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Endo Implants

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Tom Sposob

on 13 November 2012

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Transcript of Endo Implants

The Endo Implant Algorithm How do you decide which
treatment modality to pursue?
Would you know what to do? Thank you!

Questions? What would be the best treatment for your patient? Two treatment options available: 2) Extract tooth, place implant followed by restoration 1) RCT followed by
restoration In order to decide on an appropriate treatment plan, the outcome of the treatment is an important consideration Definitions of success: 1) Dental implant studies often determine success by the implant survival rate
2) Root canal studies measure the healing of existing disease and the occurrence of new disease Considerations! Considering the Cost! Implant use is growing! Analysis of insurance data of 2005 showed that:
Restored single-tooth implants cost 75% to 90% more than similarly restored endodontic-treated teeth.
The implant restoration costs twice as much as endodontic restoration.
In addition, posttreatment complications are more common with implant restorations,and these problems may increase this cost difference. So, what is the Endo Implant Algorithm?

In simple terms it is a complex decision making process that involves multiple factors What are some of the most important factors to consider in endo-implant algorithm? 1. Informed consent
2. Crown to root ration
3. Ferrule available
4. Presence of fractures
5. Cost
6. Type of bone supporting tooth
7. Is tooth to support single crown or fixed prosthesis 8. Occlusion
9. Periodontal condition
10. Patient perception of treatment
11. Overall patients health
12. Postoperative expectations
13. Practitioners proficiency 1. Informed Consent When considering endo vs. implant dentist should perform a complete and comprehensive informed-consent protocol Dentist must include a discussion of: -alternatives for care
-the advantages and disadvantages
-the costs of each
-what will happen if nothing is done 2. Crown to Root Ratio  Ratio of the length of the part of a tooth above the alveolar bone versus what lies below it.
 It is an important consideration in the diagnosis, treatment planning and restoration of teeth What is the minimum C:R ratio? 1:1 is the absolute minimum!
Any less support by the root drastically reduces prognosis of tooth and restoration 3. Ferrule Available This is determined by coronal breakdown of the involved tooth
Often major deciding factor in endo-implant algorithm!
More on that factor to be discusses later… 4. Presence of fractures Vertical fractures are especially important to detect
Use microscope and transillumination to examine pulpal chamber
Would endo resolve this problematic molar? 5. Cost of Treatment Varies drastically between countries, institutions and even various providers.
Examination of treatment costs at university settings have shown that implants cost more than twice as much (230%) as similar endodontically restored teeth 6. Type of Bone supporting Questionable tooth “Any area with questionable or abnormal bone density or the presence of potentially problematic anatomical structures should persuade practitioners to retain teeth and choose the endodontic alternative “
-Christensen GD. 7. Is the tooth to support single crown or a fixed prosthesis “For optimum longevity expectations, highly questionable nonvital teeth that are planned to provide support to fixed prostheses probably should be replaced with implants”
-Christensen GJ 8. Occlusion “In bruxers and clenchers, tooth replacement with implants and crowns also has questionable clinical success potential, because of the extreme forces placed on the teeth in such patient”. Christensen GJ 9. Periodontal Condition Also crucial factor!
We all had enough education about importance of perio and mobility for long term success 10. Patient's perception of treatment Dentist should describe candidly the potential discomfort to be expected with each type of therapy to ensure that the patient understands what to expect during treatment.
Patients’ perception of the psychological and physiological trauma related to each therapy may be one of the key factors in their decision! 11. Overall Patient Health On the basis of overall health characteristics, endodontic therapy may be indicated over implant surgery in some cases

Many systemic conditions are contraindications to implant therapy
-Blood disorders
-Osteoporosis 12. Practitioner’s proficiency The best way to go about it is to refer when in doubt.
But if patient doesn’t want to be referred and he/she feels that because of the clinical expertise of the practitioner, one or the other therapy has the greatest chance for success, that therapy is the one to choose in that situation 13. Postoperative Expectations Only when all of the preceding characteristics are considered and weighed together, experienced practitioners can estimate the overall potential for success of either implant/restorative or endodontic/restorative therapy, and they can arrive at an educated prognosis! Success of Implant vs. Endo Implants verses root canal therapy is a current controversy in dentistry.
We found that 12.4% of implants required interventions, whereas 1.3% of endodontically treated teeth required interventions, which was statistically significant (P = .0003).
The success of implant and endodontically treated teeth was essentially identical, but implants required more postoperative treatments to maintain them J Endod. 2008 Nov;34(11):1302-5. Epub 2008 Sep 19. Comparison of success of implants versus endodontically treated teeth. Hannahan JP, Eleazer PD Source Department of Endodontics, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA. The ever important: Ferrule Effect!! This is a restorative concept
The crown should envelop a certain height of tooth structure to properly protect the tooth from fracture after being prepared for a crown. How much Ferrule is available? if less than 1mm long and 1mm thick opt to extract and place implant
if more than 1mm long and 1.5mm thick ferrule tooth can receive RCT followed by restoration If sufficient tooth structure and adequate ferrule is present, RCT can precede restoration which can be either: 1) Prefabricated post and core
2) Cast post and core
NB: The amount of tooth structure remaining to retain core material indicates which of these two options should be employed J Dent. 1993 Oct;21(5):281-4. An analysis of durability data on post and core restorations. Creugers NH, Mentink AG, Käyser AF. Source Department of Oral Function and Prosthetic Dentistry, TRIKON, University of Nijmegen, The Netherlands. An attempt was made to review the dental literature since 1970, presenting clinical data of posts and core restorations, by the use of a meta-analytic procedure
The reconstructed survivals of the studies after 6 years were 81% survival (standard error 6%) for resin composite build-ups in combination with screw posts and 91% survival for two studies including cast posts and cores (standard errors respectively 3% and 2%). Deciding which core material to use (1) If two or three walls of tooth structure is present:
--> Amalgam or composite core buildup

(2) If there is not enough mechanical retention present to hold in the amalgam core, --> Composite core is indicated.

(3) If one or two walls of tooth structure is present
--> Prefab post followed by composite or amalgam core buildup

(4)If one or zero walls remain --> Cast post and core cemented with resin cement J Prosthet Dent. 1992 Oct;68(4):584-90. Fatigue life of three core materials under simulated chewing conditions. Kovarik RE, Breeding LC, Caughman WF.Source Department of Oral Health Practice, University of Kentucky College of Dentistry, Lexington. The purpose of this study was to compare three core materials that are used with prefabricated stainless steel posts.

A custom-designed chewing machine was used to cyclically load the teeth with vertical and horizontal forces for one million cycles or until failure occurred

Amalgam cores had the lowest failure rate, followed by composite resin cores. All teeth restored with crowns over glass-ionomer core buildup failed.

The type of prefabricated post used had no effect on the survival of the post-core-crown restorations regardless of the core buildup used. Implants Root Canal Tx Advantages:
preservation of bone Disadvantages:
osseointegration (3-6months)
anatomic limitations (bone quality, thickness, interarch distance)
no PDL (loss of shock absorption = higher incidence of crown fractures)
post restoration complications can be costly (ie. Maintenance)
patient limitations (ie. Acute illness, pregnancy, allergy, metabolic disease, diabetes, severe malocclusion, severe bruxism with loss of anterior guidance) Advantages:
less costly than implant
restoration results in less complications
less time to complete
preservation of bone
PDL – shock absorption Disadvantages:
disease (smokers, diabtetics, higher chance of endo failure)
success maybe limited based on certain factors
severely curved roots = short posts
endo treated teeth are weaker* *contrary to believe this is incorrect. Endo treated teeth have less moisture but have demonstrated that they may have equal resistance to fracture than non endo treated teeth. However, heavily restored teeth (ie. CPC) usually have reduced tooth structure which may lead to fracture. Oversized posts can weaken tooth structure *Costs:
- cost effective for RCT

- if failure occurs and retreatment is needed it is still more cost effective then implant

- however if additional failure occurs and surgical RCT required it is more cost effective to get implant

- implant is good 3rd line of defense if 2 endo failures have occurred
Systemic Factors Age and sex
No significant difference between survival/success
There was a trend that Both implant and NSRCT had increased failure
No difference between treatment
Increased failure for both treatments
Failure was significantly greater for implants than NSRCT Success vs. Survival Success: healing/success measures are the outcomes
Based on clinical, radiographic and subjective measures
Used in endodontic research
Survival: the retention of the tooth over an interval after an intervention
Is an outcome meaningful to the patient
Used in Implant research
Results may be inflated compared to a success definition
Allows a prediction of longevity Longevity 4 categories of longevity may be defined

(1) Success
(2) Survival with intervention
(3) Survival without intervention
(4) failure Longevity of Endodontics! In a literature review 58 papers were The success rate depends on the selected criteria and the predisposing condition
Teeth without a periapical lesion had greater success that those with a lesion
Endo therapy done by specialists and students had the greatest longevity
Success rate for endo was 86% for primary treatment and 78% for re-treatment and 65% for surgical retreat
When a coronal restoration was not placed failure was 4x greater
Eleman and Pretty, 2011 Longevity of Implants! Survival rate for implants over a 10 year period was 91%There is no statistical difference between the survival of implants and primary RCT Longevity should not play into a decision to place an implant or perform RCT
Recommendation would be that when restoration of the tooth is favourable than perform RCT Periodontitis Teeth that are periodontal hopeless should not be RCT and an Implant would be favoured
There is no difference in the survival rate of implants in patients with periodontal disease over 5 years
There is a signifigant difference in thesurvival rate over 10 years for patients with periodontal disease and peri-implantits
(Baelum and Ellegaard, 2004) Research comparing Survival of Implants and NSRCT teeth in anatomical positioning is minimal
Most Endodontic research does not report position
Studies have reported that failure is up to 35% in type IV bone for Implants (Jaffin and Berman, 1991)
At least one paper has shown that 2nd molars are the most likely NSRCT tooth to fail
10 year survival 63% (Aquilino et al, 2002) Esthetics Esthetics are subjective. Therefore patient satisfaction survey of both groups gives a good insight into success of implants versus endo treated teeth
Bone regeneration is unpredictable after extraction. Therefore areas where crestal bone height translate to papilla height.
This in turn decreases the predictability of papilla height around the crown margin.
In addition there is a natural regression within normal limits of bone after extraction.
Thus in posterior where visible crown margins are not critical implants and RCT treated crown teeth revealed similar outcomes in patient satisfaction according to Gatten in the American journal of Endodntics.
Implant group in the anterior noted the fact that there is a" dark area near the gum line that stands out when they look in the mirror and in pictures.
A few participants also noted a concavity or recession of their gingiva around their implants.“
Endo treated teeth "thought that the endodontic treatment either had no effect on their appearance or made it better Review! References Contemporary Implant Dentistry. Carl Misch (vital source)
Contemporary fixed prosthodontics. Rosenstiel (vital source)
M. W. Pennington, C. R. Vernazza, P. Shackley, N. T. Armstrong, J. M. Whitworth & J. G. Steele. Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant. Int Endo J.
Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in Type IV bone: a 5-year analysis. J Periodontol 1991;62:2– 4.
Baelum V, Ellegaard B. Implant survival in periodontally compromised patients. J Periodontol. 2004 Oct;75(10):1404-12.
 Elemam RF, Pretty I. Comparison of the Success Rate of Endodontic Treatment and Implant Treatment. ISRN Dentistry 2011.
 Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in Type IV bone: a 5-year analysis. J Periodontol 1991;62:2– 4.
 Iqbal MK, Kim S. A Review of Factors Influencing Treatment Planning
Decisions of Single-tooth Implants versus PreservingNatural Teeth with Nonsurgical Endodontic Therapy. JOE 2008; 34:5, 519-529
 Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent 2002;87:256–63.
 Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR.Retrospective Cross Sectional Comparison of Initial Nonsurgical Endodontic Treatment and Single-Tooth Implants JOE 2006; 32: 9. A group presentation by: Amrit Bains, Ben Rogala, Russel Anderes, Anik Popat, Nazar Babyak, Tomasz Sposob, Ajay Sankar and Brett Luschinski Quick Summary Would you rather? How restorations on endodontically treated and severely damaged teeth fail 1. Stress breaks anatomic crown at the neck of the tootha. Not strong enough ferrule (length and thicknessb. Core/tooth structure interface fails, shell of tooth structure suffers from stress, tooth structure fracture, crown fracture.Solution: Unless there is adequate length and thickness of ferrule, extract the tooth. Unless there is enough tooth structure available for mechanical retention and bonding, use cast dowel and core. 2. Cast dowel and core comes out from the root cement because it is not strong enough to withstand stress, especially under lateral or para functional stressSolution: Use resin cement for cast dowel and core and prefabricated post Endodontic treatment should be given priority in the treatment planning for periodontally sound teeth with pulpal or periradicular pathology, whereas implants should be given priority in the treatment planning for teeth that are to be extracted because of non-restorability or other reasons.
Many factors may influence the decision between retention or extraction of a compromised tooth with the evaluation of restorability being critical.
Decisions should be based on the patient’s informed decision concerning restorability, costs associated with procedures, esthetics, potential adverse outcomes and ethical factors 50 year old male reports to your office with a dull ache in the lower left quadrant. You take a radiograph and determine that at the apex of tooth 36 is a periapical radiolucency. You establish that the periodontal status for the tooth is poor and that after access you should have a reasonable amount of tooth structure. After reviewing the patients med history you discover that he is type I diabetic.
The correct treatment for this patient is
A)RCT, post/core and crown
B)Extraction and placement of an implant
C)Either option would be acceptable
D)Neither treatment is acceptable
A 43 year old female reports to your office with tooth 24 broken off at the gumline. You perform sounding and determine that there in only 1 mm of tooth structure coronal to the bone level. Also during your periodontal and radiographic exam you determine that there is a class I furcation on tooth 36. This patient is a smoker. The correct treatment for this patient is
A)RCT, post/core and crown
B)Extraction and placement of an implant
C)Either option would be acceptable
D)Neither option would be acceptable
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