cantilever bridge if that's really what I want (no warranty but that was expected)

3. I explained a dentist saw my occlusion and recommended moving #11 forward, but they think that orthodontic treatment is a bad idea because I would need a fixed retainer wire, can you tell me more about that? Note that they haven't seen me in person yet and I just sent them the videos of my occlusion and asked to confirm if they really think drilling the palatal surface would be preferable.

4. I live in Trois-Rivières, Quebec, Canada. The only orthodontic clinic nearby is Orthodontie Mauricie with the 2 years wait time. They don't consider my case urgent and said they can't do anything to see me faster. I checked the list on the Orthodontist Association and the Federation of Dental Specialists websites to make sure.

5. Here is a (translated) copy of my emails with the local generalist clinic:

Hello,

It is probably possible to have a Maryland Bridge done to replace your tooth #21.

It is true that we can make bridges completely out of Zircon and that this can in certain cases be done with a single wing. However, I do not do this type of restoration completely in Zircon because the adhesion with this material is not very good. Since the success of the restoration depends on adherence, it is best to avoid it. It is preferable to work with ceramic-metal which still gives an adequate aesthetic. In certain special cases (no contact with the opposing teeth and thickness of more than 1mm) the bridge can be made entirely of Emax ceramic. But given that ceramic-metal gives an adequate aesthetic appearance, it is better to use it because it will be more solid and less capricious.

As for the wings, it is preferable to have two except in cases where we believe that the teeth will move and risk promoting debonding (example after orthodontic treatment). In a case like yours where the teeth are probably stable, it is better to use two wings for strength.

Good morning,

Yes it may be possible to make a Cantilever if that is what you choose. As for partial debonding, I usually notice it during periodic examinations if it happens. And if that happens the risk of decay is still quite low if hygiene is adequate (brushing and flossing), in my opinion this should not be an issue for the choice of treatment). But both options exist (1 or 2 wings and the patient can choose once our recommendations are given).

For emax, I can't guarantee that I can do it, it really depends on the occlusion. If there is insufficient space I don't think I would recommend orthodontics in this case. Because after orthodontics, a fixed retention (lingual wire) is recommended to prevent teeth from moving. The fact of making the butterfly bridge did not allow us to place this retention and the risk of displacement of the tooth would be high which could lead to contact on the Emax.

You should also know that I cannot give any guarantee of results for this type of treatment. During manufacturing we take all necessary means to obtain the best restoration. However, if there is decimation or fracture (in the case of an emax) we have no guarantee.

 

[MattKW]

Found a local clinic that could do extraction + cantilever bridge + maybe basic ortho, but...

1. They prefer the EMAX material instead of Zirconia (2 other clinics also said the same thing) or metal/ceramic. I don't have a strong preference for this and I am not so confident about which material is the best, so it's not a dealbreaker.

2. They recommend the 2-wings design but they will let me take the final decision and make a cantilever bridge if that's really what I want (no warranty but that was expected)

3. I explained a dentist saw my occlusion and recommended moving #11 forward, but they think that orthodontic treatment is a bad idea because I would need a fixed retainer wire, can you tell me more about that? Note that they haven't seen me in person yet and I just sent them the videos of my occlusion and asked to confirm if they really think drilling the palatal surface would be preferable.

4. I live in Trois-Rivières, Quebec, Canada. The only orthodontic clinic nearby is Orthodontie Mauricie with the 2 years wait time. They don't consider my case urgent and said they can't do anything to see me faster. I checked the list on the Orthodontist Association and the Federation of Dental Specialists websites to make sure.

5. Here is a (translated) copy of my emails with the local generalist clinic:

1. Given your difficult bite, I'd prefer metal-ceramic. Definitely not zirconia because of bonding issues, and altho eMax has good bonding, your bite is too harsh.
2. 1-wing as less complications. Also, if you're only moving 11 forward a bit, then 2-wing would be difficult with your bite.
3. I think they're probably unclear about what we've been discussing. A fixed retainer wire would only be used after full-mouth ortho. Yes, you really should go and talk to them in person, let them take models, photos, etc. I will DM you my personal email address and they are welcome to contact me if desired - I think I can trust you not to abuse my offer.
4. Ah, hence your familiarity with FDI tooth numbering. Dentistry Forums is a US-centric website where the counting system is the unwieldy UNS (Universal Numbering System) - which nobody else in the world uses!

 

[joey87]

I just came back from the dentist's clinic (took someone's cancellation) and saw the dentist who responded to the quoted emails. I showed our conversation, he checked my occlusion and agreed, not enough place on #11 for the wing

1. He can't do ortho and recommended not doing it unless doing full otho for 2-3 years. He now recommends doing a cantilever bridge on #11 and putting the wing on #12 instead. I said i'm not so confident about using a lateral incisor for abutment, as we discussed it's better when the tooth is held by a larger one. But he said that my teeth are long enough and I should try before resorting to ortho. The #12 had a carrie and a filling, but he said it wouldn't be a problem for the wing. I asked if he had ever made a RBB for a central incisor using the lateral as an abutment... he said no.

2. His reasoning for not recommending ortho is the risk of the tooth moving. I asked about the retainer wire and he said I would still need it even for just 1 tooth and that he would have to find a way to fit both the wing and the retainer wire.

3. Not sure what to do at this point. You seem to have much more ortho experience than the generalist I just saw so I value your opinion a lot. I was more confident with the plan of bridging #21 with #11. Maybe I should see a real orthodontist.

Sorry for the back & forth, really appreciate your time

 

[joey87]

I went to another clinic and just came back from an appointment with Dentist #3.

1. He disagrees with Dentist #2 about putting the wing on the lateral incisor and agrees with you that we should use the adjacent central incisor instead

2. He has experience with ortho and RBBs but said my case is too complex for him due to deep bite. He referred me to a Prosthodontist for the bridge and said I should see a real orthodontist for #11. I am now waiting for my appointment date with the Prosthodontist. I'm considering traveling 2 hours to see an Orthodontist in another city.

3. He agrees with Dentist #2 about the retention wire and the risk of the tooth moving after doing ortho but said I need a real orthodontist

4. He strongly disagrees with the cantilever bridge and says that two wings are better. I still think 1-wing cantilever is the way to go.

 

[joey87]

I am now waiting for my appointment date with the Prosthodontist.

They can't see me until at least 2 years... I'm screwed, I'm never going to find a solution, guess I'll just have to live with a missing tooth....

 

[joey87]

Well, finally some good news! I saw a real orthodontist in another city for the first time today, who was accompanied by another dentist who had experience with Maryland bridges. They were very competent and answered all my questions much better than the other dentists I had seen previously.

Good news: Invisalign will work with me and I will not need a retention wire.

Bad news: Ortho treatment will cost $11,000 plus $1,500 for a gum graft on my 2 bottom canines and then $2,000 for the bridge. It will take 2 years and a half to move #11 forward. The cost looks very high but I don't have any other choice...

Another thing - I asked about the fake teeth in the clear aligner he said he would give me white wax to put where the tooth is missing. Do you think it will look bad?