THREE-YEAR CLINICAL COMPARISON OF SURVIVAL OF ENDODONTICALLY TREATED TEETH RESTORED WITH EITHER FULL CAST COVERAGE OR WITHDIRECT 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 57 maxillary second premolars. 33mandibular second premolars-----met all the specific inclusion/exclusion criteria . 3 first mandibular premolars. 63 women) Age: 35 – 55 years old (mean: 48 years old) Education level: 61% high school/university degree Teeth included: 24 maxillary first premolars.MATERIALS & METHODS • • • • 117 subjects (54 men. 117 subjects Coin tossed GROUP 1 : GROUP 2 RCT + Composite RCT + Composite After 1 week Metal Ceramic Crown All procedures done by one operator . Photographic examination (colour slides) . Periapical radiograph 3.CLINICAL EVALUATION Success or failure Perfomed by 2 examiners other than the operator 1. Visual inspection -Continuity of margin -Periodontal probing 2. Data analyzed by use of a computer programme (StatXact-3) .FAILURE Root fracture Post fracture Post decementation Clinical/ radiographic evidence of marginal gap Clinical evidence of secondary caries The 2 groups were compared. 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 can’t 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 . i. what coronal restoration is best for endodontically treated teeth (albeit only premolars with intact cusps) .e.STATEMENT OF PROBLEM The study does try and answer an important question. 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 . 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 Premolars selected but in differing positions in the mouth – also. malocclusion or what tooth is opposed by – can affect outcome Perio attachment loss of 40% .M & M – SELECTION CRITERIA Mentions need to be in occlusal function after treatment but doesn’t take into account parafunction.bit high?!? As far as subject selection goes we weren’t sure why pt education was relevant – previous dental attendance perhaps a better indicator? . Crown prep – 6 degree convergence seems hopeful?! Crown fabrication – one lab but same technician or different ones? Standardisation of procedure creates a stronger study! . skill of operator. same operator? Post placement – why 7mm? Surely on basis of root formation. Technique used.M & M – CLINICAL PROCEDURE (GO TO FLOW CHART) RCT – too generalised. Was it blind? 3.M & M – JADAD SCORES Procedure to used independantly assess methodological quality of a clinical trial Three questions asked: 1. 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 . Was it randomised? 2. Was there description of withdrawals or dropouts? Score +1 for yes. creates independence Systemic allocation – i.M & M .RANDOMISATION Coin flip – who flipped the coin? Consistant? Could do concealed allocation . 5 of the first subjects recruited could be randomly assigned to group 1 Computer generated .e. M & M .BLINDING Blinding is difficult as the operator knows what they’re placing and the patient knows what they’ve been given BUT can do blind analysis of data – this wasn’t done however . WITHDRAWALS OR DROPOUTS (GO TO CLINICAL EVALUATION SLIDE) There was drop out – exact reasons not stated Does say that teeth lost due to trauma.M & M . 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 . but what is the relationship of the examiners to the operator. Teeth lost to endo failure not counted – how many endo failures were due to marginal gap formation but not counted? .CLINICAL EVALUATION Examiner agreement exceeded 90% . Colleagues? Juniors? Marginal gap formation considered failure.M & M . RESULTS AND DISCUSSION Findings are stated clearly based on the outcome measurements. 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? . There is no difference between the two groups. But: No power calculations for this study (explanation?). 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?? .