Factors that would influence the decision-making process - Essay Example

of the of the Health sciences and medicine 29 May A twenty one year old girl has an upper right central incisor that has been previously root filled and is still not settling. Discuss the factors that would influence the decision-making process, the management and treatment of this process using evidence based approach. Unsuccessful Root Filling When a tooth has been root filled and is still not settling, the next logical action is to evaluate and assess the reasons for the failure of root filling. The most important reason for endodontic failure is microbial infection which can be intraradicular or extraradicular.(1) There may be an extra canal that was overlooked during the original procedure and has now become infected. Even if the extra canal or isthmus is identifiable, it is sometimes not possible for disinfection manoeuvres to reach it due to an obstruction.(2) In addition, there may be a vertical fracture of the root from which bacterial contamination can take place.(2,3) Management Options after Unsuccessful Root Filling Only when the cause has been ascertained, further treatment can be planned. In this case, there can be three options after a failed root canal treatment. Firstly, the root canal retreatment can be done surgically or non-surgically.(2) However, a re-do root canal filling is a complicated procedure and may not be possible if the reason that caused the failure of treatment in the first place still exists. In certain cases, the second option is endodontic surgery (apioectomy). The third option is tooth extraction. Although, during a procedure attempts are always made to retain the natural tooth, it is sometimes necessary to remove the tooth if it is severely damaged or decayed. The patient should be explained about the treatment options with their individual prognosis in terms of pain, durability and aesthetic appearance, and the cost and duration of each treatment. The goals of the treatment and patient’s expectations must be clearly defined and the best procedure likely to reflect these goals must be performed. Thus, the factors that will influence the decision are cause of the failure of root filling, status of the tooth and patient’s preference. If the decision to extract the non restorable tooth has been made, the decision to replace the missing tooth and restoration has to be made simultaneously. This can be done with an implant, a bridge or a removable partial denture. Bridge and removable partial denture are cumbersome and less appropriate than an implant. For a 21 year old female whose upper right central incisor has been extracted; tooth implantation with an osseointegrated root form implant seems to be the best choice for aesthetic as well as functional purposes.(4) Dental Implant placement Goals of an implant placement in the aesthetic (maxillary) zone are to achieve natural looking tooth in harmony with the rest of the teeth and oral profile, and achieve a durable and good functional outcome.(5) To achieve these goals, the procedure must be carefully planned, should involve the final restoration and should be evidence based. Planning involves clinical assessment, collection of radiographic data, patient preparation and counselling, and planning of the surgery and restoration. Clinical Assessment Clinical assessment encompasses history taking and examination, bone and hard tissue assessment and analysis of the bone and soft tissue relation. Patient’s medical, surgical and dental history should be elicited. Relevant oral and extra-oral examination must be performed. The aim of the examination is to determine the status of the affected tooth, periodontal status and occlusal relationship, and identify focus of infection, if any. In this case, it’s important to examine the crestal and interproximal bone, gingival tissue and smile line before undertaking implant surgery in the aesthetic zone.(6) Collection of Data Data relevant to the case is collected in the form of photographs, diagnostic casts, preextraction periapical and panoramic radiographs.(7) It is also recommended that three dimensional cone beam or computerised tomographic (CB/CT) scans should be performed prior to tooth extraction to assess the anatomy and bone of the affected region.(8) this can greatly assist in planning the surgical steps as the bone dimensions are clearly visualised. Surgical Planning This planning incorporates decisions regarding bone grafting and augmentation and the timing and staging of the key steps of the procedure. Main components that need to be timed are tooth extraction, augmentation or preservation of hard and soft tissue, placement of implant, abutment connection, provisional and ultimately, definitive restoration.(5) Once the treatment plan is formulated, a written and informed consent should be obtained from the patient. Timing of implant placement In this case, the preferred technique should be immediate implant placement. Traditionally, implants after the extraction of tooth were placed only after a suitable interval of time had passed to allow healing of the socket and the alveolar ridge.(9) However, numerous studies have now been performed to assess the clinical outcome of implants placed immediately after tooth extraction. (5,6,8,10-21) All of these have proved the reliability of immediate placement of an implant which has variably been defined as implant placement into a fresh extraction socket (21,22) to within 48 hours of tooth extraction. In addition to the reduction in the duration of treatment which is an inherent advantage of the technique, other advantages of immediate implant placement that have been cited are better aesthetics and more patient satisfaction,(10) improved survival rates of the implant, and no distortion of the bone and the soft tissue at the site of extraction.(23) Infact, this techniques is recommended on the premise that the natural resorption of bone and soft tissue that occurs when the extraction site is left to heal will be prevented if the implant is immediately placed at the site. In view of a large body of evidence supporting the immediate placement and no apparent contraindications in this patient, the implant may be placed in the fresh extraction socket immediately after removal. The factors that can influence this decision are active infection at the site, length of bone to accommodate and anchor the implant < 3mm or extensive gingival recession. If infection is extensive with the involvement of surrounding tissue, it may be prudent to defer implant placement till infection is healed, even though investigators have determined and commented differently.(18) Optimal condition and length of bone is a prerequisite for implant placement and osseointegration. (26) It is recommended that at least 3-5 mm of implant must be screwed inside the bone.(20,41)The bone can be observed on a radiograph or CB/CT scan though differences in radiological and clinical measurements have been reported.(42) Anaesthesia The procedure can be done under local anaesthetic with added epinephrine for haemostasis and can be supplemented by conscious sedation if required.(27) The anaesthetic solution is infiltrated on buccal and palatal gingiva. The concentration of epinephrine in the solution should be 1in 100000 to 1 in 50000. Local anaesthetics alone should not be used as the bleeding may be increased at the surgical site due to vasodilatation caused by them. Tooth extraction Right central maxillary incisor must be extracted atraumatically using thin elevators. In order to reach the tooth, marginal tissue can be displaced buccal-lingually and periodontal ligament is dissected.(24) The extraction socket is to be carefully curetted and cleaned of all the infected tissue so that osseointegration can take place unhampered. After the extraction, integrity of buccal plate should be confirmed.(6) Bone Augmentation For a dental implant to be successful there must be enough bone to act as a foundation for the implant. In this case, it is possible that bone defect may have occurred because of infection, fistula, root fracture or periodontal disease. If that is the case, then she will need bone augmentation for the implant procedure. (48) Many techniques have been cited in the literature for augmentation of the bone such as bone grafting with autogenous bone grafts, allo or xenografts, freeze dried demineralised bone or barrier membrane, ridge expansion, distraction osteogenesis and sinus augmentation.(5) Specifically in this patient, a gap may result from placement of the implant into a freshly extracted alveolus. This gap will depend upon the shape and size of implant as well as the anatomy of the socket. In this context, it is important that tooth extraction be performed atraumatically to avoid injury to the socket walls and prevent further loss of bone. As has been reported in various human and animal studies, spontaneous bone growth can occur and no difference in healing has been found in patients who underwent a bone augmentation procedure compared to those not subjected to it.(25) However, in view of the previous pathology and a failed root filling, it will be prudent to fill the gap with bone grafting procedure. Bone grafting can be done prior to the placement of implant or at the time of placement. (48) Bone grafting in this case would be done at the time of implant placement. Extraction socket is prepared with bone graft. Although, many types of grafts exist such as allograft, xenograft and synthetic graft, autogenous graft would be the choice of bone graft in this case.(26) It is the graft that is harvested from the same patient from same or alternate site. An autogenous graft provides a matrix for bone remodelling and is also biologically acceptable.(35) On the other hand, there arises a problem for harvesting of the graft which could involve another, albeit minor surgery and pain. In this case, the graft can be harvested at the operative site itself from an area with adequate crestal bone.(43) An instrument which scrapes off the bone in this intact area is utilised to harvest the graft.(43) Depending upon the patient’s condition, she may need a sinus augmentation procedure to increase the thickness of the bone and prevent a breach of the wall of maxillary sinus. Implant Placement The steps of the surgery depend upon a number of factors. There is no standard protocol to approach a tooth to be extracted and an implant to be put in its place. The incision will depend upon the size of the socket; status of the periodontal tissue, operating instruments and the tyoe and size of the implant. In general, the below mentioned scheme can be followed with modifications and alterations on a case to case basis. Implant size can be estimated by measuring the socket in all dimensions, horizontal, vertical and saggital. In this case, care should be taken that implant is not placed directly into extraction socket. This can lead to implant failure due to buccal plate perforation.(6) Buccal flap is raised to expose the structures. Full thickness flap should be raised which should be protected during the surgery. Flapless technique may interfere with adequate visualisation and surgery. However, no significant differences have been reported between flapless procedure and when flap protocol was followed during implant insertion on survival rates or bone levels.(49)To penetrate the palatal wall, surgical guide and precision drill are used. Saline irrigation should be used throughout the drilling procedure in making an osteotomy for the implant. For proper restoration, the axis and direction of the implant in relation to the adjacent teeth should be carefully measured with a direction indicator. To ensure implant stability, the shoulder of the implant should be 2 mm below the cervix of adjacent teeth.(41) The long axis should be directed in a slightly lingual direction to the incisal edge.(5) In general, wrong positioning is evident by aesthetic compromise in an immediate placement. There must be a distance of atleast 2 mm where the lateral alveolar bone projects beyond the implant body to stay put against bone remodelling.(47) Implant stability can be indicated by a Torque resistance of 35- 40 Newton centimetres. However, higher torque can cause osteonecrosis and bone loss and should not be applied.(6)After implant insertion, bone grafting is done with bone shavings harvested during preparation of the implant site.(44) Fixture impression is taken after implant placement so that provisional restoration can be fabricated.(6) If during the procedure, wall of the maxillary sinus is breached, the procedure should be postponed. A repeat attempt should be preceded by sinus augmentation and bone regeneration. For closure of the soft tissue after implant placement, many techniques have been suggested such as a rotated buccal flap, gingival graft and palatal advanced graft. Depending on the size of the defect, any of these can be chosen. A smaller defect can be corrected by the buccal flap whereas, palatal advanced graft can be used for a larger defect.(6) 2nd Stage Procedure To increase the chances of success of the implant, a two stage protocol for implant insertion can be followed. In this protocol the implant that is inserted is kept submerged under the soft tissue. Once healed, a second surgical procedure is performed to expose the implant. It has been seen that if movements occur during healing, soft tissue encapsulation of the implant occurs instead of osseointegration. To prevent soft tissue encapsulation, the implant should be kept submerged. When a 2 stage procedure is used, micromotion and transmission of loading forces to the osseointegrating zone of the implant are prevented. However, no significant difference has been found between the two types of surgery regarding prosthesis and implant failures, bone resorption and marginal tissue recession.(28,29,46) Still, a trend in the favour of a 2 stage procedure was observed. Only short term results have been reported for immediate implants placed transmucosally in the aesthetic areas. (19) So, in this case a 2 stage surgery is acceptable in this patient and is more likely to be conducive for osseointegration. Osseointegration is the direct attachment of bone to the titanium of the implant without any intervening connective tissue. It is necessary for the implant stability as it keeps the implant in place. It typically takes 3-6 months to occur in the anterior maxillary area.(33,38,44) A healing abutment is applied to the top of the implant once osseointegration has taken place. This is done by putting a minor incision in the mucosa and exposing the top of the implant. Provisional restoration is applied to support and preserve the structure of soft tissue around the implant. It has been recommended that some time be given for the healing of the soft tissue that is manipulated during the 2nd stage of the surgery. Many studies exist in favour of immediate loading of a dental implant in the mandible. However, evidence is less convincing for maxillary implants as is relevant in this case.(30-38) Interim prosthesis is fabricated in such a way that occlusal loading is eliminated.(30) Balshi et al (30)reported a success rate of 95.7% for immediate provisionalization of single tooth implants. However, Felice et al (36) concluded that immediately loaded non occlusive post extractive implants could be at a higher risk of failure. The advantages of early loading that have been cited are better mastiactory function, psychological satisfaction to the patient, better bone growth and remodelling, and better aesthetics. (33) Restoration Provisional Provisional restoration should be used in this case because the patient is a young female and the affected tooth is in the aesthetic zone. Patient is likely to be embarrassed and uncomfortable without a provisionally restored tooth until permanent restoration is done. Also, provisional restoration will serve a diagnostic purpose.(39) It will help the patient to visualise and realistically expect what the final outcome will be. In case, she is not satisfied with the result, the provisional can be modified. This modified provisional can then be copied exactly by the technician while making permanent restoration.(39,45) Definitive When provision restoration is successful in terms of patient satisfaction, an impression should be made and the cast should be employed as a guide for the permanent restoration. (39) A metal ceramic or porcelain only crown can be used and it can be attached to the abutment by cement. Usually, it may take two to three months for a temporary restoration to become definitive. Latest studies have reported good outcomes for implants that were definitively restored within 2 weeks, comparable to the results achieved with a delayed definitive restoration. Other researchers have, however cautioned against expediting the surgical and repair process. The concepts of early loading and early restoration have shown promising results but the long term assessment is yet to be done. It’s important to make an individual treatment plan for the patient and not blindly follow the upcoming or latest techniques which are still under trials. The aim is to achieve the best outcome without undue prolongation of the treatment duration, not to shorten the time. So far as soft tissue and gingival appearance is concerned, after sometime slight soft tissue recession may occur. This can be corrected by subepithelial connective tissue grafting in order to gain the maximum aesthetic outcome. Postoperative care After the surgical procedures, the patient should be instructed to meticulously follow dental hygiene procedure, chlorhexidine oral rinse and soft diet. She should be cautioned against smoking and grinding of teeth as these can cause implant failure. Diclofenac or ibuprofen should be prescribed for analgesia. In case of extensive or persistent infection, antibiotics should also be prescribed. Follow up visits should be scheduled with the patient along with periodic radiological evaluation for assessment of bone loss. Conclusion This 21 year old patient needs management of an unsuccessful root filling of the maxillary right central incisor. The goal is to achieve an aesthetic, functional as well as a convenient outcome. There are many ways to achieve this goal and the treatment should be individualised for this patient. There cannot be a set protocol for managing such cases. Formulation of a plan to extract the tooth, put in an implant immediately after extraction, perform bone grafting, 2 stage procedure, provisional followed by permanent restoration is based on the results of evidence based established procedures. This management plan has been conceived depending upon the information about the condition of the patient. 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