Factors That Affect Tooth Prognosis And Choices In.ppt

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1. Good Morning

2. REDDY PRIYA DARSHINI
2
ND
YEAR MDS
Factors That Affect Individual Tooth Prognosis And
Contemporary Treatment Planning For Implants

3. •Introduction
•Review
•Factors affecting individual tooth prognosis
Overall clinical factors
Systemic and environmental factors
Local factors
Prosthetic and restorative factors
•Implant placement
Indications
contraindications
•Conclusion
•References
CONTENTS

4. Prognosis :
Prediction of the probable course, duration,
and outcome of a disease based in a general
knowledge of the pathogenesis of the disease and
presence of risk factors for the disease.
Prognostic factors :
Characteristics that predict the outcome of
disease once the disease is present
INTRODUCTION

5. FAVORABLE PROGNOSIS: the local or systemic factors can be
controlled and the periodontal status of the tooth can be stabilized
with comprehensive periodontal treatment and maintenance.
QUESTIONABLE PROGNOSIS : the local or systemic factors may or
may not be controlled. However, the periodontium can be
stabilized with comprehensive periodontal treatment and
periodontal maintenance if these factors are controlled; otherwise,
future periodontal breakdown may occur.
UNFAVORABLE PROGNOSIS, the local or systemic factors cannot be
controlled, and periodontal breakdown is likely to occur even with
comprehensive. periodontal treatment and maintenance. For teeth
with a hopeless prognosis, extractions are indicated.

6. •Periodontally involved : Teeth requiring root
amputations, hemisections or advanced
periodontal procedures may have a questionable
prognosis and patients should be given the
implant option before these procedures are
implemented.
•Endodontically involved : Non vital teeth,
fractured at the gingival margin with roots
shorter than 13 mm, should be considered for the
implant option.
BRITISH DENTAL JOURNAL VOLUME 201 NO. 4 AUG 26 2006

7. Save a natural tooth or to
extract it and place an implant
—
which is best ???

8. Kinsel et al – compared treatment of furcated molars with root
resection versus single-tooth implants.
He suggested that surgical and restorative procedures related to
implant placement may be less difficult than management with root
resective therapy, and long-term results with this type of therapy
require a high level of periodontal, endodontic, and restorative
expertise.
REVIEW

9. Thomas and Beagle – compared the outcome
of endodontic therapy and tissue-supported
complete dentures with implant restoration.
He concluded that implant restoration may
have a level of predictability equal to or greater
than “traditional” dental treatment.

10. De Moor and De Bruyn - discussed the choice
between conservation of a tooth through endodontic
treatment and crown restoration versus extraction of the
tooth and its replacement by an implant.
He reported long-term success of endodontically treated
teeth in more than 90% of patients. A conservative
approach using more endodontics and less implant
therapy was recommended.

11. Holm-Pedersen et al - reported in a systematic
review that periodontally compromised teeth treated
and maintained regularly had a survival rate of 92% to
93%, while the survival of oral implants after 10 years
varied between 82% and 94%. Therefore, it was
concluded that oral implants, when evaluated after
many years, do not surpass the longevity of even
compromised but successfully treated natural teeth.

12. Gotfredsen et al - reported the results of a
consensus conference on the topic of implants versus
natural teeth to answer the question:
Do implants have a better prognosis than teeth
with reduced marginal bone support?
The conclusion reached was that the survival rates of
teeth in periodontally well maintained patients were
generally higher than those of implants.

13. Overall clinical factors
•Patient age
•Disease severity
•Plaque control
•Patient compliance
Systemic and environmental factors
•Smoking
•Systemic disease or condition
•Stress
FACTORS AFFECTING TOOTH PROGNOSIS

14. Local factors
•Plaque and calculus
•Subgingival restorations
Anatomic factors
•Short, tapered roots
•Bifurcation ridges
•Root concavities
•Root proximity
•Furcation involvement
Tooth mobility

15. Individual tooth prognosis includes factors such as
1)Percentage of bone loss
2)Probing depth
3)Distribution and type of bone loss
4)Presence and severity of furcation involvement
5)Mobility
6)Crown – root ratio
7)Pulpal involvement
8)Tooth position and occlusal relationship
J PERIODONTOL 2008;79:971-977.
Grant ; PERIODONTICS in the tradition of Gottlieb and Orban,

16. Overall prognosis includes factors such as
1)Age
2)Medical status
3)Inividual tooth prognosis (distribution and severity)
4)Degree of involvement, duration, and history of
disease (rate of progression)
5)Patient cooperation
6)Economic considerations
7)Etiologic factors
Grant ; PERIODONTICS in the tradition of Gottlieb and Orban,

17. PATIENT’S AGE :
PLAQUE CONTROL :
•Bacterial plaque – primary etiological factor
• Patient’s ability to perform adequate plaque control
is clearly important in determining whether or not
the disease can be arrested
OVERALL CLINICAL FACTORS

18. PERIODONTAL POCKETS:
•The depth, size, and location of periodontal pockets provide a
preliminary assessment of the extent of disease.
•In general, the deeper the pocket, the POORER THE PROGNOSIS .
•If the deeper pocket - greater loss of alveolar bone – QUESTIONABLE
PROGNOSIS
•Pockets associated with single-rooted teeth usually respond to
treatment better than those associated with multirooted teeth, especially
if the furcation area is involved.
DISEASE SEVERITY

19. FURCATION INVOLVEMENT
•Long term follow-up of periodontal treatment indicates periodontal
lesions in the majority of patients will respond well. The one exception
to this seem to be lesions in multi-rooted teeth that have advanced
into the furcation area between the roots. (Hirschfield 1978, McFall
1982, Goldman 1986)
•In teeth with furcation lesions a tooth mortality rate for periodontal
reasons of 31% - 57% has been observed over periods averaging about
20 years compared to an overall tooth mortality for all teeth of only
7% - 10%. (Hirschfield 1978, McFall 1982)

20. Bone loss can occur at any point on the buccal
surface of molars so pocket depth must be
checked at several points and the deepest
measurement recorded.
Bone loss in furcations can occur in a horizontal
or vertical plane

21. •The presence of furcation involvement does not indicate a
hopeless prognosis.
•However, involvement of the furca area by periodontal disease
causes two significant problems:
•Limited access for scaling and root planning and for performing surgery and
•Limited access for plaque removal by the patient.
•The more accessible the pocket for treatment, the better the
prognosis.
•Deep proximal and circumferential infrabony defects do not
respond predictably to treatment.

22. Treatment for furcation invovement
•can be surgical or non – surgical
•Incipient or early bone defects – oral hygiene,
scaling, and root planning
•Shallow horizontal involvement without vertical
bone loss – localized flap procedures with
odontoplasty and osteoplasty
•Advanced defects – surgical treatment – root
resection, hemisection, reconstruction
EXTRACTION

23. •The greater the bone loss, the more guarded the
prognosis.
•As bone loss approaches and exceeds 50% and as
the pattern of bone loss becomes more irregular, the
prognosis worsens.
•Irregular, vertical, and trough like intrabody
defects adversely affect prognosis, especially if the
interradicular bone of a furcation is involved.
BONE LOSS
The Hopeless Tooth: When is Treatment Futile? John W. Harrison,Quintessence
International, Vol. 30, Num. 12 1999

24. •If the roots are widely spread and root concavities are
minimal, furcation involvement is more amenable to root
resection procedures (after endodontic therapy when
possible) and other types of corrective surgery.
•If the entire interradicular septum has been lost or if
the roots converge or fuse at or near the apices, the
prognosis is hopeless.
The Hopeless Tooth: When is Treatment Futile? John W. Harrison,Quintessence
International, Vol. 30, Num. 12 1999

25. An isolated vertical intrabony defect may result from a
fracture extending vertically and apically along the root
(vertical root fracture).
This type of fracture may be due to occlusal trauma
(especially in teeth with restorations involving the mesial and
distal marginal ridges), post placement, or excessive
compaction (condensation) forces during root canal
treatment.
If only one root of a multirooted tooth is involved, root
resection is an option.
Otherwise, vertical root fractures have a hopeless prognosis.
The Hopeless Tooth: When is Treatment Futile? John W. Harrison, Quintessence
International, Vol. 30, Num. 12 1999

26. SMOKING :
•A patient who continues to smoke will have a worse
prognosis than one who either does not smoke or quits
•Smokers had significantly greater probing depths than
non-smokers but also increased tooth mobility
•Smokers have decreased levels of oral hygiene when
compared to non-smokers.
•The tooth brushing efficiency of smokers was much less
and the calcium concentration in the dental plaque of
smokers was found to be significantly higher than in
non-smokers, suggesting an influence on the rate of
calculus formation and further deterioration of oral
hygiene.
SYSTEMIC AND ENVIRONMENTAL FACTORS

Smoking and periodontal disease; Basavaraj. Indian Journal of Stomatology,
2011, Vol. 2 Issue 2, p120-122

27. •Smokers with mild to moderate periodontitis –
Questionable To Unfavourable Prognosis
•Smokers with severe periodontitis –
Unfavourable To Hopeless Prognosis
•Smoking cessation in mild to moderate periodontitis –
Favourable Prognosis
•Smoking cessation in severe periodontitis – Questionable
To Unfavourable Prognosis.

28. DIABETES:
•The vast preponderance of studies find a strong association between both
Type 1, Type 2 diabetes and periodontal disease.
•Diabetes is known to reduce resistance to infection and to compromise
healing. Thus, patients with diabetes, especially poorly controlled
diabetics, will generally have a worse overall prognosis than patients who
are not diabetic or who are well controlled
Other systemic conditions like immunodeficiency states,
neutrophil disorders, osteoporosis have increased risk for
periodontal problems
The Art and Science of Periodontal Prognosis, steven e; cda j o u r n a l , vol 3 6 , no 3

29. STRESS:
•Stress adversely affects periodontal prognosis.
•A recent metaanalysis of the literature suggests
that psychological stress can lead to increased
periodontal disease and hence, a worse overall
prognosis.
The Art and Science of Periodontal Prognosis, Stevene; CDA J o u r n a l , vol 3 6 , no 3

30. SUBGINGIVAL MARGINS :
•Increases plaque accumulation
•Increased inflammation
•Increased bone loss
•Discrepancies in margins - -ve impact on periodontium
•Tooth with discrepancy in subgingival margins – unfavourable
prognosis
•Well contoured subgingival margins – favourable prognosis
LOCAL FACTORS

31. •Teeth with short, tapered root and large crown –
unfavorable prognosis
•Developmental grooves, root proximity and
furcation involvement – with inaccessible areas –
questionable to unfavorable prognosis.
ANATOMIC FACTORS

32. •Teeth with deep pockets and bone loss have a more
favorable prognosis if they are stable rather than mobile.
•Mobility may be caused by inflammatory changes in the
periodontal ligament, trauma from occlusion, or loss of
alveolar bone.
•Mobility caused by inflammation and traumatic occlusion
are often easily corrected, but mobility caused by loss of
alveolar bone support presents a much greater problem.
TOOTH MOBILITY
The Hopeless Tooth: When is Treatment Futile? John W. Harrison,Quintessence
International, Vol. 30, Num. 12 1999

33. •Teeth with 50% loss of attachment and 2 to 3 degrees of
mobility have a very guarded prognosis, perhaps hopeless.
•If the cause of mobility can be eliminated and the mobility
can be controlled (by splints, fixed prostheses, etc), then
the prognosis is better. In general, a direct association
exists between increasing mobility and worsening
prognosis.
•If a tooth is depressible, the prognosis is usually hopeless
The Hopeless Tooth: When is Treatment Futile? John W. Harrison,Quintessence
International, Vol. 30, Num. 12 1999

34. Becker et al suggest that if at least two of the following
conditions exist, then a tooth is hopeless and further treatment
is futile:
(1)Loss of bone support over 75%,
(2)Probing depths greater than 8 mm,
(3)Class III furcation involvement,
(4)Class III mobility with movement in the mesial, distal,
and vertical directions,
(5)A poor crown-root ratio,
(6)Root proximity with minimal interproximal bone,
(7)Evidence of horizontal bone loss, or
(8)A history of repeated periodontal abscess formation
INDICATIONS FOR EXTRACTION
Becker W, Becker B, Berg L. Periodontal treatment without maintenance. A
retrospective study in 44 patients. J Periodontol 1984;55:505-509.

35. Hirschfeld and Wasserman, 1978 :
Teeth with questionable prognosis are those
•Furcation involvement.
•A deep, noneradicable pocket.
•Extensive alveolar bone loss.
•Marked mobility in conjunction with probing depth
(2 or 2.5 degrees on a scale of three).

36. When a tooth has a pulpal involvement secondary to tooth fracture
and carious lesion, endodontic therapy has been the treatment of
choice.
Endodontic factors to be considered include the
•presence/absence of a periapical lesion,
• the type of endodontic treatment, and
•the postendodontic restorative situation.
Preoperative periapical lesions decreases the endodontic success
rate by 10%.
A study in 1990 by sjogren reported that in the absence of periapical
lesions, the healing rate was 94% compared to 79% in sites with
lesions.
ENDODONTIC
Strategic Extraction: A Paradigm Shift That Is Changing Our Profession.
Richard T. Kao, J Periodontol, 2008 , 971-977

37. Endodontic retreatment significantly reduce the 97% success
rate seen with initial endodontic therapy.
Surgical retreatment of a poorly endodontically filled tooth
can reduce the success rate by 13% to 29%. The chance of
success ranged from 37% to 85%, with an average of 70%.
In one study of endodontic retreatment, perforations were
seen in 12% of the cases; the outcome and prognosis were
so poor .
These studies suggest that surgical retreatment of root
perforation and poor root-filling quality are strong predictors
of poor endodontic outcome.

38. Periapical lesions, root
perforations, and poor
endodontic fill are factors that
complicate endodontic
evaluation; the restorability of
the endodontically treated tooth
is of greater importance.

39. Based on the factors impacting the outcome of treatment, the
following classification of root perforations, proposed by Fuss
& Trope
•FRESH PERFORATION – treated immediately or shortly
after occurrence under aseptic conditions - GOOD
PROGNOSIS.
•OLD PERFORATION – previously not treated with likely
bacterial infection - QUESTIONABLE PROGNOSIS .
ROOT PERFORATIONS
Diagnosis and treatment of accidental root perforations,TSESIS & ZVI FUSS,
Endodontic Topics 2006, 13, 95–107

40. •SMALL PERFORATION - (smaller than #20 endodontic
instrument) – mechanical damage to tissue is minimal with
easy sealing opportunity - GOOD PROGNOSIS.
•LARGE PERFORATION – done during post preparation,
with significant tissue damage and obvious difficulty in
providing an adequate seal, salivary contamination, or
coronal leakage along temporary restoration -
QUESTIONABLE PROGNOSIS.
Diagnosis and treatment of accidental root perforations,TSESIS & ZVI FUSS,
Endodontic Topics 2006, 13, 95–107

41. CORONAL PERFORATION – coronal to the level of crestal bone
and epithelial attachment with minimal damage to the supporting
tissues and easy access - Good Prognosis.
CRESTAL PERFORATION – at the level of the epithelial
attachment into the crestal bone - Questionable Prognosis.
APICAL PERFORATION – apical to the crestal bone and the
epithelial attachment - Good Prognosis.
In multi-rooted teeth where the furcation is perforated, the
prognosis differs.
Diagnosis and treatment of accidental root perforations,TSESIS & ZVI FUSS,
Endodontic Topics 2006, 13, 95–107

42. Non – surgical
Surgical
Intentional transplantation
Extraction
Before surgical intervention, the following parameters should
be considered
• Amount of remaining bone,
• Extent of osseous destruction,
• Duration of the defect,
• Periodontal disease status,
• Soft tissue attachment level,
• Patient’s oral hygiene, and
• Surgeon’s expertise in tissue management.
TREATMENT OPTIONS

43. •The more favorable the crown-root ratio, the better the tooth
can withstand masticatory forces and the better the
prognosis.
•Short, slender, or tapering roots – poorer prognosis than
those with long and broad roots.
•Multirooted teeth usually resist traumatic forces better than
single-rooted teeth.
•Flared molar roots give better support than fused, conical
roots.
•Broad occlusal tables and large crowns can contribute to
increased mobility.
CROWN ROOT RATIO

44. •The support of the tooth is determined by the height of the
alveolar crest and the length and shape of the root.
•Canines can withstand loss of support better than lateral
incisors by virtue of their longer roots and root concavities.
•Maxillary first premolars show early mobility because of the
tapered roots.
• Some patients have teeth with short roots and others have
root resorption, both of which may be the result of orthodontic
therapy.
• Such teeth are less resistant to excessive occlusal forces.

45. •Prosthetic failure,
•Vertical or horizontal root fractures,
•Severe periodontitis,
• Severe mobility, or
•An insufficient tooth structure.
•Also, a poor prognosis of the overall treatment
plan can necessitate extraction.
INDICATIONS FOR EXTRACTION
Criteria for the Ideal Treatment Option for Failed Endodontics: Surgical or Nonsurgical?
Bekir Karabucak, continuing education.

46. If an existing restoration has to be removed, it should be carefully
assessed before treatment if the tooth is restorable at all.
This includes assessing the
• Amount of remaining tooth structure,
•Possible fractures,
•The clinical crown-to-root ratio, and
•The periodontal condition.
A total of 4.0 mm of biological width and restorative finish line
with sufficient ferrule to enhance the resistance to root fracture
should be given. If this cannot be established, even with crown
lengthening or with orthodontic extrusion, the tooth is subject to
extraction.

47. Based on the review article by Penarrocha et al., 2004 and the time
elapsed between tooth extraction and implantation, the following
classification has been established relating the receptor zone to the
required therapeutic approach.
•IMMEDIATE IMPLANTATION : when the remnant bone sufficient to
ensure primary stability of the implant, which is inserted in the course of
surgical extraction of the tooth to be, replaced (primary immediate implants).
•RECENT IMPLANTATION : when approximately 6-8 weeks have elapsed
from extraction to implantation – a time during which the soft tissues heal,
allowing adequate mucogingival covering of the alveolus (secondary
immediate implants).
IMPLANT PLACEMENT
Khalid ,Immediate Dental Implants and Bone Graft , Implant Dentistry – The
Most Promising Discipline of Dentistry.

48. 3) DELAYED IMPLANTATION : when the receptor zone is
not optimum for either immediate or recent implantation. Bone
promotion first carried out with bone grafts and/or barrier
membranes, followed approximately six months later by
implant positioning (delayed implants).
4) MATURE IMPLANTATION : when over nine months have
elapsed from extraction to implantation. Mature bone is found
in such situations
Khalid ,Immediate Dental Implants and Bone Graft , Implant Dentistry – The
Most Promising Discipline of Dentistry.

49. Type I extraction (socket only)
The socket predominates, and immediate implant placement with or
without guided-bone regeneration at the time of extraction is
recommended.
Type II extraction (socket and defect combined)
An ideally placed implant from an aesthetic positional standpoint may
be exposed on the facial surface. The proper treatment sequence should
be orthodontic extrusion, tooth extraction, and implant and barrier
membrane placement with ridge augmentation.
Classification of implant extraction site (Salama) :

50. Type III extraction (defect only)
Type III socket environment is the most problematic and the least
predictable class and presents no possibility of primary stability of
the implant. A staged approach (i.e., extrusion of the hopeless tooth,
extraction, barrier membrane, ridge augmentation, and finally
implant placement 6 to 12 months after guided-bone regeneration)
is recommended

51. •Socket - degranulated with curettes and diamond rotary
instrumentation to remove all remnants of the
periodontal ligament and granulation tissue.
•Depth gauges of various diameters are inserted to
ascertain the socket architecture before the initiation of
the osteotomy.
•If primary stability of the implant cannot be achieved by
increasing the length or width of the socket as
ascertained by inserting the final diameter depth gauge,
then no attempt should be made with immediate
placement and a delayed type two or type three protocol
should be followed.
IMMEDIATE IMPLANT PLACEMENT
J Oral Maxillofac Surg;49,1269-1276, 1991

52. •Traumatic loss of teeth with a small amount of bone
loss
•Teeth lost because of gross decay without the
presence of purulent exudate or cellulitis
•Inability to complete endodontic procedures;
•Presence of severe periodontal bone loss without
purulent exudate
•Adequate soft-tissue health and quantity to obtain
primary wound closure.
INDICATIONS
Khalid ,Immediate Dental Implants and Bone Graft , Implant Dentistry – The
Most Promising Discipline of Dentistry.
J Oral Maxillofac Surg;49,1269-1276, 1991

53. •Presence of purulent exudate at the time of extraction
•Adjacent soft-tissue cellulitis and granulation tissue
•Lack of adequate bone apical to the extraction site
•Adverse location of the mandibular neurovascular
bundle, maxillary sinus, or nasal cavity
•Anatomic configuration of remaining bone preventing
ideal prosthetics
•Any clinical condition that prevents primary soft-tissue
wound closure
CONTRAINDICATION
Khalid ,Immediate Dental Implants and Bone Graft , Implant Dentistry – The
Most Promising Discipline of Dentistry.
J Oral Maxillofac Surg;49,1269-1276, 1991

54. Lindeboom (2006) - A prospective randomized study
has been conducted in 50 patients, with 25 implants
Immediately placed in periapical infected site and 25
after 3 months healing period and found 92%
survival in immediately placed and 100% in delayed.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:705-10

55. According to Frederick - Compared with long-term periodontal
and lengthy orthodontic treatments, the provision of an implant-
supported prosthesis for a malaligned tooth with severe
periodontitis is an expeditious and predictable treatment modality.

56. According to PERRY Smoking adversely affects the
outcome of implant treatment (implant survival and
success). The effect of smoking on implant survival
appears to be more pronounced in areas of loose
trabecular bone.
• Type 2 diabetes may have a negative affect on implant
outcome (survival),
• History of treated periodontitis does not adversely affect
implant outcome (survival). Patients with a history of
treated periodontitis may experience more complications
and lower success rates.
How Do Smoking,Diabetes, and Periodontitis Affect Outcomes of Implant Treatment? Perry R.
Klokkevold, INT J ORAL MAXILLOFAC IMPLANTS 2007;22(SUPPL):173–202

57. Requirements for regenerative periodontal therapy
on natural teeth vs requirements for immediate
implant placement
Tooth Implant
Stable Primary stability
Contained within envelope of bone Contained within envelope of bone
Decontaminated Sterile implant
Giano Ricci , Save the Natural Tooth or Place an Implant? Three Periodontal
Decisional Criteria to Perform a Correct Therapy Int J Periodontics Restorative Dent
2011;31:29–37

58. Implant placement and restoration is
not a technically demanding procedure. From the
results available today, which are based on follow
up studies, it seems that tooth replacement with
dental implants is more predictable than surgical
periodontal and endodontic techniques. This
however should not automatically preclude these
therapeutic modalities and lead to extraction of the
affected teeth.
CONCLUSION

59. •Giano Ricci , Save the Natural Tooth or Place
an Implant? Three Periodontal Decisional
Criteria to Perform a Correct Therapy Int J
Periodontics Restorative Dent 2011;31:29–37.
•Richard P. Kinsel The Treatment Dilemma of
the Furcated Molar: Root Resection Versus
Single Tooth Implant Restoration. A
Literature Review.. INT J ORAL MAXILLOFAC
IMPLANTS 1998;13:322–332
•The Hopeless Tooth: When is Treatment
Futile? John W. Harrison,Quintessence
International, Vol. 30, Num. 12 1999
REFERENCES

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Making:Implants Versus Natural Teeth. Dent
Clin N Am 50 (2006) 451–461
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Failed Endodontics: Surgical or Nonsurgical?
Bekir Karabucak, continuing education
•Diagnosis and treatment of accidental root
perforations, TSESIS & ZVI FUSS, Endodontic
Topics 2006, 13, 95–107
• Strategic Extraction: A Paradigm Shift That Is
Changing Our Profession. Richard T. Kao, J
Periodontol, 2008 , 971-977

61. •Jivraj, Factors effecting individual tooth
prognosis and contemporary treatment
planning in implants, BRITISH DENTAL
JOURNAL VOLUME 201 NO. 4 AUG 26
2006
•Khalid ,Immediate Dental Implants and Bone
Graft , Implant Dentistry – The Most
Promising Discipline of Dentistry.
•Michael S.Block, and Jhon
N.Kent, ,Placement of Endosseous implants
into tooth extraction site,J Oral Maxillofac
Surg;49,1269-1276, 1991

62. •Charles A.Babbush, The art and science of
implants
•Carl E Mish, Dental Implants Prosthetics
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