Cement-retained implant restorations are extremely popular, because they offer a predictable treatment outcome for patients whose teeth are failing or have already been removed. Compared to screw-retained implant restorations, cement-retained implants provide the ideal occlusal form and are a more cost-effective treatment choice for the patient. However, dental implant treatment is usually more expensive compared to conventional crowns and bridges, raising the question of whether to extract failing teeth in preparation for dental implants or try to save viable teeth.
Before implants were routinely used, the choice was much less complex. Now many clinicians have advanced skills and have invested in the specialized equipment required for relatively straightforward, reliable, and long-term dental implant treatment solutions. The initial cost of implant treatment is higher until you compare it with the costs associated with saving teeth and the unpredictable longevity of advanced endodontic care. The overall price of endodontic treatment and the restorative costs of placing a post and core and a crown can be considerable, especially if there are any concerns about the long-term viability of the natural tooth.
Determining If Natural Teeth Can be Saved
Several factors determine if a natural tooth is still viable and worth saving with a conventional crown. One important consideration is the amount of coronal tooth structure. The ferrule effect is also important, and if a tooth is to be restored, the clinician should retain as much of the coronal tooth structure as possible to maximize this effect.
Nearly all the patient’s coronal tooth structure is intact. When almost all of the coronal tooth structure is intact, and endodontic treatment is not necessary, then a cement-retained dental implant would be undesirable and inadvisable.
Approximately half the coronal tooth structure is intact. When approximately half of the tooth structure is missing then endodontic treatment and a post and core might be required, but the tooth could still be salvageable. Often, the long-term prognosis is excellent, and implant placement is not necessary or desirable.
All the patient’s coronal tooth structure is lost. When all the patient’s coronal tooth structure has been lost, endodontic therapy is frequently required. The patient’s tooth must be strengthened with a post and core. Crown lengthening may be necessary to expose more tooth structure, helping to establish a ferrule. With a tooth in this condition, it is essential to have a frank and in-depth discussion with the patient, so that they can make an informed choice about their treatment. Saving the tooth is likely to be expensive, and its longevity is questionable. Failure of the tooth will require extraction, and the patient will need a dental implant or a fixed prosthesis.
Using a post and core and crown lengthening will increase the initial costs, but this could be worthwhile if there is a decent chance that the tooth can be saved. The correct placement of a post and core and a crown could provide an excellent clinical outcome.
The choice of treatment largely depends on whether the patient feels more comfortable trying to retain their natural tooth or if they would prefer a dental implant. In most cases, the patient will prefer to retain the natural tooth despite concerns about the long-term outcome of treatment.
Determining When Dental Implant Therapy is a Better Choice
At a certain point, the patient is better served with a dental implant, but deciding when you’ve reached this point isn’t always straightforward. You must inform the patient of the potential risk of failure. Ideally, the patient and clinician will mutually decide which treatment is best.
All the coronal tooth structure is missing, and the patient has bruxism. When all the coronal tooth structure is missing, the patient has most likely received or will require endodontic treatment and a post and core. There may be sufficient tooth structure for a ferrule, or the crown can be lengthened, but if the patient has bruxism, the long-term prognosis changes. One problem with placing a dental implant in a patient with bruxism is the implant’s questionable long-term success. The implant may fail to integrate, and, unless the occlusion is appropriately adjusted, occlusal forces could damage the implant. An in-depth discussion with the patient is required to determine which treatment option will best meet their needs.
The entire tooth structure is missing to the bone. When all the tooth structure is missing right down to the bone, the patient has most likely received endodontic therapy and may have a post and core, but there will be insufficient tooth structure to provide a ferrule. One solution is to try orthodontic tooth extrusion, but this is time-consuming, and the patient will incur additional costs. Ideally, in this situation, the tooth is removed, and an implant is placed, providing the patient with a more predictable outcome.
The approximate cost for retaining a natural tooth is less expensive than the cost of removing the tooth and placing a dental implant, assuming no additional procedures, like periodontal treatment or bone grafting, are necessary. Most patients, when given a choice, will wish to retain their natural teeth, which is entirely understandable, and most clinicians will always try to accommodate this desire whenever feasible. The patient should always be involved in the decision to remove a tooth, and they must give their informed consent.
Some patients whose teeth cannot be saved may prefer not to have dental implants. The patient might not want implants because they don’t wish to have oral surgery, and instead they might opt for a conventional dental bridge. When this is the case, make sure that the patient understands how placing a conventional bridge will affect the abutment teeth. Many patients don’t realize that restorations won’t last forever. They may not understand that, while the initial cost of placing a single dental implant is a little higher, subsequent restorations will be more cost-effective compared to replacing a three-unit bridge.
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