Treatment Options
for the Compromised Tooth
A Decision Guide

American Association of Endodontists

www.aae.org/treatmentoptions

TREATMENT PLANNING CONSIDERATIONSThe Treatment Options for the Compromised
Tooth decision guide features different cases
where the tooth has been compromised inboth nonendodontically treated teeth andpreviously endodontically treated teeth.
Based on the unique individualized featuresof each case and patient, there are key
considerations in establishing a preoperative
prognosis of Favorable, Questionable or
Unfavorable.
If your patient’s condition falls into a category
other than Favorable, referral to an endodontist, who has expertise on alternate treatment
options that might preserve the natural dentition, is recommended. If the prognosis of the
tooth is categorized as Questionable/Unfavorable in multiple areas of evaluation, extraction
should be considered after appropriate consultation with a specialist.
In making treatment planning decisions, the clinician also should consider additional factors
including local and systemic case-specific issues, economics, the patient’s desires and needs,
aesthetics, potential adverse outcomes, ethical factors, history of bisphosphonate use and/or
radiation therapy.
Although the treatment planning process is complex and new information is still emerging, it isclear that appropriate treatment must be based on the patient’s best interests.

© Copyright 2010
American Association of Endodontists
211 E. Chicago Ave., Suite 1100
Chicago, IL 60611-2691
Phone: 800/872-3636 (North America) or 312/266-7255 (International)
Fax: 866/451-9020 (North America) or 312/266-9867 (International)
E-mail: info@aae.org Website: www.aae.org

2

www.aae.org/treatmentoptions

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Nonendodontically Treated Tooth

Root Amputation, Hemisection, Bicuspidization
The photographs/radiographs below illustrate favorable outcomes for our patients.
Treatment Considerations/Prognosis

Hemisection and crown lengthening

Remaining Coronal Tooth Structure
Favorable: >1.5 mm ferrule
Questionable: 1.0 to 1.5 mm ferrule
Unfavorable: <1 mm ferrule

Case One

PreOp

PostOp13 mo. Recall

Hemisection of
the distal root of
tooth #19

Crown Lengthening
Favorable: None needed
Questionable: If required will not compromise the aesthetics or periodontal
condition of adjacent teeth
Unfavorable: Treatment required that will affect the aesthetics or further
compromise the osseous tissues (support) of the adjacent teeth

PreOp                                    PostOp                           Clinical PhotographCase Two*

Endodontic Treatment
Favorable: Routine endodontic treatment or not required due to previous
treatment
Questionable: Nonsurgical root canal retreatment required prior to root resection
Unfavorable: Canal calcification, complex canal and root morphology,
and isolation complicate an ideal endodontic treatment result

Hemisection of
the distal root of
tooth #30
*These images were published in The Color Atlas of Endodontics, Dr. William T. Johnson, p. 162, Copyright Elsevier 2002.

Endodontic-Periodontic Lesions
The photographs/radiographs below illustrate favorable outcomes for our patients.

Extensive endodontic-periodontic lesions, complete healing

Treatment Considerations/Prognosis
Periodontal Conditions
Favorable: Normal periodontium
Normal probing depths (3mm or less)
The tooth exhibits pulp necrosis and isolated bone loss
Questionable: Moderate periodontal disease

Generalized periodontal probing defects throughout the patient’s mouth
The tooth exhibits pulp necrosis and there is generalized bone loss
(horizontal and/or vertical)

PostOp15 mo. Recall

PreOp

Probe/Sulcus

PostOp

Tooth #19 exhibiting
a localized mesial
furcation defect; there is
no probing defectAn isolated periodontal probing defect
The tooth exhibits pulp necrosis and moderate bone loss
Unfavorable: Advanced periodontal disease

PreOp

Case One

Case Two
Tooth #19 with extensive
osseous destruction; there issulcular communication and a
deep isolated probing defect24 mo. Recall

3

www.aae.org/treatmentoptions

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Nonendodontically Treated Tooth

Endodontic-Periodontic Lesions
The photographs/radiographs below illustrate favorable outcomes for our patients.

Extensive endodontic-periodontic lesions, complete healing

Treatment Considerations/Prognosis
Periodontal Conditions

PreOp

PostOp15 mo. Recall

PreOp

Probe/Sulcus

PostOp

PreOp

PostOp12 mo. Recall

PreOp

Facial View

Lingual View

PreOp

Clinical PhotographCase One

Favorable: Normal periodontium

Tooth #19 exhibiting
a localized mesial
furcation defect; there is
no probing defectNormal probing depths (3mm or less)
The tooth exhibits pulp necrosis and isolated bone loss
Questionable: Moderate periodontal disease
An isolated periodontal probing defect
The tooth exhibits pulp necrosis and moderate bone loss
Unfavorable: Advanced periodontal disease

Case Two

Generalized periodontal probing defects throughout the patient’s mouth
The tooth exhibits pulp necrosis and there is generalized bone loss
(horizontal and/or vertical)

Tooth #19 with extensive
osseous destruction; there issulcular communication and a
deep isolated probing defect24 mo. Recall

External Resorption
The photographs/radiographs below illustrate favorable outcomes for our patients.
Treatment Considerations/Prognosis
External Resorption
Favorable: Minimal loss of tooth structure
Located cervically but above the crestal bone
The lesion is accessible for repair
The pulp is vital
Apical root resorption associated with a tooth exhibiting pulp
necrosis and apical pathosis
Questionable: Minimal impact on restorability of tooth
Crown lengthening or orthodontic root extrusion may berequired
The pulp may be vital or necrotic
Unfavorable: Structural integrity of the tooth or root iscompromised
There are deep probing depths associated with theresorptive defectThe defect may communicate with the pulp space or is
not accessible for repair surgically4

www.aae.org/treatmentoptions

Case One
External resorption with sinus tract,with ≤ 3 mm probings; MTA internal
repair after 2 weeks CaOH, root canaltreatment and 12-month recall withresolution of sinus tract

Case Two
External resorption on the mesialof the maxillary right central incisor;
there is a peridontal probing defect on themesiolingual

Case Three
Tooth #19 unfavorable prognosis; there isa large cervical resorptive defect on the
buccal aspect of the distal root extending
into the furcation

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Nonendodontically Treated ToothInternal Resorption
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis

PreOp

PostOp

PreOp

PostOp14 mo. Recall

Case One
Tooth #28 exhibiting a mid-root
internal resorptive defectInternal Resorption
Favorable: Small/medium defectA small lesion in the apical or mid-root area
Questionable: Larger defect that does not perforate the root
Unfavorable: A large defect that perforates the external root surface

Case Two
Tooth #8 exhibiting an apical to
mid-root internal resorptive lesion

Tooth Fractures
The photographs/radiographs below illustrate favorable outcomes for our patients.
Treatment Considerations/Prognosis
Crown Fractures
Favorable: Coronal fracture of enamel or dentin not exposing the pulp; coronalfracture of enamel and dentin exposing the pulp of a tooth with mature root
development
Questionable: Coronal fracture of enamel and dentin exposing the pulp withimmature root development
Unfavorable: Coronal fracture of enamel or enamel and dentin extending onto
the root below the crestal bone; compromised restorability requiring crownlengthening or orthodontic root extrusion
Horizontal Root Fractures
Favorable: The fracture is located in the apical or middle third of the root; there
is no mobility; the pulp is vital (note in the majority of root fractures the pulp
retains vitality)
Questionable: The fracture is located in the coronal portion of the root and thecoronal segment is mobile; there is no probing defect; the pulp is necrotic
Unfavorable: The fracture is located in the coronal portion of the root and thecoronal segment is mobile; there is sulcular communication and a probing defect5

www.aae.org/treatmentoptions

PreOp

Clinical Photograph

PostOpPreOp

RCT

PostOpCrown
Fracture
Tooth #8 exhibiting
a complicatedcoronal fracture,root canal treatment
and bonding of thecoronal segment

Horizontal
Root Fracture*
Horizontal root fractures of#8 and #9; the maxillary rightcentral remained vital while
the maxillary left central
developed pulp necrosis
requiring nonsurgical andsurgical root canal treatment;
prognosis favorable*These images were published in The Color Atlas of Endodontics, Dr. William T. Johnson, p. 176, Copyright Elsevier 2002.

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Nonendodontically Treated Tooth

Tooth Fractures
The photographs/radiographs below illustrate favorable outcomes for our patients.

Case One

Treatment Considerations/Prognosis
Cracked Tooth
Favorable: Fracture in enamel only (crack line) or fracture in enameland dentin
The fracture line does not extend apical to the cemento-enamel junction
There is no associated peridontal probing defect
Cracked Tooth Progression To Split Tooth*
The pulp may be vital requiring only a crown
If pulp has irreversible pulpitis or necrosis, root canaltreatment is indicated before the crown is placed
Questionable: Fracture in enamel and dentin
ABC
The fracture line may extend apical to thecemento-enamel junction but there is no
A – Favorable prognosis
associated periodontal probing defect
B – Questionable prognosis
There is an osseous lesion of endodontic origin
Unfavorable: Fracture line extends apical to thecemento-enamel junction extending onto theroot with an associated probing defect

PreOp

C – Split tooth, Unfavorable
prognosis*Reprinted with permission from Torabinejad andWalton, Endodontics: Principles and Practice 4thed, Saunders/Elsevier 2009.

Mesial Crack

Internal Crack

Distal Crack

PostOp24 mo. Recall

Fracture in mesial
marginal ridge #5,
stopping coronal topulp floor
PostOpCase Two

PreOp

Tooth #30 exhibiting pulp
necrosis and asymptomatic
apical periodontitis; a crack
was noted on the distal
aspect of the pulp chamber
under the composite during
root canal treatment

Apical Periodontitis
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis
Apical Periodontitis
The presence of periapical radiolucency is not an absoluteindicator of a poor long-term prognosis. The vast majorityof teeth with apical periodontitis can be expected to heal
after nonsurgical or surgical endodontic treatment. Data
indicate the presence of a lesion prior to treatment only
decreases the prognosis slightly.
Favorable: Pulp necrosis with or without a lesion present
that responds to nonsurgical treatment
Questionable: Pulp necrosis and a periapical lesion ispresent that does not respond to nonsurgical root canaltreatment but can be treated surgicallyUnfavorable: Pulp necrosis and a periapical lesion ispresent that does not respond to nonsurgical root canaltreatment or subsequent surgical intervention

6

www.aae.org/treatmentoptions

Case One

PreOp

Acute Apical Abcess

PostOp

PreOp

PostOp28 mo. Recall

A largeperiapicallesion resulting
in an acuteapical abscessresulting from
pulp necrosis of
tooth #7

Case Two

Swelling Healed

Tooth #6 exhibitinga large lesion,
apical surgery,complete healing

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Previously Endodontically Treated Tooth

Procedural Complications
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis

PreOp

Nonsurgical Root Canal Retreatment
Favorable: The etiology for failure if the initial treatment can be identified;nonsurgical endodontic retreatment will correct the deficiency
Questionable: The etiology for failure of the initial treatment cannot be identified;nonsurgical endodontic retreatment may not correct the deficiency
Unfavorable: The etiology for failure of the initial treatment cannot be identified andcorrected with nonsurgical retreatment and surgical treatment is not an option

Working Length

PostOpPostOp16 mo. Recall

Nonsurgical
Root Canal
Retreatment*
Tooth #18 is
symptomatic andexhibiting apical
pathosis

70 mo. Recall

Altered Anatomy/Procedural Complications (e.g., loss of length, ledges,
apical transportation)
Favorable: The procedural complication can be corrected with nonsurgical treatment,
retreatment or apical surgery

PreOp

Questionable: Canals debrided and obturated to the procedural complication, there
is no apical pathosis and the patient is followed on recall examination

Altered
AnatomyUnfavorable: The patient is symptomatic or a lesion persists and the procedural
complication cannot be corrected and the tooth is not amenable to surgery(apicoectomy/intentional replantation)

Surgical treatment of
tooth #19 to correct
apical transportationin the mesial root
*Reprinted with permission from DENTSPLY/AAE Lecture series,“Endodontic Team Care: Educating Your Referral Network - Diagnosis and Treatment Planning.”

Procedural Complications
The photographs/radiographs below illustrate favorable outcomes for our patients.
Treatment Considerations/Prognosis
Separated Instruments
Favorable: No periapical periodontitis
In general, success/failure rates for cases that have a separated instrument in
the apical one-third of the root have favorable outcomes
Able to retrieve nonsurgically or surgically if periapical pathosis is present
Defect correctable with apical surgery
Questionable: Instruments fractured in the coronal or mid-root portion of
the canal and cannot be retrieved
Patient asymptomatic
No periapical periodontitis

PreOp

PostOp24 mo. Recall

Separated
Instrument
Tooth #30 exhibiting afractured instrument in
the mesial root; recall
examination demonstrates
a successful outcome

Unfavorable: The patient is symptomatic or a lesion persists requiringextensive procedures in order to retrieve instrument that would ultimately
compromise long-term survival of the tooth and surgical treatment is not
an option (apicoectomy/intentional replantation)

7

www.aae.org/treatmentoptions

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Previously Endodontically Treated Tooth

Procedural Complications
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis
Perforations–Location
Favorable: Apical with no sulcular communication or osseous defect

Perforations

Questionable: Mid-root or furcal with no sulcular communication orosseous defectUnfavorable: Apical, crestal or furcal with repair with sulcularcommunication and a probing defect with osseous destruction
Perforations–Time of Repair
Favorable: Immediate repair
Questionable: Delayed repair
Unfavorable: No repair or gross extrusion of the repair materials

PreOp

PostOp36 mo. Recall

Case One
Tooth #3 exhibits a coronal
perforation which is repairedwith mineral trioxide aggregate(MTA) in conjunction with
nonsurgical root canal treatment

Perforations–Size
Favorable: Small (relative to tooth and location)
Questionable: Medium
Unfavorable: Large

Procedural Complications
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis
Post Perforation
Favorable: No sulcular communication or osseous destruction

Perforations

Questionable: No sulcular communication but osseous destruction
is evident
The perforation can be repaired surgicallyUnfavorable: Long standing with sulcular communication,a probing defect and osseous destruction
Strip Perforation
Favorable: Small with no sulcular communication
Questionable: No sulcular communication and osseous destruction thatcan be managed with internal repair or surgical intervention

PreOp

PostOp24 mo. Recall

Case Two
Tooth #19 exhibiting crestal
post perforation, furcal
perforation; with ≤ 3mm
probings; MTA internal repair
after 2 weeks CaOH, and24-month recall with bony
resolution in the furcation

Unfavorable: Sulcular communication and osseous destruction thatcannot be managed with internal repair or surgical intervention

8

www.aae.org/treatmentoptions

Treatment Options for the Compromised Tooth – A Decision Guide

Treatment Options for the Compromised Tooth – Previously Endodontically Treated Tooth

Retreatment: Post Removal, Silver Points, Paste
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis

PreOp

Clinical Views

PostOp

PreOp

Post & Resin Core

PostOpCase One

Posts
With the current use of modern endodontic techniques, most posts canbe retrieved with minimal damage to the tooth and root. Ceramic posts,
fiber posts, threaded posts, cast posts and cores, and proprietary posts
placed with resins are most challenging to remove. In some instances thepost may not have to be removed and the problem can be resolved by
performing root-end surgery (apicoectomy).
Favorable: Proprietary cylindrical stainless steel placed with traditional
luting cements such as zinc phosphate
Questionable: Cast post and cores placed with traditional luting cements
such as zinc phosphate
Unfavorable: Proprietary posts (stainless steel or titanium), cast post
and cores placed with bonded resins; threaded, fiber and ceramic posts
that cannot be removed or removal compromises the remaining tooth
structure
Teeth that cannot be retreated or treated surgically have an unfavorable
prognosis

Tooth #8 requiring removalof a proprietary post

Case Two
Tooth #19 demonstrating
incomplete obturation anda threaded post placed witha bonded resin core

12 mo. Recall

Retreatment: Post Removal, Silver Points, Paste
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis
Silver Points  – Silver points were a popular core obturation material in the 1960s and early
1970s. While their stiffness made placement and length control an advantage, the material
did not fill the canal in three dimensions resulting in leakage and subsequent corrosion.
Carrier Based Systems – Carrier-based thermoplastic (e.g., Thermafil) systems are similar
to silver cones. The core material originally was metal, but has been replaced with plastic.
They can generally be removed as the gutta-percha can be softened with heat and solvents
facilitating removal.

Silver Point Retreatment
Tooth #9 treated 25 years ago requiring retreatment

PreOp

Working Length

Favorable: Silver cones that extend into the chamber facilitating retrieval and cemented with azinc-oxide eugenol sealer
Plastic carrier-based thermoplastic obturators
Questionable: Silver cones that are resected at the level of the canal orifice or have been
cemented with zinc phosphate or polycarboxylate cement
Silver cones that can be bypassed or teeth that can be treated surgicallyUnfavorable: Sectional silver cones were placed apically in the root to permit placement ofa post; if they cannot be retrieved or bypassed and the tooth is not a candidate for surgicalintervention the prognosis is unfavorable

9

www.aae.org/treatmentoptions

Treatment Options for the Compromised Tooth – A Decision Guide

PostOp

Treatment Options for the Compromised Tooth – Previously Endodontically Treated Tooth

Retreatment: Post Removal, Silver Points, Paste
The photographs/radiographs below illustrate favorable outcomes for our patients.

Treatment Considerations/Prognosis
Previously Used Root-Filling Materials
With the use of modern endodontic techniques most fillingmaterials can be retrieved with minimal damage to thetooth and root. In some instances the filling materials may
not have to be removed and the problem can be resolved by
performing root-end surgery (apicoectomy).
Favorable: Soft or soluble pastes, pastes in the chamberor coronal one-third of the root that are removed easily
Questionable: Hard insoluble pastes in the chamber
extending into the middle-third of the root
Unfavorable: Hard insoluble pastes placed into theapical one-third of the root that cannot be retrieved
and the tooth is not amenable to surgical intervention(apicoectomy/intentional replantation)

10

www.aae.org/treatmentoptions

Case One

PreOp

Working Lengths

Working Lengths

Previous paste treatmentof tooth #19 and tooth #20

PostOp

PreOp

12 mo. Recall

PostOp12 mo. Recall

Case Two
Tooth #18 with a hard
insoluble paste and aperiradicular lesion

Treatment Options for the Compromised Tooth – A Decision Guide