The treatment planning dilemma: To restore or replace the natural dentition

Many dentists find themselves facing a common dilemma when developing a treatment plan for their patients who require a comprehensive dental makeover. Over time, dentists become more sensitive to the liability associated with an incorrect decision when it comes to restoring the existing teeth or fully replacing them. The liability to the patient is financial and emotional, but the liability to the dentist is reputational. Treatment that fails to fulfill a patient’s expectations of success, related to durability and longevity, can create dentist-patient conflict and ultimately disappointment with the practice. While patients who must have their dental work replaced segmentally sooner than expected is difficult enough, a complete replacement can be devastating to all parties.

Regardless of the treatment plan, establishing the appropriate expectations of longevity as it relates to years in service is important. When asking patients, “What is the minimum period of time the proposed treatment must last to be a success?” the answer is usually a surprise. The typical 10-year prognosis won’t satisfy most patients, and the majority say they expect their treatment to last a lifetime.

Today, full-arch dental implant treatment usually refers to a dental implant-supported prosthesis replacing all teeth in either the maxilla or mandible (figure 1).

As a prosthodontist who has spent the last 25 years offering full-arch treatment to my patients and teaching the Hybridge full-arch protocols for most of that time, the phrase “Pick a Path” has come to refer to the difficult decision a patient makes to either commit to restoring their natural dentition or to replace their remaining teeth with a completely implant-supported prosthesis, as in a full-arch solution. The last decade has seen this implant modality gain in popularity.

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For many dentists, the replacement of all natural teeth in one arch, or both, is a philosophical shift that has been hard to warm up to, particularly since many of the foundational procedures in dentistry are aimed at restoring compromised teeth. Root canals, post and cores, crowns, and periodontal treatment are all aimed at making bad teeth better.

As doctors, it is our responsibility to guide our patients in making educated decisions that are right for them. As with any proposed treatment, the educational process should provide patients with enough specific information to their case so that they understand all the factors that play into their decision:

Predicted success long term
Cost
Treatment time
Number of appointments
Chair time

The Pick a Path treatment planning process should include all these factors. During this process, the patient’s treatment goals regarding the expectation of treatment longevity must be clear. Connecting those expectations with the patient’s personal risk factors then becomes the basis for the Pick a Path treatment planning process.

Figure 2: Over time, the likelihood of continued success, referred to as prognosis, diminishes. This graph represents the predicted success curves of a high-risk patient, comparing a conventional treatment path versus a full-arch path.

Risk factors should be thought of as all the variable insults that exist from patient to patient. These variable insults work against the health and longevity of any dental restoration over time. The more risk factors, the poorer the long-term prognosis. To this point, depending on the restorative path chosen, the success curve will look completely different. When comparing predicted prognosis over time, a convex curve implies a much better prognosis (low risk), as opposed to a concave curve (high risk). See figure 2.

Patient risk factors:

A. Genetic periodontal disease

B. Parafunctional habits

C. Decay, xerostomia

D. High sugar diet

E. Poor oral hygiene

F. Cigarette smoking

G. More than two root canals

H. Malocclusion

A + B + C + D + E + F + G + H = High cumulative risk

When looking at the risk factors as having a cumulative effect, the more factors a patient has, the poorer the prognosis of any treatment over time. Restoring a natural dentition with conventional crowns on a patient who has parafunctional occlusal habits, dry mouth, poor diet, and a cigarette smoking habit will always have the risk of recurrent decay and continued breakdown—no matter how great the dental work. Hence the concave prognosis arc showing poor long-term success. The argument and assumption with full-arch dental implant solutions is that implants and prosthetics don’t decay, and, therefore, the most detrimental risk factors are eliminated. In this case, the cumulative risk is much

lower over time, and the prognosis arc flips to convex, which suggests the better restorative path.

Case analysis

Case review: This 35-year-old female was diagnosed with Sjögren’s syndrome four years ago. She is a cigarette smoker and drinks multiple sodas per day. Her daily oral hygiene is marginal (figures 3–5).

Chief complaints: With multiple broken teeth and visible cavities, the patient avoids smiling and chewing hard foods.

Treatment objectives: Restore or replace all teeth to achieve full function and a natural, healthy-looking smile with a solution that is fixed and will last over the long term (20-plus years).

A patient’s multiple risk factors for decay and cumulative risk over time, combined with her own complaints and objectives, should be discussed to establish clear and reasonable expectations. The Pick a Path treatment planning process should consider both conventional and full-arch options, comparing all aspects (figures 6–8).

Today, more than ever, patients expect and hope their dental restoration will solve what has historically been a lifetime cycle of dental problems and expense. In this case, a straightforward, conventional restorative treatment plan that focuses on restoring the patient’s natural teeth may not make the most sense long term. After comparing both restorative paths, the full-arch implant option would likely prove to have a better prognosis, lower cost, and require much less time and fewer appointments.

Dentists owe it to their patients to take time to analyze the individual risk factors

involved, as well as treatment objectives, to ensure the path chosen fulfills their patients’ expectations.

Editor's note: This article appeared in the November 2021 print edition of Dental Economics.

Frank LaMar, DDS, has limited his practice to prosthodontics in Rochester, New York, for more than 30 years. He is the clinical director of the Elmwood Dental Implant and Restoration Center, assistant clinical professor at the University of Rochester’s Eastman Institute of Oral Health, and founder and CEO of Hybridge Dental Implants. His full-arch implant restorations are the foundation for the Hybridge full-arch implant protocols, which are based on simplified implant prosthodontics and prognosis-based treatment planning.