Endodontic implants.

Endodontic implants were introduced back in 1960. Endodontic implants enjoyed few successes and many failures. Various reasons for failures include improper case selection, improper use of materials and sealers and poor preparation for implants. Proper case selection had given remarkable long-term success. Two different cases are being presented here, which have been treated successfully with endodontic implants and mineral trioxide aggregate Fillapex (Andreaus, Brazil), an MTA based sealer. We suggest that carefully selected cases can give a higher success rate and this method should be considered as one of the treatment modalities.

INTRODUCTION

Endodontic implants are artificial metallic extension, which can safely extend out through the apex of the tooth into sound bone.[1] Endodontic implants increases the root to the crown ratio and stabilizes a tooth with weakened support. It serves the patient well and avoid replacement for many years.[1]

The major indication for using an endodontic implant were: (a) Periodontal bone loss, particularly the involvement of a single tooth, where extraction and replacement is difficult; (b) a horizontal fracture of a tooth that required the removal of the apical segment and the remaining coronal portion is too weak to remain due to an unfavorable crown-root ratio; (c) pathological resorption of the root apex due to chronic abscess; and (d) pulpless tooth with unusually short root.[2]

Orlay have been among the first to use and advocated endodontic implants.[3] Frank is credited however with standardizing the technique, developing proper instruments and matching implants.[24]

Frank and Abrams were also able to show that a properly placed endodontic implant was accepted by the apical tissues and that a narrow “collar” of healthy fibrous connective tissue, much such as a circular periodontal ligament, surrounded the metal implant, and separated it from alveolar bone.[5]

Weine and Frank retrospectively revisited their endodontic implants cases placed over a 10 year period. Despite many that did fail, they noted some remarkable long-term success with the technique.[6] The technique to be used in carefully selected cases.

Here, we are presenting two cases in case report, in which tooth were mobile and strategically important. Their loss was going to create a space, which would have been very difficult to manage. We have used reamer and H-file as endodontic implants because they are easily available and have been successfully used in the past. Newly introduced MTA based sealer MTA Fillapex (Angelus, Brazil) that combines the proven advantages of MTA with a superior canal obturation product.

CASE REPORTS

Case 1

The patient was a 21-year-old female, with negative medical history, presenting with a full dentition and no caries nor need for any restoration. Dental examination revealed retained 85 and congenitally missing 45. Radiographically, the findings were confirmed as retained E with apical bone loss and grade 2 mobility [Figure 1a]. Patient was very willing to retain the tooth as its extraction was going to create space.

Figure 1a

Periodontal involvement in retained E

Access opening of the canal was carried out carefully under local anesthesia with adrenaline (1:200,000) in rubber dam. After cleaning and shaping in three canals, two no. 25 and one no. 35 reamer was placed as an endodontic implants depending on the size of the canal [Figure 1b]. Files were 3-4 mm beyond apex to stabilize the tooth. Fillapex, an MTA based sealer was used. Handle and excess file was removed with bur. Pulp chamber was filled with light curable glass ionomer cement. An endodontic implant was placed in order to stabilize the tooth and retard periodontal breakdown [Figure 1c]. Six months later an oral and radiographic examination revealed reduced mobility and no further loss of bone in treated tooth [Figure 1d].

Figure 1b

Reamers were extruded to use as endodontic implants

Figure 1c

Mineral trioxide aggregate based sealer fillapex was used to obturate and glass ionomer cement was used for filling pulp chamber

Figure 1d

Six months post-operative radiograph showed healing and better stability

Case 2

The patient was a 25-year-old female, with negative medical history, presenting with a history of trauma 5 years back in the right maxillary central incisor and having grade 2 mobility. radiographic examination revealed periapical radiolucency with resorbed root and two canals in maxillary central incisor [Figure 2a]. as the tooth was esthetically very important for that female patient, it was decided to retain the tooth by placing endodontic implant.

Figure 2a

Pre-operative radiograph of maxillary central incisor with pathology and short root and two canals

The access preparation was carried out, and a working length radiograph was taken [Figure 2b]. Cleaning and shaping was carried out and the patient was scheduled for surgery, which was performed after four days and antibiotics and analgesics were prescribed. On the day of surgery bilateral infraorbital and nasopalatine block was given with 2% lignocaine hydrochloride with 1:50,000 adrenaline. A two sided vertical flap was raised from distal margin of 12 and 21. Incision was given on interdental bone and leaving the marginal papilla intact. Bone resorption was clearly evident at cervical region of central incisor and a bony defect apically. The bony defect was curetted thoroughly and simultaneously irrigated with saline. One canal was obturated with gutta percha and MTA based sealer (Fillapex) and no. 30 H-file was used for preparing a 5 mm channel in periapical area through second canal. No. 35 H-file was then threaded into the prepared channel. The complete canal was obturated with light cured glass ionomer cement. File was grooved at 16 mm from tip so that the handle can be separated once the file was in a position [Figure 2c]. 3-0 black silk sutures were placed in vertical flap, and marginal gingival and antibiotics and analgesics were prescribed. After 4 days, sutures were removed. Follow-up was done every month. Six months later an oral and radiographic examination revealed reduced mobility and bone formation in radiolucent area [Figure 2d].

Figure 2b

Files were placed in two canals

Figure 2c

The pathology was removed by doing periapical surgery and one canal was obturated with gutta percha and other with H-file as endodontic implant, with mineral trioxide aggregate based sealer

Figure 2d

Six months post-operatively shows healing and better stability

DISCUSSION

Observation of the cases showed the endodontic implants were not a reasonable bad option as opined by some. although, we agree that calcium hydroxide therapy for pathology cases are superior, but endodontic implants still can be used for rare cases that presents that could be better treated by that method.

When these patients reported the hospital, they were very keen of saving their tooth. In this process files were used as endodontic implants, because they were easily available, autoclavable, and cost effective. Though, studies have contraindicated use of files in close proximity to bone, the use of files was successful in these cases. Radiographs had shown reduced mobility and better periapical healing.

Studies had shown that most of the endodontic implant failures had occurred in the tooth with eccentrically located apical foramen, thus, forming a tear drop shaped opening.[6] That shape is extremely difficult to seal with any filling material, thus leading to periapical breakdown and failure. However in these cases, we have used MTA based sealer (MTA Fillapex) to seal the apical foramen or apex of root canal implant-dentin interface at the apex to minimize failure due to leakage. They stimulate the healing process of perapical tissues.[7]

MTA, present in the composition of MTA Fillapex, is more stable than calcium hydroxide, providing constant release of calcium ions for the tissues and maintaining a pH which elicits antibacterial effects. The tissue recovery and the lack of the inflammatory response are optimized by the use of MTA and disalicylate resin.[78910]

Endodontic implants allow us to treat teeth with mobility due to root fracture, bone resorption, reduced crown-root ratio. The success rate of endodontic implants in studies were 91%; thus, this method is an acceptable, preventive treatment to retain mobile teeth.