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Author: Claudia Zornow
Date: 2021-06-03 01:08
Has anyone here had their lower teeth (bottom front four incisors) replaced with implants and been able to continue playing? My boyfriend has bone loss around those teeth and needs extraction, bone grafting, and then either implants or a six-unit bridge anchored on the lower canines.
He has gotten opinions from two dentists. One thinks that implants would not be strong enough to withstand the forces of clarinet playing (downward and lateral pressure) due to the small size (diameter) of implants for those teeth; this dentist recommends the six-unit bridge. The other dentist thinks that implants would be more than strong enough.
I've searched the archives here and found posts from people who had implants on their top front teeth, or bridges (one person had a seven-unit bridge on top), or even dentures, and who have still been able to play. Nothing about bottom teeth being replaced, though.
Thanks for sharing any experience you might have with this.
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Author: Paul Aviles
Date: 2021-06-03 03:12
There are two issues:
1. The strength of the replacements
Normally I'd say the implants would be plenty strong, but because you refer to bone loss and bone graft, this particular implant may be less sturdy than most. The dentist who would do the procedure should help judge this.
2. The amount of force used for the embouchure
There are traditionally a wide range of acceptable approaches to correct clarinet embouchure. However, to prevent possible complications with replacement teeth I would strongly recommend trying an approach that uses the least amount of effort. What comes to my mind is the traditional German approach which uses a mouthpiece with a very small opening (1.00mm or less), a very long facing (distance from tip of mouthpiece to the point where the reed and mouthpiece come together) usually around 30mm, and a fairly SOFT reed (usually a strengty of 2 1/2).
I have posted about this before. Bas DeJong of Belgium represents Viotto German mouthpieces. Upon request he will make a mouthpiece (N1 facing is standard German facing) that fits atop Boehm clarinets. For the N1 facing, Bas recommends the use of 2 1/2 strength Vandoren White Master Traditional reeds. With this setup, one basically only needs to place the mouthpiece/reed into the mouth and just blow. Surprisingly with little to no effort you can produce a wonderful sound with the full dynamic range!
It is also so much easier to transition to double lip embouchure with this setup which will offer even more insurance against putting unnecessary pressure against the lower teeth.
.....................Paul Aviles
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Author: LFabian
Date: 2021-06-03 13:17
I had a molar implant lower left. There is a gap on lower right (tooth removed) in the back. This improves air movement go to mouthpiece. Front upper teeth were uneven and left bite marks. I brought in my mouthpiece to the dentist. He evened one tooth with the other by grinding it down. Took only 3 minutes. so I have a very grip on top. Embouchure is improved.
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Author: hans
Date: 2021-06-04 04:01
Claudia,
I have had seven implants, with no failures, so that I have had some experience with implants, but not for any front teeth and not for service as bridge supports.
The earliest one was nearly 14 years ago and it required a bone graft, which was done under general anaesthesia in hospital. The others were enhanced by inserting bone growth medium into the extraction site. I can no longer distinguish which of my teeth are my nearly 76 year old "original equipment" and which are the implants, which is how it should be, IMO.
My dentist 14 years ago was strongly opposed to implants, and preferred to install bridges. I accepted that until a few bridge support teeth roots cracked, because a bridge requires two teeth to do the work of three or more (depending on how many missing teeth are replaced by a bridge). After that, I wanted no more bridges and sought out an experienced oral surgeon. While all of my implants were done by an oral surgeon, I understand that dentists are performing this procedure as well. It may be worth consulting an oral surgeon before making a decision. Be sure to ask what the surgeon's failure rate is.
Hans
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Author: SunnyDaze
Date: 2021-06-05 16:31
Hi Paul,
That idea of playing with a german mouthpiece so as not to have to press hard on the reed sounds like a great way to help the transition to double lip playing. Would it actually help with that, or is this only a technique to use when there are tooth problems, because of other downsides that you haven't mentioned?
Thanks!
Jen
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Author: SunnyDaze
Date: 2021-06-05 18:55
Hi Paul,
I just wrote to Bas de Jong to ask about those special mouthpieces, quoting what you said above and got this reply:
"I dont make the mouthpieces.I will finish selling the mouthpieces very
soon.I can not help you."
So I think maybe that is not a thing any more. Shame as it sounded really good for double lipping.
Jen
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Author: Paul Aviles
Date: 2021-06-06 03:03
Well I'm very sorry to hear that about Bas. This was something he was quite keen on about five years ago. My ONLY reservation back then was that I thought the Wurlitzer mouthpieces, most specifically the M3+, had a better end result. The problem with straight up German mouthpieces is that you need to have the tenon shortened by 1.00mm and made smaller in diameter by 1.00mm. Actually not that hard for many techs to do this modification but it makes the whole thing a little more of a project and less "plug and play."
You could actually make a barrel 1.00 larger in diameter and 1.00mm deeper in the upper socket but THAT is much harder to do. I had to go to someone who was a dedicated machinist who also did woodwind work to make this happen.
But to answer the first question. I would recommend this to just about EVERYONE who has problems with biting (and even those who don't know they have a problem with biting.....yet). I had used a very firm embouchure (ok, I was a biter) for about fifty years, and within a period of less than a year, the German mouthpieces got me free from a lifetime of sinning!
THANK YOU BAS!
and sorry I dragged my feet on a full throated endorsement those few years ago.
.................Paul Aviles
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Author: super20dan
Date: 2021-06-06 03:54
experimented with the double lip today. as a failed oboe player i dont have much hope. i do notice an improvement in fast articulating . everything else is a struggle tho.
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Author: Paul Aviles
Date: 2021-06-06 06:04
MY reference to double lip is really more about getting an EASY, pressure neutral approach. Now I can seamlessly move from one to the other yet remain a single lip player, mostly because I have done that for fifty years.
.............Paul Aviles
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Author: SunnyDaze
Date: 2021-06-06 13:58
Hi Paul,
That's really interesting. I am definitely a biter, and I do worry about the force that that puts through my teeth too. Do you think that any German mp would be good to experiment with this technique, or would it need to be a specific one? My local techs could easily adjust the tenon.
If it wasn't for the covid situation I'm sure I could probably ask to try some German mps, but at the moment I think I'd not really be up for that.
My current mp is a J&D Hite E and for me it is so much more suitable than any of the other regular mps that I have tried, so if there is a nearest neighbour in the German mps, it would be great to know.
Thanks!
Jen
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Author: Paul Aviles
Date: 2021-06-06 15:30
One caveat I'll throw out there is that I am not directly familiar with the panoply of German facings. When I played Oehler system Wurlitzers (back in the day) INCORRECTLY, I had interacted with Dave Hite who collected the measurements of just about every major player in the world (and all his custom measurement clients). I sent him my favorite of a group of Wurlitzer mouthpieces and asked him to put that dimension on some of the others I did not like so much. The main one that worked for me also turned out to be only one minor dimension off from that used by Karl Leister and I got the impression that the M3+ was a pretty standard, traditional facing........back then.
Today there are many Germans using French reeds AND doing the same "hard reed thing" that American players have been obsessed with for generations (a good example is Ottensamer in Berlin).
So I might say, if you get one around 0.95 tip opening and a facing length of 29.00mm millimeters or so (like the M3+ or the N1 Viotto) that would be what works well with the 2.5 strength reed for the whole old school German approach.
You still have to firm up your mid-section when you blow (as always one MUST work the abdominals and diaphragm in opposition to create the proper platform for the vibrating column that actually extends from the bottom of the lungs through the end of the clarinet......really a foot beyond). But the embouchure is almost taken out of the equation as something to think about.
.............Paul Aviles
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Author: SunnyDaze
Date: 2021-06-06 16:02
That's really interesting, thank you. I love that Hite collected all those particulars for all the players. As a bioinformatician, that kind if behaviour speaks to my soul.
I will ask at the shop about an M3+ or N1 Viotto.
I totally get what you mean about firming up support. My son is teaching me to play his french horn just now and it's pretty amazing for working those muscles. An excellent add-on for any clarinet player :-)
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Author: Kalashnikirby
Date: 2021-06-07 01:12
As a dentist, well, does your boyfriend really need 4 implants down there?
Is there a possibility to go with a bridge, using the canini instead (which are excellent for that purpose)?
The "prosthetic value" (can't translate it any better, sorry) of lower incisors ist extremely low. Thus, having them removed, often due to periodontal issues is rather common. Now if the canini are fine, bridges are a much cheaper way to replace these teeth, as the forces that occur down there are generally lower than one would expect.
Now consider the following: Neither implants nor a bridge can simulate the feeling of a real tooth (with its pulp and elastic fibers attaching it to the bone), so either will be a compromise. Then again, your upper incisors put way more force on the mouthpiece. Would'nt worry about implants not being able to handle the force, granted they are done well. Yes, a small diameter is likely going to be used, but that doesn't affet them too dramatically.
Honestly, while of course it depends on the patient's individual oral situation, I would'nt worry too much about having implants down there. The other question is, why would you use 4 of them, that is actually way too much for these tiny incisors. 2 implants should suffice.
Current clinical evidence suggests that for a complete solid replacement of ALL teeth, 6 implants would be enough. So I'm surprised he needs 4 for these rather "irrelevant" teeth. Placing 4 in that area will force one to be extremely precise, as implants need about 2mm of space around them.
Another thing: Consider that after implant surgery, the usually need 2-3 months for osseointegration. Only then can crowns or bridges be put on them and they can withstand greater loads.
Best regards
Christian
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Author: hans
Date: 2021-06-07 01:46
Christian,
While bridges may be cheaper (much!), faster, and functional, in my case there was significant bone loss in the places where two of my bridges were replaced by implants; i.e., the jaw bone shrinks when there is no tooth in it.
Is there a way to avoid that?
Best regards,
Hans
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Author: smokindok
Date: 2021-06-07 02:15
If Claudia is still following this, after the detour into yet another mouthpiece facing/embouchure pressure discourse...
Disclaimer: After 37 years of practice, I retired a bit over a year ago, to have more time for music... until Covid hit :-(
I am no longer licensed to practice dentistry. What I write below are just some things to consider, when making a decision, based on my experience placing many bridges, restoring many implants, and working with many musicians over the years.
First off, read carefully Hans' excellent comments above. His experience reflects the transition dentistry has gone through over the past few decades. As implant designs have been refined, and techniques for planning, placing, and restoring them have improved, the advantages of implants over bridges has, in most cases, made implants the first choice for replacing missing teeth.
One consideration is the health of the canine tooth on each side of the space where the teeth are missing. These canines have a much larger and stronger root than the incisors, so for decades they have been used to support a bridge to replace four missing incisors. Is the bone support for these canines sound, or has there been bone loss in this area also? If there is compromised bone support for the canines, the additional torqueing force of a bridge could accelerate breakdown of the supporting tissue, leading to mobility of the bridge and its eventual loss.
Do the canine teeth have existing restorations? If there are no existing restorations, it is a shame to unnecessarily strip all the healthy enamel off the tooth, weakening it and risking creating the need for root canal treatment, in order to make the clearance needed to place the bridge. On the other hand, if there are existing large restorations in the canines, the risk of fracture or restoration failure often increases.
That said, advanced bone loss can make implant restoration more complicated. This is where planning is critical! Modern 3D imaging techniques make planning the correct placement of implants much more manageable. Assuming the surgeon placing the implants and the restorative dentist constructing the replacement teeth are not the same person, communication between the two throughout the entire process IS CRITICAL. There can be situations where placing an implant in its "ideal" position in the bone puts the esthetics or function of the replacement teeth at risk. This needs to be resolved in the planning stages. When in practice, I always dreaded getting a call from an oral surgeon, after they had already placed implants, asking me to do the restorative work. At times, when multiple implants were placed, an implant would have to be "put to sleep" in the bone and not used to support the replacement teeth, because of the way it was positioned. PLANNING IS CRITICAL for a good result.
Examples of the details that need to be planned from the start: How much grafting needs to be done, using what technique? How long to wait after grafting before implant placement? What design and what manufacturer for the implant? What diameter implant? What length implant? How many implants? What is the best implant position in the bone for strength, function and esthetics? How long to allow for integration of the implant with the bone before any load on the implants? Will a temporary restoration be made for esthetics, while healing is taking place? What is the number and position of teeth in the final restoration? Will each implant be restored separately, or splinted together?
It is complicated, but done right, implants offer many advantages over traditional fixed bridges. If the implant route is chosen, understand that it may be a rather lengthy process. Feel free to contact me at the email in my profile, if you have any questions.
Hope all goes well with the treatment!
John
Edit: While writing this lengthy post, I see the discussion was already brought back on course!
Post Edited (2021-06-07 02:20)
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Author: SunnyDaze
Date: 2021-06-07 10:29
Hi Smokindok ,
Why are you being so rude to Paul? I thought he made a very helpful suggestion about how to reduce pressure on the teeth. I was just following up on that to find out more details, which I assumed would help Claudia.
I think this forum is particularly notable for the goodnatured kindness of the participants, and I would really like to see it stay that way.
Jen
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Author: Paul Aviles
Date: 2021-06-07 18:41
No offense taken.
I did think about that for a hot second but realized that it is actually a good point considering that the direct question was about the soundness of the dental side of this issue.
A lot of us clarinet players are fastidious to a fault.
SunnyDaze,
thanks for pointing to that mouthpiece chart. I'm having difficulty finding it. What does the blue graph at the bottom indicate? Looks like a sound wave picture gram.
..............Paul Aviles
Post Edited (2021-06-07 18:50)
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Author: smokindok
Date: 2021-06-07 20:27
Not sure if I am to apologize to Paul, who apparently was able to appreciate the point of my gentle ribbing, or to Jen who took offense. So, my apologies to both of you. I do not wish to create a hostile environment.
During my career as a restorative dentist, often treating musicians, my primary goal was to provide a restorative solution that allowed the patient to continue performing, without having to accommodate changes in technique. That said, woodwind and brass playing treads a thin line between function and parafunction which can make that goal difficult or impossible. When forced into a compromise, some players were able to adapt to some pretty significant changes, others had trouble with what appeared to be insignificant changes.
One thing that has not been mentioned is the importance of being certain that the underlying pathology that caused the initial bone loss is being managed. A premature failure of an expensive restorative treatment is a catastrophe to be avoided. Treatment of all existing pathology, along with careful daily hygiene and ongoing maintenance care, will lead to a good long term prognosis.
Again, my apologies, Paul... although I know you have been poked much harder by other members of this board... and survived ;-)
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Author: SunnyDaze
Date: 2021-06-07 22:09
Hi smokindok,
Thanks so much for that. I spend a bunch of time on some other forums that can be wildly toxic and I love that this one is so gentle. I'm really so relieved to hear that it is staying that way. :-)
Jen x
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Author: Kalashnikirby
Date: 2021-06-08 00:43
All John has said is correct and should be considered. Then again, diagnosis and treatment happen in person and we can only guess so much.
Still, since my boss just placed 2 implants (exact the same situation: replacement of lower incisors) today, consider the following:
1)3D imaging is a must and don't accept anyone placing implants without out. I for one love it too, though for other indications (I've yet to learn placing implants, but will do that too at some point...)
2) 4) implants for 32,31,41,42 just don't make much sense, given the limited amount of space in that area (this would apply to almost any patient!)
Hans:
Bone loss can be caused by several factors, but if we're talking about alveolar bone that has been without teeth for a longer time, the main cause is that the lack of physiological forces that the natural tooth would exercise. Lost bone can only be regaines through rather difficult means.
An implant can have an "osteoprotectice" function, as it stimulates it in a similar way.
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Author: kdk
Date: 2021-06-08 02:31
Kalashnikirby wrote:
> 2) 4) implants for 32,31,41,42 just don't make much sense,
> given the limited amount of space in that area (this would
> apply to almost any patient!)
Which teeth are those? I'm only familiar with numbering teeth 1 to 32 (starting with the upper right "wisdom tooth." Where are 41 and 42?
Karl
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Author: smokindok
Date: 2021-06-08 03:19
Karl,
Unlike the system in the USA, a lot of the world uses a two digit system to number teeth. The first digit is the quadrant where the tooth resides. 1=upper right; 2=upper left; 3=lower left; 4=lower right. The second digit is the number of tooth starting with 1 in front (anterior) and counting back (posteriorly) to 8, which would be the wisdom tooth. This is for the permanent teeth. Primary teeth are numbered similarly, using 5, 6, 7, 8 to designate the quadrant and 1 - 5 (anterior to posterior). The USA system uses letters for primary teeth, in the same pattern as the numbers are used for the permanent teeth.
32, 31, 41, 42 would be 23, 24, 25, 26.
Also, I absolutely agree with Christian in his assessment that two implants, just about all the time in this situation, are all that is needed. Also completely agree with his recommendation for 3D imaging as part of proper planning and to get things in the right place.
John
Post Edited (2021-06-08 03:26)
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Author: Claudia Zornow
Date: 2021-06-08 03:55
Thanks to John, Christian, and all who have contributed their wisdom here . We consulted with an oral surgeon last week, who did 3-D imaging, and he felt that two implants would be just fine. (I misspoke when I said four implants -- I meant four teeth replaced by some kind of implants.) The canines are fine and have plenty of bone. There is no reason to grind down those healthy teeth at this point, but if the implants should fail somehow, the six-unit bridge could be a backup plan.
The oral surgeon mentioned that he would work closely with the dentist for planning, so I think the points that John raised will be covered. Healing time will definitely be several months.
It turns out that I need an extraction and implant on an upper front incisor due to resorption, so we will be having his-and-hers oral surgeries, and there won't be any clarinet playing around our house for a while!
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Author: kdk
Date: 2021-06-08 04:59
smokindok wrote:
> Karl,
>
> Unlike the system in the USA, a lot of the world uses a two
> digit system to number teeth. The first digit is the quadrant
> where the tooth resides. 1=upper right; 2=upper left; 3=lower
> left; 4=lower right. The second digit is the number of tooth
> starting with 1 in front (anterior) and counting back
> (posteriorly) to 8, which would be the wisdom tooth. This is
> for the permanent teeth. Primary teeth are numbered similarly,
> using 5, 6, 7, 8 to designate the quadrant and 1 - 5 (anterior
> to posterior). The USA system uses letters for primary teeth,
> in the same pattern as the numbers are used for the permanent
> teeth.
>
> 32, 31, 41, 42 would be 23, 24, 25, 26.
Learn something new every day! Thanks!
Karl
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Author: smokindok
Date: 2021-06-08 06:44
Sounds like you are both in good hands, Claudia. Hope all goes smoothly!
John
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Author: Claudia Zornow
Date: 2022-06-08 02:07
Followup to this useful discussion from a year ago:
My boyfriend and I have completed the process of getting implants. I got one for my upper right front incisor (#8), and he got a four-unit restoration anchored to two implants where his bottom four front teeth were (#23-#26).
The results have been excellent. We are both able to play clarinet without difficulty (though the lack of pressure sensation on #8 for me feels quite strange), and my boyfriend is finding it easier than ever to play, now that his bottom teeth are strong and straight.
Thanks to smokindok John and everyone else who contributed to the discussion!
Claudia
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Author: smokindok
Date: 2022-06-09 08:27
Excellent, Claudia! Very happy to hear about the successful outcome for both of you. Thank you for letting us know.
Remember to be meticulous in your daily oral hygiene and keep up with periodic professional care.
John
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