Endodontic implants /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education

www.indiandentalacademy.com

CONTENTS
• INTRODUCTION
• DEFINITIONS
• HISTORY
• MATERIALS
• INDICATIONS
• CONTRAINDICATIONS
• SUCCESS AND FAILURE
• TECHNIQUE
• REFERENCES
• CONCLUSION


DEFINITIONS
1) An endodontic implant is a metallic extension of the root
with the object of increasing the root-to-crown ratio, to
give the tooth better stability in the arch.
GROSSMAN.

2) A metallic extension of the root of a tooth, usually a
vitallium pin or post prepared for that purpose,
extending beyond the root apex and inserted into the
previously prepared channel in the bone above the root.
WALTON & TORABINAJAD.


3) An endodontic implant refers to the stabilization of the
root with an inert metallic implant that extends through
the apex into the periapical bone.
ALFRED L. FRANK

4) An endodontic endosseous implant consists of a metallic
extension beyond the root apex in order to improve the
crown-root ratio and thus stabilize an inadequately
supported tooth.
F J HARTY

THEY ARE ALSO CALLED AS:

- DIODONTIC IMPLANTS
- STABILIZERS -OR-
- ENDODONTIC STABILIZERS
- ENDODONTIC ENDOSSEOUS IMPLANTS.

Souza (1953)
Orlay (1960)

Frank (1967)

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• When metals are implanted into the human tissues, they
should be biocompatible (nontoxic and nonantigenic),
resist corrosion, resist stress, and be easily fabricated.

• FERGUSON (1959)…

• METALS USED FOR ENDODONTIC IMPLANTS
INCLUDE: Cobalt-chrome alloys (Vitallium) and
Titanium.


TISSUE RESPONSES TO IMPLANTED MATERIALS: 4

1) Tissue death if the material is toxic

2) Replacement by the surrounding bone if the material is
nontoxic .

3) Formation of fibrous capsule of variable thickness if
the material is biologically inactive, and

4) Formation of an interfacial bond if the material is
nontoxic and biologically active.


VITALLIUM IMPLANTS
• VITALLIUM is an alloy consisting of:
- 62 – 65% Cobalt
- 27 – 30% Chromium
- 5% Molybdenum
- 2 – 3% Nickel

• It has been extensively used as an implant material in the
human body.

• Venable et al. (1937) … earlier claims: electro passive,
inert and non irritating to the human tissues.
• VENABLE et al. (1939), BERNIER & CANBY (1943) –
Vitallium implants were well tolerated by the bony tissue
unless infection supervened.

• Several studies have shown that the alloy corrodes.
• SEM – pitting corrosion of Vitallium implants.

• LAING (1959), FERGUSON (1959) – corrosion products
are released to the surrounding tissues and metallosis
results.

• HERCHFUS (1954), FITZPATRICK (1968) –
concentrations of chromium ions were found dispersed
through out the body tissues, often at some distances
from the implants.


• SELTZER et al. (1973) – vitallium implants corroded in
the teeth and these corrosion products were cytotoxic to
the periapical tissues.

• ZMENER & DOMINQUEZ (1982) – by electron
microscopy and electron microprobe analysis, found
extensive corrosion of vitallium implants and these
corrosion products were detected in the surrounding
bone.

Thus, Vitallium is not inert, nor does it resist corrosion
when implanted in human body.


TITANIUM IMPLANTS
• A desirable, biocompatible material for use as an
endodontic implant, based on reported corrosion and
tissue toxicity studies.

• CORROSION PRODUCTS of titanium – oxides such as
Ti2O3. 5TiO2. TOMASHOV et al. (1972).

• MILLER & GREENER (1970) – corrosion rate of
titanium appears to be lower than that of most other
metals.


• Well tolerated …..

• ALBREKTSSON et al. (1985) – titanium implants in
rabbit tibias became osseointegrated.

• SELTZER et al. (1970) – presence of severe periapical
and lateral inflammatory lesions.

• “PIER EFFECT”


Indications


1) Periodontally involved teeth requiring stabilization.

STABILIZATION OF PERIODONTALLY
INVOLVED TOOTH
Radiograph of Periodontally
Involved lower incisor

Endodontic implant was
Placed to reduce tooth mobility.
14 year recall radiograph showing
No further bone loss.


)Transverse root fracture involving loss of the apical fragment or
he presence of two fragments that cannot be aligned.

HORIZONTAL
FRACTURE OF
THE ROOT

Placement of an endodontic implant
following the removal of an apical fragment

15 year recall
radiograph

3) Pathological resorption of the root apex incident to a
chronic abscess.

APICAL
RESORPTION
Endodontic implant
Placed to improve the
crown – root ratio
15 year recall
radiograph

4) A pulpless tooth with unusually short root

5) Internal resorption affecting the integrity and
strength of the root.

6) A tooth in which additional root length is desired
for improving its alveolar support.


7) When it is necessary for a tooth to have additional root length
to serve as a satisfactory bridge abutment or support for an
overdenture.

ADDITIONAL TOOTH LENGTH
TO SERVE AS ABUTMENT FOR
OVERDENTURE

9 year recall radiographs

Photograph of overdenture
With endodontic implants

8) EXCESSIVE MOBILITY DUE TO ABSENCE OF BONE
SUPPORT OR THE ROOT LENGTH

Absence of bone support Inadequate root length


9) Previous apical surgery, or where the elimination by
apical surgery of a perforation in the coronal or
middle part of the root would lead to undue mobility.

10) The technique is useful in teeth that have lost bony
support in either the coronal or the apical half of the
root.


Contraindications


1. Active progressive periodontal disease associated with
the tooth.

2. Periodontal communication (probing defect)
near the apex of the tooth

3. Anatomical structures in close proximity of the apex
of the tooth.

4. The buccolingual alignment of the tooth and
configuration of the cortical plate are such that the
stabilizer would project into soft tissues.

SUCCESS & FAILURE


• High failure rate.

• Success depends on proper case selection & on close
adherence to the following criteria:

1) Routine endodontic treatment can be carried out
without difficulty.
2) Alveolar bone is sufficient for the retention &
stability of both tooth and the implant.


• Endodontic implants have the histological
advantage of being totally intraosseous, without
communication into the oral cavity.

CRITERIA FOR SUCCESS:
1) There must be no communication to the oral cavity,
as demonstrated by probing.
2) There must be no radiographic evidence of apical
pathosis.
3) There must be no gingival suppuration.
4) The patient should be experiencing no discomfort.

SIGNS OF FAILURE
OF IMPLANTS

Radiograph taken 17 years following endodontic Implantation.
Note apical radiolucencies. There was a draining sinus tract
associated with the tooth

THE ACHILLES HEEL OF THE ENDODONTIC
IMPANT IS ITS APICAL SEAL

• HOLLAND & COLLEAGUES (1977) – attributed failure to a
defective seal between the implant and the root apex.

• SILVER BRAND & ASSOCIATES (1979) – claimed 90%
success rate for endodontic implants, despite the presence
of periapical lesions in 18% of their cases.

• OHNO & CO-WORKERS (1977) – implant and the sealer
were found to be encapsulated by fibrous connective tissue.

• SIMON & FRANK (1980) – Evidence of resorption of
dentin and cementum at the root apex because of the faulty
seal. www.indiandentalacademy.com

SOUND CLINICAL CRITERIA FOR A
SUCCESSFUL ENDODONTIC IMPLANT:

1) A normal gingival crevice containing a normal
epithelial attachment.

2) A radiographically normal attachment apparatus
including the bone, cementum and dentin.

3) A stabilized, functional and symptom less tooth.


ENDODONTIC IMPLANTS, WHICH CAN
RESULT IN FAILURE :
1) Poor apical seal resulting in periapical rarefaction around the root apex.

2) Extrusion of the excessive sealer through the apical foramen into the
periapical tissues, with resulting irritation.

3) Limitation in the length of the osseous portion of implant by local
anatomic factors in the maxilla or mandible such as maxillary sinus,
nasal fossa, and mandibular canal, or labio- or linguoversion of the
tooth in the jaw.

4) Perforation of the lateral surface or perforation of a curved root near
the root apex.

5) A structurally weakened tooth, instrumented to a much larger size than
usual, to receive an inflexible implant, which may fracture during
function.

ERRORS IN CASE SELECTION
AND DIAGNOSIS.


ERRORS IN CASE SELECTION
1) TERMINAL PERIODONTAL PROBLEMS.

2) ANATOMICAL FACTORS.


ANATOMICAL FACTORS


TREATMENT ERRORS
1) APICAL DISTORTION DURING CANAL
PREPARATION.

2) INADEQUATE FIT OF THE ENDODONTIC
IMPLANT.
- Over preparation of the root canal

3) INADEQUATE INTRA CANAL LENGTH OF
THE IMPLANT.


Over preparation of the canal resulting
in a lateral perforation


Pre- & post treatment photographs

INADEQUATE
LENGTH

Left bicuspid was successful Right bicuspid failed only
For 12 years. after 2 years.

oTo ensure satisfactory retention within the root, the
stabilizer should extend at least 5 to 6 mm into the tooth
and should make close contact with the walls of the
prepared canal for as great a distance as possible.

oPreparation is done entirely with reamers.

oAnterior teeth should whenever possible be enlarged to
atleast 70.

oAccess to the pulp cavity of an anterior tooth has to be
through the incisal edge, or close to it.


oTo avoid unnecessary pressure and irritation and to
ensure that it is completely seated with in the prepared
canal, the apical end of the stabilizer should be clear of
bone.

oFollowing insertion, sufficient room should be left in
the coronal part of the root to allow post crown
construction should this be necessary later.

oThe stabilizer is used to root fill the tooth in the same
way that a sectional silver filling is performed.


3 different techniques:

1) TECHNIQUE WITH PERIAPICAL SURGERY.

2) TECHNIQUE WITHOUT PERIAPICAL
SURGERY.

3) ALTERNATIVE TECHNIQUE FOR FRACTURED
ROOTS.


TECHNIQUE WITH TECHNIQUE 1
PERIAPICAL SURGERY

• This technique is used where surgical removal of the
apical part of the root is necessary because of root fracture
or perforation, or where an existing filling can only be
removed by a surgical approach.


1) Preliminary root canal preparation to a level just
short of the root apex.

2) Periapical surgery is then performed and the
apical part of the root removed.

3) Root canal preparation is now completed with
reamers to the level of the root apex.


4) The appropriate stabilizer is tried in the tooth and
the fit and the apical extension checked.

5) Cement is applied to the walls of the prepared canal
and to the coronal part of the stabilizer, and the
latter seated firmly in position.

6) Excess cement is removed and the wound is closed
with sutures.


TECHNIQUE 2
TECHNIQUE WITHOUT
PERIAPICAL SURGERY

• This technique is used when the tooth mobility is the
result of periodontal disease. Periapical bone is
removed by way of the root canal using reamers
40mm in length.

• The removal of periapical bone will necessitate local
anesthesia lingually as well as bucally.

• Equipment:
Same as for endodontic treatment, with the addition of
extra-long reamers, 40mm in sequential sizes and
implants of the corresponding size


• Tapered cobalt – chrome endodontic stabilizer
• Matching 40 mm hand reamer
• Engine driven drill for apex preparation.


ST P IN T CH
ES E NIQUE
1) Anesthetize the tooth and involved area with local
anesthesia.

2) With the rubber dam in place, aseptically complete
the usual treatment of access preparation,
enlargement and irrigation of the root canal.

3) A marker is then set on the 40mm reamers at the
level equivalent to the length of the tooth plus the
number of millimeters the implant will extend
beyond the root apex.


4) Osseous preparation is performed.

5) This channel is widened with progressively larger
instruments until the root canal preparation and the
periapical preparation form a continuous taper, with
simultaneous cutting of dentin and bone.

6) Select an implant of equivalent size to the last
instrument used, score it lightly to indicate the
desired length, that is from the occlusal tip to
through the root canal to the exact length cut into
the cancellous bone, and insert it into the root canal
and bone. See for the fit and extent.


7) Dry the root canal again. Shorten the implant at its
apical tip by 1mm, to ensure that it will seat snuggly
and will not bind in the cut osseous bed.

8) Insert a plugger into the access opening until it
binds, and measure the exact length it can be
inserted unimpeded into the canal. the plugger will
be used to seat the implant during cementation.


ALTERNATIVE TECHNIQUE 3
TECHNIQUE FOR
FRACTURED ROOTS

• Drilling is continued for a further 2-3 mm into the
bone, and this forms a base into which the
endosseous implant can be firmly seated.

• Try – in of the implant done.

• When the post core implant is seen to fit correctly at
both ends, it is removed, washed in sterile saline and
dried. The apical bone cavity is irrigated and the
root canal is dried.

• A root canal cement is now introduced in to the
deeper portions of the root canal.


• Post is now coated with an EBA cement.

• The post is placed into the root canal so that it seats
correctly in its apical end and also at the root face.
The jacket crown may now be cemented on to the
core and the post – core jacket held in position until
the cement sets hard.

• The apical end is now examined and any excess
cement removed.

• The flap is repositioned and sutured.


• Splinting is generally not necessary, but the
occlusion should be checked and freed of any
contact with the opposing teeth.

• The patient must also be instructed not to chew in
the area for 2- 3 weeks.

• Sutures are removed 4 – 7 days later.


REFERENCES:
1. ENDODONTIC ENDOSSEOUS IMPLANTS : CASE REPORTS &
UPDATE OF MATERIALS. J.O.Endo,1989;15(10):496-500

2. APPLICATION OF TITANIUM-ALLOY ENDODONTIC IMPLANTS

IN CONJUNCTION WITH PERIRADICULAR SURGERY.
OOO,1999;88:484-7

3. CUSTOM-FABRICATED ENDODONTIC IMPLANTS :
A REPORT OF TWO CASES.
J.O.Endo,2000;26(5):301-3


CONCLUSION
THE USE OF ENDODONTIC IMPLANTS HAS DROPPED SIGNIFICANTLY
IN RECENT YEARS. THIS IS UNFORTUNATE DUE TO THE MANY
VARIED SITUATIONS IN WHICH THEY CAN BE USED EFFECTIVELY
TO IMPROVE THE PROGNOSIS OF MOBILE TEETH. FOR VARIOUS
REASONS, INCLUDING POOR CASE SELECTION, IMPROPER USE OF
MATERIALS, & INADEQUATE APICAL SEAL OF THE IMPLANT, A HIGH
NUMBER OF FAILURES OCCURRED. HOWEVER, BECAUSE
OSSEOINTEGRATED ENDOSSEOUS IMPLANTS ARE NOW REPLACING
EXTRACTED TEETH, LITTLE ATTENTION IS NOW FOCUSED ON THE
USE OF ENDODONTIC ENDOSSEOUS IMPLANTS FOR TOOTH
STABILIZATION.

Thank
You


Endodontic implants /certified fixed orthodontic courses by Indian dental academy

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