implants - international magazine of oral implantology

I special _ endo-implant algorithm Fig. 2a_The use of dyes, colouring agents and micro-etching is invalu- able in visualising a suspected crack in tooth structure. Cohen et al. found that when premolars were used as bridge abutments, a surprising number of these abutments sustained a VRF.61 Fig. 2b_The dental literature reports a statistically higher level of accuracy using CBCT (cone-beam computed tomography) scans for detecting VRF than with the use of peri-apical radiography alone. Fig.2c_Themultivariatenatureof theendo-implantalgorithmmandates theuseofCBCTtodetectandevaluate thedegreeofperi-apicalpathosis. Analysisofthesize,extent,natureand positionofperi-apicaland resorptivelesionsinthreedimensions isessentialfortheoptimallevelof standardofcareindiagnosis. The prosthodontic pundits maintain that the spiralling costs of saving endodontically retreated teeth, for which extraction may well prove to be the commonendpoint,bringintoquestionwhethersuch teeth should be sacrificed early. Ruskin et al. con- cluded that implants have greater success than en- dodontic therapy, are more predictable, and cost less when one considers the ‘inevitable’ failure of initial root-canal treatment, retreatment and peri-apical surgery.2 Isitresponsibletherapeuticsorirresponsible expediency that justifies the removal and restoration of such teeth from the outset with an implant-sup- ported restoration? Can one ethically argue that ex- tractioniswarrantedbecausethefinancialcostofor- thodontic extrusion/soft-tissue surgery, endodontic retreat-ment and post/core/crown fabrication is greater than extraction with an implant-buttressed restoration, and in all likelihood, more predictable?3 Jokstad etal.4 identified over 220 implant brands in the dental marketplace. With variability in surface, shape, length, width and form, there are potentially morethan2000implantsforanygiventreatmentsit- uation. A systematic review by Berglundh et al.5 as- sessedthereportingofbiologicalandtechnicalcom- plications in prospective implant studies. Their find- ings indicated that while implant survival and loss were reported in all studies, biological difficulties, such as sensory disturbance, soft-tissue complica- tions, peri-implantitis/mucositis and crestal bone loss, were considered in only 40 to 60% of studies. Technicalcomplicationssuchascomponent/connec- tionandsuperstructurefailurewereaddressedinonly 60to80%ofthestudies.Areweasaprofessionstand- ing idly by and watching marketing pressures force treatment decisions to be made empirically, with untested materials and techniques? There is an un- settlingsimilaritybetweentheseeventsandtheearly days of implant development.6 The endodontic pundits argue that major studies published to date suggest there is no difference in long-term prognosis between single-tooth implants andrestoredroot-canaltreatedteeth.Infact,regard- less of the similarity of treatment outcomes, the pre- ponderanceofpost-treatmentcomplicationsfavours endodontictherapy.Therefore,thedecisiontotreata tooth endodontically or to place a single-tooth im- plantshouldbebasedoncriteriasuchasrestorability of the tooth, quality and quantity of bone, aesthetic demands,cost-benefitratio,systemicfactors,poten- tial for adverse effects and patient preferences.7–11 A review of endodontic treatment outcomes by Fried- man and Mor12 used radiographic absence of disease and cli-nical absence of signs and symptoms as the definingparametersforsuccess.Theysuggestedthat the chance of having a tooth extracted after failure from initial endodontic treatment, retreatment and apical surgery collectively would be roughly one in 500 cases. The dialogue comparing endodontic treatment to implant therapy jarringly overlooks the crucial fact that it is often the calibre of the restoration and its prognosis, and not the endodontic prognosis per se, thatisthedeterminantofthetreatmentoutcome.The primary biological mandate of any dental procedure is the retention of the orofacial ecosystem in a dis- ease-free state. Surgical and non-surgical endodon- tic therapies have historically been key modalities in the attainment of this foundational goal. Friedman noted that “the patient weighing one ‘success’ rate against the other may erroneously assume their def- initionstobecomparableandselectthetreatmental- ternativethatappearstobeofferingthebetterchance of‘success.’”13 Theconundrumwithwhichresearchers and clinicians alike wrestle increasingly includes the non-science of emotion as well. This publication will address non-surgical and/or surgical resolution of failing primary endodontic treatment outcomes and the historical and ongoing efforts of the dental industry to engineer the bio- mimetic replacement of natural teeth successfully and replicate the structural predicates that comprise the substitution algorithm of bone, soft tissue and tooth.Therearemanylevelstotheaccrualof‘bestev- idencedentistry’.Thepurposeofthispaperistoensure that all variables in the treatment planning equation of foundational dentistry are understood and given equalweightinthedecision-makingprocessforcom- prehensive care. 08 I implants2_2011 Fig. 2b Fig. 2cFig. 2a