THREE-YEAR CLINICAL COMPARISON OF SURVIVAL OF ENDODONTICALLY TREATED TEETH RESTORED WITH EITHER FULL CAST COVERAGE OR WITH DIRECT

COMPOSITE RESTORATION
Fracesco Mannocci MD, DDS, PhD Egidio Bertelli MD,DDS Marlyn Sheriff BSc, PhD Timothy Watson BSc, DDS, PhD T.R Pitt Ford BDS, PhD

STATEMENT OF PROBLEM

Little information exists regarding outcome of crown build-ups on endodontically treated teeth restored with MCC or with only direct placed CR

PURPOSE

Evaluate clinical success rate of endodontically treated premolars restored with fiber posts and direct CR snd compare similar treatment with MCC

MATERIALS & METHODS

117 subjects (54 men, 63 women) Age: 35 55 years old (mean: 48 years old) Education level: 61% high school/university degree Teeth included: 24 maxillary first premolars, 57 maxillary second premolars, 3 first mandibular premolars, 33mandibular second premolars-----met all the specific inclusion/exclusion criteria

117 subjects

Coin tossed
GROUP 1 : GROUP 2

RCT + Composite

RCT + Composite
After 1 week
Metal Ceramic Crown All procedures done by one operator

CLINICAL EVALUATION
Success or failure Perfomed by 2 examiners other than the operator

1. Visual inspection
-Continuity of margin -Periodontal probing

2. Periapical radiograph 3. Photographic examination (colour

slides)

FAILURE
Root fracture Post fracture Post decementation Clinical/ radiographic evidence of marginal gap Clinical evidence of secondary caries

The 2 groups were compared. Data analyzed by use of a computer programme (StatXact-3)

RESULTS

SUMMARY OF RESULTS

Year 1
No Failure reported Recall for Group 1=55 Recall for Group 2= 57

Year 2
Recall for Group 1= 48 Recall for Group 2=57 Failure due to: Post decementation Marginal gaps formation

Year 3
Recall for Group 1=50 Recall for Group 2=54 Failure due to : Marginal gaps formation

DISCUSSION
Equivalent failure rate between Group 1 and Group 2 Suggest to include matched pairs of teeth to reduce bias Results cant be compared to other studies on post-crown and composite restorations of endodontically treated teeth

Failures might be correlate due to fiber post become flexible Wear rate not included Planned to continue until year 6

CONCLUSION

Ceramo-metal crown coverage did not enhance clinical performance of endodontically treated and restored teeth compared to composite

CRITICAL APPRAISAL
Tom and Ryan

OPENING

Must be said that this is an experimental clinical study and these are often very difficult to set up but the purpose of today is to critique the study and see where improvements could be made. So we may seem a bit harsh!

TITLE

We felt the title does not accurately describe the method: states teeth rather than premolars fails to state that it is a direct composite restoration AND a fibre post

STATEMENT OF PROBLEM

The study does try and answer an important question, i.e. what coronal restoration is best for endodontically treated teeth (albeit only premolars with intact cusps)

PURPOSE AND INTRODUCTION

States that MCC most common system for anterior and premolar crown coverage for aesthetic reasons function needs to be considered Not entirely clear whether posts are being used with the teeth that are being crowns

M & M SELECTION CRITERIA

Premolars selected but in differing positions in the mouth also, one group may have contained more of one type than the other Both cusps intact but was access for endo minimal to preserve tooth structure was all endo done by the same operator and if so to what skill level? Students or specialist? We also felt that both cusps intact could mean a significant amount of tooth structure left need for crown or need for post justified?

M & M SELECTION CRITERIA

Mentions need to be in occlusal function after treatment but doesnt take into account parafunction, malocclusion or what tooth is opposed by can affect outcome Perio attachment loss of 40% - bit high?!? As far as subject selection goes we werent sure why pt education was relevant previous dental attendance perhaps a better indicator?

M & M CLINICAL PROCEDURE

(GO TO FLOW CHART)

RCT too generalised. Technique used, skill of operator, same operator? Post placement why 7mm? Surely on basis of root formation. Crown prep 6 degree convergence seems hopeful?! Crown fabrication one lab but same technician or different ones? Standardisation of procedure creates a stronger study!

M & M JADAD SCORES

Procedure to used independantly assess methodological quality of a clinical trial Three questions asked: 1. Was it randomised? 2. Was it blind? 3. Was there description of withdrawals or dropouts? Score +1 for yes, 0 for no Additional points given if: method of randomisation described and appropriate method of blinding described and appropriate Points deducted if either of above points inappropriate

M & M - RANDOMISATION
Coin flip who flipped the coin? Consistant? Could do concealed allocation - creates independence Systemic allocation i.e. 5 of the first subjects recruited could be randomly assigned to group 1 Computer generated

M & M - BLINDING

Blinding is difficult as the operator knows what theyre placing and the patient knows what theyve been given BUT can do blind analysis of data this wasnt done however

M & M - WITHDRAWALS OR DROPOUTS

(GO TO CLINICAL EVALUATION SLIDE)

There was drop out exact reasons not stated

Does

say that teeth lost due to trauma, endodontic or periodontal problems were considered missing data but how much was this and how much was non attendance? Non attendance could possibly be attributed to failure

Could do intention to treat the patient is counted even though they have been lost to follow up

M & M - CLINICAL EVALUATION

Examiner agreement exceeded 90% - but what is the relationship of the examiners to the operator. Colleagues? Juniors? Marginal gap formation considered failure. Teeth lost to endo failure not counted how many endo failures were due to marginal gap formation but not counted?

RESULTS AND DISCUSSION

Findings are stated clearly based on the outcome measurements. There is no difference between the two groups. But:
No

power calculations for this study (explanation?); problematic for ethical approval nowadays? Were there differences between the various types of premolar? They suggest matching pairs of teeth but rightly state this is difficult to do in sufficient numbers

Improve tooth selection more broken down?

RESULTS AND DISCUSSION (CONTD)

Numbers are small so statistical significance may not have been picked up (however must be said numbers are good for a clinical trial) Tooth wear is mentioned as a factor that might affect long term clinical performance of composite crown build ups Longer study needed 6 year review planned

CONCLUSIONS
Within the limitations of this study acknowledges that that further scope is required It is an experimental clinical trial and these are often difficult to set up strengths are that it is in vivo and clinical Will it change our clinical practice? Not likely on the strength of this study alone

QUESTIONS??