In his 1984 book, Future Shock, Alvin Toffler examines the impact of rapid technological change upon society. For the same year, a search of the National Library of Medicine website using the key words “dental” and “implants” brings up 14 papers.
A decade earlier, 12 were published and a decade previous to that there were none. Over the last 12 months, the same search strategy shows 427 titles, with a total of nearly 6,200 to date. A third of these were published in the last four years!
These data, coupled with the estimate that 69.5 percent of adults over 18 years of age in the US (and by extension, Canada) are missing one or more teeth1 strongly suggest that science based implant treatment is one of the prime examples of the impact of technological change upon society. Every discipline within dentistry is affected. This paper will examine implant treatment versus endodontic re-treatment.
A crown supported by a single implant is an alternative to endodontic re-treatment. Success rates of 97 percent have been reported for this modality.2 On the other hand, the long-term failure rate for endodontic re-treatment is 34 percent.3
Comparing the documented success rates for the two procedures suggests that implant treatment will become the standard of care in cases of failed endodontic treatment assuming that the patient is able to tolerate the associated surgery.
Should the re-treatment fail and the tooth require removal, as happens 34 percent of the time, then immediate implant placement should be considered. This method has become increasingly acceptable. Animal4 as well as prospective human studies5 show that the clinical outcomes and implant-bone surface area measured by histomorphometry are the same whether implants are placed into fresh extraction sockets or in healed, mature bone. The advantages of immediate single “staged” method of placement are that such method helps to preserve the bony crest and alveolar anatomy, it shortens treatment time and eliminates one surgical procedure.
In making a decision as to which alternative to used one should do a comparative evaluation of the chances of success of either options. The following factors should be considered:
— Tooth location and (strategic) importance of the tooth in question.
— Bone shape and quality
— Condition of the dentition in general
— Endodontic history. The degree of confidence in identifying the reason for the endodontic failure and the practitioner’s ability to rectify the failure is the key to the decision.
— General state of health and life expectancy.
— The patient’s expectations and preference of either one of the treatment options.
If the evaluation is objectively conducted, the implant option will be the first choice in many cases.
CASE 1 (Figures 1-8)
A 38-year-old female who had received endodontic treatment for tooth 1.5 as well as re-treatment including root re-section and retrofill presented for full coverage of the tooth. The adjacent 1.6 was slated for a full coverage crown as well because its large amalgam restoration was failing.
Examination of the 1.5 confirmed the suspected vertical fracture at the lingual aspect of the root. The patient was a non-smoker and a moderate drinker.
During a consultation she was informed that the prognosis for the tooth was hopeless. The recommendation for extraction and immediate implant insertion was made. She was told that the dental literature now supports immediate implant placement and that there would be no additional surgical trauma to the one that usually occurs after the surgical extraction of the tooth.
In addition, she was informed that the three-unit, fixed bridge option was an acceptable choice for replacing the 1.5 but such replacement may result in bone loss at the site of the extraction socket. After all her questions were answered she chose the immediate implant placement. It was concluded that the process of informed consent was fulfilled.
Using oral sedation, anti-inflammatory and antibiotic premedication and local anesthesia, tooth 1.5 was carefully extracted. The bone removed during the process of preparation of the osteotomy site was saved using an osseous coagulum trap and mixed with a bioactive glass graft material.
An implant was placed and stabilized in the site and the graft mixture was used to fill the crestal void between the implant surface and the extraction socket.
The patient agreed to go without an interim prosthesis that would serve a cosmetic purpose only. Seventeen weeks later, a crown and bridge abutment was cemented into the implant and the restorative treatment was completed.
Follow-up appointments over the past four years did show that she has been functioning problem-free function, enjoys acceptable cosmetics and that the periimplant bone was stable.
Images of implant treatment for three similar cases (Case 2–Figures 1-16; Case 3–Figures 17-24; Case 4–Figures 25-32) are also shown.
Given the above evidence, both anecdotal and literature-supported, should we re-treat an endodontic failure or extract the tooth and place an implant in its place at the same time? Although there is no answer that will fit all cases, the implant option must be carefully considered as a viable alternative.
All cases illustrated were treated with the Tenax Dental Implant System of Collingwood ON, Canada. Dr. Milan Somborac is the co-inventor of The Tenax Dental Implant System. He has a financial interest in Tenax Implant Inc.
Oral Health welcomes this original article.
REFERENCES
1.Marcus SE, Drury TF, Brown LJ, Zion GR. Tooth Retention and Tooth Loss in the Permanent Dentition of Adults: United States, 1988-1991. J Dent Res 75(Special Iss): 684-695 Feb. 1996.
2. Henry PJ. Laney WR, Jemt T et al, Osseointegrated implants for single-tooth replacement: a prospective 5-year multicenter study. Int J Oral Maxillofac Implants. 1996 Jul-Aug;11(4):450-5.
3.Allen RK, Newton CW, Brown CE Jr, A statistical analysis of surgical and nonsurgical endodontic retreatment cases. J Endod. 1989 Jun;15(6):261-6.
4.Schultes G, Gaggl A.Histologic evaluation of immediate versus delayed placement of implants after tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001 Jul;92(1):17-22
5.Polizzi G, Grunder U, Goene R, Hatano N, Henry P, Jackson WJ, Kawamura K, Renouard F, Rosenberg R, Triplett G, Werbitt M, Lithner B.Immediate and delayed implant placement into extraction sockets: a 5-year report. Clin Implant Dent Relat Res 2000;2(2):93-9
