In Dr. Gordon Christensen’s October JADA column, "Implant Therapy Versus Endodontic Therapy" (
JADA 2006;137[10]:1440–3
), he mentioned many factors related to whether a questionable tooth should be extracted and replaced with an implant and implant-supported crown, or whether conventional endodontic and restorative therapy should be accomplished.
I liked his listing of the many things to consider when deciding on the best approach to this situation, but I think there should be an additional item to consider in his list—namely, any consideration of future orthodontic treatment.
Extraction of teeth and their replacement with implants is becoming more popular as implant success rates, predictability and quality continue to improve. I think in some instances where a tooth could be treated with endodontics successfully, implant replacement sometimes is becoming the treatment of choice by default. However, I think clinicians should consider whether the patient may desire orthodontic therapy in the future, and consider endodontically treating that tooth as a contingency.
Endodontically treated teeth are still surrounded by a periodontal ligament and, as such, can be moved orthodontically in the future. No such option exists with an osseointegrated implant. I think the finality, so to speak, of an implant should be discussed with the patient as part of the informed consent process. If there is any indication that the patient may desire better alignment of the teeth, then the patient should be informed of the benefits of having the tooth endodontically restored.
If the tooth is deemed hopeless and the only option is extraction, informed consent should still include future orthodontic limitations with a fixed position implant. A referral to an orthodontist should be sought out prior to implant placement, if the patient indicates that he or she would consider orthodontics in the future.
Many times the implant won’t interfere with the future orthodontic treatment plan, and many times the implant will actually aid orthodontics, utilizing the absolute anchorage it provides. But if the implant is placed anteriorly, or if multiple implants are being considered, then a referral to an orthodontist would be prudent to alleviate any headaches down the road.
