|Back from the edge
In cases of tooth extraction, it's wise to consult an endodontist (root canal specialist), since often a ‘condemned’ tooth can be saved and restored to full use. Making a decision is not always easy and a number of different factors need to be taken into account. You can start by posing the right questions.
What's a dental implant?
Fig. 1 Implant by Dr Michael Zybutz: Root canal treatment by Dr Tony Druttman
The implant is a titanium screw that's placed into the jawbone to which an artificial crown is attached (Fig.1, screw image). It's designed to replace the natural tooth, both in terms of function and aesthetics. It requires an adequate quantity and quality of bone for the implant to become secure. If there's insufficient bone then various additional procedures may be required to enhance the amount of the existing bone, such as grafting natural or artificial bone.
What are the alternatives to implants?
Provided the natural tooth is still in place, root canal or endodontic treatment may be an alternative to an implant. This involves the removal of the dental pulp (nerves and blood vessels) from the root canals of teeth. The canals are cleaned and shaped and then filled with a sealant (Fig. 1, middle tooth). A root canal treatment may be technically more difficult than placing an implant. However it may be a more appropriate solution if well performed.
Factors influencing extraction
1. How much of the tooth is left?
Fig. 2 X-ray of a molar tooth with the entire tooth above the gum line destroyed. Although restoration would be technically possible, the tooth would be very weak. The better decision would be to replace it with an implant.
The most important factor is the amount of tooth remaining that shows above the gum line, on which a crown can be attached and the tooth restored to give a functional and aesthetic result. If very little of the original tooth material remains, then although technically the tooth can be root-filled and restored, the final result may not be strong enough to last any length of time (Fig. 2).
2. How technically difficult is it to save the tooth?
Those teeth with a single canal at the front of the mouth are often more straightforward to treat than molars, which have multiple canals that may be quite curved. The problem is that replacing molar teeth with implants is not always easy, either through lack of bone or because of major nerve channels that could be damaged if the implant is placed too deep.
A tooth with an existing root filling may fail and then becomes a candidate for extraction and an implant. Often it can be saved by being root-treated again - provided this is done by a specialist with the requisite skill, experience and equipment (Figs 3, 3b).
Fig.3a Inadequately root filled teeth showing infection at the root tips
Fig.3b Re-root treated showing healing of bone after eight months
3. How much bone is left around the tooth?
The amount of bone required to keep a tooth in place is less than that required to place an implant. Having said that, if there is enough bone to secure an implant, it may be a better solution than keeping a loose tooth.
4. What are the chances of success?
Fig. 4 Poor aesthetic result after the placement of two adjacent implants
With high professional care and the correct instruments, both root canal treatments and implants enjoy high success rates. But there's no 100% success. An implant can fail to osseo-integrate (create a biological fusion with the bone) and there are no published figures for these failures. Additionally, the implants can be difficult to place in exactly the right position and this can be critical especially at the front of the mouth.
Inadequate treatment planning can lead to serious aesthetic failures (Fig 4) and at times correction of an underlying aesthetic problem can be enormously challenging (Fig 5). A dental implant that fails has to be removed. With a failed root canal treatment it may still be possible to undertake the re-treatment of the tooth - either surgically or non-surgically. Extraction is the final option.
Questions to ask your dentist
Fig.5a Front tooth with a fractured root
Fig.5b Tooth has been extracted and an implant placed by Dr. Michael Zybutz
- Is there an alternative to tooth extraction and an implant?
- Can the tooth be saved by root canal treatment?
- How difficult is the root canal treatment and would a referral to a specialist be
- How long is the tooth likely to last if it is kept?
- What would be the situation if the treatment proposed were to fail?
If you have doubts about having your tooth extracted, consult another dentist or a specialist. The General Dental Council has lists of endodontic specialists in your area.
About Dr Tony Druttman
Dr. Tony Druttman, MSc. B.SC. B.Ch.D, is an Endodontics consultant with two practices in Central London. He teaches Endodontics at the Eastman Dental Institute for Oral Healthcare Sciences. He has lectured in the UK and at international congresses on wide-ranging topics dealing with root canal treatment.
Dr Tony Druttman
London Endo Ltd
38 Devonshire Street
London W1G 6QB
Tel: 020 7935 9943