The Endodontic / Implant Controversy Innovations in Endodontics Series Robert Handysides DDS Associate Professor and Chair Department of Endodontics Loma Linda University School of Dentistry Endodontic Treatment Planning Knowledge of tooth restorability and restorative concepts Understanding of implant planning placement and restoration Competence in deciding between all options Proficiency in providing all clinical skills ADA Recognised Specialties Endo or Implant? Endodontics Oral Surgery Orthodontics Pediatric Dentistry Periodontics Prosthodontics Survey by Dr. Huan Su University of Pennsylvania Why do they prefer an implant over a conventional restoration? Tooth Supported Restoration Implant Supported Restoration 0 6 13 13 0 7.5 15 22.5 30 Perio, Prosth, Rest Faculty Perio, Prosth, Residents Endo Faculty Endo Residents 6 3 4 Root canal therapy is very expensive. Treatment to save the compromised tooth is unpredictable. Impression for an implant is easier Implant has no problem with secondary caries
How to Define Success? Success of Periodontal Therapy Function / Survival Repair / Regeneration Esthetics Success of Periodontal Therapy Definition of Questionable Tooth Percentage of periodontally treated teeth extracted during long term periodontal maintanace Hirschfield, J Periodontol, 1978 8.4% McFall, J Periodontol, 1982 11.4% Wood, J Clin Periodontol, 1989 7.1% Tonetti, J Clin Periodontol, 2000 4.2% Konig, J Clin Periodontol, 2002 2.9% Faggion, J Clin Periodontol, 2007 5.5% Biological Factors- Treatment of periodontal diseases is highly successful except for questionable teeth Good Prognosis Fair Prognosis Poor Prognosis Questionable Prognosis Hopeless Prognosis Control of the etiologic and adequate periodontal support Approximately 25% of attachment loss and / or Class I furcation involvement 50% attachment loss and/or Class II furcation involvement that allows proper maintenance Greater than 50% attachment loss, Class III or Class II furcation involvement that is difficult to maintain, 2+ mobility or greater Inadequate attachment to maintain the tooth McGuire, MK, & Nunn ME J Periodontol 1996ab Success of Implant Therapy Success of Implant Therapy Albrektsson s Criteria Individual unattached implant is immobile No radiographic evidence of peri-implant radiolucency Bone loss less than 0.2 mm annually after first year of service No persistent pain, discomfort or infection is attributed to the implant Implant does not preclude placement of crown or prosthesis with satisfactory appearance to patient and dentist Albrektsson et al., JOMI, 1986
Success of Implant Therapy Misch s Criteria / Quality Assessment Implant Quality Scale Group Success (Optimum Health) Satisfactory Survival Compromised Survival Failure Clinical Conditions No pain or tenderness to percussion 0 mobility <2 mm radiographic bone loss from initial surgery No history of exudate No pain on function 0 mobility 2-4 mm radiographic bone loss No history of exudate May have sensitivity on function 0 mobility >4 mm radiographic bone loss but less than 1/2 of implant body Probing depth > 7 mm May have history of exudate Pain on function Mobility Radiographic bone loss greater than 1/2 length of the implant body Uncontrolled exudate No longer in the mouth Misch et al., Implant Dentistry, 2008 31% implant failure in smokers Bain & Moy, JOMI, 1993; debruyn & Collaert, COIR, 1994 more bone loss around implants than smoking 16-35% implant loss in type IV bone Galindo-Moreno et al., COIR, 2005 Jaffin & Berman., JOMI, 1991 Unsatisfactory Oral Hygiene Schou et al., COIR, 2002; Jovanovic SA, Adv Dent Res, 1999 Unsatisfactory Oral Hygiene Parafunctional habits and occlusal overload Johansson & Palmqvist, Int J Prosthodont, 1990; Misch CE, Dent Today, 2003
Unsatisfactory Oral Hygiene Parafunctional habits and occlusal overload Medically Compromised Unsatisfactory Oral Hygiene Parafunctional habits and occlusal overload Medically Compromised All of these are exclusion factors when doing Implant Success Studies Success of Endodontic Therapy Success of Endodontic Therapy Brynolf 1967 Histological examination Success of Endodontic Therapy Success of Endodontic Therapy Brynolf 1967 Histological examination Strindberg 1956 Clinically no symptoms Initial Walton and Green found almost the exact opposite Radiographically PDL within normal limits and an intact lamina dura 1 Yr Recall
Does Apical Pathology affect Success? Does the Operator affect Success? No Radiolucency Radiolucency Strindberg, 1956 89% 68% Seltzer, 1963 92% 76% Grossman, 1964 99% 62% Kerekes, 1979 94% 84% Swartz, 1983 94% 83% Bystrom, 1987 94% 85% Akerbloom, 1988 98% 63% Sjogren, 1990 96% 86% Molven, 1993 91% 68% Smith, 1993 88% 86% Friedman, 2003 92% 74% Dammaschke, 2003 88% 64% 93% 74% General Practitioner 64.4% Pre Doctoral Student 68.4% Post Doctoral Student 82.9% Specialist 87.6% Ng et al. IEJ 2007 Endo Treatment by general dentist 89.7% -5 year follow upby endodontist 98.1% Survival Alley et al. OOOOE, 2004 Endodontic vs Implant Survival Endodontic Survival Studies Study # cases / follow up Percentage of Survival Larzarski et al. JOE, 2001 Sahlerabi, Rotstien, JOE, 2004 44,613 / 3.5 years 94.4% 1,462,936 / 8 years 97% Chen et al. JOE 2007 1,557,547 / 5 years 92.9% Endodontic vs Implant Survival Endodontic Survival Studies Study # cases / follow up Percentage of Survival Larzarski et al. JOE, 2001 Sahlerabi, Rotstien, JOE, 2004 44,613 / 3.5 years 94.4% 1,462,936 / 8 years 97% Chen et al. JOE 2007 1,557,547 / 5 years 92.9% Meta-analysis of implants in partial edentulism Study Lindh et al. Clin Oral Impl Res, 1998 ADA Council, 2004 type /# cases / follow up Percentage of Survival SC / 2123 / 6-7 years 96.7%- 97.5% FPD / 4840 / 6-7 years 92.5% - 93.6% Endodontic vs Implant Survival Tooth or Implant? Endodontic Survival Studies Study # cases / follow up Percentage of Survival Larzarski et al. JOE, 44,613 / 3.5 years 94.4% 2001 Time Point of 72 months Survival Sahlerabi, Rotstien, 1,462,936 / 8 years 97% JOE, 2004 Chen et al. JOE 2007 1,557,547 / 5 years 92.9% Endodontic Therapy 94% Meta-analysis of implants in partial edentulism Study type /# cases / follow up Percentage of Survival Implant Therapy SC / 2123 / 6-7 years 95% 96.7%- 97.5% Lindh et al. Clin Oral Impl Res, 1998 Restorability Questions Is the remaining tooth structure compromised? Will it be an abutement? Will it survive 10+ years? What about esthetics? ADA Council, 2004 FDP / 4840 / 6-7 years 92.5% - 93.6%
Treatment Complications? Single unit restorations - retrospective evaluation 196 matched pairs of single implants versus initial NSRCT 1993-2002 Implants by Oral Surgeons, Periodontists and Residents RCT by Endodontists, Residents and Dental Students All teeth and implants were restored Treatment Complications? Implant Endo 0% 25% 50% 75% 100% Success Survival Survival with Intervention Failure Doyle et al., JOE, 2007 Doyle et al., JOE, 2007 Treatment Complications Treatment Complications Similar failure rates Survival without intervention Endo 90.3% and Implant 76.1% Implants had longer time to function and higher incidence of complications More complication with implants compared to conventional restorations Goodacre et al. J Prosthet Dent, 2003 Underestimated incidence of biological and technical complications with dental implants Berglundh et al. J Clin Periodontol, 2002 Doyle et al., JOE, 2007 What s in a smile?
Thick /Flat Square Crown Parallel Roots Thin / Scallopped Triangle Crown Tapered Root Ochsenbein & Ross, DCNA, 1969; Weisgold AS, Alpha Omegan, 1977 Tarnow DP, J Periodontol, 1992 >/= 5 mm = 100% loss of papilla 30-60 min after extraction papilla is affected Vertical Dimension changes Restoration of Treated Teeth Vertical Dimension changes Multiple Implants adjacent to each other A most critical aspect for success Needs to occur as soon as possible
Conclusions No generalizations on success rates Success needs to be clarified Plan in the best interest of the patient Avoid inadequate restorations Thank You