Problems/Solutions

1. Take home whiteners — The newer materials are generally effective after two to three weeks of using a simple custom-fitted bleach tray as little as one hour a day. Yellow/light brown teeth generally bleach best. Dark brown/blue-gray teeth can be more resistant. A certain percentage of teeth are not readily responsive to bleaching.
2. In-office power bleaching — If you don't want to wait or know you don't want to wear the clear, wafer thin, soft bleach tray, it is possible in may cases to see noticeable change in one to two appointments in the office. Using essentially the same, but more concentrated, material as the take home method — hydrogen peroxide or a precursor of hydrogen peroxide called carbamide peroxide — some teeth can be lightened after one hour and a half appointment. The same tooth color guidelines as the take home still hold. A certain percentage of teeth are not responsive to immediate whitening or need a take home booster.
3. Porcelain veneers and/or porcelain crowns — When stains are too dark, teeth are too resistant to bleaching or when teeth are filled or decayed, porcelain veneers and full porcelain crowns (a veneer is actually a half crown that only covers the front of the tooth with a porcelain shell) can transform your smile into what you want.

1. Direct bonding — When the wear or lost tooth structure is minimal, just rebuilding the missing portion with direct bonding material may be all that is needed. The life span before having to retouch or redo the bonding (wear, staining, etc) is about 5 to 7 years.
2. Porcelain veneers — Longer lasting that the direct bonding and more color stable, laboratory fabricated porcelain veneers can be used when the wear or lost tooth structure is moderate. The thin porcelain veneers are bonded to the teeth. The life span of porcelain veneers can be 10+/- years. Severe grinding can compromise the longevity.
3. All porcelain crowns — With severe wear or lost tooth structure, more of the tooth must be covered and full crown restorations are indicated. They are actually just an extension of the veneers. The life span is 10+/- years. On rare occasions (with severe grinding of the teeth for example), porcelain fused to gold crowns are needed to prevent porcelain cracking or breaking. Generally, porcelain crowns are bonded to the teeth for strength.

1. Implant prosthesis — Whether one tooth has been lost or multiple teeth, implants in the right situations can replace the loss without involving other teeth. The restoration of the space is a two step procedure. First the implant is placed and the area left to heal for 3-4 months. Then the crown, bridge or denture is placed on the implant support.

   They have been used for over 30 years and are predictable when the situation has been carefully evaluated. Not all situations are amenable to implant replacement (e.g. severe tooth grinders, poor bone quality, etc.).

2. Fixed porcelain-fused-to-gold bridgework — In the majority of situations, the "workhorse" of dentistry in replacing lost teeth has been the fixed (cemented) porcelain-fused-to-gold bridge. It is predictable, strong, esthetic and the "simplest" of the so called permanent restorations in that it can be placed immediately once healing has taken place (assuming no periodontal work is needed).
3. Maryland bridges — A less predictable replacement than a fixed bridge, but less expensive and less invasive, the Maryland bridge (named because it was developed at the University of Maryland) is a metal frame with the replacement teeth attached and is simply bonded to the anchor teeth. It is not appropriate for all circumstances, but in the right situations it can do the job with no anesthesia and minimal tooth shaping.
4. Metal free bridgework (very limited) — In very selective situations with light stress and minimal spaces, where esthetics are compromised by metal, metal free bridgework can be used.
5. Removable partial dentures — Another simple, relatively inexpensive, replacement for lost teeth is the simple clasp partial denture. It attaches to the remaining teeth with clasps and is removed for cleaning and at night. It involves minimal tooth shaping and no anesthesia.
6. Combination of fixed bridgework and removable partial dentures — In situations where the remaining teeth need restoration or are weak and need splinting together, and in situations where the edentulous span is more than 2 missing teeth (too long for a traditional fixed bridge) this solution involves a combination of fixed bridgework (frequently with interlocks embedded in the bridgework) and a precision or semi-precision removable partial denture. It is generally more stable and more esthetic than the simple clasp partial (because the retention is hidden).
7. Full dentures — When there are not enough healthy teeth to support any of the above, a full denture may be the best solution. If this is an initial placement of a full denture and there are teeth still remaining, there are three approaches to a full denture:
• Coping dentures — This is used where there are some teeth that can be saved for a short or longer time and covered with some type of gold "thimble" (sometimes with retentive devices on them, sometimes not), that is then covered by the full denture. Even keeping two or more teeth can improve the stability, retention and function of the denture (especially on the lower arch).
• Full immediate dentures — When all teeth are compromised or when the expense of keeping the few teeth is a factor (each retained tooth almost always need a root canal and, depending on the home care, decay rate and other factors, further needs the gold coping or thimble), removal of the remaining teeth and the placement of the new denture at the time of extractions is generally done. It is called an immediate denture. The remaining gum may continue to shrink over the next several years and the denture will probably need to be relined one or more times.
• Implant overdenture — If there is sufficient bone support remaining, implants can be placed as anchors for full dentures.

1. Orthodontics — Ideally, the solution to teeth out of place is to put them back in place with orthodontics (assuming there is enough room in the arch to accomplish the movement. After they are in ideal position, some type of stabilization is needed to keep them from migrating back where they were to start. This can be done with a removable retainer or various splinting options.
2. "Instant" Orthodontics — In certain situation, the problem can be remedied cosmetically in one or two visits with direct bonding, porcelain veneers and/or porcelain crowns without orthodontics.
3. Combinations of 1 and 2 above.

1. Routine "fillings" — Depending on the extent of the lost tooth structure, many teeth can be restored or repaired with a "filling". In some instances this can be an interim solution; in other situations, it can be the definitive solution.
• Direct composite — Tooth colored restorations constitute the vast majority of fillings done in our office. They are bonded to the tooth structure and can seal internal cracks and restore lost tooth structure esthetically.
• Amalgam — Once the main restorative option, silver amalgam is still used in certain situations.
2. Indirect composite or porcelain onlays — When extensive tooth structure has been lost to breakage or decay, and full crown restorations are not indicated, a partial non metal crown (called an onlay because it covers the top of the tooth but doesn't go down to the gumline) can be used if the bite is not destructive. It is made of tooth colored composite or porcelain and is fabricated in a dental laboratory on a model taken in the office. It is a multi-appointment restoration.
3. Gold onlays and full crowns — Long the standard for strength and indestructability, gold onlays and full crowns have fallen out of favor with the general public but still remain the durability standard of dentistry. If the gold color doesn't bother you, it may offer the most durable restoration in situations where the biting surface of the tooth has to be restored (when over 50% of the top of the tooth is filled or decayed, undermining the tooth cusps).
4. All porcelain crowns — Where esthetics is paramount and the tooth won't be subject to heavy function or lateral biting forces, the newer porcelains (metal free) may be used to restore back teeth. They are still not as strong as the traditional porcelain fused to gold crowns, but are getting closer, especially when they are bonded (instead of just cemented) to the prepared tooth.
5. Porcelain-fused-to-gold crowns — This is the workhorse for restoring badly broken down or decayed teeth. With the strength and fit of gold

1. External splinting — When teeth are loose, they can be stabilized by connecting the teeth together into one strong unit in several ways. When teeth are unrestored and fixation is indicated (especially the lower front teeth), an external wire or nylon mesh splint can be used, frequently without anesthesia and with minimal tooth preparation.
2. Internal splinting — In situations where the bite interferes with placing an external splint, grooves may be placed in the inner (tongue side) surface of the loose teeth and a wire or tooth colored nylon cord is embedded internally and fixed with bonded composite.
3. Splinted fixed bridgework — In certain extreme situations, partial or full mouth reconstruction may be indicated, necessitating the crowning and connecting the loose teeth into one solid unit. This is usually the treatment used when teeth are in danger of being loosened further and lost if not stabilized, are periodontally compromised and/or are previously restored in some way.
4. Occlusal adustment — In certain isolated circumstances, relieving the stress of traumatic biting or grinding pressure by reshaping the teeth involved can allow constantly traumatized teeth to tighten. This can also be used in conjunction with the above splinting procedures.

1. Nightguard — The simplest treatment is a clear plastic horseshoe shaped bite guard worn on the upper teeth (called a nightguard because it is worn at night). The purpose of the guard is to redirect the clenching or grinding that frequently is present in TMJ cases into patterns that put less stress on the muscles around the head and neck.
2. Selective occlusal adjustment — In a certain amount of TMJ situations, the pain can be generated because of bite discrepancies. It is possible that selective reshaping of the offending teeth can relieve the spasms in the jaw muscles that are causing the pain.
3. Restorative therapy (bite collapse) — When a lot of teeth have been lost and there has been no restoration of the spaces, frequently, teeth overerupt, move or tilt. When enough of them have done this, the bite is said to be "collapsed". We overclose, in short, because the teeth that supported our bite are either gone or out of alignment. The jaw muscles get overstretched and traumatized. When the bite collapse gets severe enough the muscles may hurt. Constantly. It can radiate to the ear, simulate migraine headaches, and manifest as neck, jaw or back pain. This is what is called TMJ or TMD syndrome. Sometimes it is necessary to rebuild the entire dentition with extensive crown and bridge reconstruction. Sometimes restorative therapy has to be combined with other therapies to afford relief. And sometimes even with the best efforts, the TMD symptoms persist to one degree or another.
4. Referral — The solution to TMJ/TMD problems can be quite complex and involve several medical/dental specialties over a long period of time if the above simpler intervention treatments don't relieve the symptoms.