Therapeutic conservatism vs. surgical progress: the choice between tooth preservation and implantation

A key clinical decision in full-mouth rehabilitation is the choice between preserving compromised teeth and extracting them followed by implant-supported restoration. The selected option should be based on an integrative assessment of clinical, radiographic, and biopsychosocial factors, as well as the patient’s ability to maintain the chosen treatment over time.

Assessment methodology

Before planning full-mouth rehabilitation, it is essential to systematically analyze a number of key parameters. Below is a structured checklist with clinical commentary for the practicing dentist.

Periodontal status and oral hygiene

Assessment: bleeding index, probing pocket depths, presence of recessions, tooth mobility, radiographic bone support level, microbiological tests if necessary.

Comment: In patients with progressive generalized periodontitis, the prognosis for tooth preservation reduces the likelihood of long-term success. In such cases, an interdisciplinary assessment is recommended — periodontal therapy with a follow-up evaluation after a set period before making a final decision regarding extraction.

Caries risk and salivary function

Assessment: history of caries recurrence, condition of existing restorations, medication history (drugs causing xerostomia), head and neck radiation therapy, sialometry if indicated.

Comment: A high frequency of recurrent caries and persistent xerostomia create an unfavorable prognosis for tooth preservation; in such patients, a strategy of full extraction and implant-supported prosthetics should be discussed as a predictable alternative.

Restorative and endodontic status

Assessment: quality of existing restorations, recurrent caries under prostheses, perforations, coronal tooth structure integrity, success of previous endodontic therapy.

Comment: Multiple failed restorations and previously repeatedly revised endodontically treated teeth more often lean toward a decision for full rehabilitation; stable crowns and high-quality endodontic treatment are arguments in favor of tooth preservation, provided adequate hygiene maintenance is possible.

Occlusion, vertical dimension, and parafunctional habits

Assessment: occlusal contact conditions, loss of vertical dimension of occlusion, signs of bruxism, wear of dental hard tissues, periodontal adaptive capacity.

Comment: Significant functional disorders may require comprehensive prosthetic rehabilitation (including full-arch implant-supported restorations) or load adaptation (preference for delayed loading). Protective measures (night guards, occlusal adjustment) must be planned.

Bone volume and surgical feasibility

Assessment: CBCT to determine alveolar bone volume, presence of anatomical limitations, prognosis for the need for bone grafting.

Comment: In cases of significant resorption, a discussion of bone augmentation or alternatives — such as tilted implants or All-on-4/6 concepts — is required. It is important to consider the patient’s financial and time preferences when selecting a strategy.

Outcomes and literature data

Comparing literature and clinical experience yields the following practical conclusions:

• Progressive periodontal infections are associated with an increased risk of tooth loss and may negatively impact the outcomes of implant therapy; early periodontal intervention and supportive maintenance are essential (see Chrcanovic et al., Tonetti et al.).
• Xerostomia and associated cardiovascular, medication-related, or radiation factors increase the risk of caries and restorative failures; in such patients, it is advisable to discuss a strategy of full extraction and implant-supported prosthetics as an option with more predictable long-term maintenance.
• Multiple failed restorations and an unstable endodontic history increase the likelihood of repeated interventions; in a clinical context, this may justify transitioning to full-mouth rehabilitation.
• Functional factors (wear, loss of vertical dimension, bruxism) influence the choice of implant loading protocol and may require protective measures or delayed loading.
• In cases of bone deficiency, augmentation methods are evidence-based and effective; however, to minimize surgical burden, alternative protocols (tilted implants, immediate loading provided primary stability is achieved) are indicated — Cochrane reviews describe the efficacy and limitations of these approaches (Esposito et al.).

Relevance to practice

The clinical decision to “preserve or extract” must be personalized and multidisciplinary. The recommended sequence of actions in the clinic is as follows:

• Comprehensive periodontal and restorative assessment with documentation (photographs, models, CBCT).
• Individual risk stratification for periodontitis, caries, xerostomia, and functional factors.
• Multidisciplinary case discussion: conservative rehabilitation with supportive therapy vs. full extraction with implant-prosthetic planning (considering the need for augmentation and timeframes).
• Mandatory informed consent from the patient, discussing prognosis, potential complications, costs, and maintenance requirements.

Expert commentary: In practice, it is crucial to rely not only on isolated clinical signs but also on the dynamics of the condition during controlled preparatory therapy. Patients showing improvement in periodontal status and low caries risk may be candidates for tooth preservation with subsequent phased restoration; when the cumulative risk burden is high, an implant-oriented approach often proves more predictable.

Sources

Marchand F, Raskin A, Dionnes-Hornes A, et al. Dental implants and diabetes: conditions for success. Diabetes Metab. 2012;38:14-19.

Tonetti MS, Chapple IL, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference. J Clin Periodontol. 2015;42 Suppl 16:S1-4.

Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent. 2005;53:423-432.

Chrcanovic BR, Albrektsson T, Wennerberg A. Periodontally compromised vs. periodontally healthy patients and dental implants: a systematic review and meta-analysis. J Dent. 2014;42:1509-1527.

Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants — a Cochrane systematic review. Eur J Oral Implantol. 2009;2:167-184.

Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol. 2010;3:189-205.

The material is based on: Chang B. The evolution of full-arch implant rehabilitation. Decisions in Dentistry. 2025;11(3):10-15.