Treatment of advanced periodontal cases has changed significantly due to implants. Long successful term results outcome in strictly periodontal cases depend by a proper diagnosis and an adequate execution of surgical procedures which will allow to obtain a good prognosis even in teeth extremely compromised. The sophisticated clinician must be able to avoid indiscriminated extraction of the natural dentition in order to position implants. The everyday dilemma is the decision making process on the opportunity to perform advanced periodontal therapy versus teeth extraction and placement of implants. During this presentation the periodontal guidelines in order to take the proper decision and to choose which one of these therapeutic modalities should be selected will be discussed.