LITERATURE REVIEW

Natural Tooth Versus Implant: A Key to

Treatment Planning
Rita Chandki, BDS, MDS*
Munniswamy Kala, BDS, MDS
Since time immemorial, man has constantly contrived to replace natural body parts that are
either congenitally absent or lost subsequent to disease or injury, so as to maintain a perfect
amalgam of form and function. Dental implants have recently become established as a
standard treatment protocol for replacing missing teeth. Ostensibly, a dilemma has arisen
whether the implant should obviate the necessity to preserve teeth with debatable
restorative prognosis. This article attempts to review the work done hitherto and to
formulate a combined perspective in such cases.
Key Words: natural tooth, implant, treatment

INTRODUCTION
The only constant in life is change.
Heraclitus, Greek philosopher

he goal of modern dentistry is to

restore normal contour, function,
comfort, esthetics, speech, and
health, regardless of the atrophy,
disease, or injury of the stomatognathic system. For decades, the underlying
objective of preserving natural dentition has
provided the foundation for clinical decision
making in dentistry. To patients and practitioners alike, tooth extraction has been
relegated to be a last-ditch attempt when all
other possible options fail. However, current
trends in implant dentistry have made inroads
in this age-old paradigm. A practitioners
attention is now being drawn toward providing tooth substitutes, often touted as equal or
even superior to natural teeth, and many
clinicians have moved swiftly to adopt

Department of Conservative Dentistry and Endodontics, Government Dental College and Research Institute,
Bangalore, India.
* Corresponding author, e-mail: chandki.rita@gmail.com
DOI: 10.1563/AAID-JOI-D-10-00108

implant dentistry as the new standard of

care, so much so that the rapidity of this shift
has actually come to be a cause for concern.1
While it is true that implant dentistry holds a
great deal of promise, when posed with a
choice between endodontic treatment and
implants, a cautious approach to embracing
this technology has to be followed, especially
since a dental implant is an invasive procedure, is financially more demanding to the
patient, and involves the psyche of living with
a foreign material within oneself.
AN IMPLANT IS NOT A TOOTH: A GUIDELINE TO
TREATMENT PLANNING
Implants are fundamentally different from
natural teeth in that they do not decay,
have no dental pulps to function as early
indicators of disease, and have no periodontal membrane. The factors involved in
the decision-making process regarding
whether a tooth should receive endodontic
treatment or be extracted and replaced by
an implant pertain to the patient, the tooth
and periodontium, and treatment-related
considerations.2
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Natural Tooth Versus Implant

PATIENT-RELATED FACTORS
Age
The fact that the implant behaves as an
ankylosed unit restricts its use to individuals
who have completed their jaw growth. There
is no upper age limit to implant treatment
provided that the patient is fit enough and
willing to be treated.
Untreated dental disease and
systemic diseases
Concomitant unaddressed systemic illnesses
can be a limitation for implant success.
Severe mucosal lesions
Unhealed mucosal lesions are often more
problematic around the natural dentition
than around an implant site.
Tobacco smoking and drug abuse
Tobacco smoking is a very important risk
factor in periodontitis and affects healing
after implant placement.
Previous radiotherapy to the jaws
Radiation of the jaws results in endarteritis,
which compromises bone healing and can
lead to osteoradionecrosis.
Patient comfort and perceptions

best option because of frequently required

reinterventions. It may be prudent to extract
such teeth and place implants instead. In
addition, implants may be a more viable
alternative for patients who have a limited
ability to maintain routine oral hygiene.
Teeth with unique color characteristics
Color matching can be a significant challenge for a highly visible tooth, such as one
with unique dentin hues or large areas of
enamel translucency. When such a tooth
requires endodontic treatment but does not
need a ceramic crown, it may be esthetically
advantageous to retain the tooth. When
such a tooth requires both endodontic
treatment and a ceramic crown, it may not
be possible to achieve an appropriate color
match because of thickness limitations imposed by the amount of required tooth
reduction; the dentist usually can achieve a
better result with implants.
Quantity and quality of bone
Regions of low mineralization or poor trabeculation are often associated with a thin or
absent cortex, referred to as type 4 bone.4
Soft-tissue anatomy

Most endodontic procedures are performed

with minimal patient discomfort and fewer
complications compared with implants. Stereognostic ability is impaired in subjects rehabilitated with osseointegrated implants by
about one-third to one-quarter compared
with subjects with natural teeth.3

The esthetic result around crowns can be

affected negatively by an interdental papilla
that does not fill the cervical embrasure space.
When the biotype is thin but healthy
around a natural tooth, preservation of
the tooth through endodontic therapy may
provide more appropriate soft-tissue esthetics than a dental implant.

TOOTH AND PERIODONTIUM-RELATED FACTORS

TREATMENT-RELATED FACTORS

Biological considerations

Adjunctive procedures

A considerable number of patients we

encounter in office practice feel plain frustrated because of recurring problems of caries
and periodontal disease. Retaining such teeth
via endodontic treatment may not be the

Retaining some teeth via endodontic therapy may result in the need for treatment
for periodontal disease, crown lengthening
through surgery or orthodontic extrusion, a
core buildup or a post and core, or a crown.

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Chandki and Kala

Each of these procedures adds complexity.

Implant therapy presents similar complexities. Before or in conjunction with implant
placement, the clinician may need to perform grafting or distraction osteogenesis so
that adequate bone is available.
Procedural complications
Endodontic treatment is occasionally associated with procedural mishaps, which can
occur during access preparation, cleaning
and shaping, obturation, and post space
preparation.5 Complications such as hematomas, ecchymosis, and neurosensory disturbance, however, are not uncommon even
with dental implants. Implant loss can occur as
a result of the failure of the implant to
integrate with the bone or due to bone loss
subsequent to integration. Soft-tissue complications such as inflammation with or without
proliferation, soft-tissue fenestration with or
without concomitant dehiscence before stage
2 surgery, and fistulas have been reported.
Mechanical complications such as screw
loosening, screw fracture, prosthesis fracture,
and implant fracture can also occur.4
Treatment outcomes
Based on survival rates, it appears that more
than 95% of teeth that have undergone
endodontic treatment remain functional
over time.68 Multiple previous studies have
quoted 5-year implant survival rates of 95%
and Kaplan-Meier estimates of 10-year survival of up to 90%.9

FROM THE EYE OF A PROSTHODONTIST

When considering a fixed prosthesis vs
dental implants, one must take the following
factors into account:
N Jaw bone resorption: Implant placement
prevents long-term bone loss in that area
over a fixed prosthesis.
N Improved oral health: Dental implants do
not affect the other healthy teeth, while

N
N

N
N

prostheses may require the cutting down

of healthy teeth.
Durability: Dental implants seem to offer
a more permanent solution over a fixed
prosthesis.
Oral hygiene: Individual dental implants
allow easier access between teeth.
Esthetics: Generally a dental implant has
a better visible appeal due to modern
technology, although results may vary with
operator skill.
Treatment plan flexibility: Dental implants
enable more flexibility in treatment planning.
Price: A fixed prosthesis is a more economic
option.

FROM THE EYE OF A PERIODONTIST

Advanced periodontal disease may be addressed with extraction more frequently, provided that the resulting edentulous area offers
sufficient bone for predictable endosteal implant
placement and a more predictable prognosis.
Herodontics is, however, discouraged
when the prognosis is poor, and failure of
treatment may result in inadequate bone for
implant placement. The cost of the questionable
periodontal treatment may result in the inability
of the patient to afford the more predictable
implant therapy on a subsequent occasion.
Endodontics, root amputation, post and core
placement, and a nevertheless remaining angled
root with poor root surface area are cost
prohibitive for the service provided. On the
other hand, the recent trend to extract teeth
with good prognosis after corrective periodontal
treatment is discouraged. The success of implants is not 100% predictable, and implants
should not be substituted for natural teeth
presenting a good or even fair prognosis.
The decision-making protocol can be
summarized as follows.
Prognosis
.10 years:
N Keep tooth and restore as indicated.
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Natural Tooth Versus Implant

510 years:
N Make independent implant restoration.
N If abutment must be included, make
coping and retrievable prosthesis.
N Make tooth a living pontic by adding
more implants or splinting to additional
teeth.

prepared with adequate retention and resistance form. Other indications for implants
include edentulous sites adjacent to teeth
without restorations or the need for restorations and edentulous sites adjacent to
abutment teeth with large pulp chambers
and those with a history of avulsion or
luxation.13

,5 years:
N Extract and graft.
N Consider implant in site after healing.

FROM THE EYE OF A RESTORATIVE DENTIST

There is no perfect system, and the choice
may be bewildering. It is easy for the
clinician to believe that a new system is
an advancement over the existing ones, but
adequate consideration must be given to
treatments aimed at preserving and restoring compromised teeth before rushing to
extraction and replacement. An ideal treatment plan should address the chief complaints of the patient, provide the most
durable and cost-effective treatment, and
meet or exceed patients expectations
whenever possible. And, in a large measure,
it should be applicable to both the developed world and third-world countries,
where poor dental hygiene is still a major
health issue.
Indications for endodontic treatment10
N
N
N
N
N
N

Irreversible pulpitis
Necrotic pulps
Restorable crowns
Treatable periodontal conditions
Salvageable resorptive defects
Favorable crown-to-root ratio

Endodontic treatment is contraindicated

when there is limited remaining tooth
structure and the definitive crown will not
be able to engage at least 1.5 to 2.0 mm of
tooth structure with a cervical ferrule.11,12
Implants are indicated when teeth cannot be
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EVIDENCE-BASED RECOMMENDATIONS
It is well documented that properly treated
natural teeth with healthy but markedly
reduced periodontal support, are capable
of carrying extensive fixed prosthesis for
a very long time, with survival rates of
about 90%, provided the periodontal disease is eradicated and prevented from
re-occuring.14
Based on assumptions that implants
perform better than periodontally compromised teeth, teeth that could be saved and
used as support, are extracted and replaced with implants, sometimes on doubtful indications.14
Peri-implantitis has been found to
occur in 1628% of implant patients after
510 years with higher prevalence among
patients with multiple implants.14
Oral implants when evaluated after
10 years of service do not surpass the
longevity of natural teeth even of those that
are compromised, for either periodontal or
endodontic reason.15
Implants do not have a better prognosis
than teeth with reduced marginal bone
support. The dentist should not recommend extraction of such teeth. There is
no evidence available to support an aggressive approach in early extraction of
teeth, to preserve bone for later implant
placement.16
Partnership with commercial enterprise
now dominates continuing education. We
risk overlooking safety, simplicity and prudence in our clinical judgment.16

Chandki and Kala

TABLE
Natural tooth vs implants
Parameter

Tooth

Composition
Nature
Gingival sulcus depth
Junctional epithelium
Connectivity issue
Gingival fibers
Crest of bone
Nerve supply
Proprioception
Physical characteristics

Adaptive characteristics

Connection
Junctional epithelium
Connective tissue

Biological width
Vascularity
Probing depth
Bleeding on probing

Implant

Calcium and phosphorus

(hydroxyapatite)
Living
Shallow

Primarily titanium and titanium

based alloys
Nonliving
Depends upon abutment length
and restoration margin
On enamel
On titanium
Perpendicular to tooth surfaces
Parallel and circular fibers; no
attachment to implant or bone
Complex array inserted into
No organized collagen fiber
cementum above crestal bone
attachment
1 to 2 mm apical to cementoenamel According to implant design
junction
Present
Absent
Highly sensitive
No ligament receptors
Physiologic mobility caused by
Rigid connection to bone, as if
viscoelastic properties of the
ankylosed
ligament
Width of ligament can alter to allow No adaptive capacity to allow
more mobility with increased
mobility; orthodontic
occlusal forces
movement impossible
Cementum, bone, periodontium
Osseointegration, bone functional
ankylosis ligament
Lamina lucida and lucida, lamina
Lamina, lamina densa, and
dense zones
sublamina lucida zones
Thirteen groups: perpendicular to
Two groups: parallel and circular
tooth surfaces
fibers
Decreased collagen, increased
Increased collagen, decreased
fibroblasts
fibroblasts
2.04 to 2.91 mm
3.08 mm
Greater, supraperiosteal and
Less, periosteal
periodontal ligament
3 mm in health
2.5 to 5.00 mm
More reliable
Less reliable

CONCLUSION
Dental implants have an established place as
a standard treatment protocol for replacing
missing teeth. The debate that has arisen
whether implants should obviate the necessity to preserve teeth is, as yet, far from
having reached a point of culmination. Both
treatment strategies have their respective
advantages and shortcomings. It is important to realize that no treatment strategy is a
panacea for all ills. A detailed, comprehensive clinical evaluation and understanding of
patients concerns and expectations should
be accounted for, before formulating a
definitive treatment strategy. The natural
tooth should be looked upon as a possibility
rather than an obstacle, whether or not the
treatment involves implant placement. In

this sense, implants are here to replace

missing teeth; they are not intended to
replace the natural ones.
Mother Nature, after all, knows best.
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