Dr. Satinder Matharu discusses the success and outcomes of endodontically treated teeth versus implants



There is considerable debate among endodontists and restorative dentists regarding the success and outcomes of endodontically treated teeth versus implants. Current treatment using magnification, ultrasonics, nickel-titanium instruments, evolving materials, and re-treatment strategies has made endodontics more predictable in preserving teeth.

Typically quoted outcomes for endodontic treatment range from 65% to 95%, a wide-ranging spectrum, depending on whether endodontic surgery is carried out on a previously treated tooth without root canal re-treatment compared to a vital, noninfected tooth. Endodontic success is currently defined in terms of the retention of a symptom-free tooth. Implant literature tends to discuss success in terms of survival, which may be misleading. The presence of a tooth or implant after a period of time should not be regarded as success, although it could be regarded as survival. Recent research comparing matched pairs of implant-retained crowns and endodontically treated teeth has suggested similar success rates for the two treatment modalities; however, the implant-retained prostheses required more post-treatment intervention (i.e., dealing with broken screws).

As an endodontist endeavoring to offer total patient care, I am aware that there is a case for the provision of implants when teeth are not restorable. Recent indications from periodontists reveal that nonsurgical periodontal treatment of natural teeth may be preferable to implants for their long-term health and function even if endodontic treatment is required, and attempts should be made to preserve such teeth. At our practice, we are occasionally involved in a multidisciplinary approach with our referring dentists in planning patient care. This useful dialogue, often between periodontists, restorative specialists, orthodontists, and endodontists, enables us to be involved in treatment to be formulated and carried out in a planned manner. This is not only immensely satisfying professionally, but of immense benefit to the patient. However, as we are all aware, treatment plans can change during treatment. The following case demonstrates such an approach.

Case report
A 64-year-old healthy woman was referred for endodontic treatment of tooth No. 13 due to gross caries. Teeth Nos. 12 and 13 were linked crowns with a distal slot for a fixed-movable bridge replacing teeth Nos. 14 and 15. Tooth No. 13 had been previously endodontically treated (Figure 1). The major retainer was a porcelain-bonded crown at tooth No. 16. In discussion with the restorative dentist, it was decided to carry out endodontic treatment at tooth No. 13 as an interim measure to allow a single-unit post-retained crown to be constructed.



The bridge was sectioned and temporary crowns placed at teeth Nos. 12 and 13 (Figure 2). Under magnification and on removal of the existing gutta-percha root filling, the original canal was found to have been transported and close to a buccal perforation. Root canal re-treatment was carried out over two visits, and a short post space was provided (Figure 3).
The prognosis for this tooth as a definitive bridge retainer was guarded, and the patient was advised that the long-term solution may necessitate an implant-retained prosthesis for restoration of the edentulous space; however, as an interim measure, esthetics and function could be maintained with a temporary bridge.

With the long-term future of tooth No. 13 in doubt, a periodontist/implantologist’s opinion was sought. A decision to extract tooth No. 13 (Figure 4) and place two implants in the No. 13 and No. 14 sites was discussed and carried out by her dentist (Figure 5). A new temporary bridge from tooth No. 14 to tooth No. 16 was constructed while the implants integrated. At this stage, tooth No. 16 was also assessed and gave positive responses to vitality testing, though the patient was advised of the possibility of future pulpal symptoms. Subsequent to implant integration, a fixed-movable bridge (implant-tooth supported) was constructed from tooth No. 14 to tooth No. 16, with a movable joint on tooth No. 26 to allow for its intrusion if loaded. A new crown at tooth No. 12 was also provided. However, the patient later reported symptoms of an irreversible pulpitis from tooth No. 16, which necessitated endodontic treatment through the retainer.

An access cavity was prepared not to encroach on the movable joint, and the tooth was treated conventionally over a single visit. Commonly in these teeth, a single canal was located and prepared. The access cavity was restored with a glass ionomer/composite sandwich to reduce the chance of microleakage. Subsequently, symptoms have settled, and healing is expected to be uneventful (Figure 6).

In a practice mainly involved with primary and re-treatment endodontics prior to further restorative work, it is not always possible to see the end product. This case was planned and followed to its conclusion, and highlights the importance of teamwork and the flexible approach sometimes needed to help our patients. In this case, a tooth that would not predictably survive as a long-term bridge abutment was endodontically treated to give time to consider other restorative options. Patients are often grateful for heroic attempts at trying to save teeth, and when this is not possible, all treatment options have to be offered; implants do have a role to play, and I have no hesitation in including them as a treatment option when the need arises.

Satinder Matharu, BDS, MSc, is a specialist in endodontics at EndoCare Harley Street, London.