Dental prosthesis planning: when do teeth have to be extracted?

When does a tooth have to be extracted?

Before working out a denture concept to replace existing teeth, it should be clarified whether a tooth needs to be removed at all. There is no clear distinction between when a tooth is pulled and when it is worth preserving.

A denture without "Wackelkandidaten", teeth with poor prognosis can be planned better. However, extraction is not always the best solution.

In some situations, a tooth simply cannot be saved.

In other cases, the therapy costs are too high. General medical reasons may require timely tooth removal.

Persistent toothache can also leave the patient with no choice but to have the pest removed.

Various factors can question the preservation of a tooth:

  1. Periodontitis (periodontitis)
  2. Caries
  3. Problems with tooth roots
  4. Acute chronic toothache
  5. General medical reasons
  6. Prosthetic reasons
  7. Malocclusion
  8. Lack of time and money
  9. Sum of all problems (multicausal)

We have summarized for you what influence the various factors have on the tooth and subsequent restoration with dental implants.

1. Pulling teeth in periodontitis (periodontitis)

The main cause of tooth loss in adulthood is periodontitis: a bacterial-inflammatory tooth bed disease that usually remains undetected for a long time due to the lack of symptoms. The body’s defense reaction to the bacteria attached to the tooth root cause inflammation of the tooth-holding apparatus. This inflammation then causes bone loss around the tooth, which loosens the tooth. The entire dentition is usually affected; The decision as to whether a tooth needs to be removed or can be obtained through periodontal treatment depends on certain factors:

How far has the bone loss progressed??

The longer the periodontitis remains undetected and therefore untreated, the further the gradual bone loss can progress. With a bone bed loss of more than 50%, the prospect of tooth preservation is not good; from 70%, the success of periodontitis therapy is no longer to be expected. However, there is no exact measurement of when a tooth has to be extracted and is in no way worth preserving.

Advanced periodontitis: inflammation-related complaints

The course of the periodontitis is usually insidious, that is, without severe symptoms. In acute inflammatory phases, suppuration can occur, which is accompanied by considerable pain. Teeth are often pulled during this phase. Strong loosening of the teeth (caused by bone loss) is also responsible for pain and the associated removal.

When periodontitis is not the only problem

In addition to periodontal disease, other accompanying circumstances can further worsen the prognosis of the teeth (accumulation effect). For example, the effort to maintain teeth with periodontitis and deep caries is great and the prospect of success is not guaranteed. Inflammation of the root is equally problematic; in connection with periodontitis, a paro-endo lesion can occur. A tooth extraction is obvious.

Periodontitis therapy is not always a success

Every patient reacts differently to a treatment due to biological reasons. A periodontitis patient can therefore quickly respond to an initiated therapy and the disease subsides. However, on the other hand, despite all possible therapy measures, periodontitis can continue, and the "exhausted" patient only has the tooth removal as an option to stop the bone loss. In such cases, a reaction must be made in good time in order to be able to maintain a certain amount of bone, otherwise implant treatment is difficult to implement (complex bone-building measures).

Differences in the treatment of individual teeth are also possible: the therapy of multi-rooted teeth is much more difficult because the hiding places of the roots serve as a “hiding place” for bacteria and cannot be combated. Additional difficulties in bacterial control arise if the bone between the roots is also affected (furcation).

Dentures after periodontitis must be strategically planned

If a periodontal disease is successfully treated, a tooth can work well on its own despite bone loss. However, if you are planning a fixed denture (bridge) in which such a tooth is to be used as a pillar, early loss due to overload is inevitable. A removable denture that is anchored to periodontitis-damaged pillars can work. A better option here, however, is the provision of dental implants, since pillars are gained and your own (already weakened) teeth are relieved.

Dental implant care after periodontitis

In the case of periodontitis, there is usually no deep inflammation of the bones, but implantation is made more difficult by the broken bone. Bone build-up after many years of untreated periodontitis is sometimes unavoidable. When is the best time for an implantation to be weighed individually.

When is the best time for an implantation?

The right time for an implantation after a periodontitis that has been treated is not to be mentioned in general. Whether you place the implant or implants directly after tooth loss, or only a short time later, has to be decided individually.

Is possible:

2. Caries: Destruction of the hard tooth substance

A small hole in the tooth does not question tooth preservation – that is clear. A filling therapy can almost completely fix it. In the case of carious defects, i.e. larger holes, the repair is associated with a little more effort: the shape and function of the tooth can be restored using partial crowns / crowns or inlays.

However, if the tooth crown (the visible part of the tooth) is destroyed by caries in this way, restoration measures using a crown (root post / filling) can also be unsuccessful. The tooth must be removed at the latest when the tooth decay has penetrated further and the tooth root dissolves. This also applies to multi-rooted teeth. If the floor of the tooth penetrates the jawbone, the tooth can usually no longer be “saved”.

The removal of cariously destroyed teeth

If the damage caused by caries to a tooth is so great that it is classified as not worth preserving, the extraction takes place. Removal is only easy when the root retention of the tooth is no longer pronounced (e.g. for periodontitis) and the tooth crown offers enough contact surface for the firm hold of a pair of pliers.
If this method does not work, luxators or levers can be used to widen the tooth compartment (alveolus) and remove the tooth from the jaw in a way that is gentle on the bone. It is particularly important to protect the jawbone in the event of a planned implant placement.
If this method does not work either, the only option left is the removal of the tooth root by an osteotomy. To do this, the gums must be opened and the bone removed until one of the above methods can be used successfully.

When is the best time for an implantation?

After cariously destroyed teeth are removed, there is usually no relevant inflammation in the jaw bone that could stand in the way of an implantation. The bone supply is usually still very good. Unless tooth extraction was a difficult undertaking to suffer bone loss (e.g. through osteotomy).

Is possible:

  • immediate implant placement, definitely recommended for single-root teeth;
  • the delayed immediate implantation as possible – and the
  • Late implantation as the safest method; possible bone loss and the extended treatment time must be accepted.

3. Problems with tooth roots

As far as the tooth root is concerned, two findings may require tooth removal:

a) root inflammation of dead teeth and

b) Root fractures (a fracture of the tooth root

a) Root infections of dead teeth

Before a tooth has to be removed due to endodontic causes (inflammation of the tooth root), there are many conservation options that can be used first.

In most cases, tooth preservation is possible with sufficient effort.

Antibiotic therapy is only possible in exceptional cases and is not reliably able to cure the inflammation.

The ways to eliminate inflammation are:

  • the primary root canal treatment,
  • (if necessary) the revision (repetition) of a root canal treatment,
  • and the root tip resection.

If a root infection does not heal despite the primary root treatment being carried out, the next step as a rule, the revision usually has a good chance of success in getting the inflammation under control. However, the statutory health insurance companies do not cover the costs of a revision; Therefore, as a measure after the primary root canal treatment, a root tip resection (WSR) is carried out directly. However, the revision is no longer possible after a WSR.

The following findings in connection with root-dead teeth speak against tooth preservation:

  • Inflammation of tooth roots, the channels of which cannot be prepared, e.g. Canal / access blocked by pin tooth or stuck older root filling, root canal treatment is then not possible.
  • In spite of root canal treatment and root tip resection (WSR), inflammation of the root did not subside: a new WSR would not be promising.
  • In the case of very large inflammations, a cure is not certain despite complex and time-consuming therapy.
  • Cooker rehabilitation: the inflammation should / must be removed promptly for general medical reasons "experiment" is then not possible.
  • Additional negative factors (accumulation effect), e.g. severe periodontitis: then there is little chance of success.

When is the best time for an implantation?

Basically, implants can be used to treat gaps after extraction of root-damaged teeth, but the inflammation must have healed before an implant is inserted. There is a great risk that the remaining bacteria will prevent implant healing.

Is possible:

  • Immediate implantation is not recommended in the presence of inflammation; implant loss is likely.
  • Delayed immediate implantation is possible, but it is also associated with the risk of early implant loss, as it is possible to encapsulate bacteria within the jawbone (restostitis). If one implants in the area of ​​a restostitis, the previously subacute accumulation of bacteria can lead to an early peri-implantitis – implant loss preprogrammed;
  • The late implantation is the safest way to rule out the risk of inflammation and is therefore absolutely to be recommended, possible bone loss and an extended treatment period must be accepted.

b) Root fracture: fracture of the tooth root after an accident (anterior tooth trauma)

Anterior teeth are particularly likely to break after sudden application of force (due to an accident or impact). Not every fracture questions tooth retention – a knocked-out tooth corner, for example, is not a cause for concern, but a blow to an anterior tooth can also lead to a fracture line right into the root tip. Such a root fracture then makes pulling a tooth inevitable.

Fractures on the tooth are not limited to the anterior region, especially in the upper jaw, the posterior teeth are broken due to sudden or permanent overload. This can be triggered by a bite on a hard body, the tooth structure is usually already weakened (e.g. due to large fillings).

The course of the fracture line determines whether the fractured tooth is preserved or extracted:

  • Fracture of the tooth crown, above or just below the bone boundary:
    With a root canal treatment (endodontics) and a post build-up, the probability of being able to keep the tooth is high.
  • Longitudinal fracture of the tooth root:
    In this case, there is no rescue option for the tooth, it must be pulled.
  • Longitudinal fracture between the roots of multi-root teeth:
    In this case, preservation of the tooth is only possible in exceptional cases.
  • Cross fracture in the bone:
    In the case of a transverse fracture in the jawbone, the tooth can only be obtained in exceptional cases.

Implant restoration after accidental tooth loss

Gap restoration with implants after accidental tooth loss is considered the gold standard. If the jawbone has not been damaged, the following is:

  • Immediate implantation is the best treatment option, tooth loss due to trauma is the typical indication for immediate implantation;
  • Delayed immediate implant placement is a good option, even seen by some practitioners as a better option;
  • late implantation is a safe way, but probably with more disadvantages than advantages (e.g. restructuring and removal of the bone).

Bone and tooth compartment damaged?

The violent effects on teeth and jaws often also loosen the affected teeth. A bone fracture is not uncommon. A fracture in the bone can in turn partially or completely remove the tooth from the tooth compartment (partial or complete dislocation), the result: the well-known "knocked out tooth".

The extent of the injury to the surrounding tissue determines the further course

Tooth preservation by replanting (replanting) with splinting is possible. Provided the bone compartment is not too badly damaged and the root skin is intact (the tooth must not dry out: storage in the oral cavity or in a tooth rescue box is necessary). In many cases such favorable conditions are not to be expected and permanent tooth retention is unlikely. A quick alternative therapeutic approach should be considered (e.g. an immediate implant).

When is the best time for an implantation?

Gap restoration with implants after accidental tooth loss is considered the gold standard. Even if the jawbone has been damaged, implants are considered ideal care. The time of implantation should be chosen individually depending on the degree of trauma.

Is possible:

  • Immediate implantation is the best option depending on the condition of the bone bed, the more intact – the better;
  • Delayed immediate implantation is also a good option if the bone compartment is largely intact;
  • The late implantation is the only option if there is considerable damage to the bones and the tooth compartment.

4. Acute and chronic toothache

Anyone who has had a sleepless night due to excruciating toothache knows how uncomfortable this pain can be and how little pain medication can help. Toothache can have different causes and is usually not a reason for tooth removal because the causes can be treated with dentistry. The most common cause of acute toothache is a "hole in the tooth" – caries.

If a lengthy therapy is necessary: ​​pull a tooth?

However, if there is another problem that requires more time-consuming treatment than filling therapy (periodontitis, pulpitits, inflammation of the roots), the willingness to "get through" this over a longer period of time decreases, and the problem tooth is removed for pain reasons. quick solution.

Acute toothache caused by inflammation of the tooth nerve (pulpitis)

Irritation of the tooth nerve (pulp) can be responsible for mild complaints. Pulp irritation can manifest itself in particular through a hypersensitivity to sweet and cold associated with pain.
If this nerve ignites irreversibly, it is called pulpitis. It causes severe pain because the tooth nerve swells due to the inflammation, but cannot make room for it in the hard tooth. Pain relievers or an antibiotic usually don’t help, and the only way to stop the pain and keep the tooth is by root canal treatment (nerve removal and treatment of the root canal)..

Inflammation of the tooth root causes pain

Inflammation of the root tip can also occur with already dead teeth and cause severe pain when biting / pressure.
Advanced inflammation can even lead to suppuration of the jaw (e.g. submucosal abscess). The acute phase of the inflammation can be temporarily treated with an antibiotic, but a root canal treatment is necessary for permanent tooth preservation.

Other causes of acute toothache

The inconspicuous (creeping) periodontal disease usually only causes pain in very acute inflammation phases due to suppuration (periodontal abscess). Strong loosening of the teeth can also cause complaints; the removal of the affected teeth is then obvious (see above).
Other causes of toothache, e.g. in the event of tooth fractures or overloading, can ultimately be attributed to irritation of the tooth nerve (pulp) or pulpititis.

Chronic toothache may require tooth extraction

Permanent or recurring toothache can be caused by irritation of the tooth nerve (pulp) and can be the preliminary stage of pulpitis. Concomitant symptoms are often hypersensitivity to cold or bite sensitivity.
Pulp irritation can be caused by caries, grinding of the teeth for crowning, previous filling therapies or a chronic overload of a tooth.

The nerve irritation can subside – experience has shown that it turns into a more or less intense pulp pit and can be successfully treated with endodontic therapy (root canal treatment).
The dormant inflammation of a dead tooth can also be the reason for chronic toothache (see above: root infection of dead teeth).

Toothache from non-dental causes

The cause of toothache in the mouth is not always found. With a flu-like infection ("head flu") toothache is not uncommon; Infections of the maxillary sinus and sinusitis cause severe pain, especially in the maxillary posterior teeth, due to the close relationship between the roots of the teeth and the maxillary sinus floor.
Episodes of herpes simplex or herpes zoster (shingles) can cause pain in the teeth and jaw area.

When is the best time for an implantation?

Basically, an implant restoration is possible after tooth extraction due to pain, but the cause of pain should be clarified and treated before implantation.

Is possible:

  • Immediate implantation is not recommended in the case of an unexplained / chronic pain situation, inflammation can pass to the implant – increased risk: implant healing unsuccessful or early peri-implantitis and implant loss;
  • delayed immediate implantation is possible;
  • Late implantation is the safest way to rule out diseases, achieve successful healing and permanent implant health.

5. Refurbishment: General medical reasons require tooth extraction

In principle, the potential bacterial spread of an inflammatory focus represents a risk for the entire organism. In certain underlying diseases, this risk can even become unpredictably high.

The precautionary removal of a focal point is, among other things, in connection with some heart diseases, rheumatic forms of disease and before heart operations, radiation, transplantation, chemotherapy and much more. strongly recommended from a medical point of view.
This removes teeth that have a very good prognosis with the right therapy, e.g. Teeth with inflammation of the roots.

In the case of mild to moderate periodontitis, teeth are usually not removed, since this superficial inflammation is not classified as a focus of inflammation for bacteria without an existing hiding place.

When is the best time for an implantation?

Implants are possible for patients with certain underlying diseases, but the risks and benefits should be weighed very clearly. An implantation is a surgical procedure and not without risk; For a weakened cancer patient, for example, such additional burdens are better avoided and the choice of an alternative denture is recommended.

Is possible:

  • the immediate implantation. It is not recommended for high-risk patients (e.g. weakened immune system, further foci of inflammation in the body, etc., high risk of early implant loss and additional stressful surgery)
  • the delayed immediate implantation. A very possible option.
  • the late implantation. It is the safest way to rule out inflammation and to be able to assess the general medical condition of the patient.

6. Tooth removal for prosthetic reasons: Only plan dentures with stable pillars

Planning, especially when it comes to fixed and no longer changeable dentures, should only include stable abutment teeth. The existing teeth are checked for their so-called value in order to be able to assess which dentures are possible. Teeth have good value, without periodontitis or caries, which are stable in the bone with a good root length. Since not every remaining tooth may have this value, further teeth may have to be removed for the planned denture in order not to jeopardize long-term success.

In addition to the poor quality, there are other reasons to remove teeth in order to achieve a better prognosis for the planned dentures:

  • a tilted or migrated tooth,
  • a tooth that has grown out too long (tooth elongation),
  • and a (partially) retained tooth,

can restrict / hinder the function of dentures. A supply of dentures is even partially not possible at all.

When is the best time for an implantation?

First of all, the teeth are removed in order to implement the planned dentures. This does not include dental implants as a supply solution.
In addition to the factors to be clarified individually, e.g. the general state of health (possible diseases that speak against an implant supply), dental implants offer the possibility of maintaining your own teeth with poor quality (teeth do not have to be removed). This means that implants close existing gaps without straining the remaining teeth. When choosing a dental bridge, you have to grind your own teeth, for example, to be able to wear crowns (crown preparation). Due to the permanent load of a bridge, the ground teeth can also be damaged (tooth loosening, early tooth loss).
Then whether one immediate implantation, a delayed immediate implantation or one late implantation The best solution as a concept must be clarified individually.

7. Defective teeth: Removal of functionally or aesthetically disruptive teeth

Not all teeth are optimally positioned in the bit, the defect can be aesthetically disturbing, but also functionally stressful. The temporomandibular joint or neighboring teeth can be damaged. While misaligned teeth are usually corrected by orthodontic treatment in childhood or adolescence, this possibility also exists in adulthood. In particularly serious cases or when orthodontic treatment cannot be carried out, tooth extraction should be considered. It is also necessary to decide individually whether a removed tooth has to be replaced.

Not every tooth removed needs to be replaced

A typical reason for pulling teeth without subsequently replacing them is the shifted wisdom teeth. Due to lack of space, they often only endanger the teeth of the remaining teeth. Also, the teeth removed due to lack of space during orthodontic treatment do not have to be replaced afterwards.

8. Tooth removal due to time and / or cost reasons

If the tooth preservation of a damaged tooth is possible from a medical point of view, but neither the patient nor the health insurance company wants to cover the costs for the treatment (e.g. in the case of the fund guidelines of a root canal treatment), tooth preservation must be waived.

Tooth maintenance can be uneconomical

In many cases, the effort does not justify the benefit. For example, the preservation of a partially destroyed wisdom tooth without function, through costly crowning, makes little sense.

Tooth maintenance not possible due to lack of time

Therapy can sometimes be time-consuming. The larger and more pronounced an inflammation on a tooth, the longer the treatment will take. But even a time-consuming treatment can not always cure pronounced inflammatory processes. A quick restoration request can also prevent tooth retention.

When is the best time for an implantation?

If teeth are removed for cost reasons, implant restoration is hardly an option. After tooth extraction due to lack of time, illness and the exact circumstances are the determining factors, whether an implantation is possible and which concept (immediate implantation, delayed immediate implantation or late implantation) makes the most sense.

9. Multi-causal: there are many reasons against tooth preservation

While each individual disease is not a medical problem and is easy to treat (e.g. tooth decay, inflammation of the roots), the interaction of various diseases makes it difficult for teeth to be preserved.
In the case of a shaky tooth with moderate periodontitis, which bears a bridge and has developed caries at the crown edge. It is possible for this tooth to have a root filling that shows inflammation of the root tip (endodontic problem).

Preservation of teeth is not always sensible

The sum of the illnesses ultimately speaks against tooth preservation, because investing time and costs in an already shaky tooth without guaranteeing the prospect of success makes little sense.
In some situations, refraining from tooth preservation can mean a better prognosis of the denture and a higher profitability.

Gap restoration through dental implants after extraction of multiple damaged teeth

The nature of the various diseases determines whether implants make sense as a form of care and which concept (immediate implantation, delayed immediate implantation or late implantation) is the best solution.

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Christina Cherry
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