endo implant controversy - health ministries...196 matched pairs of single implants versus initial...

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


Smoking Habits

Alcohol Abuse

more bone loss around implants than smoking

Galindo-Moreno et al., COIR, 2005


Smoking Habits

Alcohol Abuse

Inferior Bone Quality

16-35% implant loss in type IV bone

Jaffin & Berman., JOMI, 1991


Smoking Habits

Alcohol Abuse


Unsatisfactory Oral Hygiene

Schou et al., COIR, 2002; Jovanovic SA, Adv Dent Res, 1999


Smoking Habits

Alcohol Abuse



Parafunctional habits and occlusal overload

Johansson & Palmqvist, Int J Prosthodont, 1990; Misch CE, Dent Today, 2003


Smoking Habits

Alcohol Abuse




Medically Compromised


Smoking Habits

Alcohol Abuse




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




44,613 / 3.5 years 94.4%


1,462,936 / 8 years 97%



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


ADA Council, 2004FPD / 4840 / 6-7 years 92.5% - 93.6%

Meta-analysis of implants in partial edentulism




44,613 / 3.5 years 94.4%


1,462,936 / 8 years 97%



Study type /# cases / follow up Percentage of Survival


ADA Council, 2004

SC / 2123 / 6-7 years 96.7%- 97.5%Lindh et al. Clin Oral

Impl Res, 1998

ADA Council, 2004


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


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


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


Smile line

Biotype

Thick /FlatSquare CrownParallel Roots

Thin / ScalloppedTriangle Crown

Tapered Root

Ochsenbein & Ross, DCNA, 1969; Weisgold AS, Alpha Omegan, 1977


Smile line

Biotype

Tarnow DP, J Periodontol, 1992>/= 5 mm = 100% loss of papilla

30-60 min after extraction papilla is affected


Smile line

Biotype

Vertical Dimension changes


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

endo implant controversy - health ministries...196 matched pairs of single implants versus initial...

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