Treatment
Options for theCompromised Tooth:A Decision Guide
www.aae.org/treatmentoptions

Photo by Lindsey Frazier submitted
by L. Stephen Buchanan, D.D.S.

Root Amputation, Hemisection, Bicuspidization

Case One
Hemisection of the distal root of tooth #19.

PreOp

PostOp13 mo. Recall

PostOpClinical PhotographCase Two*
Hemisection of the distal root of tooth #30.

PreOp

* These images were published in The Color Atlas of Endodontics, Dr. William T. Johnson, p. 162, Copyright Elsevier 2002.

Treatment Considerations/Prognosis

2Favorable

Questionable

Unfavorable

Remaining Coronal
Tooth Structure

Greater than 1.5 mm ferrule

1.0 to 1.5 mm ferruleLess than 1 mm ferrule

Crown Lengthening

None needed

If required will notcompromise the aesthetics
or periodontal conditionof adjacent teeth

Treatment required thatwill affect the aesthetics
or further compromise theosseous tissues (support) of
the adjacent teeth

Endodontic Treatment

Routine endodontic
treatment or not required
due to previous treatment

Nonsurgical root canalretreatment required prior
to root resection

Canal calcification, complex
canal and root morphology,
and isolation complicate anideal endodontic treatment
resultAmerican Association of Endodontists | www.aae.org

Endodontic-Periodontic Lesions

Case One
Tooth #19 exhibiting probing to the distal apex. Treated in two steps using interim calcium hydroxide.

PreOp

Calcium Hydroxide

PostOp12 mo. Recall

Case Two
Tooth #21 exhibiting a wide, but deep probing on the mesial aspect. Treated in two steps using interim calcium hydroxide.

PreOp

Calcium Hydroxide

PostOp12 mo. Recall

Case Three
Tooth #19 with an 8 mm probing into furcation. Interim calcium hydroxide used.

PreOp

PostOp12 mo. Recall

Treatment Considerations/Prognosis

Periodontal Conditions

Favorable

Questionable

Unfavorable

Normal periodontium

Moderate periodontal
diseaseAdvanced periodontal
diseaseAn isolated periodontal
probing defectGeneralized periodontal
probing defects throughout
the patient’s mouth

Normal probing depths(3 mm or less)
The tooth exhibits pulp
necrosis and isolated boneloss to the involved toothor root

The tooth exhibits pulp
necrosis and moderatebone loss

The tooth exhibits pulp
necrosis and there is
generalized bone loss
(horizontal and/or vertical)

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

3External Resorption

Case One
External resorptive defect on buccal aspect of tooth #29. Mineral trioxide aggregate (MTA) placed in the coronal 6 mmof canal and surgical repair with Geristore.®

PreOp

PostOp27 mo. Recall

Case Two

Case Three

Tooth #8 questionable prognosis; external
resorption on the mesial with a periodontal
probing defect on the mesiopalatal.

Tooth #19 unfavorable prognosis; there is a large cervicalresorptive defect on the buccal aspect of the distal root
extending into the furcation.

Facial View

PreOpPreOp

Clinical Photograph

Lingual View

Treatment Considerations/Prognosis

External Resorption

Favorable

Questionable

Unfavorable

Minimal loss of tooth structure

Minimal impact on
restorability of tooth

Structural integrityof the tooth or root iscompromised

Located cervically but above thecrestal bone
The lesion is accessible for repair
Apical root resorption associatedwith a tooth exhibiting pulp
necrosis and apical pathosis

4

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Crown lengthening or
orthodontic root extrusion
may be required
The pulp may be vital ornecrotic

There are deep probingdepths associated with theresorptive defectThe defect is not accessible
for repair surgicallyInternal Resorption

Case One
Tooth #28 exhibiting a mid-root internal resorptive defect.

PreOp

PostOp14 mo. Recall

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

PreOp

PostOpTreatment Considerations/Prognosis

Internal Resorption

Favorable

Questionable

Unfavorable

Small/medium defectLarger defect that does not
perforate the root

A large defect that
perforates the externalroot surface

A small lesion in the apical or
mid-root area

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5

Tooth Fractures

Crown Fracture
Tooth #8 exhibiting a complicated coronal fracture, root canal treatment and bonding of the coronal segment.

PreOp

Clinical Photograph

PostOpHorizontal Root Fracture*
Horizontal root fractures of #8 and #9; the maxillary right central remained vital while the maxillary left central developed
pulp necrosis requiring nonsurgical and surgical root canal treatment; prognosis favorable.

* These images were published in The Color
Atlas of Endodontics, Dr. William T. Johnson,
p. 176, Copyright Elsevier 2002.

PreOp

RCT PostOp

Surgical PostOp

Treatment Considerations/Prognosis

Crown Fractures

Favorable

Questionable

Unfavorable

Coronal fracture of enamel
or dentin not exposing
the pulp

Coronal fracture of enameland dentin exposing thepulp with immature root
development

Coronal fracture of enamel orenamel and dentin extending
onto the root below the crestal
bone

Coronal fracture of enameland dentin exposing the pulpof a tooth with mature root
development
Horizontal Root
Fractures

The fracture is located in
the apical or middle thirdof the root
There is no mobility
The pulp is vital (note in themajority of root fractures thepulp retains vitality)

6

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Compromised restorability
requiring crown lengthening ororthodontic root extrusion
The fracture is located in
the coronal portion of
the root and the coronalsegment is mobile
There is no probing defect
The pulp is necrotic
A radiolucent area is notedat the fracture site

The fracture is located in thecoronal portion of the root andthe coronal segment is mobile
There is sulcular communication
and a probing defectTooth Fractures

Case One
Fracture of the mesial marginal ridge of tooth #5, stopping coronal to pulp floor.

PreOp

Mesial Crack

Internal Crack

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

PreOp

Distal Crack

PostOpPostOpCracked Tooth
Progression To
Split Tooth*ABC

A Favorable prognosis
B Questionable prognosis
C Split tooth, Unfavorable prognosis* Reprinted with permission fromTorabinejad and Walton, Endodontics:
Principles and Practice 4th ed, Saunders/Elsevier 2009.

Treatment Considerations/Prognosis

Cracked Tooth

Favorable

Questionable

Unfavorable

Fracture in enamel only
(crack line) or fracture inenamel and dentin

Fracture in enamel and dentin

Fracture line extends
apical to the cementoenamel junction extending
onto the root with anassociated probing defect

The fracture line does
not extend apical to thecemento-enamel junction
There is no associatedperiodontal probing defect

The fracture line may extend
apical to the cemento-enamel
junction but there is no associatedperiodontal probing defect
There is an osseous lesion ofendodontic origin

The pulp may be vital
requiring only a crown
If pulp has irreversible
pulpitis or necrosis, root
canal treatment is indicatedbefore the crown is placed

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

7

Apical Periodontitis

Case OneA large periapical lesion resulting in an acute apical abscess from pulp necrosis of tooth #7.

Acute Apical Abscess
PreOp

PostOp24 mo. Recall

Swelling Healed

Case TwoNon-healing endodontic lesion involving teeth #23, 24 and 25. Biopsy revealed lesion was a periodontal cyst withmucinous metaplasia. Super-EBA retrofillings were placed in each tooth.

PreOp

Cyst

PostOp28 mo. Recall

Treatment Considerations/Prognosis
Apical Periodontitis
The presence of periapicalradiolucency is not an absoluteindicator of a poor long-term
prognosis. The vast majority ofteeth with apical periodontitis
can be expected to heal
after nonsurgical or surgicalendodontic treatment. Data
indicate the presence of alesion prior to treatment only
decreases the prognosis slightly.

8Favorable

Questionable

Unfavorable

Pulp necrosis with orwithout a lesion presentthat responds to nonsurgical treatment

Pulp necrosis and aperiapical lesion is present
that does not respond tononsurgical root canaltreatment but can be treatedsurgicallyPulp necrosis and aperiapical lesion is present
that does not respond tononsurgical root canaltreatment or subsequent
surgical intervention

American Association of Endodontists | www.aae.org

Procedural Complications

Nonsurgical Root Canal Retreatment: Missed Canal
Tooth #19 demonstrating poor obturation and a missed mesial canal.

PreOp

PostOp6 mo. Recall

12 mo. Recall

Surgical Root Canal Treatment: Altered Anatomy
Surgical treatment of tooth #19 to correct apical transportation in the mesial root.

PreOp

PostOp16 mo. Recall

Treatment Considerations/Prognosis

Nonsurgical Root
Canal Retreatment:
Missed Canal

Surgical Root
Canal Treatment:
Altered Anatomy(e.g., loss of length, ledges,
apical transportation)

Favorable

Questionable

Unfavorable

The etiology for failure of
the initial treatment can beidentified

The etiology for failure of theinitial treatment cannot be
identified

Nonsurgical endodontic
retreatment will correct thedeficiency

Nonsurgical endodontic
retreatment may not correct
the deficiency

The etiology for failureof the initial treatment
cannot be identified andcorrected with nonsurgicalretreatment and surgicaltreatment is not an option

The procedural complication
can be corrected with
nonsurgical treatment,
retreatment or apicalsurgery

Canals debrided andobturated to the proceduralcomplication, there is noapical pathosis and thepatient is followed on recall
examination

The patient is symptomaticor a lesion persists and theprocedural complication
cannot be corrected andthe tooth is not amenable
to surgery (apicoectomy/intentional replantation)

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

9Procedural Complications

Separated Instruments: Case One
Hemisection of the distal root of tooth #19.

PreOp

PostOp24 mo. Recall

Separated Instruments: Case Two
Separated NiTi rotary instrument in palatal canal of tooth #4. Removed file with ultrasonics and copious irrigation;
obturated with gutta-percha and AH Plus® sealer.

PreOp

Separated Instrument

12 mo. Recall

24 mo. Recall

PostOpTreatment Considerations/Prognosis

Separated Instruments

Favorable

Questionable

Unfavorable

No periapical periodontitis

Instruments fractured in thecoronal or mid-root portionof the canal and cannot beretrieved

The patient is symptomaticor a lesion persists requiringextensive procedures inorder to retrieve instrumentthat would ultimately
compromise long-term
survival of the tooth andsurgical treatment is not
an option (apicoectomy/intentional replantation)

In general, cases that have aseparated instrument in theapical one-third of the root
have favorable outcomes
Able to retrieve nonsurgically or surgically if
periapical pathosis is present
Defect correctable withapical surgery

10American Association of Endodontists | www.aae.org

Patient asymptomatic
No periapical periodontitis

Procedural Complications

Perforations: Case One
Tooth #3 exhibiting a coronal perforation. Repaired with MTA in conjunction with nonsurgical root canal treatment.

PreOp

PostOp36 mo. Recall

Perforations: Case Two
Tooth #30 with previous retreatment attempt resulting in furcal perforation. Retreatment performed using interim
calcium hydroxide and furcal perforation repaired with MTA.

PreOp

PostOp12 mo. Recall

Treatment Considerations/Prognosis
Favorable

Questionable

Unfavorable

Perforations:Location

Apical with no sulcularcommunication orosseous defectMid-root or furcal withno sulcular communication
or osseous defectApical, crestal or furcal withsulcular communication
and a probing defect withosseous destruction

Perforations:Time of Repair

Immediate repair

Delayed repair

No repair or gross extrusionof the repair materials

Perforations:
Size

Small (relative to toothand location)

MediumLarge

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

11Procedural Complications

Post Perforations: Case One
Tooth #27 with sinus tract that traced to apical extent of post (no abnormal probings). Orthograde repair performed with MTA.

PreOp

Sinus Tract Tracing

PostOp12 mo. Recall

Post Perforations: Case Two
Tooth #30 post perforation with screw post previously treated with paste obturation.
Perforation repaired with MTA and tooth retreated.

PreOp

PostOp12 mo. Recall

Treatment Considerations/Prognosis

Post Perforation

Favorable

Questionable

Unfavorable

No sulcular communication
or osseous destruction

No sulcular communication
but osseous destruction isevidentLong standing withsulcular communication, aprobing defect and osseousdestruction

The perforation can be
repaired surgically
Strip Perforation12Small with no sulcularcommunication

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No sulcular communicationand osseous destructionthat can be managed withinternal repair or surgicalintervention

Sulcular communication andosseous destruction thatcannot be managed withinternal repair or surgicalintervention

Retreatment: Post Removal, Silver Points, Paste, Carrier-Based Obturation

Post Removal: Case One
Tooth #8 requiring removal of a prefabricated post.

PreOp

Clinical View

Clinical View

PostOpPost Removal: Case Two
Tooth #30 demonstrating incomplete paste obturation with threaded post and bonded resin core.

PreOp

PostOp12 mo. Recall

Treatment Considerations/Prognosis
Posts
With the use of modern
endodontic techniques,most posts can be retrieved
with minimal damage tothe tooth and root. Ceramic
posts, fiber posts, threaded
posts, cast posts and cores,
and prefabricated posts
placed with resins are mostchallenging to remove. In
some instances the post may
not have to be removed andthe problem can be resolved
by performing root-end
surgery (apicoectomy).

Favorable

Questionable

Unfavorable

Prefabricated cylindricalstainless steel posts placedwith traditional luting
cements such as zinc
phosphate

Cast post and cores placedwith traditional luting
cements such as zinc
phosphate

Prefabricated posts(stainless steel ortitanium), cast post andcores placed with bondedresins; threaded, fiber andceramic posts that cannot
be removed or removal
compromises the remaining
tooth structure
Teeth that cannot beretreated or treatedsurgically

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

13

Retreatment: Post Removal, Silver Points, Paste, Carrier-Based Obturation

Silver Point Retreatment: Case One
Tooth #9 treated 25 years ago requiring retreatment.

PreOp

Working Length

PostOp

Silver Point Retreatment: Case Two
Tooth #18 previously treated with silver points, filled short. Calcium hydroxide placed for two weeks.

PreOp

PostOp24 mo. Recall

Treatment Considerations/Prognosis
Silver Points
Silver points were a popular
core obturation material in
the 1960s and early 1970s.
While their stiffness madeplacement and length control
an advantage, the material
did not fill the canal in three
dimensions resulting in leakage
and subsequent corrosion.

Favorable

Questionable

Unfavorable

Silver cones that extendinto the chamber facilitating
retrieval and have been
cemented with a zinc-oxide
eugenol sealer

Silver cones that areresected at the levelof the canal orifice or
have been cemented
with zinc phosphate or
polycarboxylate cement

Sectional silver cones
placed apically in the root topermit placement of a postthat cannot be retrieved or
bypassed and the tooth is
not a candidate for surgicalintervention

Silver cones that can bebypassed or teeth thatcan be treated surgically14

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Retreatment: Post Removal, Silver Points, Paste, Carrier-Based Obturation

Carrier-Based Systems
Tooth #3 demonstrating overextended carrier-based obturation.

PreOp

PostOp12 mo. Recall

Paste Retreatment
Tooth #30 demonstrating resorcinol-formaldehyde resin-based obturation. Retreatment carried out using interim
calcium hydroxide.

PreOp

PostOpResorcinol Paste

12 mo. Recall

Treatment Considerations/Prognosis
Carrier-Based Systems
Carrier-based thermoplastic(e.g., Thermafil®) systems
are similar to silver cones.
Historically, the core material
was metal, later replaced withplastic. Current technology
includes cross-linked guttapercha. They can generally beremoved as the gutta-percha
can be softened with heat andsolvents facilitating removal.

Favorable

Questionable

Unfavorable

Soft or soluble pastes,pastes in the chamber orcoronal one-third of theroot that are removed easily

Hard insoluble pastes in thechamber extending into the
middle-third of the root

Hard insoluble pastes placed
into the apical one-thirdof the root that cannot be
retrieved and the tooth is
not amenable to surgicalintervention (apicoectomy/intentional replantation)

Plastic carrier-based
thermoplastic obturators

PastesWith the use of modernendodontic techniques mostfilling materials can be retrieved
with minimal damage to thetooth and root.

Treatment Options for the Compromised Tooth: A Decision Guide | www.aae.org/treatmentoptions

15

Treatment Options for theCompromised Tooth: A Decision
Guide features different cases where
the tooth has been compromised inboth nonendodontically treatedteeth and previously endodonticallytreated teeth.
Based on the unique individualizedfeatures of each case and patient,
there are key considerations inestablishing a preoperative prognosisof Favorable, Questionable or
Unfavorable. The photographs andradiographs in this guide illustratefavorable outcomes for our patients.

Phone:

800-872-3636(U.S., Canada, Mexico)or 312-266-7255

Fax:

866-451-9020(U.S., Canada, Mexico)or 312-266-9867

Email:

info@aae.org

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American Association of Endodontists (AAE),
All Rights Reserved

If your patient’s condition falls intoa category other than Favorable,referral to an endodontist, who has
expertise on alternate treatment
options that might preserve thenatural dentition, is recommended.
If the prognosis of the tooth iscategorized as Questionable/
Unfavorable in multiple areasof 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-specificissues, economics, the patient’s
desires and needs, aesthetics,
potential adverse outcomes, ethicalfactors, history of bisphosphonate
use and/or radiation therapy.
Although the treatment planning
process is complex and new
information is still emerging,it is clear that appropriate
treatment must be based on
the patient’s best interests.