ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Findings Are Inconclusive as to Association Between Implants and Development of Vertical Root Fractures in Adjacent Teeth
Clinical Question In a population of patients receiving implant-supported crowns, is the risk of vertical root fracture (VRF) increased in teeth adjacent to the implants?
Clinical Bottom Line A possible association between implant-supported rehabilitation and the development of cracks in adjacent teeth has been noted. To conclude a direct causal relationship, however, all variables affecting the cracked teeth in question need to be controlled; therefore, more research is needed to support this association. VRF is a multifactorial phenomenon with many independent variables contributing to its occurrence, such as the type of restoration on the cracked tooth, the time since the teeth were initially restored, and the length of time in occlusion. All these factors need to be taken into consideration when planning implant rehabilitation and be communicated to the patient during treatment planning.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 27106717Rosen/20168 VRF cases in 7 patientsCase series and systematic review
Key resultsThe case series analysis revealed that the time from implant placement to the diagnosis of VRF was between 5 and 28 months (average = 11 months). The majority of cases occurred in female patients who received 2 or more implants. Six of the 7 patients were older than 40 years, with an average age of 54 years. The majority of teeth with VRF were premolar or mandibular molar teeth (6/8 teeth). All fractured teeth had been restored with a crown and had a post present, and the quality of the root canal filling was determined to be adequate. A systematic review revealed that implant-associated VRF has not been investigated or reported in the literature yet.
#2) 14651239Krennmair/2003148 teeth adjacent to an implantProspective Cohort Study
Key resultsThe clinical findings for implants (one loss), peri-implant structures, and prosthetic complication rates (three crown fractures) were excellent. There was a high proportion of intact adjacent teeth in both anterior and posterior regions at crown placement and at the follow-up examination. No adjacent teeth required extraction or endodontic treatment, and only four required restoration. Comparison of the periodontal status at crown placement and at follow-up revealed no differences for plaque and bleeding indices or for pocket depth of adjacent teeth. There was a significant influence of the horizontal distance (between the implant edge and the adjacent tooth) on approximal bone loss in the anterior region where this distance was smaller, but not in the posterior region where implant-tooth distances were larger.
#3) 19053930Misch/20081,162 patients with single implantsRetrospective study
Key resultsThis case series study evaluated posterior single-tooth implant survival and the long-term conditions of the adjacent teeth. Of the 1,377 implants inserted, there were 11 surgical failures from stage I to stage II healing. There was one failure from stage II healing to prosthesis delivery. There were two prosthetic-phase failures. The surgical success rate was 99.2%, whereas the overall survival rate was 98.9% at an average of 61 months of follow-up (range, 12 to 125 months). A total of 2,589 adjacent teeth were followed during the study. No natural adjacent tooth was lost during this period. Interproximal decay developed in 129 adjacent teeth (5%), and nine adjacent teeth required RCT (0.4%) as a result of decay or restoration.
#4) 27106717Misch/20081,162 patients with single implantsRetrospective study
Key resultsOf the 1,377 implants inserted, there were 11 surgical failures from stage I to stage II healing. There was one failure from stage II healing to prosthesis delivery. There were two prosthetic-phase failures. The surgical success rate was 99.2%, whereas the overall survival rate was 98.9% at an average of 61 months of follow-up (range, 12 to 125 months). A total of 2,589 adjacent teeth were followed during the study. No natural adjacent tooth was lost during this period. Interproximal decay developed in 129 adjacent teeth (5%), and nine adjacent teeth required RCT (0.4%) as a result of decay or restoration.
Evidence Search "Implant adjacent tooth fracture"
Comments on
The Evidence
Rosen 2016 reported on a series of cases and also performed a systematic review of implant-associated VRF. However, none of the articles located via a literature search addressed the topic of interest; therefore, no articles were included in the systematic review. A second, larger case series published in 2017 by the authors of Rosen/2016 found similar results. In that study, most of the cases occurred in female patients (61%), over 50 years old (78%, with an average age of 59 years). Nine (50%) of the cracked teeth were molars, 7 (39%) were mandibular premolars, and 2 (11%) were incisor teeth. Most of the cracked teeth (61%) had an amalgam restoration, 50% had deep periodontal pockets, and 78% had vital pulps. In 78% of patients, multiple implants were placed (with an average of 3 implants per patient). The time from implant loading to the diagnosis of a crack was longer than 1 year in 78% of cases. There appears to be a relationship between occurrence of VRF and adjacent implants. None of the studies controlled for all potential contributing variables. Larger studies that control for possible confounders such as post type need to be done before any causal relationship becomes apparent. In the two larger studies (Krennmair/2003 and Misch/2008) no adjacent teeth had to be extracted, so it is doubtful that vertical root fracture occurred in those patient cohorts. Therefore, when all potential variables affecting cracked teeth are eliminated, adjacent natural-tooth complications appear to be minimal.
Applicability The significance of these findings depend on how they are presented. It is important to inform the patient of the risks and benefits of implant therapy. Within the informed consent, the patient should be made aware of the potential risk of VRF to adjacent teeth by implants. When the dentist is planning therapy, he/she should look at all factors that could make adjacent teeth more susceptible to VRF if an implant is placed, and adjust the planned treatment accordingly.
Specialty/Discipline (Endodontics) (General Dentistry) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords Dental implants, vertical root fracture
ID# 3315
Date of submission: 07/19/2018spacer
E-mail jonesat@livemail.uthscsa.edu
Author André T. Jones
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Kevin Gureckis
Faculty mentor/Co-author e-mail gureckis@uthscsa.edu
Basic Science Rationale
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