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Classification of Extensively Damaged Teeth to
Evaluate Prognosis
Article in Journal (Canadian Dental Association) · September 2011
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Classification of Extensively Damaged Teeth to Evaluate Prognosis | JCDA | Essential Dental Knowledge 11/10/11 12:05
Classification of Extensively Damaged Teeth to Evaluate
Prognosis
Helder Esteves, DMD, MDSc; André Correia, DMD, PhD; Filipe Araújo, DMD, MDSc
Posted on September 29, 2011
Tags: dental caries diagnosis endodontics restorations treatment
0 Gosto 0
Cite this as: J Can Dent Assoc 2011;77:b105
ABSTRACT
The restoration of teeth with extensive structural damage is an important clinical procedure in dental practice. However, despite the
availability of a variety of materials, techniques and studies in the scientific literature, the criteria for selection of such teeth for
restoration need clarification. The approach to severely compromised teeth should be based on consistent scientific evidence to
reduce dental error and improve the prognosis. If restoration is indicated, it must conserve and protect the remaining tooth structure. In
this article, we develop and suggest clinical criteria and guidelines that clinicians may use to identify and classify extensively damaged
teeth to help in the diagnosis, treatment plan and prognosis.
Introduction
A tooth with extensive damage is one that has lost substantial structure as a result of caries, previous restoration failures, fractures or
even procedures related to endodontic treatment. The restoration of such teeth with endodontic treatment is an important clinical
procedure in dental practice; however, various studies have taken different perspectives on this issue.1,2 The loss of dental tissue and
the weakening of the remaining structure present a challenge in terms of prosthetic rehabilitation. Although the current success rate of
dental implants is high,3 the clinician must be able to assess the probability of restoring severely damaged teeth successfully.4-10 The
dimensions of the remaining tooth tissues as well as several biological and occlusal factors must be properly assessed to establish the
correct treatment plan.
The aim of this article is to present clinical guidelines to help the clinician easily diagnose and establish a treatment plan for the
rehabilitation of severely damaged teeth.
Assessing the Probability of Successful Restoration
Remaining Tooth Tissues
The extent of the remaining tooth structure is among the most important and critical factors in determining the prognosis for restoration
of a damaged tooth. Evidence indicates that the dimensions of the crown dentin are important.4 Some studies11,12 agree that a dentin
thickness < 1 mm increases the risk of failure. This minimum thickness is more often achieved in buccal or palatal/lingual than
interproximal areas after endodontic treatment and tooth preparation.4,13-15 The ferrule effect—the need for a 360º collar 2 mm in
height (1.5 mm minimum)—was described by Sorensen and Engelman11 in 1990. Smaller dimensions are associated with a greater
risk of failure.4,6,9,16-22
A post should be used only when there is insufficient tooth substance remaining to support core material or the final restoration. The
height of the post should always be the same or greater than that of the future crown, and its width should be established by the width
of the canal after root canal treatment. Increasing post diameter in an effort to increase retention is not recommended, as this creates
unnecessary weakening of the remaining tooth structure.1,9,23-25
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Biologic Considerations
Caries, previous restorations and fractures can affect the biologic width of the remaining structure and lead to accumulation of bacteria,
inflammation, increased probing depth, gingival recession or a combination of these problems. When sulci are normal (2–3 mm) and
healthy and bands of attached gingiva are adequate, margins can be placed up to 0.5 mm inside the sulcus. When tooth structure is
insufficient to allow adequate soft tissue attachment, other procedures (such as surgical crown lengthening or orthodontic extrusion)
may be necessary to achieve optimal results.26-34
In preparing a root canal for a post, the main barrier against reinfection of the periapical region is the endodontic obturation material.
The length of the remaining apical seal after post preparation can influence the long-term success of the restoration.4,5,10,35-38 There is
some evidence for leaving 3–5 mm of undisturbed apical endodontic obturation material after post preparation. Only some teeth have a
1-mm thick layer of dentin 5 mm from the apex. At distances less than 3 mm from the apex, there is unlikely to be 1 mm of sound
dentin surrounding the apical end of the post.4,10,39
Occlusal Factors
Occlusal load is also an important consideration in estimating the chances of successful restoration of a damaged tooth. In a
retrospective study, Sorensen and Martinoff40 found that, although the success rate for single-unit crowns was 94.8%, it was 89.2% for
fixed partial denture abutments and only 77.4% for removable partial denture abutments. Nyman and Lindhe41 found that fractures in
abutment teeth occurred more frequently in root-treated teeth. Hatzikyriakos and colleagues42 reported a failure rate for endodontically
treated teeth used as abutments for fixed and removable partial dentures that was more than twice that for such teeth not used as
abutments.
Some conclusions can be drawn from these studies. Extensively damaged teeth cannot be considered reliable as abutments for fixed
or removable dentures (especially long-span fixed bridges and distal extensions of removable dentures) or cantilevers or for patients
with severe bruxism and clenching habits.4,8,9,11,41,42
Clinical Protocol for Diagnosing Extensively Damaged Teeth
For a severely damaged tooth, some elements of a treatment plan are mandatory:
Removal of all caries and old restorations to achieve access to the remaining tooth structure.
Elimination of all periodontal infection and control of plaque.
Predetermination of the value of the tooth, e.g., is it important for occlusion or esthetics?
The following criteria should then be assessed in this sequence: ferrule effect, relation between root and crown length, endodontic
condition.
Criterion 1 – Ferrule Effect
The ferrule effect is determined from vertical and horizontal intraoral measurements. The vertical measurement is from the top of the
gingival margin to the top of the remaining tooth wall at 4 points: mesial, distal, buccal and lingual or palatine. This can be easily
assessed using a periodontal probe with a stop and an endodontic ruler. Values are positive if the top of the remaining tooth is above
the gingival margin (Fig. 1) or negative if it is below (Fig 2).
The horizontal measurement is the thickness of the remaining tooth walls at the level of the future crown margin at 4 points: mesial,
distal, buccal and lingual or palatine (Fig. 3). This can be easily measured with calipers, which are commonly used to measure
framework thickness of fixed prosthodontics (Fig. 4). If space does not permit the use of calipers, a periodontal probe (with a stop) can
be used instead (Fig. 5).
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Figure 2: Measurement of the remaining
buccal wall of tooth 22 with a periodontal
probe and stop. The value is negative as
the tooth wall is below the gingival margin.
Figure 1: Measurement of the Figure 3: Location of
remaining buccal wall of tooth horizontal intraoral
15 with a periodontal probe measurements.
and stop. The value is positive
as the top of the remaining
tooth is above the gingival
margin.
Figure 4: Measurement of the remaining buccal wall of a damaged tooth with calipers Figure 5: Measurement of the remaining
(1.4 mm). distal wall of a damaged tooth using a
periodontal probe.
Criterion 2 – Relation of Crown to Root Length
This factor is important in predicting the retention of the future restoration. As noted above, to promote retention of the crown, a post
should be at least the same length as the future crown. Future crown length may be measured from the top of the supposed tooth to
the hypothetical margin, intraorally or using a model (Fig. 6).
Root length may be measured radiographically (Fig. 7).
If needed, on a buccal (Fig. 8), palatine or lingual face, it is possible to measure the distance of the reference level to the top of the
remaining tooth and transfer this measure to the radiograph (see d! on Fig. 8). Then measure the root length from this level to the apex
on the radiograph (see r! on Fig. 8). Using the ratio of d to d!, calculate the real dimension of the root, r, from r!.
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Figure 6: Measurement of an extensively
damaged tooth 22 from the supposed top of
the tooth to the hypothetical margin with a
periodontal probe.
Figure 7: Radiograph showing Figure 8: Determination of root length at
crown and root the buccal face of tooth 12.
measurements.
Criterion 3 – Endodontic Condition
The remaining tooth should be evaluated related to the extent of endodontic treatment required: can treatment be performed without
predictable complications, are complications likely and, thus, treatment outcome is uncertain or are complications irreversible and
cannot be resolved with endodontic treatment.
Classification of Teeth with Extensive Endodontic Damage
Class I
Ferrule effect: Height of remaining tooth " 2 mm at 4 locations (mesial, distal, buccal, palatine or lingual) and thickness of
remaining tooth walls " 2.2 mm for an esthetic restoration or " 1.6 mm for non-esthetic restorations
Remaining root length: At least as long as the future crown height plus 5 mm for the apical seal
Endodontic condition: Endodontic treatment may be performed without predictable complications
Prognosis: Good
Class II
Ferrule effect: Height of remaining tooth 0.5–2 mm or width of remaining tooth walls 1.6–2.2 mm with visible margins or 1.2–
1.6 mm with non-visible margins
Remaining root length: Less than crown height plus 5 mm but equal or greater than crown height plus 3 mm
Endodontic condition: Without predictable complications or with uncertain results
Prognosis: Moderate
Note: A tooth in this class should not be used as an abutment. A new evaluation should be performed after endodontic treatment in
cases where pretreatment prognosis is uncertain.
Class III
Ferrule effect: Height of remaining tooth < 0.5 mm or width of remaining tooth wall < 1.2 mm at future margin level
Remaining root length: Less than crown height plus 3 mm
Endodontic condition: With irreversible complications
Prognosis: Poor
Note: A tooth in this class is not a candidate for treatment; it should be extracted and replaced by a prosthesis.
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The clinical record form below may be used to evaluate severely damaged teeth using these criteria. Each parameter is evaluated
and individually classified as I, II or III. Final classification is the highest class for any parameter, i.e., a tooth rated I, II, I for the 3
parameters, is Class II.
Clinical record form for scoring teeth with extensive damage
Class I, Class II, Class III,
prognosis good prognosis moderate prognosis poor
Height " 2mm
Height " 0,5–2 mm
Height < 0.5mm
Width " 2.2 mm
Ferrule effect Width 1.6–2.2 mm (visible margins)
(esthetic)
Width < 1.2 mm
1.2–1.6mm (non-visible margins)
"1.6 (non-esthetic)
< crown height + 5 mm
< crown length + 3
Root length " crown height + 5 mm
mm
" crown height + 3 mm
Endodontic Without predictable Without predictable complications or uncertain With irreversible
condition complications treatment results complications
Final classification _________________________
Additional Clinical Considerations
Pre-prosthetic treatment may affect the initial classification.
Concern about special stress patterns (bruxism, abutments for a removable partial denture, cantilevers, extensive bridges or
secondary abutments) raises the class level from I to II or from II to III.
Class level also increases by 1 if there are esthetic concerns.
In cases where there is no antagonist, no occlusal issues, the antagonist is a removable denture or there is clinical evidence of
small to no loads over the remaining tooth, the class level decreases by 1.
For patients with poor oral hygiene, uncontrolled periodontal disease or caries, an extensively damaged tooth should be
considered Class III.
Conclusion
Clinical guidelines help the dentist arrive at the correct diagnosis and treatment plan, avoid errors, increase the predictability of dental
treatment and increase the quality of service. Although the literature describes the rehabilitation of teeth with extensive endodontic
damage, no clinical guidelines have been published. Our goal in this article is to provide the clinician with such guidelines for selection
of extensively damaged teeth for rehabilitation.
THE AUTHORS
Dr. Esteves is head of fixed prosthodontics, School of Dental Medicine, Portuguese Catholic University, Viseu,
Portugal.
Dr. Correia is head of dental informatics, School of Dental Medicine, Portuguese Catholic University, Viseu,
Portugal.
Dr. Araújo is a lecturer in fixed prosthodontics School of Dental Medicine, Portuguese Catholic University, Viseu,
Portugal.
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Correspondence to: Dr. Helder Esteves, Área Disciplinar de Prostodontia Fixa, Departamento de Ciências da Saúde, Centro
Regional das Beiras, Universidade Católica Portuguesa. Estrada da Circunvalação 3504-505 Viseu. Email: [email protected]
The authors have no declared financial interests.
This article has been peer reviewed.
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