Endodontist and Periodontist have different opinions - CBCT images attached

[funandez]

Hi folks,
I'm 35 years old, long story short, the endodontist thinks there's a chance of saving my tooth, but the periodontist thinks it's a goner and I should just get an implant.

Sequence of events:

• Late 2018 - my Dentist sent me to the endodontist as he suspected I would need a root canal. Endodontist confirmed a root canal was required
• Jan 2019 - Endodontist attempted root canal but was unsuccessful. She had issues locating the canal or something along those lines. Patched me up and asked I go get a CBCT to assist. Got the CBCT which is attached below.
• Feb 2019 - Re-attempted root canal, everything seemed to have gone well.
• Oct 2020 - I was feeling some discomfort and noticed abscess had re-appeared. Visited endodontist, she confirmed root canal had failed. She advised we might be able to save the tooth, but wanted me exanimated by the periodontist from the same dental office.

Today I was examined by the periodontist and later met with the endodontist.

• Endodontist believes that while I'm not an ideal candidate, there's a chance the tooth could be saved with an apicoectomy and regeneration. This is contingent that when they open up my gums, there's no crack in the tooth.
• Periodontist believes the remaining bone is too short, and even if we save it, it'll be short lived and likely fall out after a few years. He suspects the root canal failed because the tooth is cracked. He also warned that if I try to save the tooth, once we cut into my gums, it could impact my gum line around that tooth. Contingent the bone hasn't degenerated significantly since my original CBCT, his recommendation is an implant that won't require my gums be cut open, and avoid impacting my gum line.

The game plan is to get a new CBCT to confirm the current status of the remaining bone, and meet with both for a decision. Cost wise, attempting to save it will run me about $3000, the implant will cost about $1500-$2000 more.
So based on the information I was given, I have to decide whether to risk $3000 and my gum line to keep my tooth, or just get the implant now. My instinct is to try to keep my tooth if it has a chance, although I'm not sure what benefit there really is with that. How will the real tooth benefit me over a solid implant?

Referral instructions for new CBCT

Jan 2019 CBCT

 

[Dr M]

Good day

Firstly without any clinical photos of the gingiva around the affected incisor as well as relevant probing depths, to determine quality and quantity of remaining attached gingiva, it is difficult to give an opinion regarding the periodontal status of your dentition.
With an apicoectomy, the gum is cut to gain access to the underlying bone, by means of a flap. Once the bone is exposed, the facial bone is removed in relation to the root apex of the incisor, to gain access to the infected region, so that the area can be cleaned of all diseased bone, granulation tissue, and then the root apex is sectioned at an angle and sealed.
In your case, you will have an apicoectomy as well as a re-treatment of a failed root canal.
On the images you provided, there is no image where the endodontic treatment was completed previously, so we can't say if the root was maybe short-filled, leading to endo failure.
As a general rule, anterior incisors are usually treated quite easily.
If your endodontist could not find the canal the first time around, you might be an exception to the rule, with either difficult or abnormal anatomy. During her first fill of the canal, there might have been some infected tissue left, which caused a secondary infection due to the difficult treatment of the tooth.
With the planned treatment of redoing the root canal and cutting of a piece of the root, success might be achieved, but there is a few factors you also have to keep in mind.

1. Cutting of the root tip, reduces the root-crown ration, which ideally should be 1/3 crown and 2/3 roots. A root-crown ratio of 50/50 could still work, but if the diseased tissue and area removed is greater than planned and the root crown ratio is smaller than 50/50, then the stability of the tooth , as well as strength, will be affected.
2. During the re-treatment endo or apicoectomy, a fracture can occur and then the tooth has to be removed.
3. A endodontically treated tooth is actually a dead tooth, i.e weaker than a normal tooth and a low root-crown ratio might cause the tooth to fracture.
4. To prevent fracture of endodontically treated teeth, the teeth should be crowned ideally, and this could lead to increased cost. You don't want to crown a tooth with a compromised root-crown ratio.
5. A retreated root canal, with a apicoectomy, has a lower success rate than a "first time success " root canal. Especially when looking at long term prognosis.

The chances are that the root canal might give future problems and then the tooth will need to be extracted. Especially after 10years or so.
This being said that there was no fracture to begin with, which lead to the first endo failing. In such a case implant is the only option.

If your periodontal status is good enough, I would strongly suggest an immediate implant. In terms of long term outcomes, this will most likely last you the rest of your life. Keeping in mind that the bone graft takes without any issues. And your systemic health and habits are good.
The success rate of modern implants over 20 years is impressive.
Paying a bit more in this instance might save you in the future.

Hope this helps a little.
Just some thoughts.

 

[funandez]

Thank you for your feedback, this was informative and helpful. I do have some questions...

Firstly without any clinical photos of the gingiva around the affected incisor as well as relevant probing depths, to determine quality and quantity of remaining attached gingiva, it is difficult to give an opinion regarding the periodontal status of your dentition.

The periodontist probed the depths, dont recall the numbers he was calling out, but ultimately he said I still had good structure around the tooth. It was only in the front of the tooth that I had lost bone. I added some pictures below, probably not the greatest photos, but I hope they help. I'll provide an updated CBCT once I get it done, this will show endodontic treatment.

If your endodontist could not find the canal the first time around, you might be an exception to the rule, with either difficult or abnormal anatomy.

This is what I was told, that I had a difficult anatomy with this tooth. However, I have a sneaking suspicion that if my tooth is cracked, it occurred during the first or second attempt of the root canal. The periodontist got real uncomfortable when I asked when/how my tooth could crack and called for the endo to come in to explain it, and she didn't really give an answer.

The chances are that the root canal might give future problems and then the tooth will need to be extracted. Especially after 10years or so.
This being said that there was no fracture to begin with, which lead to the first endo failing. In such a case implant is the only option.

Sorry, can you clarify what you mean by the bold?

Money aside, are there long term implications of trying to save the tooth and it fail and have to get pulled? The endo said the root will be about 50/50 root to crown ratio if we do an apicoectomy, assuming the bone hasn't deteriorated further. However she suspects it might hold well since I have a permanent retainer in place (currently cut at that tooth due to the root canal).

 

[Dr M]

Good day

It is good thing that you have a permanent retainer in place. It will help to stabilize the tooth. In terms of the bold text, if there is a crack on the tooth, and the crack extended into the root, then unfortunately no root canal treatment will save the tooth.
If you want to try the endo route first, there shouldn't be any long term negative outcomes if it fails and you extract it at a later stage-only in terms of money you might lose out some.
I would then suggest that you consider a permanent crown on the tooth, after it was deemed that the apicoectomy and re-do root canal was succesfull

 

[funandez]

Thank you Dr M.
I've booked the appointment for a new CBCT scan, hopefully things haven't deteriorated much since Jan 2019.