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CDEWorld > Courses > When to Save or Extract a Tooth in the Esthetic Zone: A Commentary

When to Save or Extract a Tooth in the Esthetic Zone: A Commentary

Gary Greenstein, DDS, MS; John Cavallaro, DDS; and Dennis Tarnow, DDS Learning Objectives:
February 2009 Course - Expires February 28th, 2012
After reading this article, the
Parkell Online Learning Center
reader should be able to:
Figure 1
Abstract describe the consequences of
surgical procedures in the maxillary
BACKGROUND: In the esthetic zone, difficult decisions must be made regarding
anterior region.
extraction or retention of compromised teeth. Numerous factors need to be
considered to arrive at a proper treatment plan, which may differ from a plan devised discuss factors that need to be
for the posterior region of the mouth. TYPES OF REVIEWED STUDIES: Studies were considered when treatment planning
selected that provided background information for clinical decision-making in the esthetic zone.
concerning whether a compromised tooth should be retained or removed. RESULTS: In
Figure 2

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the esthetic zone, before resective surgical procedures are used to resolve list alternate treatment plans for the
periodontitis, consideration should be given to the esthetic outcome. If endodontic premaxilla zone that can be used to
therapy is required, additional issues need to be reviewed before initiating treatment, maintain esthetics.
including restorability of the tooth, presence of a large periapical area, use of the tooth
as an abutment, etc. Furthermore, before initiating periodontal or endodontic
treatment, the patient’s susceptibility to additional periodontal disease progression and Disclosures:
caries should be evaluated. CLINICAL IMPLICATIONS: In the esthetic zone, deciding Figure 3
whether to treat or remove a compromised tooth requires careful deliberation. The The author reports no conflicts of
interest associated with this work.
possibility that additional bone loss can compromise a future implant site needs to be
considered before providing periodontal therapy. This is particularly true if recession will
be induced. Endodontic therapy is effective; however if crown lengthening is required
because of subgingival caries or tooth fracture, thought needs to be given to removal
of the tooth before altering the gingival topography. Numerous other factors need to Figure 4
be considered when deciding whether to save or extract a tooth in the esthetic zone:
restorability, disease susceptibility, papillary and gingival considerations, tooth esthetics,
etc. In conclusion, the decision to extract or maintain teeth must include deliberation
with regard to benefits versus risks of retaining compromised teeth. The judgment to
remove a tooth may be based on one critical issue or it may rely on collective risks
related to a few factors. Figure 5

The goal of restorative dentistry is to 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. With regard to problematic teeth, questions should be resolved concerning the
need for their therapy or replacement. For instance, can a tooth be effectively restored? Will endodontic Figure 6a
treatment be successful? Is periodontal therapy a reasonable option? After therapy will a treated tooth
be a suitable abutment? What effect will extraction of a tooth have on the final treatment plan? Articles
have addressed some of these issues; however none of them have specifically discussed these issues
as they pertain to teeth in the esthetic zone.1-3 Therefore, numerous factors were evaluated to
determine if they can be used to arrive at a correct judgment regarding whether to retain or extract
Figure 6b
compromised teeth when esthetics is an additional criterion for success. These factors are discussed
with regard to four major subjects: periodontal status and gingival contours, restorability, endodontic
considerations, and resistance to disease (periodontitis and caries). Ultimately, when developing a
treatment plan, the decision to retain or extract teeth is based on the risks vs benefits of alternate
treatments. Sometimes one factor can be the critical determinant dictating that a tooth should be
removed; other times, decisions to remove a tooth are based on cumulative risks associated with
Figure 7
several factors.

Case Evaluation
To develop an optimal treatment plan the clinician must envision the completed dental rehabilitation. In
this regard, factors that contribute to achieving a cosmetic result in the esthetic zone include: smile line,
midline, tissue level, height, width, and position of teeth. The smile line is considered high if there is
exposure of the teeth and gingiva.4 It is judged average when 75% to 100% of the maxillary incisors are
displayed and low if < 75% of the teeth are seen.4 It is more difficult to achieve an optimal esthetic
result when there is a high smile line because discrepancies in tooth and gingival or papillary height are
visible.

The average length of the maxillary central incisors and canines for men is 10 mm (range 7.7 mm to
11.9 mm) and the corresponding teeth for women are approximately 1 mm shorter.5 Lateral incisors are
approximately 1.4 mm shorter than central incisors for both genders.5 The gingival crest of the central
incisors and canines is approximately 1 mm above the crest of the lateral incisors; the crest of the
canines may be a little higher.6 The peak of the gingival parabolic curve on the central incisors and
canines is slightly distal to the long axis of the teeth, whereas it is at the midline of the long axis of the
lateral incisors.6,7 This subtle shift of the gingiva enhances a pleasing smile line. At the incisal edge,
the lateral incisor is approximately 1 mm shorter than the central incisor.7 The position of the anterior
teeth’s incisal edges are important for esthetics and phonetics. The width of the lateral incisor is usually
two-thirds the width of the central incisor, which provides an attractive proportion to anterior teeth.6,7

In a healthy dentition with no bone or clinical attachment loss, the underlying alveolar crest follows the
scallop of the cementoenamel junction (CEJ) and is around 2 mm apical to the CEJ. The maxillary
anterior interdental crests are around 3 mm coronal to the facial bone height (range 2.1 mm to 4 mm).8
On average the free gingival margin is approximately 3 mm coronal to the crest of the bone (biologic
width plus sulcus depth).9 Interproximally, interdental papilla between the central incisors are 4.5 mm
coronal to the osseous crest and 4.5 mm to 5 mm coronal to the facial gingiva.9 The additional height of
the papilla (1.5 mm) is caused by hypertrophy of the interdental tissue and includes the col area when a
contact point is present. The absence of osseous support and proper gingival contours need to be
considered when developing a treatment plan in the esthetic zone. Compromised teeth may be
deficient in diverse ways; therefore, treatment planning in the premaxilla should consider esthetics,
form and function, and biology. In particular, retention or removal of compromised teeth must be
considered with regard to the esthetics of the final case.

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Periodontal Considerations
Prevalence and Incidence of Periodontal Disease Progression
According to the National Health and Nutritional Examination Survey (NHANES III), among dentate
individuals who are 30 years of age or older, approximately 30% of adults develop periodontitis of
varying degrees.10 The patterns of bone destruction may be linear, episodic, at the same location, or
random events.11 Different models of disease progression can occur at various sites within the same
mouth or at a particular location at different times. Currently, it is not possible to accurately forecast
which sites will manifest disease progression. Therefore, if patients continue to deteriorate, despite
periodontal therapy, it is prudent to remove com-promised teeth before additional supporting bone is
resorbed and the residual osseous support decreases to < 10 mm. In a systematic review, Goodacre et
al12 found that ≥ 10 mm of bone is desirable when placing an implant because integrated implants ≥ 10
mm in length demonstrated better survival rates than shorter implants. Furthermore, bony support is
critical for the esthetic form of the gingival tissues.

Size of Periodontal Defects

It is usually desirable to maintain shallow rather than deep probing depths around teeth for multiple
reasons: shallow depths facilitate supragingival hygiene, which impacts the subgingival microflora;
there is less bleeding on probing; at shallower sites it is easier to instrument root surfaces; there is less
predisposition for disease progression; and shallow depths are better forecasters of periodontal
stability.13 Pertinently, periodontal surgery is often done to reduce or eliminate deep probing depths.14
However, a usual consequence of periodontal surgery is recession of the gingiva and interdental
papillae, which may create undesirable “black triangles” between teeth. Therefore, resective
procedures that create an unesthetic gingival topography are contraindicated on teeth that have a
questionable prognosis in the esthetic zone. In addition, surgical procedures may result in large
interdental embrasures, which are plaque retentive and may cause increased thermal sensitivity (Figure
1).

The judgment call by the clinician whether to extract or retain a tooth needs to include consideration of
the smile line, severity of the periodontal condition, expected recession induced by pocket elimination
procedures, the need for endodontic intervention with or without post/cores, and the emotional and
esthetic concerns of the patient. Ultimately, in the esthetic zone, it is prudent to remove periodontally
questionable teeth and replace them with implants if this will assist in maintaining the height of the
gingiva and bone. A consequence of maintaining the gingival height where bone loss has occurred is
the need to tolerate increased probing depths around implants when they are placed, or the acceptance
of the commitment to rebuild osseous support before implants are placed (site development). Atassi15
found that it is preferable to have shallow sulci around an implant, but that deep probing depths do not
necessarily reflect peri-implantitis unless there is disease progression.

Preservation of Bone
Six months after an extraction of maxillary anterior teeth, there is loss of bone ridge width (x = 4.56 mm)
and height (x = 1.5 mm) if socket preservation techniques are not used (eg, bioabsorbable barrier).16
Most of the osseous resorption occurs during the first 3 months after tooth removal.17 This expected
bone loss must be considered in light of the deterioration that already occurred because of
periodontitis. Even immediate placement of implants into extraction sites does not prevent initial bone
resorption from occurring.18 Subsequently, integrated implants provide stimulation to the alveolar bone
and retard osseous resorption,19 whereas an edentulous ridge without implants continues to resorb if a
removable prosthesis rests on the ridge.20,21

Restorative Considerations
Biologic Width
The term biologic width refers to the junctional epithelium and connective tissue attachment coronal to
the bone; it does not include gingival sulcus depth. The biologic width consists of approximately 1 mm
of junctional epithelium and 1 mm of connective tissue,22 but it can range from 1 mm to 4 mm.23 This
region must be respected when restorations are fabricated; otherwise there may be chronic gingival
inflammation, pain, and unpredictable bone loss. Accordingly, when crown-lengthening procedures are
performed, the bone needs to be placed 2 mm to 3 mm apical to the margin of the fixed prosthesis.24
Therefore, problematic teeth in the esthetic zone that require a crown-lengthening procedure (eg, caries
under a crown) should be evaluated for extraction, because these measures may result in an
unesthetic appearance. Furthermore, increasing crown height usually involves osseous recontouring of
the proximal surfaces of adjacent teeth, thus more than one tooth is affected.

Remaining Tooth Structure

Prediction criteria for successfully restoring a tooth that underwent endodontic therapy include 5 mm of
suprabony structure: 2 mm for the biologic width, 2 mm for the ferrule, and 1 mm sulcus depth.25 A
ferrule is the cervical portion of a restoration that extends 1 mm to 2 mm onto sound tooth structure to
prevent fractures.26 Finally, after the post is prepared, there should be enough root length remaining to
permit a 4-mm apical seal to impede bacterial penetration.27

Surgical crown lengthening of a compromised tooth that has a poor crown-to-root ratio should be
avoided.1 Furthermore, even though some teeth can be retained, strategic extractions of compromised

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teeth need to be considered to facilitate an optimal restorative result.1

Caries

Caries is an infectious disease and affects many adults over 50 years of age.28 Factors that influence
the incidence of caries include environment, oral hygiene, genetics, diet, salivary flow, level of
Streptococcus mutans, etc.29 In addition, among patients with recession, cementum and dentin are
more susceptible to caries than enamel because of their lower mineral content.30 Caries is a major
concern among patients undergoing prosthetic rehabilitations, as it is the main reason for loss of fixed
partial restorations.31

In the esthetic zone, if a patient has caries under a fixed prosthesis, crown lengthening should be
avoided because it will induce recession and usually result in asymmetric gingival margins (Figure 2).
Individuals with a high caries index are prone to additional caries;32,33 therefore, for these patients, it is
prudent to avoid crown lengthening and advisable to replace the tooth with dental implants, which
cannot decay.

An alternate therapy to crown lengthening to expose subgingival caries is extrusion of a tooth, which
can reduce esthetic issues. Orthodontic extrusion for approximately 8 to 12 weeks followed by 4 to 6
weeks for stabilization also can align disharmonious gingival margins and improve the osseous
topography at a compromised site.34 However, after forced eruption, some interproximal crown
lengthening may still be needed. In this regard, the length of therapy, additional costs to retain the
tooth, and the willingness of the patient to wear braces for several months need to be considered.
Furthermore, the new crown will have a narrower cervical third because a segment of the root will now
be positioned where the crown margin was previously located. In particular, this may produce an
unesthetic result if only one central incisor is extruded because asymmetry is created between the
necks of the central incisors.

Teeth Adjacent to Edentulous Area

The decision to extract or retain teeth affects adjacent teeth, especially if they are to function as
abutments for a fixed or removable partial denture. Pertinently, Aquilino et al35 reported that patients
wearing removable partial dentures over a 10-year period lost 44% of abutment teeth, and Wagner et
al36 noted that only 42% of removable partial dentures remained in service for 8 years. Therefore,
treatment planning must include consideration of the functionality of adjacent teeth. At present, there
are no studies that indicate loss of bordering teeth occurs when implants are inserted. In contrast, a
large edentulous area may require the span of a fixed partial denture to be extended to incorporate
teeth that require endodontic or periodontal treatment, thereby possibly compromising the long-term
stability of the prosthesis.

It is also important to evaluate the functional load which will impact on restored teeth. Several studies
reported that fixed partial dentures, which used endodontically treated teeth as abutments, failed more
often than crowns prepared on vital teeth.37-39 In general, single endodontically treated teeth should be
used cautiously as abutments to support distal extension partials or cantilevers because they are
subject to additional occlusal loading.25 However, there are exceptions to this concept, which will
depend on the clinician’s judgment related to the survivability of the retained tooth.

Numerous investigations have addressed success rates of fixed partial dentures (FPDs) and implant
restorations. Walton et al40 reported that the long-term survival rate of FPDs was 87% at 10 years and
69% after 15 years. A recent meta-analysis concerned with the success of FPDs found that after 10
years the success rate (retained without problems) was 71.1% and the survival rate (maintained) was
89.1%.41 In contrast, the following survival rates were reported with single-unit implant restorations:
97.5% after 6 to 7 years;42 97.4% after 10 years;43 and 96.5% over 11 years.44

Endodontic Considerations
Success of Endodontic Therapies

Conventional endodontic therapy has a high success rate.45,46 However, numerous issues need to be
considered before endodontic therapy with a post and crown on a tooth in the esthetic zone. The
2003/2004 Toronto study found the endodontic success rate on vital teeth to be 92%, on nonvital teeth
without a periapical area to be 89%, and on nonvital teeth with a periapical area to be 74%.47 For
endodontic retreatment, the study found the success rate for teeth without a periapical area to be 95%
and, when there is a periapical area, 66%.48 It is also necessary to differentiate between success (no
periapical area) and survival (asymptomatic with periapical radiolucency present) with regard to
retained endodontically treated teeth. Survival rates indicate that 95% of teeth that underwent
endodontic therapy are functional.45,46

With respect to apical surgeries, apicoectomies have a success rate of 74% and a survival rate of
91%.49 Wang et al49 noted that when there was a large periapical radiolucency present (> 5 mm) on a
nonvital tooth, 65% of the sites healed, whereas if the lesions were small (< 5 mm), 86% did not
manifest any periapical radiolucencies (Figure 3). A recent systematic review reported that endodontic
surgery had a weighted average of 64% success rate and that resurgery was successful 36% of the
time.50 Unfortunately, apicoectomies do not always avoid the need for dental implants. Furthermore,

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buccal fenestrations created to gain access to the periapical area may not heal with an intact buccal
plate of bone. Therefore, these procedures may compromise an implant site and precipitate the need
for additional bone grafting when an implant is needed.

Other Endodontic Concerns

Before any teeth are crowned, Whitworth et al51 advised that the teeth be assessed to determine if
endodontic therapy is needed. This evaluation consists of a history of patient discomfort, a clinical
examination (eg, fistulas, color, percussion, palpation), special tests (thermal or electrical), and
radiographs. Determination of the need for endodontic therapy may impact the decision to retain or
remove a tooth.

When considering endodontic therapy or apical surgery, a number of other criteria suggest that a tooth
should be extracted and replaced with a dental implant: if there is abnormal root anatomy precluding
successful endodontic obturation; when the root is short or thin and a post will predispose the tooth to
post loosening or root fracture; and when there is a misaligned post that will weaken the root structure.

The etiology of internal root resorption is unknown.52 It is considered a benign proliferate fibro-osseous
disorder, and the result of endodontic therapy and filling these lesion sites is not predictable. Therefore,
these teeth should be considered for extraction if this condition is detected in the esthetic zone to avoid
compromising an implant site if endodontic therapy fails.

Pulp Mortality Among Crowned Teeth

Individual teeth that require endodontic therapy or that will be used as abutments for a fixed prosthesis
call for crown preparation. In this regard, studies disagree on the number of teeth that will develop
endodontic problems after crowning. For example, a retrospective study found a percent range of 0% to
2.19%,53 but when Valderhaug et al54 studied 291 endodontically treated teeth over 25 years, they
found the percentage to be as high as 10%. Furthermore, other studies have indicated that during a 3
to 30 year period, 13.3% of teeth restored with crowns became nonvital,55 and 20% of vital teeth
prepared as overdenture abutments developed periapical lesions within 2.5 to 3 years.56 Among
patients with advanced periodontal disease, it has been found that 9% of crowned teeth vs 2% of
uncrowned teeth become nonvital.57 Thus, it appears that a small percentage of teeth become nonvital
after crowning, and this percentage may increase with time. Another factor that could contribute to teeth
becoming nonvital is the preparation of teeth beyond what is usually done to correct tooth position: for
example, if multiple teeth had to be made parallel to create a line of draw for a fixed prosthesis.

Previously Treated Root Canal Teeth

Endodontically treated teeth left uncrowned because of defective or lost restorations should be
considered unreliable, because saliva and microorganisms migrate alongside exposed root fillings.2,58
Researchers observed that, in vitro, dye penetration reached 85% of the root length in 3 days.59
Therefore, Whitmore et al51 suggested that if a tooth were exposed more than 1 month, the filling
should be revised.51 If this is not possible, then the tooth should be considered for removal, because it
is at risk for failure.

The main function of endodontic posts is to retain the core; however, these posts offer no reinforcement
for the tooth. Furthermore, dentin removal to facilitate post insertion may weaken the tooth and create
stress concentration at its terminus.51 Therefore, whenever possible, posts should be avoided. The
incidence of problems associated with posts can vary. In 1970, Roberts60 reported failure rates as high
as 22% over a 5-year period.

It can be concluded that routine endodontic therapy is very successful, and survival rates for both
endodontically treated teeth and dental implants are high. Therefore, it isn’t appropriate to conclude that
one therapy is superior to the other based solely on success rates.61 The other factors outlined need to
be considered when deciding if a tooth should be endodontically treated or replaced with a dental
implant. If there are multiple issues associated with endodontic therapy that place the final restoration
at risk, it may be prudent to remove the tooth and avoid potential complications.

Resistance to Disease
There is no accurate method to predict which site will experience caries in an individual. However,
several authors confirmed that past caries experience was the most significant predictor for future
caries development.32,33 Thus, in individuals who have a high caries index or advanced periodontitis,
consideration needs to be given to using dental implants if a prosthesis is being treatment planned. At
present, the preponderance of data indicate that implants can be successfully placed in patients who
have lost teeth because of periodontitis. Recently, a systematic review concluded there was no
increased risk of losing implants among patients who lost teeth because of progressive periodontitis,
over individuals who never had periodontal disease.62 However, the patients who lost teeth because of
progressive peridontitis did have a higher incidence of peri-implantitis. Baelum and Ellegaard63 also
reported that implants inserted in individuals with a history of periodontitis had a 5-year survival rate
compared with implants placed in nondiseased patients. In this regard, additional studies are needed to
determine which surface textures affect the ability of the implant to resist peri-implantitis.

When to Save Teeth

Psychological Impact of Losing or Retaining Teeth
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In general, endodontic and implant procedures cause minimal postoperative discomfort and a low
incidence of complications. Nevertheless, patients’ past experiences with either treatment modality may
influence their decisions and their preferred course of action.64,65 Therefore, besides dental status,
time, and cost of therapy, patient preference needs to be taken into account when establishing a
treatment plan.66 Strategies need to be presented and decisions should be made together to meet
each patient’s best interest. Accordingly, if an individual is very emotional when the word extraction is
used, consideration should be given to retaining teeth even if a better esthetic result could be attained
with extraction of teeth and replacement with implants. However, the long-term consequences of
delaying an extraction(s) should be explained to the patient and noted in the patient’s record.

Avoiding Two Adjacent Implants

To achieve an esthetic result, it is advantageous to have papillary symmetry between contralateral
sides of the dentition and avoidance of short papillae between implants. Tarnow et al67 demonstrated
that implants should be placed at least 3 mm apart to avoid bone loss, which can result in recession of
papillae. In a later study, Tarnow and colleagues68 noted that the average height of a papilla between
two implants was 3.4 mm and that > 50% of the papillae between implants were ≤ 3 mm in height
(Figure 4).68 Therefore, to attain the best esthetics, if two adjacent implants are to be placed,
modification of the treatment plan may be necessary. If possible, consideration should be given to
saving one tooth to avoid short papillae.

Several scenarios may be encountered that require different management approaches to achieve the
best cosmetic results. In the maxilla, if teeth Nos. 8 and 9 are missing, they can be replaced with
implants, because the short papilla that will form between them can be camouflaged by creating a long
contact area (Figure 5). Because the short papilla is in the midline, it does not cause asymmetry.69 On
the other hand, if teeth Nos. 7 and 8 were lost, then one implant should be placed at site No. 8 and an
ovate pontic should be cantilevered at site No. 7.69 If necessary, the gingiva can be augmented before
ovate pontic construction. Similarly if teeth Nos. 6 and 7 were missing, then an implant could be placed
at site No. 6 and an ovate pontic placed at site No. 7 (Figure 6A and Figure 6B).69 If teeth Nos. 7
through 10 were extracted, then implants should be placed at locations Nos. 7 and 10 (Figure 7).69 This
will allow normal sized papillae to form distal to site Nos. 7 and 10 because the papillary height is
determined by the supracrestal fibers from the adjacent natural teeth.70,71 Then the shortened mesial
papilla on site Nos. 7 and 10 will be symmetrical and can blend with the short papilla between site Nos.
8 and 9.

Thin Biotype
If there is an option to retain a tooth that needs endodontic therapy, and which also has a thin, healthy
biotype, then consideration should be given to retaining the tooth. This may facilitate attaining a more
esthetic result than extracting the tooth because a thin biotype is prone to recession. In this regard, Kan
et al72 found that when thick and thin biotype periodontiums were compared with regard to papillary
height after single-tooth implant placement, the thin biotype demonstrated a shorter papilla by
approximately 0.7 mm and the facial tissue was approximately 0.4 mm shorter.

Conclusions
The decision to extract or retain a compromised tooth in the esthetic zone requires guarded forward-
thinking with respect to the desired outcome. All therapies have potential risks of complications and
failures. Therefore, considerations concerning esthetics, functionality, and personal preferences
expressed by the patient all impact the decision-making process. Ultimately, practitioners need to base
their definitive therapy on: data from clinical trials, reasonable interpretation of that data concerning
patient management, clinical experience, patient preferences, and the medical and dental histories of
each patient.

References
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3. Mordohai N, Reshad M, Jivraj SA. To extract or not to extract? Factors that affect individual tooth
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4. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):24-28.

5. Sterrett JD, Oliver T, Robinson F, et al. Width/length ratios of normal clinical crowns of the maxillary
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8. Becker W, Ochsenbein C, Tibbets L, et al. Alveolar bone anatomic profiles as measured from dry
skulls. J Clin Periodontol. 1997;24(10):727-731.

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11. Goodson JM, Tanner AC, Haffajee AD, et al. Patterns of progression and regression of advanced
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prostheses. J Prosthet Dent. 2003;90(2):121-132.

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16. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets
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17. Schropp L, Wenzel A, Kostopoulos L, et al. Bone healing and soft tissue contour changes following
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18. Cardaropoli G, Araújo M, Hayacibara R, et al. Healing of extraction sockets and surgically produced
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19. Finne K, Rompen E, Toljanic J. Clinical evaluation of a prospective multicenter study on 1-piece
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About the Author

Gary Greenstein, DDS, MS, Department of Periodontology and Implant Dentistry, New York University
College of Dentistry, New York, New York; Private Practice, Freehold, New Jersey

John Cavallaro, DDS, Associate Professor, Department of Periodontology and Implant Dentistry, New
York University College of Dentistry, New York, New York; Private Practice, Brooklyn, New York

Dennis Tarnow, DDS, Professor and Chairman, Department of Periodontology and Implant Dentistry,
New York University College of Dentistry, New York, New York; Private Practice, New York, New York

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