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A dental implant is an artificial tooth root replacement and is used in prosthetic dentistry. There are several types. The most widely accepted and successful is the osseointegrated implant, based on the discovery by Swedish Professor Per-Ingvar Brånemark that titanium could be successfully incorporated into bone when osteoblasts grow on and into the rough surface of the implanted titanium. This forms a structural and functional connection between the living bone and the implant. A variation on the implant procedure is the implant-supported bridge, or implant- supported denture.- More from Wikipedia

 Retreatment Vs Implants
The opinions and photographs within this web page are not ours. Authors have been credited for the individual posts where they are. - www.rxroots.com

From: Marga Ree To: ROOTS Sent: Monday, February 12, 2007 10:02 AM Subject: [roots] Retreatment versus implant I had a hard time on this one, in particular the removal of the distal post. It took my 3 sessions to complete the case. There were 2 posts and 2 separated instruments inside. The distal post was tough to remove, it took me almost a whole session. After finishing the endo, I placed of a fiber post in the distal canal with a BU of Build-it. Unfortunately the crown could not be recemented, I had to cut a wide access opening to get access to the post and sep instruments. When vibrating the post, it came loose, and we decided to have a new one made after finishing treatment. I know that people critize the amount of time that is involved in this type of treatment. 3 sessions spent at the endodontist's office, and a new crown. This cannot be cheap. Why not take it out and place an implant? Cheaper? In our country an uncomplicated implant placement (without bone augmentation) and a suprastructure is about the same price as a complicated retreatment including a BU plus a new crown. Very often in retreatment cases, the existing crown can be saved, but this one was an exception. So no difference in cost for the patient, but an implant takes less time, you don't need to spend 3 sessions of almost 2 hours in the dental chair. It is often said that the placement of an implant is easier than a doing a complicated retreatment. The impression for a suprastructure takes also less time than a crown prep. No prepping, no cord that needs to be packed, no critically subgingival margins that need to be exposed, etc. And then the prognosis. I am not going to argue the success rates of implants vs retreatment, because an important variable here is the operator, in spite of what the lit says about this topic. This one has healed up nicely, but was it worth the extra effort? I think it was, and so does my patient. But what do my colleagues think? Are we going to treat only uncomplicated cases? Because the complicated cases take too much time and effort, and ask too much from the patient and the clinician? I hope not! What do you think? - Marga

Implants are to replace missing teeth. Implants are not to replace teeth. (it was Jan Lindhe who said this) - Michael Depends. This may the correct answer to retreatment vs implants but elsewhere some people don't fit into this pigeon hole. I have a female patient in her 70s with Sjögrens that has been affecting her for at least twelve years. We are struggling with dissolution of the minerals in her teeth that is not reversed by normal saliva production - not the typical caries that one would see. We have tried to manage this in as many ways as we can - fluoride, CCP-ACP, saliva stimulants, xylitol, chlorhexidine, diet, you name it - the problem is the well is dry and there is no silver bullet. Her dental IQ is high and she attends regularly. The current battle involves exposed dentine - the pH to dissolve enamel is 5 - my recent notes from Terry Donavan's lecture here on Friday says that dentine dissolution pH is 6.7. The other issue that may be at hand is Candida which is present in her mouth as a sequela of Sjögrens - C. albicans possesses the ability to dissolve HAP to a greater extent (approximately 20-fold) when compared with S. mutans. I have selected to have three teeth replaced by implants on a patient that traditionally we would have crown lengthened, endodontically treated, and crowned. 15(4) had sub gingival pulpal caries. 31(24) and 41(25) were about to meet a demise similar to previously extracted 32(23) and 42(26) - sub gingival caries to the pulp. Any crown lengthening on 15 would have left 16 and 14 with exposed dentine which in this case would have left these teeth vulnerable. My clinical experience told me that 31 and 41 restored with herodontics would have not lasted any length of time. 15 was extracted and replaced by an implant. 31 and 41 were extracted and implants were placed in the site of 32 and 42 which had previously been replaced by cantilevered pontics off of 33 and 43 respectively. I would choose to replace any teeth on this woman with implants over endodontics and crown lengthening except now she has thrown in a wild card... she is taking fosamax. Just when I thought we had a winning solution...Cheers - Bob March issue of Endodontic Tribune will have the material forwarded to you yesterday I believe, or at least I think I did. This topic is crucial and I'd encourage you all to consider working with Endodontic Tribune to publish your commentary and thoughts and case reports. If we continually rely on a small coterie of folks to raise the bar, then it's their bar they're raising, not necessarily yours............ - Kendo Dear Marga, Very very very nice case!!! In my country the price of an uncomplicated implant placement (without bone augmentation) and a suprastructure is much higher (a lot ...a lot more) than the most complicated retreatment incluiding a BU plus a new crown. So the difference in cost for the patient is that the retreatment is cheaper. The problem here is other...for some people is much easier to take the option of the implant because is more expensive and they´re going to win more money... I completely agree with what you say "it is worth the extra effort and time taken for that molar"... And also...that the success rates for sure depends a lot of who is the operator!!! Thanks a lot for sharing this case! - Noemí Pascual Badalona - Barcelona Dear Marga, In my opinion and personal experience, it worths to have your own tooth save! 15 years ago my father (a GREAT dentist by the way) did a RCT in my UL6 (26). It worked for a very long time but 3 years ago I started to feel a little discomfort when I bit so I told my father the bad news and, although we couldn't see anything bad in the xray, he retreated the palatal canal; but months later the discomfort persisted. At that time I was dating a dentist with special interest in endodontic who kindly offered to do the RCT again for me. I accepted his offer (with my father's authorization of course :-) I spent I think that 3 appoint of 2 hours each! Fighting for not falling asleep! But it worth it, right now I am symptom-free. I had a fiber glass post and a new crown fitted. I will repeat all the process again. I already know that there is a high risk that perhaps one day I'll fracture this tooth but until then I prefer to keep my tooth and delay the implant. I would like to post the xray but although the tooth is mine I think that the "treatment copyright" belongs to him and I need his authorization first.. I love to read your post! - Marcela

Marga, congrats. of course is worthing every penny, at least from my point of view. rct vs. implant is a closed subject to me, why?becouse even if an overall rct cost beats an implant cost, the root has a natural joint to bone, and it is "self" . A root beats by far an implant speaking of prosthetic load on it. My country(romania) is still a heaven for rcts becouse they are at least 2 times cheaper than an implant....(anyway, both of them are very cheap comparing the prices from us by example; we are speaking about 100-200$ at most for a rct, and 400-800$ for an implant) - Serglu Nicola And as would be expected, Marga, you did a fantastic job. Guy Marga, great case as always!!! I think patient deserves our best effort to keep their natural tissues, healthy in the long term. Implants are the option when the case is not restorable, but the first choise when there is not a good endodontist available. Just the way I think and work. Best regards and thanks for sharing!!! - Carlos Marga, I go through that every day with cases like that every day. You are right. The problem is health entrepreneurialism which is health exploitation rationalizing expedient treatment as the “best” treatment. I could elaborate and go on, but it would cause another Brouhaha regarding who I would be showing as one of the guru culprits of the problem - Terry Marga: I would have taken as much time and as much money from the patient to do the implant and the crown. Those arguments are not valid. Your comments on the operator are crucial. A marga ree endo retreat has a far better prognosis then a mediocre treatment elsewhere. As far as success rates, way too much is made of that in my estimation in both endo and implantology. That is a statistical game designed to support whatever side of the argument you would like to defend. There are only two success rates to the patient: 100% or 0%. And I agan submit, if you feel in your best clinical judgement the tooth is retreatable endodontically, that should be the only course of action. If we are wrong, the implant option is still available - Gary Hi Marga, great case as usual. Concerning the lit on prognosis of treatment we have a lot of controlled studies on implants, but what is missing is a sufficient number of cross-sectional studies, especially those concerning success of an implant, than survival. I point on this, cause you are absolutely right, to hint on the importance of the operator. I attache a similar one, where I especially indicated to the patient, that the big perf questions the prognosis: Big perf Big fractured instrument All closed with thermafil Control after 6 month is promising. Let’s see! - Carsten

Amazing work – I like the capillary tip ‘tip’ - Simon Bender How do you remove that post?Only with US vibration? - Marcos Marco, I removed the posts with a combination of US vibration with lots water cooling, see papers below, a post puller, lots of good music on the radio and some persistence. These were titanium posts, not the easiest to remove (I'd rather remove cast posts) and sometimes hard to see on a radiograph, because they have the same radiopacity as gutta-percha. I will post another example - Marga

1: J Endod. 2006 Nov;32(11):1085-7. Epub 2006 Sep 25. The effect of ultrasonic post instrumentation on root surface temperature. Huttula AS, Tordik PA, Imamura G, Eichmiller FC, McClanahan SB. Naval Postgraduate Dental School, Bethesda, Maryland, USA. This study measured root surface temperature changes when ultrasonic vibration, with and without irrigation, was applied to cemented endodontic posts.

Twenty-six, extracted, single-rooted premolars were randomly divided into two groups. Root lengths were standardized, canals instrumented, obturated, and posts cemented into prepared spaces. Thermocouples were positioned at two locations on the proximal root surfaces. Samples were embedded in plaster and brought to 37 degrees C in a water bath. Posts were ultrasonically vibrated for 4 minutes while continuously measuring temperature. Two-way ANOVA compared effects of water coolant and thermocouple location on temperature change.

Root surface temperatures were significantly higher (p < 0.001) when posts were instrumented dry. A trend for higher temperatures was observed at coronal thermocouples of nonirrigated teeth and at apical thermocouples of irrigated teeth (p = 0.057). Irrigation during post removal with ultrasonics had a significant impact on the temperature measured at the external root surface. Publication Types: Comparative Study Randomized Controlled Trial PMID: 17055912 [PubMed - indexed for MEDLINE] 2: J Endod. 2005 Apr;31(4):301-3 Analysis of heat generation using ultrasonic vibration for post removal. Dominici JT, Clark S, Scheetz J, Eleazer PD. University of Louisville School of Dentistry, Louisville, KY, USA.

This study measured the temperature of the root surface and post during the application of ultrasonic vibration to cemented posts to simulate post removal procedure. Root canal therapy was performed on ten extracted maxillary incisors.

A stainless steel Parapost was cemented into each prepared post space. Ultrasonic vibration was applied to the post and temperatures were recorded at the coronal post and the cervical root surface. Data were analyzed with ANOVA using the independent variables of (a) time of ultrasonic application (15, 30, 45 and 60 s) and 2) location (post and root surface). Greater temperature increase was observed at the post (52.6 degrees C, SD 11.1; 82.6 degrees C, SD 20.1; 111.0 degrees C, SD 29.1; 125.3 degrees C, SD 33.2) compared to the root surface (9.5 degrees C, SD 4.6; 17.5 degrees C, SD 4.8; 25.4 degrees C, SD 7.3; 32.2 degrees C, SD 8.1) for each time period, P < 0.001. Ultrasonic application to the post for longer than 15 s generates high temperature on the root surface. Publication Types: Research Support, Non-U.S. Gov't PMID: 15793389 [PubMed - indexed for MEDLINE]

Thanks to everybody for their imput on my post retreatment versus implants. It's always nice to get support from people who think alike! - Marga Display Pagerank   Geo Visitors Map