Extractions of Asymptomatic Natural Teeth to Facilitate Prosthodontic Treatment
Position Statement of the American College of Prosthodontists
Extractions of natural teeth that are commonly performed in a dental office can be broadly grouped into two categories. The first category is the extraction of symptomatic teeth. The primary reason for extractions in this category include teeth affected by dental caries, periodontal disease, hard and soft tissue impactions, root fractures, and periapical infections.1 Each of these conditions warrants a careful consideration of whether to save the natural tooth/teeth with assessment of the risk-benefit ratio in the best interest of the patient. The second category of dental extractions is the extraction of asymptomatic teeth, where typical reasons include hard- and soft-tissue impactions, odontogenic and non-odontogenic pathology, facilitation of orthodontic treatment, and facilitation of prosthodontic and maxillofacial prosthodontic treatment.1 Extractions of asymptomatic natural teeth to facilitate their replacement by prosthodontic treatment may appear paradoxical, but several reasons this treatment is warranted are further discussed.
Comprehensive prosthodontic treatment is designed to improve a patient’s dento-facial esthetics and function along with facilitating a long-term low maintenance solution for the restorations.2 Extractions of asymptomatic natural teeth to facilitate prosthodontic treatment should be recognized as being similar to extractions of asymptomatic natural teeth that are routinely performed to facilitate orthodontic therapy.3 The caries and periodontal status of asymptomatic teeth may or may not be compromised. Occasionally, these teeth may even be considered healthy by common dental parameters. However, their unfavorable position in the oral cavity and their low strategic role in the comprehensive treatment plan may necessitate their extraction. Some common examples of such scenarios include:
1) multiple supra-erupted, tilted, or rotated asymptomatic teeth, and the patient refuses orthodontic treatment or is not a candidate for orthodontic treatment due to poor oral hygiene, periodontal status, increased treatment cost, or lack of compliance;4-6
2) asymptomatic but supra-erupted maxillary or mandibular anterior teeth with bilateral posterior edentulous spaces (Kennedy’s Class I situation) with severe bone resorption when a patient desires comprehensive implant prosthodontic solutions. In this scenario, it is also important that subsequent ostectomy (formerly called alveolectomy) procedures are systematically performed to reposition the alveolar bone, provide a harmonious platform for implant placement and optimal prosthetic space, and ensure an esthetic and functional result for the patient;7-9
3) asymptomatic natural teeth (with good native bone), adjacent to edentulous spaces affected by congenital conditions (cleft palate), trauma, failed bone graft sites, or when a patient refuses corrective regenerative surgery for these sites;
4) asymptomatic healthy natural tooth/teeth that would need to be “sacrificed” as part of oncologic surgery to obtain negative tumor margins or to facilitate resection of the jaw to appropriately fabricate a maxillofacial prosthesis.10
Often, patients are burdened with multiple suboptimal dental restorations on their natural teeth for several years and have often endured a cycle of failing endodontic treatments and multiple failing restorations and elect to have their asymptomatic natural teeth extracted and desire an immediately loaded fixed implant-supported prosthesis as a definitive solution.11-13
It is important to note that retention of natural teeth (restored and unrestored) with subsequent prosthodontic treatment is especially preferable when the tooth has a low risk of disease, has long roots, is amenable for long-term function and maintenance, allows preservation of scalloped gingival softtissue architecture (in high smile and thin gingival phenotype situations), or plays a vital role in the overall prosthodontic treatment.14
Irrespective of the cause of extraction of asymptomatic natural teeth, it is the dentist’s responsibility to provide the patient with a clear explanation of anatomic considerations, advantages, disadvantages, alternative treatment options, risks/complications, sequence, and approximate cost of treatment and long-term maintenance. An informed consent form and a clearly designed treatment plan on how the comprehensive treatment would be executed to replace the missing teeth are also paramount for proper care. Additionally, patients should be provided with an informed refusal form for any refused treatment options (such as pre-prosthetic orthodontics).
Replacement of a missing tooth or teeth is a core component of prosthodontics, and therefore, extractions of asymptomatic natural teeth should not commence until a clear treatment plan is in place for replacement of the teeth with optimal esthetics and function. Patients should be informed before any extractions that not all replacement options include fixed prosthodontic solutions nor all replacement options encompass dental implant therapy. Patients should always be cautioned about the risk of future implant failure, implant-related complications, and need for expensive long-term maintenance. Contrarily, patients who refuse to have their asymptomatic natural tooth/teeth extracted to facilitate prosthodontics treatment should also be cautioned of compromised prosthodontic outcomes with respect to esthetics, function, and treatment satisfaction.
It is the position of the American College of Prosthodontists (ACP) that comprehensive prosthodontic treatment involves optimizing esthetics and function in the long-term interest of the patient, and extractions of asymptomatic natural teeth may be required as part of necessary pre-prosthetic surgery to facilitate prosthodontic treatment. However, to avoid injudicious extractions of healthy natural teeth, dentists must perform a risk assessment for various solutions that will eventually be used for replacement of the missing teeth and discuss this with the patient before any extractions. Patient education is paramount, and dentists should discuss advantages, disadvantages, alternative treatment options, risks/complications, sequence, and approximate cost of treatment and long-term maintenance before obtaining the patient’s informed consent and approval of a clearly designed treatment plan for replacement of missing teeth.
1. Batal, HS, Jacob G: Surgical extractions. In Koerner KR (ed): Manual of Minor Oral Surgery for the General Dentist (ed 1). Ames, IA, Blackwell Munksgaard, 2006, pp. 20-48
2. Bidra AS, Daubert DM, Garcia LT, et al: Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Prosthodont 2016;25 Suppl 1:S32-40
3. Janson G, Maria FR, Bombonatti R: Frequency evaluation of different extraction protocols in orthodontic treatment during 35 years. Prog Orthod 2014;15:51
4. Zawawi KH: Patients’ acceptance of corticotomy-assisted orthodontics. Patient Prefer Adherence 2015;9:1153-1158
5. Meier B, Wiemer KB, Miethke RR: Invisalign--patient profiling. Analysis of a prospective survey. J Orofac Orthop 2003;64:352-358
6. Sanders NL: Evidence-based care in orthodontics and periodontics: a review of the literature. J Am Dent Assoc 1999;130:521-527
7. Jensen OT, Adams MW, Cottam JR, et al: The All-on-4 shelf: maxilla. J Oral Maxillofac Surg 2010;68:2520- 2527
8. Jensen OT, Adams MW, Cottam JR, et al: The all on 4 shelf: mandible. J Oral Maxillofac Surg 2011;69:175- 181
9. Bidra AS: Technique for systematic bone reduction for fixed implant-supported prosthesis in the edentulous maxilla. J Prosthet Dent 2015;113:520-523
10. Beumer J 3rd, Marunick MT, Garrett D, et al: Rehabilitation of maxillary defects. In Beumer J 3rd, Marunick MT, Esposito SJ (eds): Maxillofacial Rehabilitation. Chicago, Quintessence, 2011, pp 155-212
11. Malo P, de Araújo Nobre M, Lopes A, etal: A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310-320
12. Malo P, de Araújo Nobre M, Lopes A, et al: "All-on-4" immediate-function concept for completely edentulous maxillae: a clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14 Suppl 1:e139-150
13. Scala R, Cucchi A, Ghensi P, et al: Clinical evaluation of satisfaction in patients rehabilitated with an immediately loaded implant-supported prosthesis: a controlled prospective study. Int J Oral Maxillofac Implants 2012;27:911-919
14. Zitzmann NU, Krastl G, Hecker H, et al: Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth. J Prosthet Dent 2010;104:80-91
John R. Agar, DDS, MA FACP
Avinash S. Bidra, BDS,MS, FACP
Approved ACP Board of Directors: October 4, 2016
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