Dr Malek - Endodontic- Prosthodontic Considerations.pdf

Endodontic- Prosthodontic Considerations MAT THEW MALEK, DDS DIRECTOR OF ADVANCED EDUCATION IN ENDODONTICS DIPLOMATE, AMERICAN BOARD OF ENDODONTICS DEPARTMENT OF ENDODONTICS NYU COLLEGE OF DENTISTRY Quality of Which is More Important: Root Canal Filling or Crown? Pre-operative Master-cone select...

Endodontic- Prosthodontic Considerations MAT THEW MALEK, DDS DIRECTOR OF ADVANCED EDUCATION IN ENDODONTICS DIPLOMATE, AMERICAN BOARD OF ENDODONTICS DEPARTMENT OF ENDODONTICS NYU COLLEGE OF DENTISTRY Quality of Which is More Important: Root Canal Filling or Crown? Pre-operative Master-cone selection 6-month follow up Success of Root Canal Treatment in Relation to the Quality of Restoration and Root Filling A Systematic Review On the basis of the current best available evidence, the odds for healing of apical periodontitis increase with both adequate root canal treatment and adequate restorative treatment. Although poorer clinical outcomes may be expected with adequate root filling–inadequate coronal restoration and inadequate root filling–adequate coronal restoration, there is no significant difference in the odds of healing between these 2 combinations. Brain M. Gillen et al. Impact of the Quality of Coronal Restoration versus the Quality of Root Canal Fillings on Success of Root Canal Treatment: A Systematic Review and Metaanalysis. J Endod 2011;37:895–902. The Impact of Full Coverage Restoration on the Outcome of Root Canal Treatment Endodontic Treatment Outcomes in a Large Patient Population in the USA: An Epidemiological Study ◦ 1,462,936 teeth of 1,126,288 patients. ◦ Assessed over a period of 8 years. ◦ 97% of teeth were retained in the oral cavity. ◦ 85% of the 3% extracted teeth had no full coronal coverage. Robert Salehrabi and Ilan Rotstein. Endodontic Treatment Outcomes in a Large Patient Population in the USA: An Epidemiological Study. J Endod. 2004. 30: 12: 846-850. The Impact of Full Coverage Restoration on the Outcome of Root Canal Treatment Influence of Clinical Factors on the Outcome of Primary Root Canal Treatment The following conditions were found to improve the outcome of primary root canal treatment significantly. 1. Pre-operative absence of periapical radiolucency. 2. Root filling with no voids. 3. Root filling extending to 2mm within the radiographic apex. 4. Satisfactory coronal restoration. Y.-L. Ng et al. Outcome of primary root canal treatment: systematic review of the literature–Part2. Influence of clinical factors. International endod J. 2008: 41, 6-31. The Impact of Full Coverage Restoration on the Survival of Endodontically Treated Teeth Tooth Survival Following Non-Surgical Root Canal Treatment: A Systematic Review Teeth survival over 2-10 years following root canal treatment ranged between 86% and 93%. The following factors were identified as significant prognostic factors; 1. Crown restoration after RCT. 2. Tooth having both mesial and distal proximal contacts. 3. Tooth not functioning as an abutment for removable or fixed prosthesis. 4. Non molar teeth. Y.-L. Ng et al. Tooth survival following non-surgical root canal treatment: a systematic review of the literature. International Endodontic Journal, 43,171–189,2010. Why Did this Tooth Become Infected? Crown became loose and was replaced 4 months later The Effect of Crown Preparation on the Health of the Pulp Each of the following procedures poses a potential threat to the integrity of the pulp through desiccation of dentine and production of frictional heat and exothermic reactions: ◦Removal of enamel and dentine ◦Fabrication of provisional restoration ◦Impression taking (conventional) ◦Temporary and permanent cementation The Effect of Crown Preparation on the Health of the Pulp A prospective study of the incidence of asymptomatic pulp necrosis following crown preparation ◦ 120 healthy teeth with healthy pulps from 33 patients. ◦ The final restorations were permanently cemented 6–10 weeks after treatment inception. ◦ 9% (11 teeth) become necrotic either before impression taking (6), or before final cementation (5). ◦ The odds of pulp necrosis of teeth with preoperative caries, restorations or crowns were eight times higher than those of intact teeth. A prospective study of the incidence of asymptomatic pulp necrosis following crown preparation . E. G. Kontakiotis et al. International Endodontic Journal, 2015, 48- 512-17 The Effect of Crown Preparation on the Health of the Pulp Retrospective study on the fate of vital pulps beneath a metal-ceramic crown or a bridge retainer ◦ 122 metal ceramic crowns and 77 bridges with 14 and 15 years follow up. ◦ The survival rates for pulp vitality were 81.2% (metal ceramic crowns) and 66.2% (bridges) after 15 years. ◦ The difference between the two groups was significant. G. S. P. Cheung et al. Fate of vital pulps beneath a metal-ceramic crown or a bridge retainer. International Endodontic Journal, 38, 521–530, 2005. The Effect of Crown Preparation on the Health of the Pulp Retrospective chart review of 2177 teeth with large restorations and at least one year follow up ◦ 9% of teeth with large restorations develop pulp necrosis. ◦ Teeth with full-coverage restorations were less likely to be extracted. Devon, Park et al. The Pulpal Response to Crown Preparation and Cementation. J Endod 2023;49:462-468. How Much Time Do We Have After Root Canal Treatment To Restore the Tooth? The number of days required for bacteria to penetrate the entire root canal in an unsealed tooth: In an in vitro study, over 50% of the root canals were completely contaminated after day 19. (Torabinejad 1990) How Much Time Do We Have After Root Canal Treatment To Restore the Tooth? Eight year retrospective study on the critical time laps between root canal completion and crown placement: ◦ Endodontically treated teeth that received composite/amalgam buildup restorations were 2.29 times more likely to be extracted compared with the ones that received crown. ◦ The 8-year survival rates of endodontically treated teeth that received crown within 4 months was 85%. ◦ The 8-year survival rates of endodontically treated teeth that received crown after 4 months of RCT was 68%. ◦ Teeth that received crown 4 months after RCT were almost 3 times more likely to get extracted compared with teeth that received crown within 4 months of RCT. Anita Aminoshariae’s group: Eight-year retrospective study of the critical time laps between root canal completion and crown placement: Its influence on the survival of endodontically treated teeth. J Endod 2016;42:1598–1603. How Does Post Preparation affect the Health of an Endodontically Treated Tooth? How does Post Preparation and Placement Affect the Survival of the Endodontically Treated Tooth? Retrospective chart review of 185 patients with an average recall of 2.7 years after RCT and post placement ◦ Twenty-six patients (30 teeth) had a post placed with the use of a rubber dam. ◦ 159 patients (174 teeth) had a post placed without a rubber dam. ◦ In the non-RD group, 128 (73.6%) teeth were considered successful at follow-up. ◦ In the RD group, 28 (93.3%) teeth were considered successful at follow-up. (P = .035). Joshua Goldfein et al. Rubber Dam Use during Post Placement Influences the Success of Root Canal–treated Teeth. 2013. J Endod 39:12:1481-84. How does Post Preparation and Placement Affect the Survival of the Endodontically Treated Tooth? Pre-op Post-op 6-month How does Post Preparation and Placement Affect the Survival of the Endodontically Treated Tooth? Pre-op. Excessive removal of pulpal floor Pre-op. Perforation visible Post-op. Perforation repaired Post space prepared Second perforation during post preparation How does Post Preparation and Placement Affect the Survival of the Endodontically Treated Tooth? Ninety four endodontically treated tooth, followed up for 1-5 years: ◦ (I) no gap between the gutta-percha and the post: 83% normal periapex. ◦ (II) a gap of >0 to 2 mm: 53.6% normal periapex. ◦ (III) a gap of >2 mm. 29.4% normal periapex. Moshonov et al. The Effect of the Distance Between Post and Residual Gutta-Percha on the Clinical Outcome of Endodontic Treatment. J Endod 2005. 31:3:177-9 How does Post Preparation and Placement Affect the Survival of the Endodontically-Treated Tooth? Hundred and five extracted teeth were examined: o In an in-vitro experiment teeth were distributed to 4 groups: 3mm, 5mm, 7mm, and full-length root canal filling. o Root canal fillings of 3, 5, and 7 mm have an inferior seal, compared with that of a full-length root canal filling. o The sealing is proportional to the length of the remaining filling. Metzger et al. Correlation Between Remaining Length of Root Canal Fillings After Immediate Post Space Preparation and Coronal Leakage. J Endod. 2000:26:12: 724-728. How did this happened? What is the problem? How to fix it? Conclusion o o o o o o o o o Restoration component of the treatment plan is as important as the endodontic portion of the treatment plan. Crown preps are injurious to the tooth: o Make sure you have baseline sensibility testing (with EPT or Cold). o If there are deep caries/filling or the tooth remains sensitive for more than few weeks after crown prep, suggest RCT. After RCT, make sure you restore the tooth within 4-6 weeks. (NOT MORE THAN 2-3 MONTHS) Temp falling out it is a dental emergency! Bring the patient back in a day or two, or re-do the RCT. Always use rubber dam for post preparation. Have accurate measurements in post preparation so that you don’t end up with gaps. When removing GP, don’t use Peso Reamers. Always use Gates or appropriate drills and if you don’t see Gutta Percha coming out, STOP!! Take a PA to confirm your direction during post preparation. Document if perforation occurred!! Thank you!