SPECIALTY UPDATE
ENDODONTICS

Endodontic treatment options after
unsuccessful initial root canal
treatment
Alternatives to single-tooth implants
Mahmoud Torabinejad, DMD, MSD, PhD;
Shane N. White, BDentSc, MS, MA, PhD
F
or patients who have had pulpal and periapical
diseases caused by caries or trauma, the main
objectives of root canal treatment are to provide
long-term comfort, function, aesthetics, and
prevention of reinfection. These objectives are achieved
through complete cleaning and shaping, obturation of
canals, and restoration of affected teeth (Figure 1).1-4
A considerable weight of evidence supports the value
of initial root canal treatment. Results from systematic
reviews with meta-analyses,5-7 studies with large sample
sizes,8-11 and practice-based research network studies12,13
all indicated high and long-term survival rates for teeth
initially treated by means of nonsurgical root canal
treatment without intervention. Likewise, results from a
systematic review of the prevalence of root canal treat-
ment have indicated that billions of teeth are retained
through root canal treatment, although some disease
and unmet need remain.14
Patients choose nonsurgical root canal treatment to
retain teeth and preserve the natural aesthetics of their
smile and for relief of pain.15-18 Authors of a systematic
review reported that the incidence of short-term post-
operative pain is lower for single-visit nonsurgical root
canal treatment than it is for multiple-visit nonsurgical
root canal treatment.19 A high percentage of patients
report willingness to choose root canal treatment again.20
Overall satisfaction ratings for root canal treatment are
high, generally higher than the 90th percentile.17,21 Initial
costs, lifetime costs, cost-effectiveness, cost utility, and
Copyright ª 2016 American Dental Association. All rights reserved.
ABSTRACT
Background and Overview. Initial root canal
treatment is highly successful, appreciated by patients, and
cost-effective, but failures occur. Should a tooth with
unsuccessful initial root canal treatment be treated by
means of other endodontic procedures or be replaced by
a single-tooth implant?
Results. Results from systematic reviews of the outcomes
of nonsurgical retreatment, apical surgery, replantation,
and autotransplantation show high tooth survival rates.
Nonsurgical retreatment generally is prioritized before
surgical endodontic treatment. Microsurgical endodontic
treatment is superior to traditional surgical endodontic
treatment and has high survival rates. Intentional replan-
tation remains a viable alternative to extraction. Auto-
transplantation has a place, particularly in growing patients
with an appropriate donor tooth. Single-tooth implants
have higher survival rates, but the natural state has intrinsic
value.
Conclusions. The first-line treatment option after failure
of initial root canal treatment is nonsurgical retreatment.
Endodontic surgery, intentional replantation, and auto-
transplantation should be considered before extraction and
replacement by a single-tooth implant.
Practical Implications. Comprehensive case assess-
ment, evaluation of all endodontic options, and risk
assessment for caries and periodontal disease are always
necessary when choosing the optimal treatment for a pa-
tient when initial root canal treatment has failed to heal.
Key Words. Endodontically treated; retreatment;
endodontic surgery intentional replantation; auto-
transplantation; dental implant; outcome studies; review.
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Figure 1. A. Radiograph showing mandibular first molar with necrotic
pulp and a large periradicular lesion. B. Radiograph showing complete
cleaning and shaping, obturation of canals, and restoration. C. Radio-
graph showing resolution of the periradicular lesion after 4 years.
Reproduced with permission of the publisher from Torabinejad and
Walton.1
cost-benefit of root canal treatment all compare well
with the alternatives involving replacement using fixed
dental prostheses or single-tooth implants.6,22,23 The
incidence of long-term postoperative complications ap-
pears to be lower than it is for single-tooth implants and
fixed dental prostheses.16,24 Typical endodontic compli-
cations include symptoms, swelling, and need for
retreatment.24 Ten-year complication rates for retained
teeth treated by means of root canal treatment are only
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approximately 4% in comparison with approximately
18% for retained single-tooth implant restorations.24
Because of the anatomic complexity of root canal
systems, intricate and resilient pathogenic microbial
communities, inherent limitations of chemomechanical
instrumentation and obturation methods, and leakage of
permanent restorations, complete elimination of bacteria
from the root canal systems is not always achievable.25,26
Therefore, it is inevitable that some initial root canal
treatment may not produce apical healing. However, it
is critically important that initial root canal treatment
is performed carefully so that the risk of failure will be
minimized.
The high survival rates of dental implants have created
a paradigm shift in treatment planning that sometimes
has resulted in needless extraction of these teeth.
Although investigators in implant studies report high
survival rates, broader implant outcome measures—that
is, success criteria—are rather blunt, not discriminating,
and not patient centered.27 The purpose of this article
is to describe the outcomes of endodontic treatment
options after unsuccessful initial root canal treatment.
TREATMENTS AFTER FAILURE OF INITIAL
NONSURGICAL ROOT CANAL TREATMENT
Treatment options after initial unsuccessful root canal
treatment include nonsurgical retreatment, endodontic
surgery, tooth replantation, transplantation, extraction
and replacement by using a single-tooth implant, extrac-
tion and replacement by using a fixed dental prosthesis,
and extraction without replacement. From the perspective
of health care economics, the alternative to retaining the
natural tooth must result in lower total lifetime costs or
provide greater lifetime function, freedom from disease,
comfort, or acceptability to a patient.6 The burden of
proof lies with the alternative to retaining the natural
tooth. To be retained usefully, a natural tooth must not
have residual disease of clinical significance, must fulfill its
function within the dentition, must be comfortable, and
must have acceptable aesthetics. Comprehensive case
evaluation, including risk assessment for caries and peri-
odontal disease, is always necessary when choosing the
optimal treatment for a patient when initial root canal
treatment has failed to cause healing.28-30
NONSURGICAL RETREATMENT
The historical success rates of nonsurgical retreatment
have ranged widely. As far back as 1956, Strindberg31
reported that the results of retreatment were as successful
as those of initial treatment. In the prospective Toronto
Study, endodontic retreatment cases had a survival rate,
with function, of 93%.32 Likewise, Ng and colleagues33
ABBREVIATION KEY. MTA: Mineral trioxide aggregate.
 SPECIALTY UPDATE

Figure 2. A. Radiograph showing a mandibular first molar with necrotic pulp and a large periradicular lesion. B. Postoperative radiograph showing
retreatment of the initial root canal treatment and repair of root perforation with mineral trioxide aggregate. C. Postoperative radiograph 1 year later
showing restored tooth with initial healing at the site after perforation. D. Postoperative radiograph 4 years later showing complete healing of
periradicular tissues after nonsurgical retreatment of this tooth. Reproduced with permission of the publisher from Torabinejad and Chivian.36

reported a 4-year survival rate of 95%. Torabinejad
and colleagues34 performed a systematic review to
compare the clinical and radiographic outcomes of
nonsurgical retreatment with those of endodontic sur-
gery. They found that although endodontic surgery
offered more favorable initial success rates, nonsurgical
retreatment offered more favorable long-term outcomes.
Additional healing occurs over time with nonsurgical
retreatment, whereas, with apical surgery, additional
failure occurs over time. On the basis of these results,
it appears that if a failure is retreated with conven-
tional nonsurgical means, the success rate is high, espe-
cially in teeth without periapical lesions and when the
cause of failure has been identified and corrected
(Figure 2).35,36
ENDODONTIC SURGERY
Torabinejad and colleagues34 compared the clinical and
radiographic outcomes of nonsurgical retreatment with
those of traditional surgical endodontic treatment. They
reported a significantly higher success rate for traditional
surgical endodontic treatment at 2 to 4 years (78%)
compared with that for nonsurgical retreatment for the
same follow-up (71%). At 4 to 6 years, this relationship
was reversed, with nonsurgical retreatment showing a
significantly higher success rate (83%) than did tradi-
tional surgical endodontic treatment (72%).
Over the past decade, the outcomes of surgical end-
odontic treatment have improved substantially because
of the use of the microscope, angled ultrasonic surgical
instruments, and new root end filling materials such
as mineral trioxide aggregate (MTA) among other new
calcium silicate materials. Results from long-term follow-
up studies of modern endodontic microsurgery show
high success rates (Figure 3).37-39 Torabinejad and col-
leagues27 compared the outcomes of tooth retention
through modern endodontic microsurgery with tooth
replacement involving use of a single-tooth implant.
Teeth treated by means of a microsurgical technique had
survival rates of 94% at 2 to 4 years and 88% at 4 to 6
years. This finding indicated that modern microsurgical
endodontic treatment is superior to traditional surgical

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Figure 3. A. Radiograph showing a maxillary right central incisor with necrotic pulp and a large periradicular lesion. B. Radiograph showing the extent
of the periradicular lesion associated with this tooth. C. Postoperative radiograph showing cleaned and shaped canal filled with mineral trioxide
aggregate. D. Postoperative radiograph after a periapical surgery and resection of the root to the intracanal mineral trioxide aggregate. E. Post-
operative radiograph 1 year later showing complete resolution of the periradicular lesion. F. Postoperative radiograph 15 years and 4 months after
surgery showing normal periradicular tissues and the use of this tooth as a bridge abutment. Reproduced with permission of the publisher from Bogen
and Kuttler.37

endodontic treatment and that microsurgically treated
teeth tend to be lost at low rates over time.
TOOTH REPLANTATION
Tooth replantation (intentional replantation) is the
insertion of a tooth into its own alveolus after the tooth
has been extracted for the purpose of performing
treatment, such as root end filling or perforation repair.40
Tooth replantation is indicated when there is no
other treatment alternative to maintain a strategic
tooth. Replantation of these teeth is often successful,
particularly if careful case selection is performed

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Figure 4. A. Radiograph showing a mandibular first molar with previously treated root canals and symptomatic apical periodontitis. B. Postoperative
radiograph after performing tooth replantation and using mineral trioxide aggregate as a root end filling material. C. Postoperative radiograph 12
months later showing resolution of the periapical lesion. Reproduced with permission of the publisher from Torabinejad and Walton.41

(Figure 4).41 A mean survival rate of 88% for replanted
teeth has been reported after systematic review and
meta-analysis.42 Orthodontic extrusion before tooth
replantation appears to improve survival rates.42 Tooth
replantation remains a viable alternative to extraction
and replacement.
TRANSPLANTATION
Transplantation (autotransplantation) is the transfer of
an embedded, impacted, or erupted tooth from 1 site
to another socket or surgically prepared socket either in
the same or another person.40 The clinical procedures
include socket preparation, extraction, transplantation,
stabilization, and root canal treatment if the tooth is
mature. Appropriately indicated teeth with appropriately
performed transplantation have a good prognosis
(Figure 5).43-45 Ankylosis and resorption are the most
common failure modes of replanted and transplanted
teeth. Transplantation has a place, particularly in
younger patients with an appropriate donor tooth, whose
ongoing craniofacial growth would allow an implant to
become deeply buried and misplaced.
CONCLUSIONS
Survival rates of teeth treated by means of root canal
treatment are high, and patient benefit is great. It is

Figure 5. A. Radiograph showing a nonrestorable mandibular first molar with necrotic pulp and normal periapical tissues. B. Radiograph showing the
presence of a third molar for transplantation. C. Postoperative radiograph after performing root canal treatment on the third molar. D. Postoperative
radiograph after transplantation of the third molar into the socket of the nonrestorable first molar. E. Postoperative radiograph 9 years later showing
excellent results.

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 SPECIALTY UPDATE
important that initial root canal treatment be performed
to high standards to reduce the risk of future failure. The
first treatment option after failure of root canal treatment
is not extraction of the tooth and replacement by using a
fixed prosthesis or a single-tooth implant. There is value
in retaining an otherwise sound natural tooth. End-
odontic treatment options for failed initial root canal
treatment include nonsurgical retreatment, endodontic
surgery, replantation, and transplantation. Results of
systematic reviews regarding the outcomes of these
treatments show high survival rates for these procedures.
Nonsurgical retreatment and apical surgery are particu-
larly effective when performed using contemporary
techniques to address the cause of any remaining un-
healed periapical disease appropriately. Therefore, these
procedure options should be considered before extrac-
tion of teeth initially treated by means of nonsurgical
root canal treatment. n
Dr. Torabinejad is a professor, Endodontics, and the director, Advanced
Specialty Education Program in Endodontics, Loma Linda University, 11092
Anderson St., Loma Linda, CA 92350, e-mail mtorabinejad@llu.edu. Address
correspondence to Dr. Torabinejad.
Dr. White is a professor, School of Dentistry, University of California Los
Angeles, Los Angeles, CA.
Disclosure. Drs. Torabinejad and White did not report any disclosures.
Endodontics is published in collaboration with the American Association
of Endodontists.
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