Implants vs. Crown and Bridgework: Which is better?

Dr. Edward Feinberg works with dentists who want to improve their crown and bridgework skills and deliver better treatment outcomes. A graduate of Tufts University, he practiced dentistry in Scarsdale, New York, for more than 40 years and now serves as Director of ONWARD, an online teaching organization for full coverage restorative dentistry. He has created more than 35 online courses and authored numerous scientific and educational articles, along with books and textbooks on restorative dentistry. A nationally recognized lecturer, Dr. Feinberg has also served on four American Dental Association councils and currently serves on the Arizona Dental Association’s Council on Annual Sessions. He is the recipient of several professional awards, including the Ninth District Dental Association D. Austen Sniffen Award.

The Proper Use of Implants

One of the greatest innovations in the dental profession is the osseointegrated dental implant. Where appropriate, dental implants can be a godsend by restoring form and function to patients who have lost their teeth. However, dental implants are currently being overused and used inappropriately by dental practitioners. It is no wonder that the failure rate for dental implants is rising. The surgical placement of dental implants should be a last resort, except in certain circumstances (such as congenitally missing lateral incisors among virginal teeth with no restorations and no periodontal bone loss).

Unfortunately, dental implants today are routinely placed as a first resort.

When osseointegrated implants first came to this country in the 1980s, they were used only for fully edentulous (no teeth) arches. Dr. Branemark was a true scientist and he invested 20 years of scientific research before bringing his invention to this country.

Following his recommendations was a guarantee of achieving a success rate of at least 85 to 90 percent. In the 1990s, practitioners started placing implants for single tooth restorations and small bridges. Since the 2000s there has been a veritable explosion of implant placement, as if they were a panacea for every conceivable type of restorative problem.
Today, implants are commonly placed in areas of poor anatomy and overloaded with forces in such a manner that they are likely to fail.

The Epidemic of Tooth Extraction and Implant Placement

There is also an epidemic of tooth extraction in order to place implants. Teeth are being extracted that Dentistry can EASILY save, such as teeth with little or no clinical crowns above the gingiva. One reason is that the majority of dentists do not know how to save these teeth.

Many dentists have lost confidence in their crown and bridge techniques. They are having difficulty with recurrent decay under their restorations and loss of retention (crowns falling out). These problems were solved in the 1930s. Dentists today are taught in every single dental institution to create butt-joint crown and bridge restorations. The term ‘butt-joint” comes from carpentry and consists of preparing a ledge around a tooth and making the restoration to the ledge. Butt joint restorations can never be sealed as bacteria are 2 to 10 microns in size and the best marginal adaptation of restoration to tooth structure is in the neighborhood of 80 to 120 microns. Bonding and cements cannot reliably seal restorations at the micron level.

The butt-joint approach to crown and bridgework did not come from Dentistry’s “roots.”

My father and his teacher did not have the problems today’s dentists are having with recurrent decay and crowns falling out. The original restorations were modeled on the Mason Jar Cover, which is the best method ever devised for food preservation. With this design, crowns are extended beyond the ledge to seal the tooth completely against decay. This design also allows the restoration to adequately grip the root surface, so that the restorations cannot dislodge and fall out.

Dentists often do not appreciate that crowns and bridges are corrective and not merely “tooth coverings.” Corrective crowns and bridges are designed according to basic principles of engineering to create an ideal architecture that eliminates destructive forces on the supporting bone and roots. Corrective restorations compensate for existing periodontal bone loss to prevent additional periodontal bone loss. Corrective dentistry works because of Wolff’s Law. In the 1800s, Julius Wolff discovered that bone is deposited and resorbed in accordance with the stress placed upon it. Corrective dentistry is designed to eliminate destructive forces inflicted on the teeth and supporting bone. Seventy years of documented evidence demonstrate that a high percentage of corrective dental restorations completely nip periodontal bone loss in the bud.

Overall Approach vs Piecemeal Approach

Corrective Dentistry follows an overall approach to patient care because it is designed to prevent disease. A piecemeal approach, by contrast, only fills a hole or a space. The signature of a piecemeal approach to dentistry is the single tooth implant. It is rare to find presentations and articles where implants are placed among teeth with no restorations and no periodontal bone loss. Most of the time the teeth surrounding an implant already have crowns and fillings or are compromised with periodontal bone loss. It is a certainty that these teeth will require further treatment in the future. In these cases, corrective bridgework is a better treatment solution than a single-tooth implant because it completely solves the patient’s problems in the entire area. By contrast, a single tooth implant only fills a space and does nothing for the teeth around it. The patient’s problems are never solved.

“Patients Should Understand that They Have Choices”

Many dentists today have become “one-trick” ponies in that they are extremely proficient in implant therapy but lack adequate crown and bridge skills in their treatment armamentaria. Practitioners who excel at both therapies can pick and choose which one is best for each patient. There is no “one-size-fits-all.” Patients should understand that they often have choices, but choices are not always presented to them. If one practitioner cannot save their teeth, perhaps another one can. Patients should not hesitate to seek additional opinions so that they can make the best choice for their optimal care.