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

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: 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.