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Implants vs. endo
Complimentary treatment strategies or adversarial threats?
The article has been accredited by Health Authority - Abu Dhabi as having educational content and is acceptable for up to 2
(Category 1) credit hours. Credit may be claimed for one year from the date of subscription.
By Richard Mounce, DDS
Implant therapy and endodontic therapy are complimentary
treatment strategies each with
relatively precise indications
and contraindications. When
carefully evaluated, cases of
endodontics vs. implants might
be evenly weighted in their indications, and occasions in
which a choice between one
modality or the other is not
clear are exceptional and uncommon.
Comparison of the two
modalities should include,
amongst many possible issues,
the type of implant placed as
well as the care and skill behind either of the treatment
modality, a parameter that is
challenging, at best, to measure across populations of clinicians. The best choice between
the two modalities is often
clearly present when the patient is allowed to choose between options that are clearly
defined and in which the financial benefit of the clinicians has
been taken out of the equation.
The endodontic literature indicates that the success rates of
endodontic treatment are very
evenly matched to implants
(James Porter Hannahan, Paul
Duncan Eleazer, Journal of
Endodontics, November 2008
{Vol. 34, Issue 11, Pages
1302–1305} and Scott L. Doyle,
James S. Hodges, Igor J. Pesun,
Alan S. Law, Walter R. Bowles,
Journal of Endodontics, September 2006 {Vol. 32, Issue 9,
Pages 822–827} ). In essence,
the choice between the two
modalities should be made on
the merits of the individual
clinical situation and of course,
as mentioned, primarily, the
patient’s wishes once he or she
has been informed of the objective facts.
As a starting place, underpinning all treatment planning
for retention of the natural
tooth is a correct diagnosis and
case assessment even before
any restorative treatment is
undertaken.
Is caries present? Does the
given crown or contemplated
restorations have to be placed?
All efforts that reduce pulpal
trauma are beneficial and ultimately will diminish the need
for endodontic therapy. Secondarily, having the clinician
be aware of the pulpal status at
all stages in the restorative
continuum has significant
value for all involved.
Clinically, this is manifest
as a restorative doctor that
knows both the present vitality
of the tooth being treated as
well as the future viability. Obviously, placing restorations on
teeth that ideally should be ex-
Fig. 1: The surgical operating microscope (Global Surgical, St. Louis,
Mo.).
tracted or have endodontic
therapy at that given moment is
contraindicated.
A careful assessment of
present vitality and future viability at all times in the process
can lead to early intervention
as well as more confident predictability of restoration and
natural tooth retention relative
to the alternatives.
This proactive approach is
far superior to being reactive to
teeth that become symptomatic where such a pulpal
breakdown could have been
entirely anticipated. Such anticipation can lead to a more informed patient, much greater
retention of tooth structure,
more well organized and
planned treatment, less endodontics and less tooth loss
relative to the alternatives.
In a hypothetical yet common clinical example, if a
lower molar is tipped to the
mesial; has no response to cold
testing (relative to the control
teeth); shows calcification in
the pulp chamber and a
widened PDL; and a bridge is
planned from #29 to #31 to replace a missing #30, it makes
sense to inform the patient that
the pulp in #31 is likely partially necrotic, even in the absence of overt symptoms, and
that the tooth is a candidate for
a root canal.
To restore the tooth without
endodontic intervention is to
invite a future symptomatic
painful event that now violates
the bridge and risks iatrogenic
events as well as create a cycle
of microleakage. At a minimum in this scenario, the patient must be informed that the
tooth has a strong likelihood of
becoming symptomatic and
given a choice as to his or her
preference for early intervention or to place the bridge and
risk its subsequent violation.
The microleakage mentioned can occur if the tooth is
not properly restored after the
endodontic treatment under a
rubber dam and ideally with a
surgical operating microscope
(Global Surgical, St. Louis,
Mo.) (or enhanced visualization) and using bonded obturation with a material such as RealSeal* in master cone or obturator form.
In this realistic clinical scenario, addressing the patient’s
needs correctly and properly at
the initial indication for endodontic intervention can
make manifest the best indications for natural tooth retention of #31. Alternatively, #30
might be replaced with an implant, #31 up righted and
treated endodontically and
crowned, thus in either event, a
proactive outcome (Figs. 1–2).
Fig. 2: RealSeal bonded obturation; SEM courtesy of Dr. Martin Trope.
Restorabilityandperiodontal
status
Clinical choices between
firsttime endodontic treatment, retreatment or extraction and implant are primarily
a matter of determining
whether the tooth is restorable.
This said, there are a host of
secondary factors that must be
considered and will be discussed below as well.
Knowing
which
teeth
should be removed and implants placed is a vital diagnostic skill. The author, a fulltime
endodontist, empirically estimates at one out of 10 or 15 of
the referrals for retreatment or
consultation is made on a nonrestorable tooth (Figs. 2, 3). As
a result, a workable criterion
for restorability is absolutely
vital as treatment of these teeth
would in all likelihood lead to
later extraction.
Primary factors to consider
in restorability include: the patient’s wishes and needs with
regard to expected function
and esthetics of the given tooth,
pulpal status, remaining tooth
structure, presence of existing
iatrogenic events, risk of future
iatrogenic events if the contemplated treatment/retreatment were to be completed,
possible existing vertical fracture, risk of vertical fracture if
the contemplated retreatment
were to be carried out, remaining bone support, periodontal
health or disease status of the
tooth, mobility, gingival tissue
health, oral hygiene, medical
history (especially patients undergoing
radiation
and
chemotherapy to the head and
neck, as well as those who have
taken biophosphanates, especially in IV form), dental history, bruxism and parafunctional habits, presence or absence of pulpal vitality, the
quality of the previous cleansing, shaping and obturation;
patient anxiety, arch position,
tipping, rotation, calcified
canals, atypical root anatomy
Fig. 2: RealSeal bonded obturation;
SEM courtesy of Dr. Martin Trope.
of all types, resorptive defects
and endo perio lesions.
It is an essential aside to
mention that the quality of
firsttime endodontic treatment
is in some measure determined by three things: the
length control, the degree of
microbial control during the
case, the coronal seal and the
taper prepared in the shaping
of the root canal system.
This is directly relevant to
one of the indications for implant therapy, the presence of
vertical fracture that results
from failed endodontic therapy. It should be stated that it is
not the endodontic therapy that
fractures the teeth, but the lack
of a correct taper choice for the
given root canal system.
Much like a tooth that is not
restored properly after endodontic therapy and is allowed to become contaminated (and the root canal therapy fails), it is not the root canal
procedure that has failed but
the manner in which it was carried out. In essence, choosing
the correct taper for the given
root form will diminish the risk
of vertical fracture as much as
placing the correct coronal
seal after treatment minimizes
the chances for failure of either
firsttime orthograde treatment
or retreatment.
Making superficial judgments as to the indications for
endodontic treatment and/or
extraction can easily be biased
by assumptions made on previous treatment that was done incorrectly and which unnecessarily risked vertical fracture.
Figs. 3-4: Teeth that were referred for
endodontic retreatment or surgery,
which were not restorable.
Informedconsent
The patient should be told
realistically, and without bias,
what the likely outcome of
treatment will be with either
treatment modality (endodontics versus implants) when the
financial interest of the clinician is taken out of the picture.
Arbitrarily removing #8 and
placing a single tooth implant
because of open apex after
trauma, for example, without
an endodontic consultation, is
shortchanging the patient by
not giving all the possible options.
Alternatively, doing a second surgery on a failed root
canal or possibly doing a first
exploratory surgery where the
longterm prognosis is guarded
at best, (case dependent) often
is better handled definitely by
extraction and placement of an
implant. There is an old expression that applies: “A horrible ending is better than a horror that never ends.”
Simply put, remove teeth
that more ideally would be better served with implant therapy and keep those teeth where
the predictability of restoration is such that this is the superior service.
Isendodonticdiseasepresent;
hasthecasefailed?
While on the surface it
might seem simple to address
this issue, it is not always entirely clear when endodontic
therapy has succeeded or
failed.
What of the upper molar
tooth that has had root canal
therapy and is less sympto-
DTME0110-new_ME 1/30/2010 9:29 PM Page 7
DENTAL TRIBUNE
matic than at the time of treatment and yet is still mildly sensitive to percussion, perhaps
from a missed MB2 canal? Or,
as can happen, what of the clinical case where the lesion of
endodontic origin that was
present heals partially and yet
still remains, albeit smaller
than it first appeared?
Each of these cases must be
addressed on a casebycase basis, but as a starting place, it is
advised to take a minimum of
two or three radiographs of the
given tooth from different angles: buccal, mesial and distal.
The presence or absence of
symptoms is recorded. An absence of symptoms to some
may mean the tooth does not
need retreatment, but actually
may be the beginning manifestation of failure.
For example, overt coronal
microleakage,
missed
canal(s), vertical fracture, lesions of endodontic origin
where one did not exist before,
etc., would all be cases that
need retreatment or extraction
(case dependent), but which
are not yet overtly manifest if
they are asymptomatic.
Asymptomatic failed endodontic cases can easily and
rapidly erupt into symptomatic
ones. Once a determination is
made that the previous root
canal has failed, the clinician
should default into a list of the
restorability considerations,
such as those given above to
determine if the tooth would be
better removed or retreated,
all things being equal.
Part of this determination of
retreatment/restorability vs.
extraction must consider
whether an apical seal can be
obtained and the technical deficiency that was present in the
initial treatment can be overcome. For example, if an apical
blockage and ledge has been
created, can it be bypassed and
addressed optimally? In any
event, the patient should be
told clearly what the challenge
that must be overcome is and
what the realistic probabilities
are for successful retreatment
(Figs. 5a, 5b).
Isanimplantbetterthanfirsttimeorthograderootcanaltreatment?
The answer to this question
is a more straightforward one
relative to cases where retreatment may also be an option.
Assuming that the periodontal support and restorability of the tooth are adequate, it
is difficult to justify an arbitrary removal of a tooth where
an orthograde root canal treatment has not first been attempted unless there are significant mitigating circumstances. Performing the root
canal treatment optimally is
essential to give the tooth the
best longterm prognosis and
preserve the natural dentition
(Fig. 6).
Anatomicconsiderations
There are few, if any,
anatomic considerations that
absolutely contraindicate orthograde root canal treatment
or retreatment. Apical surgery,
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if the cause of failure is not
clear.
A clinically relevant discussion of considerations that
should be made when evaluating endodontic versus implants has been presented.
Emphasis has been placed on a
careful assessment of the restorability of the given tooth,
whether the existing root canal
has indeed failed, if retreatment is feasible and what the
future prognosis is for the tooth
in view of the options for extraction and replacement with
an implant. DT
as an adjunct to retreatment,
has similar precautions relative to implants with regard to
impingement on vital structures such as the mandibular
canal, the mental nerve, perforation of the lingual cortical
plate in the mandibular posterior region as well as precautions related to the maxillary
sinus, amongst others. Horizontal and vertical lack of bone
and adequate attached gingival tissue are also considerations that might argue for retention of the natural tooth.
Costs:directandindirect
The direct and indirect
costs of implant therapy are
greater than those of retreatment or firsttime orthograde
therapy, but this assumes that
the endodontic therapy is successful in an applestoapples
comparison.
The worst of all situations is
one where the patient has the
tooth treated or retreated or
has surgery, then loses the
tooth and ends up with an implant. This unfortunate circumstance can be addressed
and most often avoided
through a proper restorative
evaluation and consideration
for treatment prior to the firsttime orthograde treatment and
possible retreatment as outlined in this article.
* SybronEndo, Orange, Calif.
About the author
Fig. 5: Clinical case that initially had coronal microleakage, uncleaned and unfilled space and a resulting apical lesion. Retreatment of this tooth (pictured here)
located and treated an MB2 canal as well as provided an adequate apical seal.
Advantagesandindications
forimplanttherapy
Advantages of implant therapy include the prevention of
bone loss after tooth removal if
the implants are placed six to
nine months after tooth removal, and functional and esthetic tooth replacement,
amongst other factors.
A primary consideration
that must be taken into account
to provide an optimal implant
utilization is the placement of
the implant in a location that
does no harm to vital existing
structures, and in which the
implant will be given enough
time to properly integrate. Additional considerations are
correct loading of the implant
with regard to avoidance of lateral forces and correct axial
loading forces.
Implant utilization also carries with it the advantage that it
can be of service in a variety of
other situations that might be
beneficial to the patient, where
this might not exist otherwise:
complete upper and lower denture stabilization and the single tooth implant (especially in
the upper anterior region and
combined single crown/fixed
partial denture restoration
scenarios assuming that the
implants are loaded correctly
as well as placed into areas of
adequate bone and tissue
health and receive adequate
postoperative care).
In all implant treatment it is
essential that the clinician appreciates how the bone will
heal post extraction, the effects
of systemic medications and
the changes and variations in
bone quality that may occur in
various clinical scenarios. A
reduced amount of bone into
which an implant is placed,
parafunctional habits, limited
7
Fig. 6: Clinical treatment carried out to the highest standard with the surgical
operating microscope, rotary nickel titanium Twisted Files*, RealSeal bonded obturation* and a bonded composite occlusal filling, Maxcem (Kerr, Orange,
Calif.).
space between the upper and
lower arches and atypical sinus anatomy may all lead to
changes in implant length or
placement strategies relative
to other areas.
In a similar manner, a resorbed lower ridge poses a
challenge for clinicians placing implants in this area. The
use
of
computerized
conebeam technology is invaluable to fully appreciate
these challenges clinically as
well as planned treatment. In
any event, it is a matter of debate as to which bone grafting
materials and techniques
might be optimal for situations
where the mandible is resorbed.
Sound clinical judgment
and principles must obviously
be applied on a casebycase basis.
And while this is an article
directed at making treatment
planning decisions with regard
to choosing between endodontics vs. implants, it bears mention that endodontic surgical
intervention should be noted
as an option in this continuum
both with and without known
sources of odontogenic failure.
Apical surgery is invaluable
to address cases where the
tooth has had optimal endodontic treatment, and possibly retreatment as well as ideal
coronal seal and yet failed, to
biopsy lesions of unknown origin in combination with the
need for root end surgery and
to perform exploratory surgery
Dr. Richard Mounce lectures globally
and is widely published. He is in private practice in endodontics in Vancouver, Wash. Mounce offers intensive,
customized
endodontic
single-day training programs in his
office for one to two doctors at a time.
For more information, contact
Dennis at (360) 891-9111 or write
[email protected].
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