Crowns and bad/open bite

[Dental Impatient]

I had an extraction on tooth 19. I am scheduled for an implant a month from now. I also had a root canal on tooth 5 the other day and have a temporary filling in it which will last "eight weeks".

I have a notoriously bad bite. My teeth don't touch each other in the front. They do in the back, but in an odd way that's developed over the years. I grind them a lot too, especially at night.

My current dentist doesn't want to crown either tooth while my bite is bad. He doesn't want to do a bridge either. His plan to restore my bite seems good on paper, but I worry it's going to snowball (more issues will arise as he works on all of my teeth) and become more costly in the future. Is there no way I can just get these two teeth crowned and move on with my life? I can live with the bite, but missing a huge lower tooth is really messing with me.

 

[Busybee]

How frustrating for you! It can take forever to restore a bite and in the meantime you can end up with more problems and living with temps etc is not good and can also mess up your bite even more. Of course at the same time some of the problems you've had may be down to the bad bite. The dentist doesn't want the restorations to fail so he's being cautious for your sake. What is the plan for restoring the bite? It's really not that simple a task and you can end up in more discomfort and with different problems.

 

[Dental Impatient]

He wants to build up my front teeth and maybe do some veneers so they touch and guide, then do the back teeth in a second phase with some composite some new crowns where badly needed etc. Like I said sounds good on paper but I'm very iffy at this point. He did a mold and has a model but I feel like he'll get it perfect from a dentistry standpoint and my jaw will just do its own thing. There's a chance any of these back filings will need a root canal if they're opened up again so I posed that concern and waiting for a response. If I end up with a bunch of extra work this could wind up costing 20k

 

[Busybee]

Sounds very lucrative for him. Does he have a back up plan for guaranteeing the finances don't go up if any of his plan doesn't work out?

 

[Dental Impatient]

Well. The last message I relayed was the concern that I had 7-8 large fillings in the back, that if they reveal the need for a root canal and crown while he's messing with them, will completely hose me on cost. I had broken a filling and gone in to see him, and the cavity was to the nerve, so I had a root canal the other day. All of these other fillings are about as old as that one. Ticking time bombs. Of course, once he's in there what's done is done. A root canal and a crown typically cost about $700 for one tooth, assuming I haven't wiped out my benefits for the year, which would easily happen if several teeth do that. So I don't know what he's going to say to put my mind at ease.

 

[Busybee]

So you mentioned your "current" dentist. Is that not the dentist who did the temp filling and pulled your tooth and plans to implant? I was just wondering if your dentist changed his mind about what to do after having made an initial treatment plan for you. You also mention both an implant and a bridge - is that for the same tooth that was pulled?

 

[Dental Impatient]

Tooth 19 was a mess. It was the first tooth I ever had work on. Over the pass 10-12 years it's had two root canals and four crowns. Barely any surface left. We discussed both options for replacing (implant and bridge), initially I had thought the bridge sounded more logical, but quickly became deadset on an implant. He thinks that putting a regular crown on it once the implant is in, with my bite, will potentionally cause trauma to and maybe even loosen the implant in my jaw, so he wants to go through this lofty grand plan while he puts a composite/provisional crown there in the meantime.

 

[Busybee]

It does sound as though that missing tooth implant would be exposed to too much pressure if you have had the original tooth redone so many times. There is an underlying problem. If you waste money on an implant that's bound to fail then you are throwing it down the drain because you'd have to have it redone and maybe face failure again. You don't always need to open up fillings if they are composite in order to build them up. You only have to do this if they are amalgam. Or the filling can be taken down a little rather than completely removed. Can he not build up the front teeth with composite too? Veneers usually require the removal of natural tooth. An alternative is to grind down the back teeth and that's a lot cheaper but can cause just as many problems as building them up. Plus it is irreversible removal of natural tooth which cannot be replaced. It takes a rare dentist who can really fix bite because bite is very complex. It takes a lot of time and it's hard to adjust to changes because your brain is looking for places the muscles in the jaw used to recognise. Badly done bite adjustments can cause headaches, jaw pain, neck pain and even backache. Can also cause pain in other teeth and ringing in the ears. No two dentists will have the same approach and there is no such thing as a bite specialist. Exceptional skills aside, the most important thing is that you feel you can talk to your dentist and that you feel your dentist is really listening to you. I hope your dentist is a restorative and implant specialist. Have you thought of getting a second opinion?

 

[Dental Impatient]

He is the second opinion, but now I am leaning toward third and fourth and beyond. The first opinion was asinine, he just wanted to crown all my teeth (for 15k). This second guy is not an implant specialist or prosthodontist, he is an older and clearly very experienced DDS. I do like his demeanor and the fact that he will work with me on cost and talk to me, but I feel like this procedure will end up costing triple what he is telling me it will be, and I may not end up better for it. I'm probably going to tell him on Monday that I've changed my mind again.

As far as #19 goes, yes, it had to be redone a lot, but I feel that was less about the bite and more about that particular tooth and certain circumstances. I had not seen a dentist for 7 years at that point (which I'm paying for now). It had a large cavity and needed a root canal (throbbing, excruciating pain). The root canal was done first, and then the first crown was placed. That was the point where I became serious and picked a dentist to start going to. I ended up needing 19 fillings done, which were done over the course of a year, and I'm pretty sure that's what hosed my bite. Anyway, eventually that first (ill fitting) crown broke and took a huge chunk of the tooth with it. They did another root canal for good measure and inserted a post, then crowned it again. That crown became - unglued? - basically it could be wiggled back and forth in place. He was not able to reattach that one, so another one was done. By that point there was too little tooth surface. Finally this new guy saw a shadow on the X-Ray under the crown that hadn't been there three months prior and we extracted.

I've got some tough conversations to had. I'm going to reach out to the oral surgeon and get more information about the implant I'm slated to get and how the bite could adversely affect it. With my current dentist I'm going to put the kaibosh on this grand scheme, and probably go get some other opinions.

In my mind I still want to proceed with the implant. The longer I wait the more likely it is I'll need a bone graft to get it later. After it's placed I will still have time to decide how to proceed.

 

[Busybee]

19 fillings are bound to alter your bite. It's not normal for a crown on that size tooth in the position you described to break the tooth off. Even if it's badly fitted it's not likely to be under that kind of pressure because it's a grinder rather than a slider. So there must be some unusual dynamic in your mouth. I'm just going by the same teeth in my mouth and they don't touch the sides of the upper teeth with any force. When I chew they grind the food but they are protected from breakage by their position and the surrounding teeth. It's possible that the original filling was so large they had little tooth to work with to place the crowns. I think your current dentist is right to be cautious as you have now entered the category of someone with a complex issue. I'm guessing you are in the US where they tend to be quite aggressive in their approach to treatment. They will try to "fix" the bite with lots of restorations. In the UK you'd find it the opposite with nobody wanting to deal with your current situation because it's so complex that anything they do could go wrong and cause greater problems. You should have been given a night guard a long time ago if you grind at night. If you go from dentist to dentist I'm sure you will find someone who will charge you for placing the implant, but you may find it fails if the bite is putting pressure on the tooth. You should really see a specialist in restorative dentistry.

 

[Dental Impatient]

You're right about the size of the cavity, I think. They had to do "buildup" on several occasions to get crowns in there. I have several other crowns on molars and none of them have behaved this way. I'm a grinder and I have a terrible unconscious nail biting habit.

And you're right about the aggressiveness. In every scenario I'm given, it's a huge undertaking and overhaul of my mouth. At the end of these roads, I might be 20k dollars poorer and have a worse situation. The night guard is a good call, I've never worn one in the past because they'll typically charge me $300 for one, and it changes whenever you have work done and needs to be redone, but given the alternatives this would actually be a much cheaper option at this point, to get an implant and the two crowns I need, and then get a night guard made. I've always claimed I can't wear one due to gag reflex, but that is just an excuse. I've managed to get comfortable enough with the spacer apparatus that my current dentist made that keeps 18 and 20 from floating together that I can wear it while I sleep. I should be able to handle a guard now.