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When to Save or Extract a Tooth: A guide to Prognosis


When to Save or Extract a Tooth: A guide to Prognosis Evaluation of Individual Teeth Dr Wael Al-Omari BDS, MDentSci, PhD * * * * * * * * * * * * * Thank you ... – PowerPoint PPT presentation

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Title: When to Save or Extract a Tooth: A guide to Prognosis

When to Save or Extract a Tooth A guide to
Prognosis Evaluation of Individual Teeth
  • Dr Wael Al-Omari
  • BDS, MDentSci, PhD

  • Predicting the long term serviceability of a
    tooth as a functional unit of an overall
    rehabilitation is one of the most challenging
    tasks in clinical dentistry.
  • Evaluation of prognosis is a fundamental to solid
    treatment plan formulation
  • Question to save or replace should be resolved

  • Questions to be resolved
  • 1- Can a tooth be effectively restored?
  • 2- Will endodontic treatment be successful?
  • 3- Is periodontal therapy feasible?
  • 4- Will a tooth be a suitable abutment?
  • 5- What are the consequences of extraction?
  • 6- Is the patient committed to good maintenance?
  • 7- What are the alternate treatments available?
  • 8- Are technical and financial support obtainable?

  • The ultimate decision to save or extract based on
    risks vs. benefits of alternate treatments.
  • The decision is associated with many factors and
    cumulative risks assessment.
  • Special considerations must be given to the
    esthetic zone.

  • Prognosis is defined as a prediction of the
    probable course and outcome of a disease, and the
    likelihood of recovery from a disease
  • Unfortunately evidence-based published data as
    predictors for long-term prognosis are lacking in
    the dental literature.
  • There is no accepted standardization tool for
    assessing the overall status of teeth

The major factors that determine prognosis
  • Periodontal Considerations
  • Restorability
  • Endodontic considerations
  • Occlusal plane considerations
  • Patient-level considerations

Periodontal Considerations
  • It is almost impossible to predict the chance of
    survival of a periodontally compromised teeth
    (Hirschfeld and Wasserman, 1978)
  • Clinical parameters are ineffective in predicting
    any outcome other than good (McGuire et al,
  • Initial prognosis did not adequately predict
    tooth survival especially for posterior teeth
    (McGuire, 1991, McGuire Nunn, 1999)
  • Interleukin-1 and smoking improve accuracy of
    predicting tooth loss (McGuire Nunn, 1999)

  • Predicting tooth survival in well-maintained
    patients is more accurate than in the
    poor-maintained ones (Becker et al, 1984)
  • Maxillary molars more likely to be lost than
  • Anterior teeth have better prognosis than
  • However, clinical criteria that results in
    increased risk of tooth loss included
  • 1- Increasing probing depth
  • 2- furcation involvement
  • 3- Mobility
  • 4- Percent of bone loss
  • 5- Parafunctional habits
  • 6- Smoking

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Mutilated Dentition
  • Long term success of restoration of
    endodontically treated tooth is based on the
    amount of remaining sound coronal tooth
  • The critical issue is tissue preservation
  • A tooth restorability index was developed by
    Bandlish et al (2006) that quantitatively
    assessed the remaining sound dentine and graded
    from 0-3.
  • 12 of teeth with dowels have complications
    (Goodacre et al, 2003)
  • Generally 5 mm of suprabony structure is
    required 2 mm biological width, 2mm for the
    ferrule and 1mm sulcus depth (Morgano,1996)

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Endodontic Considerations
  • Success rates of endodontic therapy with respect
    to various
  • (Messer HH (1999)
  • Endodontic situations success
  • Teeth without periapical lesions 96100
  • Teeth with periapical lesions 82
  • Meets technical standards of ideal treatment 94
  • Inadequate technical standards 6876
  • Calcified canals 6070
  • Procedural problems Varied, 50 or less
  • Restoration (posterior teeth) full occlusal
  • Coverage 9095
  • No occlusal coverage 5060
  • Periodontal problems Dictated by the
    periodontal condition

Occlusal Plane Considerations
  • Super-erupted or tilted teeth
  • Super-eruption could prevent normal occlusal
  • Super-eruption may create problem when restoring
    opposing arch.
  • Prevention of super-eruption should be planned.

Occlusal Plane Considerations
  • Treatment Options
  • 1- Simple enameloplasty
  • 2- Full coverage crowning to correct
  • occlusal plane.
  • 3- Orthodontic treatment
  • 4- Extraction

Periodontal eruption
Active eruption
Classification System (Samet and Jotkowitz, 2009)
  • Dental Evaluation involves 2 sequential phases
  • 1- Takes patient-level considerations
  • into account
  • 2- Classify individual teeth

Patient-level risk factors
  • I. Biological risk factors
  • 1- Medical conditions that impair immune
  • 2- Impaired salivary flow/function
  • 3- Medical condition or disability limiting oral
  • hygiene
  • 4- High Strep. Mutans and Lactobacillus salivary
  • count
  • 5- Positive for interleukin-1 genotype
  • 6- Family history
  • 7- Other missing teeth

Patient-level risk factors
  • II. Behavioural risk factors
  • 1- Compromised or poor oral hygiene
  • 2- Cariogenic diet
  • 3- Low exposure to fluoride
  • 4- Parafunctional habits
  • 5- Adherence to long-term
  • maintenance
  • 6- Smoking

Patient-level risk factors
  • III. Financial/personal risk factors
  • 1- Motivation for treatment
  • 2- Available resources for dental care
  • 3- Willingness to commit finances, time and
  • 4- Attitude toward loosing teeth
  • 5- Understanding of patients condition and
    needed treatment.
  • 6- Esthetic expectations
  • 7- Low dental IQ
  • IV. Quality of dental treatment and the frequency
    and quality of oral maintenance

Patient-level risk factors
  • Factors that are associated with high caries rate
    and periodontal diseases are those that challenge
    prognosis evaluation.
  • Modifiable vs. Non-modifiable factors
  • Multiple non-modifiable factors results in
    inferior case prognosis.
  • Management of modifiable factors entails
    reassessment of overall prognosis

Evaluation of Individual Teeth
  • Criteria for analysis
  • 1- Periodontal conditions and alveolar bone
  • support
  • 2- Restorability (remaining tooth structure)
  • 3- Endodontic condition
  • 4- Occlusal plane and tooth position
  • Two additional factors
  • 1- Anatomic irregularities
  • 2- Iatrogenic compromising factors

Classification Rules
  • Five classes- A, B, C, D, and X
  • Requires 3 steps
  • Step 1 The single most severe criterion
  • determines the tooths class.
  • Step 2 Anatomic risk factors and/or iatrogenic
  • compromising factors may result in a
  • of a class for an individual tooth
    (more than
  • 2 findings may result in a drop in
  • Step 3 Patient-level risk factors may result in
  • decreased prognosis for the

Class AGood prognosis(Minimal risk of being
lost in the foreseen future)
  • Periodontal health and alveolar support 80-100
    bone support
  • Remaining tooth structure 80-100 remaining
    sound tooth structure.
  • Endodontic condition good endodontic therapy.
  • Occlusal plane and tooth position correct or
    slightly deviated from ideal

Class BFair prognosis(low risk of being lost in
the foreseen future)
  • Periodontal health and alveolar support 50-80
    bone support, can be maintained, vertical defects
    and furcations can be treated.
  • Remaining tooth structure 50-80 remaining sound
    coronal tooth structure, adequate ferrule, good
    crown-root ratio, minimally affect adjacent teeth
  • Endodontic condition endodontic failures
    predictably managed, or difficult primary endo
  • Occlusal plane and tooth position out of
    occlusal pane but can be adjusted.

Class CQuestionable prognosis(Medium risk of
being lost in the foreseen future)
  • Periodontal health and alveolar support 30-50
    bone support, no acute condition, maintenance
    cleansability is difficult, perio. treatment and
    maintenance sustains the tooth for acceptable
    period of time
  • Remaining tooth structure 30-50 remaining sound
    tooth structure, minimal structure, achieving a
    ferrule jeopardize crown-root ratio or may affect
    adjacent structures
  • Endodontic condition Acute/chronic failing
    treatment with unpredictable retreatment.
  • Occlusal plane and tooth position Out of
    occlusal plane and requires multiple procedures
    to adjust.

Class DCompromised prognosis(High risk of being
lost in the foreseen future)
  • Periodontal health and alveolar support lt30
    bone support, or teeth that couldnt be cleans
    and has evidence of active periodontal disease.
  • Remaining tooth structure lt30 remaining sound
    tooth structure, or extensive loss of structure
    that ferrule couldnt be achieved with
    compromising adjacent teeth or own/root ratio.
  • Endodontic condition Failing endodontic
    treatment that cant be predictably retreated.
  • Occlusal plane and tooth position Severely out
    of occlusal plane and after treatment will
    exhibit reduced crown-root ratio.

Class X Nonsalvageable(Indicated for extraction)
  • Periodontal health and alveolar support lt30
    bone support, couldn't be maintained or cleansed
    without acute outbreak of periodontal infection.
  • Remaining tooth structure No remaining
    supragingival sound tooth structure, loss of
    tooth structure deep into the root dentine/canals
  • Endodontic condition Vertical root fracture,
    retreated several times without resolution
  • Occlusal plane and tooth position Far
    super-erupted or tilted out of occlusal plane,
    and interfere with restoration of the arch or
    opposing teeth.

Factors that result in a drop of the determined
  • Anatomic irregularities
  • -Irregularly shaped roots
  • -Multiple canals and/or roots
  • -Thin and/or short roots
  • -Excessively conical roots

Factors that result in a drop of the determined
  • Iatrogenic compromising factors
  • Perforations
  • Extensive post preparation
  • Minimal remaining structure after preparation
  • Dental materials that can not be removed

The classification could be included into routine
clinical examination record
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  • Thank you
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