Save or extract: A 10-year dual-center cohort comparing tooth preservation with implant replacement

To compare long-term outcomes, complications, patient-reported outcomes, and costs of tooth preservation (endodontic treatment followed by long-term prosthodontic restoration) versus extraction with implant replacement at the endodontic-prosthodontic interface.

A retrospective dual-center private-practice cohort of adults treated with a SAVE pathway or an IMPLANT pathway was evaluated over a 10-year study period with follow-up from 1.0 to 9.6 years after the index unit entered function. Time-to-failure, complications, patient-reported outcomes, and costs were analyzed using Kaplan-Meier/log-rank methods and Cox proportional hazards regression. A propensity-score inverse probability of treatment weighting (IPTW) sensitivity analysis was performed to address confounding by indication and the numerical imbalance between treatment pathways.

The adjusted analytic cohort comprised 859 cases with complete baseline covariates (594 SAVE; 265 IMPLANT); 860 cases were eligible for survival follow-up. Median follow-up was 3.1 years interquartile range (IQR 1.8-4.7; range 1.0-9.6). Failure occurred in 51 cases (37 SAVE; 14 IMPLANT). Estimated survival at 1 year was 97.8% for SAVE and 98.5% for IMPLANT, and estimated survival at the end of the observed follow-up window was 93.8% and 94.7%, respectively. There was no evidence of a survival difference between pathways (log-rank p = 0.785). Implant replacement was not associated with a lower adjusted hazard of failure (hazard ratio [HR] 0.87; 95% confidence interval (CI) 0.47-1.62; p = 0.666), whereas current tobacco use increased failure risk (HR 2.01; 95% CI 1.05-3.86; p = 0.036). Patient-reported oral health-related quality of life (OHRQoL) and satisfaction were comparable. IMPLANT involved more visits, greater downtime, and higher initial, total observed, and cost-per-year-of-function expenses (all p < 0.001).

In this private-practice cohort, appropriately indicated tooth preservation and implant replacement demonstrated comparable survival and patient-reported outcomes within the observed follow-up period. The two options should not be treated as interchangeable substitutes; rather, selection should be individualized according to restorability, ferrule feasibility, periodontal and occlusal risk, strategic value, patient preference, maintenance burden, and cost trajectory.