By: Victor M. Sternberg, D.M.D.
January 19, 2022
Over the last 30+ years since the introduction of implants, root amputations have become somewhat passé. However, given all of the issues involved with extraction, bone grafting, and often sinus lifting, root amputations still remain a viable alternative in specific cases which I will present here as long term successes. Failed implants, especially due to bone loss, create a much greater challenge than a failing tooth.
This patient had a long standing crown and endodontic procedure performed. 10 years ago she presented with a fistula which appeared to be a fractured root, noted in the x-ray below.
The patient was offered the alternatives of extraction and bone graft and/or implant, as well as the possibility of preserving the tooth by removing the mesial buccal root.
I expressed to her that when I removed the root if the tooth was stable it would be worthwhile following it.
Currently, now 10 years later, the tooth has minimal mobility and pocket depth is minimal. The advantage in this case was that the endodontics was already done, so that variable didn't have to be dealt with in making a decision.
15 years ago a crown was dislodged on tooth #3. The tooth also had a significant endodontic lesion at the apex of all three roots. I resected the buccal roots and explained to the patient that we had a choice. If the palatal root was stable there might be an alternative to an extraction.
Now 15 years later, the tooth sits with a crown, albeit not perfectly fitting. It has good stability and is acting as the bicuspid anterior to it.
Again, the key was that the root was not mobile when the two buccal roots were removed.
This is a 26 year follow-up. The patient presented with a hopeless tooth #3. He did not want to lose it in an otherwise intact dentition with no other active disease. The choices for this patient were extraction of #3 and the fabrication of a 3-unit bridge, or a significant sinus lift, implant and crown.
The decision was made to remove the mesial buccal root and perform endodontics and periodontal surgery.
The patient disappeared for 5 years. When he returned there was deep pocketing on the mesial aspect of the tooth into the sinus and it probed 10 millimeters.
Since the patient had already invested in endodontics and two crowns, it was elected to be retreated by sealing the sinus communication and a bone graft was performed. Now 26 years later the tooth is stable with no active periodontal disease and no evidence of progression since the original hopeless presentation in 1996.
Each of these cases represent a challenging decision making process. It is easiest to make when endodontics has already been performed. The second issue becomes one of stability of the tooth without a root or roots. A third issue is whether or not the patient is committed to active maintenance of the area.
It is clear for those who have practiced for many years, particularly when we did not have the choice of implants, that other treatment plans involved preserving the dentition.
Seminars that I have attended at the American Academy of Periodontology and the American Academy of Osseointegration spend more and more time dealing with treating failing or ailing implants.
Preserving the teeth for as long as possible shortens the time that implants are necessary. Something to consider.
I do appreciate, as always, your feedback.
Victor M. Sternberg, D.M.D.
By Westchester Center for Periodontal & Implant Excellence
January 13, 2022