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CHAPTER

EFFECTS OF DENTAL IMPLANTS ON TREATMENT PLANNING FOR PROSTHODONTICS, PERIODONTICS, AND ENDODONTICS
MAHMOUD T ORABINEJAD

After ascertallllllg the chief complaint, collecting pertinent information regarding the patient's medical and dental history, performing complete subjective as well as objective and radiographic tests, and analyzing the obtained data, the demist should be able to come up with the right diagnosis. Once the nature of the problem is identified, proper treatment planning should be formulated for the patient. Treatment planning can so metimes become complicated and is affected by the views of th e stakeholders (patients, insurance companies, dentists) who have different perspectives and expectations regarding the outcome of treatment. Patients are usuall y content as long as their treatment is functionally and esthetically pleasing. Insurance co mpanies measure success by access to care, quality of care, and cost as well as survival rate of treatment. Dentists are usually concerned with the quality of delivery of provided care and fair compensation.' In addition to general expectation of the stakeholders, a number of other factors can influence the treatment planning. These include procedure involved, the restorative material used, the influence of one treatment on another, the availability of specialized expertise, the projected longevity of treatment, the functional and psychological satisfaction achievable, the ability of the patient to maintain the results of treatment, the affordability of the services, and the individual clinician's skill and support. 2

Treatment planning should be patient-centered, not based solely on dental insurance benefits or guided by the desires and clinical experience of the practitioner. It should be evidence based and ideally should preserve the biologic environment while maintaining or restoring esthetics, comfort, and function. The real art of dentistry is to coordinate and interface these perspectives and expectations among stakeholders. provide the best quality of care to the patient, and satisfy the needs of the other involved parties in most clinical situations. The art and science of dentistry have been unitized to prevent oral diseases such as caries and inflammation of the periodontium, and restore function and esthetics to teeth affected by these diseases, using periodontal treatment, root canal therapy, and restorative procedures. Advances in both the biologic and technologic aspects of dentistry have resulted in the retention and rehabilitation of millions and millions of natural teeth, to the satisfaction of patients throughout the world. Despite these advances, many teeth develop decay. severe periodontal involvement, become fractured, and succumb to extraction. Traditionally, these teeth were treated endodontically or periodontally, or if not restorable. they were extracted and replaced with either fixed or removable prosthesis. Introduction of cylindrical-style enclosseous implants3,4 to the dental profession, and their high survival rates, has significantly affected treatment planning in dentistry. The purpose of this chapter is to discuss the effects of dental

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1061 Endodontics

implants on treatment planning for prosthodontic.s, periodontics, and endodontics.

Effects of Dental Implants on Prosthodontics


The benefits of extraction and replacement of a missing tooth with a fixed partial denture (FPD) are prevention of shiftin g of the adjacent teeth, improved chewing ability, and esthetics (Figure 1). Studies have shown no adverse effect on the surrounding alveolar bones and attachment level between teeth supporting FPOs and a homologous tooth 6 and no difference in plaque

index, gingival index, and probing depths between baselines.7 It has also been found that if hygiene is maintained to a high level, no inflammation of the mucosa should be seen under the pontic, regardless of the pontic material used. s Tooth preparation, impression, tempori7.-ation, and cementation while fabricating an FPD can, however, all result in pulpal injury.9 Endodontic treatment (Figure 2) is often needed in the years following crown cemenlation. lO When examining teeth with advanced periodontal disease over an average period 0(8. 7 years, abutment teeth for bridges needed endodontic treatment five times more often (15% vs 3%) than nOI1abutment teeth . In a clinical study, Goodacre et aL II

Figure 1 R eplacement of missing teeth with a fixed partial denture can prevent shifting of the adjacent teeth. A. Clinical photo. B. R adiograph.

Figure 2 A. Pulpal necrosis occurred following tooth preparation and cementation of a crown resulting in a pcriapicallesion. B, Endodontic treatment resolved the extensive lesion. Photos courtesy of Or. GW. Harrington.

Chapte r 41 Effects of Dental Implants on Treatment Planning for Prosthodontics, Periodontics, and Endodontics 1 107

Figure 3 After 5 years of service. deelopment of decay under crown margin of second mandibular molar.

report on the incidence of decay (0-27%) (Figure 3), pulpal problems (3-38%), and periodontal problems (4%), as well as technical complications such as porcelain fracture (2%), in patients who have had fixed prosthodontics for a 5-year period. The findings in these studies should be considered during treatment planning in light of recent reports on the high success rate for single-tooth implants. Whereas previously, all efforts would have been made to extract hopeless teeth and place fixed or removable prostheses, the palpable benefi ts of implants have caused a paradigm shift in prosthetic and surgical dentistry. Cl inicians are regularly con fronted with difficult choices: Should a hopeless tooth be extracted and replaced with an FPO or single implant? Placing a dental implant, rather than an FPO , provides a functional stimulus to help preserve the remaining bon e, and prevent resorptio n, while preserving the enamel and dentin of the adjacent abutment teeth . Furthermore, this approach is less invasive to the pulp of the adjacent teeth. The biologic advantages over traditional prosthodontic methods include preservation of the natural dentition and supporting periodontium, improved esthetics, improved h ~~iene accessibility, and reduced future maintenance. I 3 In a 3-year follow-up report of 78 single-tooth implants and 148 adjacent teeth, no adjacent teeth required extraction or endodontic treatment, and on ly 4 required restorations. Comparison of the periodontal status at crown placement and at follow-up revealed no differences for plaque and bleeding indices or for

pocket probing depths of the adjacent teeth. There was, however, a significant influence of the horizontal distance on interproximal bone loss in closer distances of the anterior region, but not in the posterior region. 14 Peri-implant tissue differs from the gingiva surrounding natural teeth by having greater pocket 5 depths and twice as much bleeding on probing. 1 The connective tissue portion around implants contain s signi fi cantly more collagen (85% vs 60%) than around natural teeth, and fewer fibroblasts (1-3% vs 5-15%) .16 The majority of peri-implant tissue recession occurs during the first 3 months, with 80% showing buccal recession .16 In patients w1th appropriate oral hygiene, however, the intra-crevicular position of the restoration margin does not appear to adversely affect peri-implant health and stab ility.17 Recently, Curtis et al. 2 discussed the impact of new scient1fic advances on treatment planni ng in dentistry. According to these authors, treatment planning in prosthodontics has changed significantly because of the recent advances in the success rate of single-tooth implants. In 1994, Creugers and associates l8 performed a meta-analysis on the dental literature since 1970, presenting clinical data regarding durability of conventional fixed bridges. These authors report an overall survival rate of 74.0 2.1% after 15 years. Scurna et aJ. 19 in another meta -analysis of the literature reported an 87% lO-year survival rate for FPOs and a 69% lS-year survival rate. A recent systematic review20 compared the outcomes of tooth-supported restorations with those of implantsupported restorations. The authors concluded that at 60 months, single-tooth replacements, supported by implants, had a higher survival rate than those su pported by PPOs; however, if res1n-bonded FP])s were excluded, no difference was found. They reported that FPO success rates continued to drop steadily beyond 60 months. These results are consistent with the results of another systematic review by Torabincjad et al. 21 that reported Single-tooth implants, and endodontic treatments resulted in superior long-term survival, compared with FPDs.

Effects of Dental Implants on Periodontics


Previously, all efforts were made to save teeth with periodontal disease. Currently, the high success ra tes of implants have affected this concept, causing a paradigm shift in periodontics. Clinicians are asking:

108 / Endodontics

Should a periodontally involved tooth be extracted and replaced with a dental implant? The benefits of successful treatment of a tooth with periodontal disease include conservation of the crown and root structure, preservation of alveolar bone, and accompanying papillae, preservation of pressure perception, and lack of movement of the surrounding teeth . The harmful effects of extraction include bone resorption,22 shifting of adjacent teeth,23-15 and reduced esthetics and chewing ability.26 Studies on long-term prognosis of teeth with periodontal disease show less than 10% tooth loss due to periodontal . reasons. 27-29 S'IllgIe-roote d teet h have better prognOSIS 27 29 compared with molar teeth . - Presence offurcation involvement with or without surgical intervention is associated with poorer prognosis than those without . . . prost h 0 d ontlcs, . the IllVO Ivement. 3fl.31 ' As III fu rcation new innovations in implant dentistry have also decreased reliance on high-risk periodontal procedures for tissue preservation and regeneration for teeth with moderate to sever periodontal disease. 2 This paradigm shift in periodontics is evident in recent surveys conducted by the American Academy of Periodontology, which show 63% of periodontists are placing their primary emphasis on periodontics and 27% are placing their primary emphasis on implants. 32

Patient-Related Factors
SYSTE MIC AND LOC AL HEALTH FAC TORS
Based on available clinical data, it appears most of the preoperative factors such as age, gender, tooth location, lesion size, pulp status, and symptoms do not affect outcomes of root canal treatment. A hi story of diabetes, however, may have a n e~ative impact on the healing of periap ical lesions. 3 The presence of periapical lesions is the major preopera tive factor having a negative influence on the outcome of root canal therapy.35-38 Presence of some systemic disease can also affect the outcomes of implants.39 Diabetic patients,10 immune-suppressed individuals,39 and patients who smoke41 -44 have a higher risk of complications following placement of implants.

PULP AND PERIODONTAL CONDITIO NS


Indications for root canal therapy include teeth with irreversible pulpitis, necrotic pulps, restorable crowns, salvageable periodontal conditions, salvageable resorptive defects, and favorable crown-to-root ratio. Contraindications for root canal therapy are teeth withou t pulpal pathosis (except those done for prosthodontics reasons), with Wl-restorable crowns, with unsalvageable periodontal conditions, with unsalvageable resorptive or fract ure defects, and with poor crown-to-root ratio. Root canal treatment is contraindicated when there is limited remaining tooth structure and the definitive crown will not be able to engage at least 1.5 to 2.0 mm of tooth structure with a cervical ferrule. 45,46 Bridge abutment teeth with root canal treatment fail more often than similar teeth with vital pulps.47-49 On the other hand, crown placement has a significant positive effect on the survival of endodontically treated teeth. 5o Indications for single-tooth implants are nonrestorable tooth, un salvageable resorptive defects, poor crown- root ratio, unstable abutment , and singlerooted teeth with infractions or vertical root fractures (Figure 4). Other indications for the use of implants

Effects of Dental Implants on Endodontics


The high success rates of implants have also affected the thinking of clinicians for patients with pulpal and/ or periapical diseases. Clinicians are asking: Should a pulpally/periapically-involved tooth be extracted and replaced with a dental implant? There are factors involved during decision -making in treatment planning, as to whether a tooth receives root canal treatment or is extracted and a dental implant placed. These factors can be divided into two broad categories: patient-related and treatment-related factors. 33

Chapter 4 1 Effects of Dental !mplants on Treatment Planning for Prosthodontics, Periodontics, and Endodontics 1 109

Figure 4 Root canal therapy is not indicated for teeth with A. un-restorable crowns; B, unsalvageable resorptive defects: C , poor crown-root ratio:

or D, vertical root fractures .

include edentulous sites adjacent to teeth without restoration (Figure 5) or the need for restoration, abutment teeth with large pulp chambers, and abutment teeth with a history of avulsio n or too th luxation. 5 ) Single -tooth implants are contraindicated in patients who desire to keep their natural teeth, medically compromised patients, smokers, patients who are too old or too young, and patients with difficult surgical procedures.

BIOLOGIC ENVIRON MENTAL CONSIDERATIONS


Some patients are prone to recurrent caries or periodontal disease (Figure 6). Retaining teeth in such patients can be challenging and frustrating for the prac* titioner as well as the patients. Placement of implants
Figure 5 Singletooth implants are a treatment option in edentulous

sites adjacent to nonrestored teeth.

110 I Endodontics

Figure 6 Patients prone to A, recurrent caries or B, periodontal disease are poor candidates for fixed pania l dentures_

may be more prudent in patients needing both root canal treatment and periodontal therapy. Patients with limited abilities or interest in performing routine oral hygiene procedures are also poor candidates for root canal treatment or periodontal therapy, and may be better candidates for placement of implants.

SOFT TISSUE ANATOMY


The interdental papilla sometimes does not fill the cervical embrasure space around crowns that attach to both root-canal-treated teeth and dental implants. It has been determined, however, that soft tissue will fill the cervical embrasure around a crowned implant when the inciso----<:ervical distance from the proximal contact to the interproximal bone crest is 5 mm or less. 52 Periodontal biotype (thick or thin) can affect the potential for soft tissue to fill the cervical embrasure space around implants (Figure 7). In a thin biotype, papillae adjacent to implants can seldom be recreated when the distance is more than 4 mm between the interproximal bone crest and the desired height of the interdental papillae. s3 Preservation of a tooth through root callal treatment may provide better soft tissue esthetics than extracting the tooth and placing a dental implant in a patient with thin biotype.

bone. 54 Retaining teeth, through rool canal treatment, having a poor long-term prognosis, and performing high-risk endodontic surgical procedures as well, can substantially affect the amount of bone and prognosis of future implants in those sites. Early removal of teeth with poor prognosis and placement of dental implants may produce an environment more suitable for ideal implant positioning and optimal esthetics. 55

TEETH WITH UNIQ UE COLOR CHARACTERISTICS


Color matching in anterior teeth with unique dentin colorations can be a significant challenge for the practitioner. Retaining such teeth through root canal treatment (even with heroic efforts) without ceramic crowns may be esthetically advantageous to extracting them and placing implant crowns that do not match the surrounding environment (Figure 9). Color-matching anterior teeth needing root canal treatment and a thick ceramic crown can sometimes be very difficult. Construction of a ceramic crown made for an implant usually produces a better color result because it can be fabri cated with a greater thickness of porcelain thai enhances the color-matching potential, particularly in esthetic regions of the mouth.

QUANTITY AND QUALITY OF BONE


Quantity and quality of bone have no significant effect on the outcome of root canal treatment. By contrast, the quantity of available bone affects the feasibility of placing implants without bone grafting. Bone quality also affects implant success with type IV bone (Figure 8), producing lower success compared with types 1 to III

Treatment-Related Factors
ETH ICAL CONSIDERATIONS
Dental practitioners have an obligation to provide the longest lasting, most cost-effective treatment that addresses the chief complaint of the patient and meets

Chapter 4 / Effects of Denta l I mplants on Treatment Planning f or Prosthodontics, Periodontics, and Endodontics / 111

Figure 7 A. Patients with thick biotype gingiva and teeth in esthetic zones are good C<lndidate for dental implants. 8, Patients with thin biotype gingiva and teeth in esthetic wnes are good candidate for root canal treatment.

Figure 8 A. Mandibular molar region has good bone quality for implant placement. 8, Maxillary molar region with poor quality bone is not ideal for dental implants.

or exceeds patient expectations whenever possible. Advice to the patient and the treatment provided should be patient-centered, not based solely on dental insurance benefits or guided by the desires and existing clinical experience of the practitioner. Practitioners should strive to present a balanced perspective

regarding alternative treatments. The capacity to achieve balance requires practitioners to be familiar with both treatments. It is difficult to objectively present alternative treatment options when an individual has only substantive clinical experience with one option.

112/ Endodont ics

Figure 9 R etaining teeth throu gh ro ot canal treatment and bleaching withou t ceramic crowns in esthetic zones may be esthetica lly advantageous over placing implant crowns that are difficult to match to adjacent teeth.

tion. However, patients presenting for extraction are often in pain, as are those presen ting for root canal treatment. This may have the effect of raising the anxiety levels of both these patient populations. The question of pain associated with treatment has been analyzed to some degree in implant literature, although not to the same extent as in the endodontic literature. Andersson et al. 59 found that 88.2% of subjects gave positive responses to the question of implant treatmen t being pain-free, with 70.6% givi.ng a "Yes" response along with 17.6% stating, "Yes, with doubt." Watkins et al.,6O on the other hand, observed a mean pain score of 22.7 out of 100 in 333 subjects seeking RCT, with an addilional score of 19.9 noted "unpleasantness." Of signi6cance, 20% of the endod ontic cohort reported to the appointment in pain. One prospective stud y61 focused on im plant complications and found that 92% of the subjects felt the number of complications was acceptable. No endodontic study was found to have evaluated this question.

PROCEDURAL COMPLICATIO NS PATIE NT COMFORT AND PERCEPTIO NS


The studies that have focused on the pretreatment anxiety of patients seeking root canal treatment are inconclusive. Whereas some note no difference between root canal treatment and extraction ,56,57 others58 report higher anxiety levels in patients being considered for randomized controlled trial (RCT). A lack of data exists about examining pretreatment anxiety of patients seeking implant treatment. The most similar treatment that has been studied is extracRoot canal treatment can sometimes be associated with procedural accidents (Figure IDA). These mishaps can occur during different phases of root canal treatment. 62 Some of these accidents can have a n~ve impact on the outcomes of root canal treatment. Studies have shown that the apical extension of root canal filling materials as well as quality of obturation can affect the prognosIs . 0 f root canaI treatment. "." As with root canal treatment, complications can occur with dental implants. SurgicaJ implant complications

Figure 10 Rool canal treatment or implant placement can sometimes be associated with procedural accidents. Examples are A.. furcation perforation in a maxillary molar; 8, a large hematoma following implant surgery.

Chapter 4 / Effects of Denta l Implants on Treatment Plann ing for Prosthodontics, Periodontics, and Endodontics 1113

include hematomas (Fil\ure 1013), cchymosis, and neurosensory disturbance. 4 Inflammation andlor proliferation of gingiva as well as soft tissue fenestration/ dehiscence can occur fonow ing implant placement. Early implant loss can occur as a result of failure of the implant to integrate with the bone. Mechanical complications of implant placement include screw loosening, screw fracture, prosthesis fracture, and implan t fracture. 54 Minor complications such as screw loosening arc easily corrcr:ted, whereas major complications such as fenes tration/dehiscence can result in clinical failure.

effectiveness in comparison with any alternative where the tooth is lost.

TR EATMENT OUTCOM ES
Clinical and radiographic examinations are the most common procedures used to determine outcomes of root canal therapy. Examination of the data regarding success and failure of root canal treatment shows significant variability in material composition, treatment procedures, and evaluatio n criteria. Some studies use recognized evaluation methods, such as the periapical index. 67 The periapical index relies on the comparison of the radiographs with a set of five radiographic images representing a radiographically healthy periapex (score 1) to a large periapical lesion (score 5). Another evaluation method that has been used in several studies is the system suggested by Halse and Molven,68 who place radiographic findings in one of the following groups: (1) success, where there in no visible periapical lesion; (2) uncertain, where there is an uncerta in findi ng such as an existing increased wid th of the periodontal ligament space; and (3) failure, where there is a pathologic finding such as a periapical radiolucency. The shortcomings of these methods of evaluation are that they determine " success" strictly on the basis of radiographic find ings. As early as 1966, Bender and coworkers69 noted that radiographic interpretation is often subject to personal bias and that a change in angulations can often give a completely different appearance to the lesion, making it appear either smaller or larger. It has also been shown that different observers may not agree on what they see in a radiograph, and in fact the same observer may disagree with himself if asked to review the same radiograph some time later.7o Based on the resu lts of studies published since 1996, the American Dental Associat ion Council on Scientific Affairs reports high implant survival rates for various clinical situations. 39 With regard to the single-tooth implant, the Council's evaluation of 10 studies involving over 1,400 implants shows survival rates (without giving length of time) ranging from 94.4% to 99%, with a mean survival rate of 96.7%. High mean survival rates were also reported for partially edentulous patients with implant FPDs. This report states that immediate loading of implants does not lower the survival rates, with three studies reportin? survival rates ranging from 93.5% to 95.6%? In a systematic review of clinical implant studies, Creugers and associates71 predicted a 4-year survival rate of 97% fo r single implants. In another paper, Lindh et al. 72 performed a meta-analysis of

ADJU NCTI VE PROC EDU RES REQU I RED


A number of adjunctive procedures can be perfor med in high-risk root canal treatment or placement of an implant and crown. Saving some teeth with signifi ca nt decay or periodontal disease may require crown lengthening through surgery or orthodontic extrusion as well as periodontal disease therapy. In light of high success rates with dental implants, the value of such procedures needs to be reevaluated. Lack of bone prior to placement of an implant may require bone grafting or distraction osteogenesis, sinus grafting, and ridge augmentation. These highly difficult technical procedures are expensive, unpleasant, and time consuming.

COS T OF TREATMENT
According to the data collected by the American Dental Associatio n (Jack Brown, personal communication) thro ugh its Services Rendered Survey tha t yield natio nal and sub national estimates of fees for general practitioners (GPs) and specialists for each CDT4 code, the initial cost of an extraction, endosteal implant, abutment, and crown is approximately $2,850 and does not vary substantially whether a GP, an oral surgeon, or a periodontist provides the surgical care. On the other hand, the costs of an anterior root canal treatment provided by a GP with a resi n-composite restoration, and a molar root canal treatment provided by an endodontist followed by an amalgam build-up and a porcelai n fused to high noble metal crown are approximately $743 and $1,765, respectively. This simple analysis does not include consultatio n fees and pre-operative radiographs that may vary from simple periapical views to cone-beam tomography and CT scan for implant placement. Additional separately charged procedures such as surgical guides (stents) or provisional restorations may also be necessary. Retention of a periodontally sound tooth through root canal treatment clearly has tremendous cost benefit and cost-

114 / Endodontics

implant stud ies involving partially eden tulous patients. They reported a success rate of 97.5% after 6 to 7 years for a single-implant crown. In a recent systematic review, Torabinejad et al. 2 1 compared the outcomes of endodontically treated teeth with those of single dental implant-supported crown, FPD, and no treatment following extraction. Success data in this review consistently ranked implant therapy as being superior to endodontic treatment, which in turn was ranked as being superior to fixed prosthodontic t reatment (Table 1). At 97%, long-term survival was essen tially the same for implant and endodontic treatments and was superior to extraction and replacemen t of the missing tooth with a FPD. Iqbal and Kim 73 have reported similar fmdings when they compared the survival of restored en donticaUy treated teeth with implant-supported restorations.

ALTER NATI VE TRE ATMENTS


The treatment options following unsuccessful initial root canal treatment are re-treatment andl or endodontic surgery. In I\vo separate searches, investigators at Loma Linda University searched for clinical articles pertaining to success and failure of nonsurgical and surgical re-

treatment, and assigned levels of evidence to these st udies. Their first search, related to nonsurgical retreatment, resulted in the identification of 31 clinical st udies and 6 review articles? 4 The success rate of nonsurgical re-treatment ranged bel\veen 40% and 100%. Based on the literature, it appears that the success rate is very h igh in teeth without periapical lesions and when the cause of failure is identified and corrected properJy.74 Their seco nd search, pertaining to success and failure of periapical surgery, 10G.1.ted many clinical studies, most of which were case series. 75 The success rate of surgicaJ endodontics varied from 31% to over 90%. The significant differences in the techniques, materials, and methods of evaluation make it very difficult to compare these studies. Most recent studies using new materials and techniques ' h success rates lor C surgery. 76-79 report h Ig end a d ontIc Considering factors involved in treatment planning for patients who have been afflicted by oral diseases or traumatic injuries, decision to keep a tooth through root canal treatment or periodontal therapy, or extraction and placement of a fixed or partial denture, or an implant supported restoration, should be based on scienti fic evidellCe. ldeally one should strive to preserve the biologic environment, while maintaining or restoring long-term esthetics, comfort, and function for the patient.

Table 1 Pooled and Weighted Sur'mal and Success Rates of Dental Implants, Root Canal Treatment, and Three Umt Bridges 2-4, 4-6, and Over () Years
SlIccess 2-4 years Dental implant lpooled) De nta l Implant Iweightedl Root canal treatmentlpooledl Root canal treatme nt (weighted) Th ree Imit bridge (pooled) Three unit bridge {weighted) 4-6 years Dental imp lant [pooled) Dental implant (weighted) Root canal treatment (pooled) Root canal ueatment (weighted) ThrC!C unit bridge (!X)oled) Three umt bridge {weightedl 97 (96-981 98 (97-991 93 (87- 97) 94 (92-961 82(71-911 76 (74-79)
97 (95-98)

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