|

Received: 19 May 2019    Accepted: 21 May 2019

DOI: 10.1111/edt.12492

COMPREHENSIVE REVIEW

In the dental implant era, why do we still bother saving teeth?

Danielle Clark | Liran Levin

Division of Periodontology, Faculty of
Medicine and Dentistry, University of Abstract
Alberta, Edmonton, AB, Canada Teeth are vital sensory organs that contribute to our daily activities of living.
Correspondence Unfortunately, teeth can be lost for several reasons including trauma, caries, and
Liran Levin, School of Dentistry, Faculty periodontal disease. Although dental trauma injuries and caries are more frequently
of Medicine and Dentistry, University of
Alberta, 5‐468 Edmonton Clinic Health encountered in a younger population, tooth loss because of periodontal disease oc‐
Academy, 11405‐87 Avenue NW, 5th Floor, curs in the older population. In the dental implant era, the trend sometimes seems to
Edmonton, AB T6G 1C9, Canada.
Email: [email protected] be to extract compromised teeth and replace them with dental implants. However,
the long‐term prognosis of teeth might not be comparable with the prognosis of
dental implants. Complications, failures, and diseases such as peri‐implantitis are not
uncommon, and, despite popular belief, implants are not 99% successful. Other treat‐
ment options that aim to save compromised or diseased teeth such as endodontic
treatment, periodontal treatment, intentional replantation, and autotransplantation
should be considered on an individual basis. These treatments have competing suc‐
cess rates to dental implants but, more importantly, retain the natural tooth in the
dentition for a longer period of time. These options are important to discuss in detail
during treatment planning with patients in order to clarify any misconceptions about
teeth and dental implants. In the event a tooth does have to be extracted, procedures
such as decoronation and orthodontic extrusion might be useful to preserve hard and
soft tissues for future dental implant placement. Regardless of the treatment modal‐
ity, it is critical that strict maintenance and follow‐up protocols are implemented and
that treatment planning is ethically responsible and evidence based.

KEYWORDS
plaque, prevention, trauma

1 |  I NTRO D U C TI O N it comes to our teeth, patients and, sometimes, dental professionals
do not seem to value the preservation of them nearly as much. This
Teeth are sensory organs that function in several different aspects is a negative phenomenon because the more teeth a person has, the
of everyday life. Mastication is an important role that teeth serve, more likely they are to have a higher quality of life.3 Unfortunately,
and the ability to chew food is associated with an individual's quality these vital organs are not invincible and can be lost because of several
1
of life. Other daily activities such as speech, and even smiling, are reasons during one's lifetime. Periodontal disease, caries, and dental
done with one's teeth. As a result, teeth are important organs that trauma can all result in tooth loss across all ages.4,5 Furthermore, the
are associated with quality of life because of their role with esthet‐ treatments provided to patients for periodontal disease, caries, and
ics, chewing, and speech. 2 When other organs in the body become trauma can also lead to tooth loss or poor prognosis.
compromised, much energy is spent on preventing further damage In today's dental implant era, there are several treatment options
or even trying to reverse the damage. However, surprisingly, when available to either save teeth or replace missing teeth. Periodontal

This article is being published concurrently in Journal of Endodontics. The articles are identical. Either citation can be used when citing this article.

Dental Traumatology. 2019;00:1–8. © 2019 John Wiley & Sons A/S and |  1
wileyonlinelibrary.com/journal/edt  
American Association of Endodontists
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2       CLARK and LEVIN

treatment, guided bone regeneration, supportive periodontal therapy,

endodontic treatment, and dental implants are all available. However,
Significance
before determining the treatment plan, the proper diagnosis must be
Dental implants are a popular treatment option for pa‐
made, and, then, an unbiased assessment of the prognosis needs to
tients who are missing teeth. Nonetheless, several less
be performed.6 When evaluating prognosis, one should examine the
extensive and invasive treatment options that involve sav‐
patient to assess the long‐term prognosis of the different treatment
ing the natural tooth are available and have good prognosis
options and determine which one will best serve the specific patient
and success rates. If these options are used first, the op‐
in the long run. For instance, when assessing a diseased tooth, there
tion to place a dental implant is still available. If the dental
is a need to evaluate if taking the required steps to save the tooth will
implant fails, we no longer have the option of restoring the
lead to a better prognosis than extracting it and placing an implant.
natural tooth.
In order to properly assess and evaluate treatment options for
patients, unbiased and evidence‐based understanding of the many
factors that contribute to the prognosis for teeth and implants is re‐
quired. Assessing the true prognosis of all options and considering of this treatment option. WebMD, a popular medical site, states
the best available evidence to support each and every decision is that dental implants have success rates of 98%.18 Other seemingly
crucial before proposing the options to the patient. credible sites also report success rates between 95% and 98%.19,20
However, what these sites are often reporting are the survival rates
of dental implants, not necessarily success, and for a very short
2 |  TO OTH LOS S A N D M I S S I N G TE E TH follow‐up time. A dental implant is considered “survived” if it is
still in the mouth, which means that this includes dental implants
Several studies have explored the epidemiology of missing teeth with peri‐implant mucositis, peri‐implantitis, severe bone loss, and
related to dental trauma, periodontal disease, and caries. These sleeping implants. Nevertheless, research has shown that after 5 to
studies have limitations because of the difficulty in gathering a large 10 years 80% of implants presented with peri‐implant mucositis, and
amount of data collected with different indices. However, several 12%‐66% had peri‐implantitis. 21‒24 A dental implant with disease can
studies are available to provide an overarching view regarding the hardly be called successful; however, patients do not receive this in‐
reasons for tooth loss. formation sometimes. Thus, it is extremely difficult for patients to
In the United States, over 6 million people over the age of 50 make an informed decision. Unfortunately, even having the dental
were edentulous between 2009 and 2014.7,8 The average number implant as an option can, unintentionally, bias treatment planning.
of missing teeth because of caries ranges widely; however, there are Therefore, it is the responsibility of the clinician to educate the pa‐
reports that caries accounts for 8.35 of missing teeth (the M com‐ tient using the current evidence on dental implants and not opinions
ponent of decayed missing filled teeth) in 20‐ to 64‐year olds. 5 The or beliefs. 25
same study reported that only 15.7% of the study population did Dental implants often become a treatment option when a tooth
not have a tooth extracted.5 The reasons for extraction included is either missing or has a hopeless prognosis because of caries,
pain (34.6%), a large cavity (5.6%), periodontal problems (6.0%), and periodontal disease, or trauma. However, a study in patients with
endodontic problems (3.2%).5 Another study reporting on missing aggressive periodontal disease showed that teeth labeled as ques‐
teeth in 14‐ to 89‐year olds found caries accounted for 86.2% of tionable or even hopeless could be retained in the mouth for as long
extractions, periodontal disease accounted for 6.6% of extractions, as 15 years. 26 The available tools for establishing prognosis can
and trauma for 3.9% of extractions.9 The younger population sometimes be pessimistic, can lack predictability, and may result in
(5‐12 years old) seemed to experience extractions mostly because clinicians extracting teeth too soon. 27‒29 Furthermore, the relative
4
of caries (64.3%) and dental trauma (43.0%). European and US novelty of dental implants means that there is a lack of long‐term
studies estimate periodontitis to affect 31%‐76% of individuals.10‒13 data on their success, and this is an important consideration before
This is significant because tooth loss because of periodontal disease an extraction followed by implant placement is planned.30
14‒16
averages 0.04 to 0.08 patient/year. When tooth loss is studied When patients are presented with an option of saving a diseased
according to age, 80% of extractions because of caries are experi‐ or traumatized tooth, the comparison treatment option should not
enced in people under the age of 40 years, and 70% of periodontal be the ideal, healthy implant. Instead, it needs to be compared with
17
extractions are experienced in people over the age of 40 years. a realistic dental implant that might have complications such as peri‐
implant mucositis or peri‐implantitis. 21‒24 This is supported by evi‐
dence that shows implant survival rates are lower than teeth, even
3 |  LO N G ‐TE R M PRO G N OS I S O F TE E TH when they are compromised but properly treated and maintained.30
A N D I M PL A NT S A systematic review reported long‐term tooth loss rates to range
from 3.6%‐13.4%, whereas the rate of dental implant loss ranged
Despite the excitement and the promising results with dental im‐ from 0%‐33%.31 Another review compared the survival of dental im‐
plants, there are some misconceptions regarding the real longevity plants with endodontically treated teeth. The survival rates of dental
CLARK and LEVIN |
      3

implants ranged from 73%‐95.5%, whereas the survival rates of end‐ root canal treatment is possible, it may be a better option than dental
32
odontically treated teeth ranged from 89.7%‐98.1%. implants.32
The high survival rates of compromised teeth that were properly
treated and maintained were shown to surpass the survival rates of
4.2 | Periodontal treatment
dental implants in a long‐term follow‐up. It is also noteworthy that
extracting a tooth is an irreversible decision, and it cannot be un‐ When teeth are periodontally compromised, their prognosis is es‐
done if a dental implant fails. Thus, the decision to extract a tooth tablished, and again 2 main treatments are available: periodontal
needs to be assessed thoughtfully.32 therapy to retain the tooth and extraction. However, when it comes
to establishing prognosis for periodontally compromised teeth,
there is a lack of an ideal tool available to do this accurately. 29,31,40
4 | K E E P TH E TO OTH Therefore, focusing on saving the compromised teeth is a treatment
option worth merit.
When it comes to a compromised tooth caused because of trauma, Periodontal treatment can encompass different surgeries, bone
caries, or periodontal disease, there are 2 main options: keep the augmentations, and supportive periodontal therapy. Supportive
tooth or extract it. Keeping the tooth may not be an easy treatment periodontal therapy involves strict follow‐up, frequent scaling and
option. However, it is important to recognize that extracting a tooth root planning, and, most importantly, oral hygiene education and in‐
and placing a dental implant may include complicated procedures, struction. Periodontal treatment followed by proper supportive peri‐
such as bone augmentation and soft tissue management. If the de‐ odontal therapy showed great success in the literature and seems
cision to keep the tooth is made, the following treatments may be to be dependent on patient compliance (Figure 1).41,42 If patients’
necessary to ensure better long‐term results. compliance is good, there is an increased chance of survival of the
compromised teeth.41,42 The survival of periodontally compromised
teeth that were properly treated and regularly maintained ranged
4.1 | Endodontic treatment
from 92%‐93%.30 Furthermore, even rates of survival of hopeless
Deep caries lesions as well as traumatic dental injuries such as extru‐ and questionable teeth in patients diagnosed with grade C periodon‐
sion, lateral luxation, and intrusion can eventually lead to pulp necro‐ tal disease (formerly known as aggressive periodontitis) vary from
33,34
sis. In those cases, patients may require endodontic treatment in 60%‐88%, respectively. 26 Thus, instead of extracting teeth because
order to save the tooth. In some severe cases, extraction might be it seems to be a less complicated treatment option, using periodon‐
considered as an alternative treatment option. When these options tal treatment followed by proper supportive periodontal therapy to
are provided to the patient, it is important to detail the pros and cons retain periodontally compromised teeth should be prioritized.31 In
of either case. A 2007 systematic review reported success rates of the event that this therapy is not successful and the tooth needs to
primary root canal treatment ranging from 68%‐85%.35 A 10‐year be extracted, there is still the option of a dental implant because a
follow‐up of molars with endodontic treatment had a 89.2% success backup will have 10‐year survival rates of 82%‐94%.30
rate, whereas another 10‐year follow‐up showed an 84.1% success
rate and a 93% survival rate.36,37 Other studies in adults have found
4.3 | Intentional replantation
that survival rates after root canal therapy can reach 95% at 4 years
of follow‐up after primary or secondary (ie, retreatment) treatment, Even if a periodontally or endodontically compromised tooth is
whereas the success rates can range from 83% for primary treat‐ not salvageable, a dental implant may not be the next treatment
38,39
ment and 80% with secondary treatment. A detailed compari‐ in line. Intentional replantation involves purposefully extracting
son of endodontically treated teeth and dental implants by Setzer a compromised tooth and replanting the tooth into its socket.43
32
and Kim showed that dental implants have a higher loss rate than Although intentional replantation is considered as a last resort
endodontically treated teeth. Based on the existing evidence, if a treatment option, the treatment was reported to have a 90%

F I G U R E 1   A patient with stabilized

periodontal condition on a significantly
reduced periodontium under supportive
periodontal therapy. The teeth are not
mobile, and there are no periodontal
pockets or active disease
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4       CLARK and LEVIN

success rates in the first 6 months.43 Between 6 and 12 months, dental implants can not only mislead patients but also mislead
the survival rate decreased from 85% to 80%, and after 48 months, clinicians. It is very hard to accurately compare prognosis when
the survival rate of replanted teeth stabilized.43‒45 A meta‐analysis we assess the outcomes of a compromised tooth with the ideal,
of 6 studies also showed a high success rate of 89.1% of intention‐ fully osseointegrated dental implant. Instead, the potential com‐
ally replanted teeth.46 The success of this procedure is influenced plications of placing a dental implant need to be considered and
by several factors including the extent of periodontal disease and discussed starting with the surgical process itself. If there is insuf‐
the presence of root fracture. Nonetheless, it is a rather simple ficient bone volume, it may be necessary to treat the patient with
procedure that is less costly than dental implants and has minimal bone augmentation surgery first. After the healing time for this
morbidity for the patient.46,47 Although the survival rates of re‐ procedure, the implant can be placed. However, a common miscon‐
planted teeth do not compete with those of the classic periodontal ception among patients is that the implant is the entire tooth, with
treatment and endodontic treatment, the survival is notably high the crown included. Because this is not the case, the healing of the
and is a conservative option that may be viable for some patients. implant needs to occur before the restorative treatment. Not only
can the implant placement be a timely process, these surgeries can
also come with complications such as sinus penetration, nerve dam‐
4.4 | Autotransplantation
age, bleeding, and perforations of the bone plate. 59 Furthermore,
When a tooth is avulsed, extracted, or congenitally missing, replac‐ dental implants are not invincible and can be even more susceptible
ing the missing tooth with an implant is a treatment option. However, to oral bacteria and require proper follow‐up and maintenance.60
another available option may be replacing the missing tooth with an‐ Complications such as peri‐implant mucositis and peri‐implantitis
other tooth. Autotransplantation involves moving a donor tooth to a are prevalent; the prevalence of implants with peri‐implant mucosi‐
receptor site in the same patient (Figure 2).48 Success rates for this tis is around 80%, whereas peri‐implantitis affects approximately
procedure are as high as 96% and survival rates as high as 98% for 12%‐66%. 21‒24,61 Despite the notion that dental implants are 99%
autotransplanted teeth.49‒52 Reported complications of autotrans‐ successful, it is important to understand the current evidence and
plantation include pulp necrosis, root resorption, and hypermobility.53 apply that information during the treatment planning process. Other
Not only is autotransplantation a good option because of high success options for dealing with a missing tooth or teeth include no treat‐
rates, it is also a good option for growing patients who cannot have ment, a fixed or removable partial denture, or orthodontic move‐
dental implants placed. The placement of dental implants is not ad‐ ment to close the gap and not necessarily place dental implants.62
54,55
vised until patients are no longer growing. This can mean spending Furthermore, when a tooth is deemed hopeless, there might still
a long period of time without a tooth if it is lost to trauma, caries, and be an option to use it for preservation of soft and hard tissues for
so on at a younger age. Autotransplantation provides adolescents and future implantation.63
growing patients a treatment option to replace a missing tooth.56 If the
autotransplantation is not successful, the patient still has the option of
5.1 | Preservation of hard and soft tissue
a dental implant. However, if the implant is placed first and fails, the
second and third rounds of dental implant treatment are not as suc‐ In the event the tooth is truly hopeless after all prognostic factors are
57,58
cessful as the first round. considered, extracting the tooth still may not be the ideal treatment
option, at least not immediately. Sometimes patients may delay the
placement of a dental implant for several reasons, such as anxiety, cost,
5 |  E X TR AC T TH E TO OTH — PR E S E RV E TH E or early age.64,65 However, if the tooth is removed, the alveolar bone
TI S S U E S can resorb.66 During this process, both the hard and soft tissues might
change, and it will be more challenging to completely restore those
If the decision to extract a compromised tooth is made, the long‐ tissues when the patient is ready for implant placement. In order to
term outcomes must be carefully thought through and, most im‐ achieve the proper esthetics, the preservation of hard and soft tissue
portantly, explained in detail to the patient. The media surrounding needs to be considered before extracting a tooth.66 Using procedures

F I G U R E 2   Autotransplantation of
a maxillary premolar to an incisor area
(missing because of dental trauma) in a
13‐year‐old boy. Immediate postoperative
clinical and radiologic view
CLARK and LEVIN |
      5

such as decoronation or orthodontic extrusion have been proven use‐

5.1.2 | Orthodontic extrusion
ful in preserving or augmenting hard and soft tissues.
Another option, particularly for a growing patient, is orthodontic
extrusion of compromised teeth.72 Placing single tooth implants in
5.1.1 | Decoronation
esthetic zones can be challenging because of factors such as a pa‐
Dental trauma that results in an avulsed tooth being replanted into tient's smile line and the morphology of the adjacent teeth and the
the socket can eventually lead to ankylosis.67 In children and ado‐ hard and soft tissues.73 This can become more challenging if a tooth
lescents, this can also cause infrapositioning of the tooth and cause is extracted and bone resorption occurs, leading to altered hard and
adverse events during orthodontic therapy.68 The recommended soft tissues. However, if a tooth has a hopeless prognosis, extrac‐
treatment in some cases is to surgically extract the ankylotic tooth, tion is often the treatment. In order to avoid the bone resorption
which itself is a traumatic procedure.67 Another option is decorona‐ caused by the extraction of compromised teeth, orthodontic extru‐
tion (Figure 3).69 This treatment involves removing the crown of the sion of the tooth may be a valid treatment option.73 This treatment
tooth and leaving only the root inside the bone. Often, the tooth involves orthodontically extruding the root, leading to an increase
has been previously treated endodontically. Before covering the in the width of attached gingiva, and preserves the alveolar bone
root, the endodontic filling must be removed, allowing the canal to for future implant placement.74‒76 Orthodontic extrusion becomes
68
fill with blood. The purpose of this procedure is for the root even‐ an even more conservative option because the patient is more likely
tually to be replaced with bone, in turn preserving the volume of to not need bone augmentation when a dental implant is placed.63
alveolar bone for both esthetics and future implant placement.70 As
opposed to the traumatic surgery of removing an ankylosed tooth,
which can have negative sequalae, decoronation is a more predict‐ 6 | M A I NTE N A N C E A N D FO LLOW‐ U P
able and conservative procedure. Furthermore, decoronation can
preserve both the height and the width of the alveolar ridge for fu‐ Whether the decision is made to extract a tooth or not, mainte‐
ture implant placement.71 nance and follow‐up are important and applicable throughout the

F I G U R E 3   A decoronation procedure
performed to preserve bone for future
implant placement. Note the bone growth
coronal to the root in the follow‐up
radiograph (arrow). (Courtesy of Drs Yuli
Berlin‐Broner and Eyal Nuni)
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6       CLARK and LEVIN

treatment. As part of the treatment process, it is imperative that the implants, although seemingly successful, do not have long‐term data
mouth remains disease free, meaning no caries, infection, or active (over 50 years) and are an irreversible treatment option. If an implant
periodontal disease. This translates into educating patients about fails, we may only place another implant. If a tooth fails, at least we still
proper oral hygiene practices and ensuring that periodontal disease have the option of placing a dental implant.
is stable and there is a low risk for new caries or trauma. This includes
educating patients about the use of mouth guards and head protec‐
C O N FL I C T O F I N T E R E S T
tion for patients who participate in high‐risk sports or activities.77,78
Also, a strict recall protocol must be implemented for professional The authors confirm that they have no conflict of interest.
appointments. It is important that this recall protocol is based on the
specific needs of the patient.79 For different types of dental trauma,
ORCID
the International Association for Dental Traumatology has published
guidelines for the suggested follow‐up frequency for different inju‐ Liran Levin  https://orcid.org/0000-0002-8123-7936
ries.80‒82 If a compromised tooth is extracted and an implant is placed,
the same concept applies. With high rates of peri‐implant disease, it
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