Have you ever heard a patient say they have terminal dentition? Probably not. It’s a dental term made up by clinicians who ultimately decide the fate of a patient's remaining teeth based on their personal parameters, clinical experience and beliefs. It can be a risky decision, too, since the clinician must walk a fine line between being negligent and over-treating a patient's condition.
The fundamental aspects of concluding terminal dentition should be influenced by the patient's systemic condition, financial situation and ultimately the patient's chief complaint.
So, is it even possible for clinicians to decide the extraction or preservation of a patient's teeth from just mere clinical and radiographic diagnostic evaluation?
A decision tree, or treatment planning algorithm, can be used to make objective decisions on what should be done with remaining teeth. Decision trees help identify relevant and objective markers that should influence and assist in the decision-making process. This means there will be some evident, undisputable reasons why teeth should be extracted — but it also means there will be some evident, arguable reasons they shouldn’t.
Two undisputable reasons for a full arch extraction of the remaining teeth are:
1. Advanced structural damage (Fig. 1)
2. Advanced periodontal damage. (Fig. 2)
Sometimes not all the remaining teeth present extensive breakdown and still, in the name of a comprehensive or global strategy, it can be decided to remove the remaining teeth that otherwise could be considered worth saving.
But there are three additional contributing reasons to consider:
- The number of remaining teeth
- The distribution of the remaining teeth
- The esthetic challenge that keeping any remaining teeth may pose
Number of teeth
If there are four or more teeth remaining in one arch and they are structurally and biologically sound, the benefit of retaining them needs to be carefully evaluated and considered. (Fig. 3)
A relative symmetry of remaining teeth may provide functional and biomechanics advantages that make keeping these teeth worth considering. Also, the strategic position within the arch could make a compelling argument for keeping them. In other words, if there are sound vital intact canines or sound intact canines and molars it would definitively be worth considering keeping them. (Fig. 4)
When doing full arch reconstruction, or for that matter any reconstruction that includes the anterior or esthetic zone, assessing keeping the remaining teeth will create an esthetic problem as a result of aberrantly visible uneven gingival margins needs to be considered. However, a low lip line situation would favor keeping the remaining teeth. (Fig. 5)
If there are only a few teeth remaining and they are structurally and periodontally sound, but their distribution is unfavorable and they esthetically pose a bigger challenge to manage, a clinician may strategically choose to remove them to ensure a better outcome. (Fig. 6)
In a nutshell, it would be safe to say clinicians consider a patient's dentition to be terminal when the risks of retaining the remaining teeth outweigh the benefits of extracting them.
When speaking about these risks, clinicians need to navigate through ESFB risk assessment:
- Esthetic risks
- Functional risks
- Structural risks
- Biologic risks
In the algorithm (Figs. 7-11), the decision process can and should be linear.
The correlation of the remaining teeth to all these parameters can be seen. But if a patient has a few remaining teeth and their distribution is favorable (i.e., they are bilaterally symmetric antero-posteriorly, for example the patient has intact canines and molars) then it would make sense to maintain them.
If there is no esthetic risk dento-facially, if the patient has a low lip line, then it makes sense to keep some natural teeth, as well. Yet if a patient has a few remaining sound teeth, but their distribution is unfavorable (unilateral) and keeping them would pose an esthetic risk, then the indication for extracting is appropriate.
Like with any other area of dentistry, the decision-making process regarding the preferred therapy should always be contingent upon a patient's desire, expectations and financial capabilities. It becomes paramount to utilize treatment planning framework to review both the clinical and personal aspects to come up with the ideal treatment plan for the patient.
Ricardo Mitrani, D.D.S., M.S.D., is a member of Spear Resident Faculty.