Tuesday, February 12, 2013

Replace or Save Tooth?

To Save a Tooth or Replace It:  That is the Question

One of the most difficult decisions Periodontal Associates has to make is when to save a tooth and when to remove and replace it.  This is a difficult decision on many levels.  Numerous factors must be considered including the restorability of the tooth, the patient's susceptibility to disease, gingival and papillary conditions, and esthetics in weighing the benefits vs. risks of retaining a compromised tooth.  The decision may be based on one critical issue or on a collection of factors.  In this blog entry, Drs. Versman, Heller and Beckman will discuss these factors which need to be considered in deciding whether to remove or save a tooth.  As always, Periodontal Associates welcomes your comments and suggestions so feel free to comment here, call our Aurora office at (303) 755-4500, or please stop in!

Our goal at Periodontal Associates is to maintain or reinstate good form and function to the dentition with excellent esthetics and health. Fundamental to developing a dental treatment plan, a prognosis must be assigned to each tooth.  Can it be saved?  Should it be removed and replaced with an implant?

Osseointegration and periodontal regeneration are two significant advances in contemporary dental care and each should be utilized when appropriate. The natural dentition responds very well to definitive periodontal treatment.  And there is significant evidence that efficacious periodontal treatment can change the prognosis of a tooth from hopeless to good.  Dr. Versman, Dr. Heller, and Dr. Beckman always try to use periodontal cleanings and treatment first if they believe the tooth is savable. Extracting teeth which had lost supporting periodontium and replacing them dental implants is not always the preferred treatment approach.

Implant replacement is not infallible and does not mean the patient will not experience future complications. While osseointegration has reduced the need to save teeth with a marginal prognosis, there has been a significant rise in the incidence of peri-implant disease and bone loss associated dental implants.

Greenstein et al raise several questions when deciding whether a tooth should be saved or replaced.

These include:
1. Can the tooth be restored effectively?
2 Will endodontic treatment be successful?
3. Is periodontal therapy a reasonable option?
4. What effect will extraction have on the final treatment plan , particularly with respect to esthetics?

Restorative Considerations

Drs. Versman, Heller, and Beckamn know that an effective restoration can return teeth to normal function and acceptable esthetics. Teeth without extensive caries, a favorable crown/root ratio and adequate tooth structure offer the best prognosis for effective restoration.

Fracture and Faulty Restorations.  If a tooth is fractured, Dr. Versman, Dr. Heller, and Dr. Beckman man their best judgement to determine restorability.

Restorations must not infringe on the biologic width which can result in chronic gingival inflammation, pain, and clinical attachment loss.

Problematic teeth in the esthetic zone which require a crown lengthening procedure should be evaluated for replacement because these measures may result in an unesthetic appearance due to excessive tooth length.

Essential to cosmetic success, Drs. Versman, Heller, and Beckman perform a complete evaluation of the smile line and other factors.

Caries.  Decay which extends beyond or to the level of the alveolar bone usually represents a restorative challenge for Drs. Versman, Heller, and Beckman and increased treatment costs for the patient.

If a tooth is restorable, orthodontic extrusion, crown lengthening, or mucogingival surgical procedures may be required to salvage the tooth.  If this is necessary, Periodontal works closely with your general dentist in the Denver area to provide a thorough and individualized treatment plan.

Crown/Root Ratio. Teeth without loss of attachment or destruction of periodontal tissues usually present a favorable crown/root ratio and consequently are good candidates for restoration.

A 1:1 crown to root ratio is the minimum acceptable assuming the periodontium is healthy and the occlusion is controlled.

Remaining Tooth Structure. Teeth with 5mm suprabony structure, 2mm for the biologic width, 2mm for the ferrule and 1mm sulcus depth are candidates for effective restoration.

Often the length of the available tooth structure is insufficient to ensure the preservation of the biologic width and crown lengthening may be required.  Crown lengthening is a routine procedure that periodontists like Drs. Versman, Heller, and Beckman are specialists in.

Depending on if the patient need additional treatment like crown lengthening, this makes the final cost similar change.

The final decision to save the tooth or place an implant is often linked to financial considerations and the concerns for longevity of the results as opposed to the possibility of saving an already compromised tooth. Periodontal Associates prides ourselves in working with our patients to come up with a treatment plan that fits each individual best in terms of finances but most importantly health.

Endodontic Treatment

Survival rates for endodontically treated teeth have been estimated to be as high as 95% when associated with an excellent full coverage restoration -- if the tooth is treated with a well-fitting single-tooth crown with adequate ferrule.

Avila et al suggest the clinician should consider removing the tooth and replacing it with a dental implant if:
  • The tooth has a large apical lesion (greater than 5mm).
  • The tooth has had apical surgery.
  • The tooth needs a large post and core for support.
  • The tooth has inadequate ferrule.
  • The tooth has an abnormal root anatomy precluding successful endodontic obturation.
  • Th tooth has a root which is short or thin which will cause a post to predispose the tooth to post loosening or root fracture.
  • There is a misaligned post that will weaken the root structure.
Periodontal Therapy

In deciding whether to save or replace a periodontally involved tooth, the Dr. Versman, Dr. Heller, and Dr. Beckman considers the severity of the periodontal condition and the likelihood of recurrence.  Periodontal Associates in Aurora, CO specialized in treating periodontal or gum disease, and Drs. Versman, Heller, and Beckman are the highest qualified doctors to make this decision.

If the periodontal prognosis is poor and/or the possibility of recurrence of the disease is high, such teeth may be candidates for removal and replacement with dental implants.  However, Periodontal Associates can help treat gum disease better with hygienists who are specifically trained to treat patients with severe gum disease.
Drs. Versman, Heller, and Beckman suggest regeneration will most likely be successful in teeth with pocket depths greater than 6mm.  pocket depths are determines by measuring the gums to see how large a pocket is or how far under the gums bacteria is spreading.  Those with pockets depths beginning at 5mm is considered to have periodontal disease and is in need of immediate and frequent periodontal treatment. Do you have gum disease? Click here to see all symptoms and warning signs.

In addition, Avila et al suggest regeneration will most likely be successful in the following cases:
  • Teeth with mobility greater than normal and up to 1mm in any direction.   In addition to periodontal regeneration, these teeth can also be considered for splinting in case of secondary occlusal trauma.
  • Teeth with no recurrent periodontal abscess.
  • Teeth with less than 30% alveolar bone loss.
  • Teeth with deep, localized narrow intrabony defects.
  • Teeth without invasive furcation involvement.
  • Teeth without interproximal bone levels equal to or apical to the level of the furcaton.
  • Teeth with no root anomalies.
  • Teeth which would benefit from root resection as a conservative, therapeutic option.
Aviva et al suggest teeth should be considered for replacement if:
  • Pockets are deeper than 8mm.
  • Teeth are extensively mobile.
  • Teeth have recurrent periodontal abscesses.
  • Teeth have root anomalies -- cervical enamel projections, enamel pearls or root grooves.
Esthetic Considerations

If function and cosmetics can not be maintained or improved, this may be an indication for tooth removal.  The decision to retain a tooth or remove and replace it with an implant is dependent on the ability to achieve a functional and cosmetic results for our Aurora patients.

The Effect of Retention or Replacement on the Final Treatment Plan

The strategic value of a particular tooth is an important parameter to be considered when designing a  treatment plan.  The decision to extract or retain teeth affects adjacent teeth, especially is the plan is for the teeth to function as abutments for a fixed or removable partial denture.

It is essential to determine if a compromised tooth can withstand the functional load anticipated in the future.

Other Considerations

Other factors in the decision to retain or remove teeth are:
  • Smoking Habits
  • Use of IV bisphosphonates and other drugs
  • Patients with uncontrolled systemic conditions such as Type 1 diabetes

Tooth extraction and implant placement may not be the best therapeutic approach in all patients.  The decision to save a tooth or extract it and place an implant must include a consideration of a multitude of factors. 

To help decide what is best for you, Periodontal Associates strongly suggests you stop by for a FREE dental implant consultation in their Aurora, CO office.  As you have read, every individual can experience different needs, wants, and concerns when deciding what is right for them.  A consultation with Dr. Ken Versman, Dr. Doug Heller, or Dr. Eric Beckman allows one on one time and communication to resolve your questions, and provide you with excellent dental care.

Our office is located in Aurora, but we serve patients from all surrounding Denver metro areas.  Our patients respect Drs. Versman, Heller, and Beckman so much that some patients travel from Wyoming and Colorado cities hours away. 

Please contact Periodontal Associates at (303) 755-4500 or click here for an appointment.  Our website may also provide you more information to any questions that you have, and we urge you to to browse our website at www.periodontahealth.com. Drs. Versman, Heller, and Beckman are Denver's premiere providers of dental implants and periodontics.  We look forward to meeting you and providing you with a life changing and beautiful smile!


Dr. Versman, Dr. Heller, and Dr. Beckman would like to thank you for taking the time to visit their blog and we would love to hear from you!

For more information, to schedule an appointment or a dental consultation, please visit us at www.periodontalhealth.com