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Endo treatment planning_4_d


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Endo implant algorithm

Endo implant algorithm

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  • 1. Endodontic Treatment Planning in the Fourth Dimension by L. Stephen Buchanan, DDS, FACD, FICD“…Time loves a hero, but only Time will tell if he’s Dental examples of respect for first order issuesreal…” — Little Feet would be 1) making sure that you are not planning to retreat a root-fractured tooth, or the other extreme 2)And so it is with endodontic treatment planning. making sure that you are not replacing a tooth with anThis article discusses treatment planning rules that implant when a simple endodontic procedure couldwill help your endodontic therapy stand the test be done with a high expectation of success (Figuresof time, finishing with a report from the digital 1A & 1B).frontier about how 3D digital imaging and treatmentplanning is revolutionizing the planning as well as So what are the first order priorities in treatmentthe accomplishment of exceptional dentistry. It all planning for endodontics? I would have to say that itbegins with first order issues. boils down to four serial requirements: 1) Determine the prognosis.First Order Issues 2) List possible courses of treatment.My father, a retired control systems engineer (missile 3) Choose the best treatment.guidance), taught me that the most important thing 4) Plan the do at the beginning of any creative pursuit is tosearch out and determine the first order issues. What Regardless of how far our procedural technologyare first order issues? Here’s an example: if you were advances in the future, these four issues will alwaysdesigning a suite of software that would later run the beg an answer before any cutting of PC computers, you would want to be certainthat you leave enough character spaces in the date Determine the prognosisfield so that the software could survive Y2K. I know. Careful assessment of the overall damage a tooth hasNot that easy, but really, really important. endured and a wise determination of its prognosis isFigure 1A. Maxillary molar with failing root canal treatment. Figure 1B. Post-op result after single-visit re-treatment. TheThe dentist who originally treated the root canal system (only patient’s symptoms were immediately relieved, possibly bythe palatal canal!), after the patient complained of continuing adding the remaining three canals to the endodontic treatmentsymptoms, offered to extract the tooth and replace it with an plan.implant. Dentistry Today l October 2010
  • 2. a pre-requisite to successful treatment planning. Thisis not a paper about diagnosis, but suffice it to say,exceptional endodontic treatment after an erroneousdiagnosis is not going to benefit the patient. Likewise,exceptional endodontic treatment on a tooth that willnot hang together afterwards won’t be appreciated.Discovery of the full extent of pulpal, periodontal, orcombined disease conditions requires definitive pulptesting (with sustained sources of thermal stimulus)careful periodontal probings, and the best radiographicimaging you can get. Then, after considering all ofthe relevant data, a very well-informed prediction of Figure 2. Maxillary molar with infected vertical root fracture ofits potential longevity is made. the mesio-buccal root. The RCT was successful apically but the over-enlargement caused a coronal failure of structural integrity.The first order conditions to consider in prognosisdetermination (listed in order of importance) are: 1) Structural damage (Figures 2-4) 2) Periodontal damage (Figures 5A &5B) 3) Endodontic damage (Figure 6)Structural and periodontal conditions will alwaystrump the endodontic condition when consideringwhether to save or extract a tooth. A beautifulendodontic retreatment will not keep a structurallycompromised tooth from coming apart in the nearfuture. Nor will it heal periodontal lesions that arenot of endodontic origin. Figure 3A. Mandibular molar with deep distal decay nearly hemisecting the distal root. The structural damage is extensive.Any tooth with a root fracture extending even 1 mminto the soft tissue attachment at the CEJ should beextracted. No endodontic or restorative treatment Ihave seen can prevent the certain demise of a root-fractured tooth. Be definitive with these loser teeth.When periodontal damage has occurred, the trend ofthe disease state is informative as to the prognosisfor arresting the disease and repairing damage in thesupporting tissues around a tooth. Also importantis whether the perio defect is specific to that toothor part of a generalized periodontal condition. Anisolated periodontal lesion, coupled with suspiciousor definitively bad pulp test results, indicate an endo/ Figure 3B. Recall x-ray 4 months after immediate implant replacement of the molar. This treatment plan, with the secondperio situation that has a fair to good prognosis with implant in the edentulous space, has a much better long-termthe right treatment.1,2 prognosis than RCT and restoration would have provided. Dentistry Today l October 2010
  • 3. Damage from previous endodontic treatment iscommon and most of the mishaps that have occurredin the apical third of roots are repairable withoutapical surgery.3 When needed, surgical resectionof the apical half of a root will not significantlyreduce the longevity of that tooth.4 Conversely, over-cutting the access cavity and the coronal ½ of theroot can doom a tooth to structural failure. Postsnever strengthen roots after endodontic treatment,neither will composite bonding, and cut dentin neverreturns.5,6Conversely, when access cavities are cut Figure 5A. First and second molars with endodontic and peri-conservatively, when coronal enlargement of canals is odontal disease.Figure 4A. Maxillary central incisor broken at the gum line. Figure 5B. Two year recall exam showing successful RCT ofThe challenge of creating an adequate ferrule around the the first molar and replacement of the second molar with anremaining root structure with an ideal esthetic result suggested implant and prosthesis.replacement with an immediate implant.Figure 4B. Post-operative x-ray showing immediate implant Figure 6. Maxillary lateral incisor with a hedstrom file separatedreplacement. near the end of the canal and an osseous lesion at the root apex. This could be re-treated conventionally after removal of the crown, the core, the post, and the file segment, or – if the post and core appear to be intact – re-treat the canal from a retrograde approach. Much less cost, less treatment time, and a certain result. Dentistry Today l October 2010
  • 4. limited and restorative work is well-done, endodontic These choices should be explained to the patient intreatment nearly always offers an excellent long-term terms of operative and post-operative discomfort, thestructural prognosis. expected treatment result, the long-term prognosis after, and the cost of treatment.Prognosis determination informs but does not decidethe treatment plan—for example, it may be preferable Choose the best treatmentto retreat a tooth with a guarded long-term prognosis Recommending which treatment course to pursueif the patient is elderly, rather than subject them to is usually simple when looking at single teeth. Theextraction and implant placement, or extraction tooth may be totally unsalvageable—root fracture,without replacement. Likewise, for our younger for instance—and the only treatment that wouldpatients we must recommend and execute treatment be considered is extraction. In this case there areplans having the longest attendant prognoses. decisions to be made about restoring function and esthetics after the tooth is removed, but noneList possible courses of treatment regarding the tooth itself.So, if we have successfully assessed the diseasestate and our forecast of the current prognosis would A more difficult call is about a tooth with a little bitindicate saving the tooth, the choices are: of every type of problem—a Class I furcation, three- quarters of the coronal structure is missing, and the• Do nothing. This is not an option for necrotic previous root canal was not done well. Some of the teeth. Infected teeth need RCT or extraction. considerations in gray-area cases like this would be: Is the perio defect isolated or generalized? Was the• Conventional RCT. Well-done RCT works coronal third of the canals over-enlarged? Has the root as often as implants, it can be done in a single been damaged apically during previous treatment? visit, and the tooth is ready for a new crown in Will both conventional and surgical retreatment be 2 weeks. necessary? Would an implant replacement be easy or hard? What is the financial ability of the patient to• Surgical RCT. Calcified canals are always found fund more expensive treatment choices if indicated? from a retrograde approach, and sometimes a critical abutment should not be disturbed by If the assessments of the disease state, its extent, and cutting an access cavity through it. The whole the prognoses of each possible treatment are correct canal must be treated from the apical approach. and are adequately explained to the patient, they can• Conventional re-treatment. Only choice when make a decision that is best for them. coronal leakage has occurred, difficult when apical damage has occurred. The automatic treatment of Perhaps the first order issue for dentists recommending choice for missed canals and irrigation failures. a course of treatment is about bias. There are several kinds of bias that intrude on clinical judgments.• Surgical re-treatment. Still better than an implant Self-interested bias is easy to see and avoid in most if structure and perio are good. The best option situations. Unconscious bias can be harder to avoid, when coronal structures are tight and apical for example, the tendency of clinicians to limit their damage has occurred. recommended treatment options to procedures they feel comfortable doing themselves.• Conventional and surgical re-treatment. For those retreatment cases that absolutely must After consideration of all factors, I recommend the work. Andreason’s research showed nearly same course of treatment that I would want myself 100% success when orthograde (from both ends) or that I would want another dentist to recommend to treatment was done on teeth with failed RCT. a family member. Dentistry Today l October 2010
  • 5. Plan the Procedure • Know your patient. Pre-medicate them ifMany of us consider treatment planning to be needed.completed after the choice of treatment has beenmade. I disagree for the reason that without a • Know the patient’s anatomy and the full extentprocedural plan in place before difficult cases are of the disease.begun, endodontic therapy can quickly go awry. • Plan every single part of the procedure. DefinitelyThe best treatment plan cannot overcome mediocre have a plan B.procedural execution. So how do we better plan ourprocedures? • Have all necessary instruments, materials, and supplies with backups.I recommend that all clinicians and assisting staffread Dr. Atul Gawande‘s book, “The Checklist • Have the right staff in the right positions with theManifesto”. This guy is an excellent journalist, a right checklists.surgeon on staff at Harvard Medical and HarvardPublic Health Schools, and is the director of the 3-Dimensional Computer Tomography ImagingWorld Health Organization’s “Safe Surgery Saves Cone beam computer tomography (CBCT) imagingLives” program. For years he has pursued a campaign has changed everything in dentistry. Not a greatto improve surgical, and indeed, all health delivery number of clinicians understand this yet, but it won’toutcomes through research into best practices and be very long before most of us do. When dentists whothe feeding of that outcomes data back to operating have easy access to a CBCT machine consider therooms around the world. very low amounts of absorbed radiation that some of these machines project7 as well as the quality ofOne of the most powerful epiphanies he had was in the volumetric data captured,8 treatment planningrealizing that many, many fewer errors are made in the without it is similar to the experience of doing rootairline industry compared to medicine, and that this canal therapy without a literally because they live and die by checklists. The dimensional accuracy of CBCT machines isDr. Gawande has begun enlisting hospitals around proven,9,10 the resolutions of some of the machinesthe world in his studies about checklists for quality approach 50 microns, making it possible for lateralcontrol in healthcare and those who have participated canals to be seen preoperatively11 and it has somewhathave seen remarkable improvements in results, even delivered on one of my childhood fantasies of having x-ray vision. Even if you thought you werein complex operations with most of the operating Superman when you looked at conventional dentalstaff and surgeons unknown to each other. At the end x-rays, having volumetric x-ray imaging is like beingof the day, Dr. Gawande is improving procedural Superman in a world without Kryptonite.results by documenting them with pre-operative,mid-procedure and post-operative list checks, thereby 3D x-ray imaging allows clinicians to know everythingnipping small and large errors in the bud beforehand, about a given tooth’s anatomy and the fullest extent ofas well as creating a very effective structure on the the disease state before any invasive procedures areback end that encourages iterative improvements of done (to see a video of diagnosis and treatment planningthose procedures. with CBCT imaging visit the Product Clips section in the Media Showcase on Let’sFirst order issues for procedural planning are: look at several examples of anatomic challenges that• Know your skills. Never stop practicing or are normally hidden on 2D dental x-rays but are easily training up. seen with CT imaging (Figures 7A-C). Dentistry Today l October 2010
  • 6. Because of the contributions of CBCT imaging, prognosis determination for teeth with failing endodontic treatment is now more definitive—and just being able to weed out most of the loser teeth before cutting an exploratory access is a major bonus for dentists and patient alike. Let’s look at some clinical comparisons of conventional and CBCT imaging for assessment of disease states (Figures 8A-B, 9A-B). Digital Does It Better For those clinicians who have had a CBCT machineFigure 7A. Conventional pre-operative radiograph showing in their office for more than a year, the advantagesobscure root structure. of 3D volumetric x-ray imaging is incontrovertible.Figure 7B. CT view showing buccal canals merging apically Figure 8A. Maxillary second molar with an apparent endo/with a 3 mm long accessory canal diverging from the point of perio lesion.confluence.Figure 7C. Conventional post-operative radiograph showing Figure 8B. CT slice showing an osseous radiolucency wrappingroot canal anatomy shaped and obturated just as seen pre- from the distal aspect of the root into the distal furcation. No PAoperatively in the CT image. lesions seen at any of the root apices. Pulp testing confirmed the CT imaging suggesting a periodontal lesion without an endodontic component. Dentistry Today l October 2010
  • 7. Competitively, as an endodontic specialist, it’s an This is not pie-in-the-sky vaporware. The technologyunfair advantage. now exists to capture and reconstruct our patient’s dental anatomy and disease to a .001 mm resolution.Even beyond the diagnostic benefits of CBCT The software for surgical treatment planning in voxelimaging, the advantage of 3D imaging to the clinician space has been used for years in implant surgeryactually doing the procedure is huge (Figure 10). We and is currently under development for endodonticare currently able to set up a drill path to pass, in the surgery. And let me tell you, it is a very relaxed,3D virtual anatomic computer space of your patient’s very cool experience to secure a CAD/CAM stereo-tooth, exactly through each root apex, and then have a lithography-generated drill guide precisely onto yourdrill guide made to carry that computer plan directly patient’s teeth and in a minute or two complete all ofinto the patient’s mouth—kind of like robotic surgery the drilling and milling for a given procedure withexcept we still get to hang on to the handpiece. Now remarkable precision (Figs. 11A-B).you are talking about some very fun, very effectiveoutcomes. Faster, better, and safer—that is music to In other words, we are way beyond the early-adoptera lazy perfectionist’s ears. phase on this one. When you look at the convergence of the tools mentioned above with digital impression scanning, and CAD/CAM milling machines, the future is clear. While it may take a generational change of dentists to fully understand the advantages of these new digital tools, clinicians like myself who have reveled in The New, New Thing since the day they graduated, will chase this 3D imaging and digital treatment planning thing like a dog chasing a cat.Figure 9A. Conventional pre-operative x-ray showing noobvious periradicular pathosis.Figure 9B. CT view showing the palatal root nearly resected by Figure 10. Axial CT section showing, with 100% certainty,a large external resorptive defect. that there is no MB2 canal in this upper molar. Also seen is the normally hidden 90o buccal curvature of the DB Canal. Dentistry Today l October 2010
  • 8. Figure 11A. Initial 2 mm drill hole seen through the guide ring Figure 11B. Photograph showing a perfectly apicsected root-of a prototype drill guide for CT-guided endodontic surgery end after using the CT-based appliance to guide each of theprocedure. (Note accuracy attained.) cutting drills.Special thanks to Dr. Nestor Cohenca, an associate endodontically treated teeth. Post, core and theprofessor in the Department of Endodontic at Univ. of final restoration. J Am Dent Assoc 2005;136:611-Washington, for his assistance with the references. 9. 7. Ludlow JB, Ivanovic M. Comparative dosimetryReferences of dental CBCT devices and 64-slice CT for1. Harrington GW. The perio-endo question: oral and maxillofacial radiology. Oral Surg differential diagnosis. Dent Clin N Am 1979; Oral Med Oral Pathol Oral Radiol Endod. 2008 23:673-90. Jul;106(1):106-14.2. Rotstein I, Simon JH. The endo-perio lesion: a 8. Howerton WB Jr, Mora MA. Advancements in critical appraisal of the disease condition. Endod digital imaging: what is new and on the horizon? Topics 2006;13:34-56. J Am Dent Assoc. 2008 Jun;139 Suppl:20S-24S.3. de Chevigny C, Dao TT, Basrani BR, Marquis V, 9. Lascala CA, Panella J, Marques MM. Analysis Farzaneh M, Abitbol S, Friedman S. Treatment of the accuracy of linear measurements obtained outcome in endodontics: The toronto study-- by cone beam computed tomography (CBCT- phases 3 and 4: Orthograde retreatment. J Endod NewTom). Dentomaxillofac Radiol 2004;33:291– 2008;34:131-7. 4.4. Wang N, Knight K, Dao T, Friedman S. 10. Pinsky HM, Dyda S, Pinsky RW, Misch Treatment outcome in endodontics-The Toronto KA, Sarment DP: Accuracy of three- Study. Phases I and II: apical surgery. J Endod dimensional measurements using CBCT. 2004;30:751-61. DentomaxillofacRadiol 2006:35;410-416.5. Schwartz RS, Robbins JW. Post placement and 11. Kau CH, Bozic M, English J, Lee R, Bussa H, restoration of endodontically treated teeth: a Ellis RK. Cone-beam computed tomography of literature review. J Endod 2004;30:289-301. the maxillofacial region--an update. Int J Med6. Cheung W. A review of the management of Robot. 2009 Dec;5(4):366-80. Dentistry Today l October 2010