The Endodontic / Implant Controversy
Innovations in Endodontics Series
Robert Handysides DDSAssociate Professor and ChairDepartment 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
Endodontics
Oral Surgery
Orthodontics
Pediatric Dentistry
Periodontics
Prosthodontics
Endo or Implant?
Survey by Dr. Huan Su
Tooth Supported Restoration
Implant Supported Restoration
0 7.5 15 22.5 30
0
4
0
3
6
13
13
6
Perio, Prosth, Rest FacultyPerio, Prosth, ResidentsEndo FacultyEndo Residents
University of PennsylvaniaWhy do they prefer an implant over a
conventional restoration?
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?
Function / Survival
Repair / Regeneration
Esthetics
Success of Periodontal Therapy
Success of Periodontal Therapy
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
Percentage of periodontally treated teeth extracted during long term periodontal maintanace
Definition of ‘Questionable’ Tooth
Good Prognosis Control of the etiologic and adequate periodontal support
Fair Prognosis Approximately 25% of attachment loss and / or Class I furcation involvement
Poor Prognosis50% attachment loss and/or Class II
furcation involvement that allows proper maintenance
Questionable Prognosis
Greater than 50% attachment loss, Class III or Class II furcation
involvement that is difficult to maintain, 2+ mobility or greater
Hopeless Prognosis Inadequate attachment to maintain the tooth
McGuire, MK, & Nunn ME J Periodontol 1996ab
Success of Implant Therapy Success of Implant Therapy
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’s Criteria
Albrektsson et al., JOMI, 1986
Success of Implant Therapy
Misch’s Criteria / Quality Assessment
Misch et al., Implant Dentistry, 2008
Implant Quality Scale Group Clinical Conditions
Success (Optimum Health)
No pain or tenderness to percussion0 mobility<2 mm radiographic bone loss from initial surgeryNo history of exudate
Satisfactory Survival
No pain on function0 mobility2-4 mm radiographic bone lossNo history of exudate
Compromised Survival
May have sensitivity on function0 mobility>4 mm radiographic bone loss but less than 1/2 of implant bodyProbing depth > 7 mmMay have history of exudate
Failure
Pain on functionMobilityRadiographic bone loss greater than 1/2 length of the implant bodyUncontrolled exudateNo longer in the mouth
High Risk Factors for Implants
Smoking Habits
31% implant failure in smokers
Bain & Moy, JOMI, 1993; deBruyn & Collaert, COIR, 1994
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
more bone loss around implants than smoking
Galindo-Moreno et al., COIR, 2005
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
Inferior Bone Quality
16-35% implant loss in type IV bone
Jaffin & Berman., JOMI, 1991
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
Inferior Bone Quality
Unsatisfactory Oral Hygiene
Schou et al., COIR, 2002; Jovanovic SA, Adv Dent Res, 1999
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
Inferior Bone Quality
Unsatisfactory Oral Hygiene
Parafunctional habits and occlusal overload
Johansson & Palmqvist, Int J Prosthodont, 1990; Misch CE, Dent Today, 2003
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
Inferior Bone Quality
Unsatisfactory Oral Hygiene
Parafunctional habits and occlusal overload
Medically Compromised
High Risk Factors for Implants
Smoking Habits
Alcohol Abuse
Inferior Bone Quality
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
Brynolf 1967
Histological examination
Walton and Green found almost the exact opposite
Success of Endodontic Therapy
Strindberg 1956
Clinically no symptoms
Radiographically PDL within normal limits and an intact lamina dura
Initial
1 Yr Recall
Does Apical Pathology 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%
Does the ‘Operator’ affect Success?
General Practitioner 64.4% Pre Doctoral Student 68.4%
Post Doctoral Student 82.9% Specialist 87.6%
Ng et al. IEJ 2007
Endo Treatment -5 year follow up-
by general dentist 89.7%Endo Treatment -5 year follow up-
by endodontist 98.1%
Survival
Alley et al. OOOOE, 2004
Endodontic vs Implant Survival
Study # cases / follow up Percentage of Survival
Larzarski et al. JOE, 2001
44,613 / 3.5 years 94.4%
Sahlerabi, Rotstien, JOE, 2004
1,462,936 / 8 years 97%
Chen et al. JOE 2007 1,557,547 / 5 years 92.9%
Endodontic Survival Studies
Endodontic vs Implant Survival
Study # cases / follow up Percentage of Survival
Larzarski et al. JOE, 2001
44,613 / 3.5 years 94.4%
Sahlerabi, Rotstien, JOE, 2004
1,462,936 / 8 years 97%
Chen et al. JOE 2007 1,557,547 / 5 years 92.9%
Endodontic Survival Studies
Study type /# cases / follow up Percentage of Survival
Lindh et al. Clin Oral Impl Res, 1998
ADA Council, 2004
SC / 2123 / 6-7 years 96.7%- 97.5%Lindh et al. Clin Oral
Impl Res, 1998
ADA Council, 2004
Lindh et al. Clin Oral Impl Res, 1998
ADA Council, 2004FPD / 4840 / 6-7 years 92.5% - 93.6%
Meta-analysis of implants in partial edentulism
Endodontic vs Implant Survival
Study # cases / follow up Percentage of Survival
Larzarski et al. JOE, 2001
44,613 / 3.5 years 94.4%
Sahlerabi, Rotstien, JOE, 2004
1,462,936 / 8 years 97%
Chen et al. JOE 2007 1,557,547 / 5 years 92.9%
Endodontic Survival Studies
Study type /# cases / follow up Percentage of Survival
Lindh et al. Clin Oral Impl Res, 1998
ADA Council, 2004
SC / 2123 / 6-7 years 96.7%- 97.5%Lindh et al. Clin Oral
Impl Res, 1998
ADA Council, 2004
Lindh et al. Clin Oral Impl Res, 1998
ADA Council, 2004FDP / 4840 / 6-7 years 92.5% - 93.6%
Meta-analysis of implants in partial edentulism
Time Point of 72 months Survival
Endodontic Therapy 94%
Implant Therapy 95%
Tooth or Implant?
Restorability Questions
Is the remaining tooth structure compromised?
Will it be an abutement?
Will it survive 10+ years?
What about esthetics?
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
Doyle et al., JOE, 2007
0% 25% 50% 75% 100%
Implant
Endo
Doyle et al., JOE, 2007
SuccessSurvivalSurvival with InterventionFailure
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
Doyle et al., JOE, 2007
Treatment Complications
More complication with implants compared to conventional restorations
Underestimated incidence of biological and technical complications with dental implants
Goodacre et al. J Prosthet Dent, 2003
Berglundh et al. J Clin Periodontol, 2002
What’s in a smile? Challenges with Esthetics
Smile line
Challenges with Esthetics
Smile line
Biotype
Challenges with Esthetics
Smile line
Biotype
Thick /FlatSquare CrownParallel Roots
Thin / ScalloppedTriangle Crown
Tapered Root
Ochsenbein & Ross, DCNA, 1969; Weisgold AS, Alpha Omegan, 1977
Challenges with Esthetics
Smile line
Biotype
Tarnow DP, J Periodontol, 1992>/= 5 mm = 100% loss of papilla
30-60 min after extraction papilla is affected
Challenges with Esthetics
Smile line
Biotype
Vertical Dimension changes
Challenges with Esthetics
Smile line
Biotype
Vertical Dimension changes
Multiple Implants adjacent to each other
Restoration of Treated Teeth
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