The Failing Bridge and the Question of What to Replace
A 55-year-old woman presents with a three-unit fixed partial denture replacing tooth 25, supported by teeth 24 and 26. She reports that food traps under the pontic and that the bridge feels loose. Radiographs show that tooth 24 has a post and core with a questionable ferrule and recurrent caries at the margin; tooth 26 has moderate bone loss and a fracture line in the distal abutment. The pontic site has adequate ridge width but reduced height. She is a non-smoker with no medical contraindications. She asks whether she can simply have the bridge recemented. She is concerned about cost and wants the least invasive option.
1. Evaluate whether recementing the existing bridge is a reasonable option.
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Recementing is not a reasonable definitive option. The bridge is loose because the abutments are compromised: tooth 24 has recurrent caries and a questionable ferrule, and tooth 26 has a fracture and moderate bone loss. Recementing would mask the problem temporarily and allow caries and periodontal disease to progress. The judgment is to explain that the looseness is a symptom of failing abutments, not a cement failure. A definitive plan requires addressing the caries, assessing restorability of each abutment, and considering periodontal status. If the patient declines extensive treatment, document the risks of recementing as a temporary measure only, with close follow-up. The least invasive option should not be confused with the least appropriate option.
2. Compare replacement options and recommend one, with reasoning.
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Options include a new fixed partial denture, an implant-supported crown, or a removable partial denture. A new bridge requires both abutments to be restorable and periodontally sound; tooth 24's questionable ferrule and tooth 26's fracture make long-term prognosis uncertain. An implant-supported crown at the pontic site avoids preparing the abutments and is often the best long-term option if bone volume permits; the reduced ridge height may require grafting, which should be assessed with imaging. A removable partial denture is less invasive and less costly but may accelerate bone loss and affect comfort. Given her age, non-smoking status, and adequate ridge width, an implant is a strong recommendation if the site is suitable. Discuss cost, timeline, and the need to treat the abutments regardless of the option chosen.
3. How do you handle the patient's request for the least invasive option when it conflicts with the best prognosis?
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Use shared decision-making. Present the options with their risks, benefits, and prognoses in plain language, and explicitly state what happens if the least invasive option fails. Clarify that 'least invasive' does not mean 'no treatment'; the failing abutments still need care. Ask about her priorities-cost, time, avoidance of surgery-and document them. Offer a staged plan: stabilize the abutments first, then decide on replacement. If she chooses a temporary or removable option, set clear review intervals and exit criteria. The key judgment is to respect autonomy while ensuring informed consent, not to pressure her into the most expensive option. Record the discussion and her decision.