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Natural Tooth V/S Implant: – Restorative Advantage

July 7th, 2012 by isprp

  A fundamental principle in traditional dental practice has been the preservation and rehabilitation of natural teeth. Endodontic treatment procedures have played a key role in this context in the retention and restoration to function of teeth affected by pulp and/or periapical pathosis. The extraction of teeth has generally been considered undesirable and as a treatment of last resort due to the limitations of alternative prosthodontic replacements such as bridges and removable prostheses .In recent years however, this paradigm has been challenged by emerging trends in implant dentistry, with implant replacements being touted as equal to or even superior to the preservation of natural teeth.   Clinicians frequently face the dilemma of whether to endodontically treat and retain a questionable tooth or to extract and potentially replace it with a dental implant. Dentist appear to make the decision for extracting a tooth on the basis of multiple risk factors including endodontic and periodontal criteria, remaining tooth structure, restorability with core build-ups and post and core, extant of previous restoration as well as the perceived strategic value of tooth. An ideal treatment plan should address the chief complaint of the patient provide the longest lasting ,most cost effective treatment ,and meet or exceed patient expectation whenever possible. Evidence based principles that include identification of specific scientific evidence ,accessing its validity and using the best evidence to inform patient care decisions. The aim of this essay is to conduct a systematic review of clinical ,psychosocial,and economical out come,as well beneficial and harmful effects ,of initial non surgical endodontic care ,compared to extraction and placement of implant.   Functional & Psychological Factors Endodontically treated teeth maintain the original proproioceptive mechanism of natural teeth ,whereas implant lack periodontal ligament and ability to perceive functional load and shock absorption. Periodontal afferent signals  to control jaw actions Implant patients show impaired fine motor control of the mandible Natural tooth – proprioception- more effective occlusal contact leading to more efficient mastication Implant – osseoperception-lower maximum bite force reduced chewing efficiency and smaller contact area Tooth retention provides superior aesthetics and psychological outcome. Esthetics gingival outcome in implants will depend on tissue biotype.   Success and survival of RCT teeth Fristed et al (2004) found a 95.5% radiographic success rate with retreated teeth recalled  20-27 years postoperatively, while same sample had a 85.7% success 10 years previously. The teeth deemed to be failures radiographically at 10-17 years were still functioning after another 10 years and healing was observed after the extended observation time. According to a recent meta-analysis, the pooled outcome of primary RCT was 75% when strict success criteria (absence of periapical radiolucency) were applied, and reached 85% based on loose criteria (reduction in size of 2007). Chen et al. (2007, 2008) also reported a high 5-year tooth retention rate of 93% Following nonsurgical RCT in more than 1.5 million teeth. In all, almost 10% were affected by untoward events (6.9% of the teeth were extracted, 2.3% required nonsurgical retreatment, and in 0.5% apical surgery was performed) Success and survival of dental implants In 1996 the ADA’s Council on Scientific Affairs looked at over 1400 implants with success rates ranging between 94 to 99%. The 10-year survival rates reached 93% (implant-FDP) and 94% (single tooth implants. STI) on an implant level, whilst survival of the implant restorations varied between 87% (implant-FDP) and 90% for the ISC (Pjetursson et al. 2004a). Eckert et al.62 recently assessed the five-year survival rate of 96 %(CI: 93to 98 %) was observed for a total of 7398  implants. Creugers et al. reported that single tooth implants showed an acceptable four-year survival of 97 %. The authors included 13 studies involving RCT and 55 with implants in their meta-analysis, with only one study (Doyleet al. 2006), involving a comparison of both. With proportion estimates for survival of 94%for RCT and 96% Implant supported single crowns (ISC) at 5 ye ,and 97% (RCT) d 94% (ISC)at 6 years and overlapping confidence intervals at any time-point, the review did not reveal  any difference between the two treatment modalities.   Recent changes in endodontic treatment and implant therapies  During the last decade, RCT has benefited from improvements in techniques and equipment such as nickel-titanium rotary instruments, electronic apex locators and microscopic magnification for nonsurgical and surgical therapies (Manning 2000, John et al. 2007). When implant treatment was introduced in the 1970s, several restrictions were defined in order to minimize the risk of implant failure or complications.  Presently,many newer deigns in implants with surface coatings along with better surgical and graft procedures have enhanced success rate of implants Complications There are two major types of implant therapy complication, biological and technical (mechanical). Biological complication consist of disturbance in the function of the tissue supporting an an implant include implant loss and reaction in peri implant hard & soft tissue. Technical complication refers to mechanical damage of the implant and implant component and superstructures. Implant loss before functional loading- 2.5% Implant loss during function- 2%-3% Implant supported over denture- >5% Endodontic complications are usually measured with endodontic outcome and treated as failure, rather than as separate complication. Caries, bacterial micro leakage as a result of poor coronal seal, and periodontitis that might cause tooth loss. Failure related to non surgical  or surgical retreatment , peri-radicular surgery all end up in teeth getting extracted CONCLUSION A simple comparison of long-term survival or success rates of root filled teeth and implants does not fulfill the demand for a comprehensive decision-making process, which includes multiple factors to evaluate. If a tooth deemed restorable condition from a restorative and periodontal aspect, endodontic therapy should be first treatment option considered. if a tooth have poor restorative or periodontal prognosis, extraction and implant should be considered. it is important to note that the two treatment alternative have different aims; endodontic treatment is provides to treat or prevent apical periodontitis. Whereas implant are used to replace missing teeth In case of full-mouth rehabilitation, single tooth prognosis and the site-specific treatment recommendation is possibly overruled by the overall treatment planning and a therapy-related decision for a strategic extraction may be required to perform reasonable reconstructions with uncompromised long-term prognosis. Irrespective of the type of the selected treatment option involving teeth and/or implants, ongoing maintenance is required to assure sufficient periodontal and peri-implant care, and treat any type of biological or technical complication at an early stage to reduce the risk of compromising the longevity of the reconstruction. This post has secured first place for essay competition by Dr. Girish Kumar K.V.G.  Dental College Sullia (D. K.)

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