Teeth or Implants
Treatment Planning Considerations: Questionable Teeth or Implants
Harel Simon, DMD
Harel Simon, DMD, is an assistant professor at the University
of Southern California School of Dentistry.
Copyright 2003 Journal of the California Dental Association.
The decision concerning treatment planning should be based on the most
predictable procedures that will benefit the health and function of the
patient. When deciding upon the proper restorative treatment, the clinician
is faced with a dilemma about whether to keep or extract teeth with questionable
prognoses, as illustrated with the patient "A.K." It is well-accepted
that the individual prognosis of each tooth can influence the prognosis
of the outcome. However, since the success of the restoration is more
important than the individual tooth, the decision to keep or extract an
individual tooth should not be based on its prognosis alone but on the
prognosis of the whole prosthodontic rehabilitation and the patient’s
benefit.1
When designing a treatment plan, it is generally acceptable to maintain teeth with good prognoses and extract teeth with hopeless prognoses. Nevertheless, there is no consensus as to the proper treatment of teeth with questionable prognoses.1-8
A tooth may have a compromised prognosis from a periodontal, restorative, endodontic, and prosthodontic perspective. Different criteria have been suggested to define teeth as periodontally questionable.9-11 McFall12 followed the criteria of Hirschfeld and Wasserman9 and categorized a tooth as questionable if it had furcation invasion, deep noneradicable pocket, extensive alveolar bone loss, or marked mobility grade II or more in conjunction with pocket depth and alveolar bone loss. He further demonstrated in a 15-year study, 43.3 percent to 60 percent of the teeth with questionable prognoses were lost even though they were subjected to periodontal therapy and proper maintenance.12 Spear discussed the prognosis of a single tooth from a restorative point of view and suggested a minimum of available tooth structure as a guideline for retaining a tooth.5 Lewis discussed the management of teeth with questionable prognoses from a prosthodontic perspective. He suggested that in a prosthetic rehabilitation, the extraction of natural teeth should not depend upon the health of the individual tooth but rather on the success of the overall rehabilitation planned and the long-term service provided to the patient.1
The introduction of osseointegrated dental implants has presented the profession with additional treatment options.13-15 Dental implants can now be used predictably and serve as long-term abutments for various prostheses.8,14,16-21
Dental implants present several advantages over questionable teeth. From a restorative perspective, dental implants are made of materials with known physical properties that can provide standardized structural durability as abutments. Dental implants are not subjected to caries and may be used successfully even in caries-prone individuals.
From a prosthodontic perspective, implant placement is planned according to the requirements of the desired prosthesis. Therefore, with the use of dental implants, optimal number of abutments with adequate length and diameter can be placed to support the prosthesis as needed.
From a periodontal perspective, it has been demonstrated that the bone surrounding dental implants remains relatively stable over time. The use of dental implants to support prostheses has been shown to preserve adjacent remaining alveolar bone.22,23 Furthermore, it has been shown that dental implants are successful in oral rehabilitation of patients treated for periodontal disease. Implants placed in partially edentulous patients treated for generalized chronic periodontitis and generalized aggressive periodontitis demonstrated high success rates.24
The issue of whether to retain questionable teeth or replace them with dental implants has been debated in the literature.1-4,6,7 The maintenance of questionable teeth often requires advanced endodontic, periodontal, and restorative procedures in heroic attempts to salvage them.25-27 These extensive procedures are not only costly but also time-consuming and have various degrees of success.
Even if the procedures to salvage questionable teeth are successful, it has been shown that such teeth have an unpredictable periodontal prognosis.12,28-31 Questionable teeth do not provide optimal support as abutments for prostheses due to their reduced hard- and soft-tissue support or compromised structural integrity and may jeopardize the success of the restoration.
Teeth with questionable prognoses may continue to lose bone and soft tissue as their condition deteriorates.22 Tissue loss may adversely affect the adjacent teeth, compromise esthetics, and put the success of the restorations at risk. Furthermore, continuous bone loss around questionable teeth may also compromise the future placement of dental implants. When such teeth are finally diagnosed as hopeless and extracted, they leave a residual ridge that may not be adequate for implant placement. This may result in a compromise in implant length, diameter, location, or angulation, or may require additional augmentation procedures with various degrees of success that may jeopardize the prognosis of implants.
The treatment of patient A.K. presents a situation where questionable teeth were restored and maintained due to lack of better alternatives. Today, however, dentists know that a proactive approach is necessary to prevent this destructive process. Early intervention and extraction of questionable teeth should be considered to prevent the bone loss involved in maintaining these teeth. Dental implants can replace the questionable teeth, thereby providing a more predictable root replacement than a compromised tooth and a more stable foundation for the prosthesis by enhancing the predictability of the rehabilitation.
Acknowledgments
The author would like to thank Dr. Ziv Simon, Graduate Periodontics, University of Toronto, for his input in preparing this manuscript.
References
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To request a printed copy of this article, please contact/Harel Simon, DMD, 1400 Midvale Ave., Apt 101, Los Angeles, CA 90024-5486.
