What is Save Versus Extract Lean?
A save-versus-extract lean weighs the trade-offs between root canal therapy on the natural tooth and extraction followed by replacement (implant, bridge, or partial denture). The lean is informed by pain pattern, prior treatment, tooth position, the structure remaining above the gum, budget, and long-term goal. Only an in-person exam with an x-ray can confirm whether the tooth is restorable.
The Formula
Lean = (Restorability) + (Tooth Position Value) + (Prior Treatment) + (Long-Term Goal)
Restorability is the heaviest single signal: a tooth broken at or below the gum line is usually not salvageable regardless of other factors.
Worked Example
A 45-year-old with a deeply broken upper first molar after a failed large filling, no prior root canal, plenty of pain on biting, budget around $2,000, wants the most durable solution.
- Pain level: sharp on biting, common in pulpal involvement
- Prior treatment: previous large filling
- Tooth position: first molar, anchor of the bite
- Restorability: most of the tooth is broken; uncertain whether crown lengthening can save it
- Budget: $2,000 borderline between root canal plus crown and extraction plus implant
- Long-term goal: most durable solution
📌 Lean is exam-needed rather than a clear save or extract. The restorability signal is the deciding factor and a clinical evaluation is required. If the tooth is restorable, root canal plus crown is the natural-tooth path; if not, extraction with planned implant is the durable replacement.
Why This Matters
Natural teeth are still the benchmark
A well-treated, well-restored natural tooth typically outperforms any replacement on chewing function, proprioception, and bone preservation. Saving when possible is usually the right long-term play.
A crown is not optional
Root canal success depends on a prompt, well-fitting crown. Teeth root-canaled but left without full coverage have noticeably lower long-term survival.
Extraction creates a chain of downstream decisions
Removing a tooth without a replacement plan allows adjacent teeth to drift and the opposing tooth to over-erupt within months. The replacement decision (implant, bridge, or partial) should be part of the extraction conversation, not an afterthought.
Common Mistakes
❌ Choosing extraction because it is cheaper today
A bridge or implant replacement, plus the long-term effects on adjacent teeth and bone, often costs more across a decade than the root canal plus crown would have. The full-life-cycle cost matters.
❌ Delaying the crown after a root canal
A root-canaled tooth left without the crown for months can crack or develop new decay through the temporary filling. The crown belongs in the same treatment phase, not as a maybe-later step.
❌ Dismissing endodontist referral for complex roots
General dentists handle straightforward root canals well, but molars with curved or extra canals benefit from an endodontist who uses a surgical microscope. Retreatment after a missed canal costs more than the specialist referral would have.
Industry Benchmarks
| Category | Good | Average | Poor |
|---|---|---|---|
| Root canal 10-year survival with crown | 86-93% | 80-86% | Under 80% without crown |
| Root canal plus crown cost (US) | $1,500-2,200 | $2,000-2,800 | $2,800+ |
| Single implant plus crown cost (US) | $3,000-4,500 | $4,000-5,500 | $5,500+ |
Source: American Association of Endodontists Endodontic Survey 2024
Benchmark data sourced from American Association of Endodontists Endodontic Survey 2024.