Section Four 

– NON-ABUTMENT-PROVIDING
MODALITIES

Chapter 19 –  Endodontic Stabilizer Implants

Tooth Root Extension for Improved Prognosis BENEFITS AND
DESCRIPTION OF THE MODALITY AND SYSTEM USED IN THE
TEACHING CASE

The purpose of endodontic stabilizers is to improve the prognosis of teeth with reversible
complications, and their capability to act as abutment support. Endodontic stabilizers are not
meant to save hopeless teeth. Adding length to the roots of teeth compromised by bone loss
improves their crown-root ratio[1] ( Fig. 19-1 ). A tooth successfully treated with endodontic
stabilization may show improved gingival tissues and bone maintenance. The treated tooth is
able to withstand increased functional loads within physiologic limits of health [2] and may be used
as an abutment under a prosthesis.

Figure 19-1  Periapical radiographs of endodontic stabilizers in maxilla (A) and mandible (B).

Figure 19-1 Periapical radiographs of endodontic stabilizers in maxilla (A) and

mandible (B)

Proven Long-Term Success/Survival Rates

Endodontic stabilizers have been used for more than 40 years. In that time, predictability and
acceptable levels of success/survival have been demonstrated. [3] Early problems related to
retention of the stabilizer within the tooth root, [4] a reliable endodontically oriented apical seal[5] (
Fig. 19-2 ), preventing cement expression beyond the apex at the time of insertion ( Fig. 19-3 ),
and long-term bone maintenance around the portion of the stabilizer that projects beyond the
tooth apex ( Fig. 19-4 ) have been overcome with improvements in design.[6]

Figure 19-2  Apex, threading at area of apical seal, and opposite cortical plate (arrows).

Figure 19-2 Apex, threading at area of apical seal, and opposite cortical plate (arrows).

Figure 19-3  Smooth stabilizers lacking apical seal. Note expression of cement beyond apices (arrow).
 Figure 19-3 Smooth stabilizers lacking apical seal. Note expression of cement beyond
apices (arrow).

Figure 19-4  Excessive fibrous tissue around site of failed stabilizer.

Figure 19-4 Excessive fibrous tissue around site of failed stabilizer

The American Dental Association (ADA) Council on Education has stated that endodontic
stabilization is a viable treatment option for correctly diagnosed and fully informed patients in the
hands of a trained practitioner. The success/survival rates reported for endodontic stabilization
are comparable with those of endosteal implants.[3] There is no pergingival site, because the
stabilizer does not penetrate gingiva. It passes through a tooth root into the bone beyond, sealing
the apex as it does so ( Fig. 19-5 ).
 Figure 19-5  Stabilizer passing through apex into available bone.

Figure 19-5 Stabilizer passing through apex into available bone

Technique-Permissive One-Visit Procedure

Because of the design of the implant and associated components, each step of the endodontic
stabilization procedure is technique-permissive. The treatment protocol is precise and logical.
Endodontic stabilization is a standardized procedure that can be performed predictably as part of
one’s current endodontic regimen. Teeth that would otherwise not require endodontic treatment
do require such treatment as an integral part of the endodontic stabilization protocol. Endodontic
stabilization does not contraindicate any conventional endodontic regimen, so conjunctive use of
one’s favored endodontic protocols is recommended.

Restorative Options

Endodontic stabilization expands restorative options. All conventional restorative options

applicable to endodontically treated teeth are applicable to teeth treated with endodontic
stabilization. Depending on the condition of the crown of the tooth, options range from simple
fillings to esthetic crowns. At times, the length of stabilizer that extends into the oral cavity after
insertion may be trimmed above the level of the residual tooth structure to act as a basis for a
post-core restoration before crown fabrication ( Fig. 19-6 ). An additional option is to use a
unified post-core/endodontic stabilizer combination ( Fig. 19-7 ).

Figure 19-6  Stabilizers (arrows) reinforcing coronal tooth structure.

 Figure 19-6 Stabilizers (arrows) reinforcing coronal tooth structure

Figure 19-7  One-piece endodontic stabilizer/endodontic filling/post-core combination.

Figure 19-7 One-piece endodontic stabilizer/endodontic filling/post-core combination

Unique Features

The Oratronics Osteo-Loc endodontic stabilizers used in the teaching case in this chapter offer
several unique biomechanical advantages that are described in detail as part of the step-by-step
insertion procedure, including an increased crown-root ratio, increased efficiency of the treated
tooth root, firm retention of the stabilizer to the tooth root, a predictable apical endodontic seal,
and the osteostimulatory effect of short collagenous fiber attachment to trabeculae of bone
around the stabilizer interface ( Fig. 19-8 ). Other unique design features promote expression of
excess cement toward the oral cavity and away from the apex, and precise size-graduated
instrumentation that protects the apex from cracking as the stabilizer passes through it and into
its prepared osteotomy in available bone.

Figure 19-8  Site of successful stabilizer. Arrow indicates bone ingrowth into threading.
 Figure 19-8 Site of successful stabilizer. Arrow indicates bone ingrowth into
threading

Configurations and Nomenclature of Endodontic Stabilizers

Osteo-Loc endodontic stabilizers are parallel-sided, threaded implants fabricated of titanium alloy
( Fig. 19-9 ). Each has a hand-operated disposable handle for ease of manipulation. The one-
piece post-core/endodontic stabilizer has a tapered abutment that can be further prepared for
prosthodontic parallelism if necessary, with millimeter adjustment lines for guidance should
adjustment for interocclusal clearance be required. Each stabilizer has a continuous thread with a
sluiceway at its apex to guide cement expression coronally ( Fig. 19-10 ). Stabilizer width from
thread crest to thread crest is called the major diameter. The minor diameter is the width across
the central column from thread-base to thread-base. The land is the distance on the central
column from thread to thread. Pitch is the angle of each thread to the central column. Stabilizer
No. 3 has a major diameter of 0.044 inches, and No. 4 has a major diameter of 0.069 inches.

Figure 19-9  Endodontic stabilizers and associated instrumentation.

Figure 19-9 Endodontic stabilizers and associated instrumentation

Figure 19-10  Stabilizer threads with sluiceway indicated by arrow.

Figure 19-10 Stabilizer threads with sluiceway indicated by arrow

TYPICAL MAINSTREAM CASE—DIAGNOSIS, TREATMENT PLAN,
AND END RESULTS

Case as Presented
Patient’s Story.

The tooth under consideration has previously been treated endodontically, or may require such
treatment. A typical case involves a maxillary or mandibular anterior tooth, or first premolar.
Active bone loss is minimal, and mobility of the tooth is often observed. The candidate tooth may
show secondary or root decay, or a fracture at the gingival level that requires a crown-lengthening
procedure, which in turn will further decrease the peri-cemental area of bone support. The crown-
root ratio is unfavorable. The patient does not wish to have the tooth removed. Its prognosis, if
untreated, is marginal. If the tooth is vital, the patient is willing to undergo root canal therapy to
have it stabilized. Often, endodontic therapy is required to retain the tooth regardless of whether
stabilization treatment is indicated.

Clinical Appearance.

Examination reveals a compromised tooth, often slightly mobile, possibly broken down, and
possibly discolored. The gingival condition is acceptable or can be improved with periodontal
treatment. Crown lengthening may be required.

Radiographic Interpretation.

The radiograph reveals a compromised tooth. Bone has been lost, but enough remains to retain
the tooth.

Any periapical pathology that may exist can be successfully treated endodontically or with an
apicoectomy.

Rejected Alternative Treatment Plans

The patient does not want the tooth removed. Removal of the tooth followed by the fabrication of
a conventional fixed prosthesis, or single-tooth replacement using a root form implant, will not be
required if the tooth is retained.

Endodontic stabilization using a smooth device, parallel-sided or tapered, is not advised. A

relatively small amount of tension or compression can dislodge a smooth stabilizer from its seal
against the internal aspect of the root canal. In addition, smooth stabilizers are incapable of
sealing the apex endodontically, have the disadvantage of permitting the expression of
endodontic sealants into bone beyond the apex, and do not promote an osteostimulatory effect to
ensure long-term bone maintenance around the portion of the stabilizer that extends beyond the
apex.

Accepted Treatment Plan

The case is diagnosed for treatment using a threaded endodontic stabilizer. This procedure
requires one treatment visit that can usually be performed in approximately 1 hour of scheduled
time.

Completed Case
Having the goal of endodontic stabilization firmly in mind during the treatment visit is important.
The end result is presented now, to help the reader understand how each treatment step
contributes to the final result, and to convey the satisfaction and benefits of treatment to the
patient and practitioner.

Patient’s Story.

The treatment goals have been achieved. The treated tooth is now within the normal range of
mobility. It can be esthetically restored, and has a better prognosis for use as an abutment under
a prosthesis. Fine home care is easy to perform. The patient is fully informed about home care
procedures.

Clinical Appearance.

Unrestored, the tooth appears much is it did before treatment. Following restoration, it looks like
any other esthetic tooth. The treated tooth has normal mobility. The gingiva is healthy. Pocket
depths are within normal ranges.

Radiographic Interpretation.

The postoperative radiograph reveals a well-positioned endodontic stabilizer implant that takes
advantage of a substantial amount of available bone beyond the root apex. No cement is
expressed through the apex during seating. The apex is in good condition. A review of
postoperative radiographs of several cases reveals normal variations of this outcome ( Figs. 19-
11 and 19-12 ).

Figure 19-11  Postoperative radiograph of endodontic stabilization.

Figure 19-11 Postoperative radiograph of endodontic stabilization

Figure 19-12  Periapical radiographs of successful endodontic stabilization.

 Figure 19-12 Periapical radiographs of successful endodontic stabilization

Microscopic Interpretation at the Interface.

Following healing, light microscopy reveals that collagenous tissue of the peri-implant ligament
around the stabilizer is organized in a manner similar to that of the periodontal ligament. [7][8] Short
fibers are bundled, anastomose, and are unified by a network of reticular fibers that bind them
together.[9] The collagen fibers attach to the first and usually second layers of trabeculae around
the stabilizer implant, travel tangential to the stabilizer interface, and reinsert into other
trabeculae, forming a sling around the stabilizer implant. The fibers are stressed sufficiently in
function to stimulate the trabeculae, producing bioelectric, cell-generated, and ground substance–
generated responses, together contributing an osteostimulatory effect ( Fig. 19-13 ). See Chapter
6 for a detailed explanation of osteostimulation.

Figure 19-13  Peri-stabilizer ligament fibers stressed in function.

 Figure 19-13 Peri-stabilizer ligament fibers stressed in function

EVALUATION OF CANDIDATE TEETH

Surrounding Anatomic Structures

A minimum of 5 mm of available bone must be present beyond the apex of a tooth root to make
endodontic stabilization worthwhile. The presence of 10 to 15 mm of available bone or more is
not uncommon, and enhances the final result. Periapical radiography and digital manipulation
during clinical examination are valuable diagnostic aids. Landmarks such as the mental foramina,
inferior alveolar canal, sinuses, and nasal cavity are to be avoided. Undercut areas should be
noted to avoid possible perforation of cortical bone ( Fig. 19-14 ). Such undercut areas do not
preclude endodontic stabilization but may reduce the depth of available bone into which a
stabilizer implant can be seated. In a tooth whose long axis diverges from that of its canal,
particularly noted in the anterior maxilla, the labial enamel plate, if present, should not be
penetrated ( Fig. 19-15 ).

Figure 19-14  Stabilizer perforating undercut bone.

Figure 19-14 Stabilizer perforating undercut bone

Figure 19-15  Natural tooth. Lines show divergent axial inclinations of crown and root.
 Figure 19-15 Natural tooth. Lines show divergent axial inclinations of crown and root

In consideration of the required available bone beyond the apex, endodontic stabilization in the
mandible can be performed on first premolars, cuspids, and incisors in mainstream cases.
Second premolars and molars are in close proximity to the inferior alveolar canal, which should
be avoided because of the risk of paresthesia. In the maxilla, teeth anterior to the sinus with
sufficient available bone between the apex and the floor of the nasal cavity can be endodontically
stabilized. These are most often the incisors, cuspids, and the lingual roots of the first premolars.
In patients who have appropriate anatomy, second premolars can also be treated.

Periodontal Condition

The periodontal condition is considered at the time of diagnosis for endodontic stabilization. At
the time of examination, if periodontal therapy is not needed, endodontic stabilization treatment
may proceed. If periodontal therapy is required, it is best completed before determining whether
to perform endodontic stabilization. Sometimes, endodontic and periodontal pathology must be
treated simultaneously.

In borderline cases, in which saving the tooth may or may not be indicated, the science and art of
dentistry converge. Patient habits, type of occlusion, opposing arch, oral hygiene, and general
health have the same bearing as they do in diagnosing for conventional dental treatment. The art
of dentistry is to make a correct judgment call, taking into account the patient’s desires following
discussion of benefits and risks, alternative treatment options, and probable treatment should
complications occur.
Endodontic Condition

A precondition of diagnosis for endodontic stabilization is that the tooth can be successfully
treated endodontically. Some teeth are treated with endodontic stabilization that otherwise would
not have required endodontic therapy. Teeth that require endodontic treatment before
stabilization are treated until readiness for final filling. The stabilizer is placed at the visit during
which the tooth would have been filled. In cases that require apicoectomy, the stabilizer is
inserted during the visit at which the apicoectomy is performed. With the apical area directly
visible, the stabilizer osteotomy is prepared by passing the coordinated osteotomy drill through
the apex, beyond the void created by the apicoectomy, and into the available bone apical to it.
The stabilizer is then seated before closure. Such cases are not considered mainstream.

Tooth Root Anatomy

The anatomy of the apical third of the root and its orientation relative to available bone dictate the
appropriate stabilizer configuration. In mainstream cases, the pathway of the canal from the
crown to the apex is essentially parallel to the long axis of the root. The cross-sectional anatomy
of some roots reveals substantial dentin surrounding the apical foramen, while in others the
dentin surrounding the canal is sparse. The No. 3 Osteo-Loc stabilizer implant, 0.044 inches in
major diameter, is generally used for the mandibular incisors and maxillary lateral incisors, in
which the amount of dentin surrounding the canal tends to be sparse. When the dentin
surrounding the canal is sufficient, as is usually the case in other candidate teeth, the No. 4
stabilizer, measuring 0.069 inches in major diameter, is used.

Some tooth roots show curvature at the apical end, often observed in upper lateral incisors ( Fig.
19-16 ). In such cases, the apical end of the canal is filled from the point of curvature to the apex,
and the stabilizer osteotomy is created in a straight line, passing through the wall of the root to
create a penetration that will be endodontically sealed as part of the procedure. Although this is
not considered mainstream treatment, it is easy to visualize and treat successfully, and can be
attempted after several mainstream cases have been treated. The prognosis is good in such
cases.

Figure 19-16  Path of endodontic stabilizer implant in tooth with curved root apex.

Figure 19-16 Path of endodontic stabilizer implant in tooth with curved root apex
The alveolar bone covering the buccal/labial of the root can be extremely thin. When widening
canals of such teeth, it is advisable to exert pressure during reaming toward the lingual at all
times, thus enlarging the canal at the expense of the lingual where there is adequate bone
surrounding the apex. Preserving a thin buccal/labial plate of bone in this manner is considered
part of mainstream endodontic stabilization.

The maxillary first premolar bears special consideration. It usually has two roots. Because its
buccal root is near the buccal cortical plate, stabilization of the maxillary first premolar is best
achieved by treatment of the lingual root only.

PLANNING AND PROCEDURES BEFORE ENDODONTIC STABILIZER

IMPLANT INSERTION

The steps that are performed before the endodontic stabilizer insertion visit are shown in Box 19-
1.

Box 19-1
PREOPERATIVE PROCEDURES

   Complete all endodontic treatment until canal is ready for obturation

   Quantify available bone
   Determine whether to use standard stabilizer or post-core/stabilizer combination
   Prescribe preoperative medication
Complete All Endodontic Treatment Until Canal Is Ready for Final
Obturation
Vital Cases.

A variety of predictable endodontic treatment techniques can be performed before stabilization,

using various instrumentation, medication, filling materials, and case sequencing. Some
practitioners perform endodontic treatment as a one-visit procedure. In conventional protocols
involving more visits, the stabilizer is inserted during the visit at which the canal would have been
obturated. The most predictable results are obtained using one’s conventional office routines for
endodontic therapy.

Nonvital Cases.

A nonvital tooth does not contraindicate endodontic stabilization. The endodontic protocol is
typically longer and more complex in nonvital cases, but the same stabilization considerations
apply as for vital cases. At the point in treatment at which one would fill the canal, the endodontic
stabilizer is inserted. Treatment of nonvital cases is considered mainstream.

Previously Treated Cases.

Stabilization cases that have previously been treated with endodontic therapy are subject to the
same considerations. The materials obturating the canal are removed. The canal is retreated and
cleansed until it is ready to be obturated again, at which time the stabilization protocol begins.

Cases That Require Apicoectomy.

Endodontic stabilization in cases that require apicoectomy is not considered mainstream, but
such treatment is successful when performed by an experienced practitioner. [5] There are two
options. In cases in which the apicoectomy and the endodontic therapy are performed by different
practitioners, it is usually best to complete the endodontic therapy first, and then refer the patient
for apicoectomy without a retrofill. Endodontic stabilization is then performed after healing at the
apex, starting with removal of the endodontic filling, followed by canal enlargement and then the
remainder of the stabilization protocol.

If the same practitioner performs the apicoectomy and the endodontic stabilization, the
apicoectomy is best performed at the same visit, just before insertion of the endodontic stabilizer.
The stabilizer osteotomy preparation and insertion can be performed before closure of the
apicoectomy. Direct visualization ensures maximization of available bone and proper path of
insertion.

Quantify Available Bone Using Diagnostic Radiography

The periapical radiograph is the best diagnostic tool for evaluating available bone for endodontic
stabilization. A film packet with a millimeter grid affixed to it is used ( Fig. 19-17 ). The resulting
radiograph shows the apex and the opposite cortical plate, and allows the practitioner to estimate
the number of millimeters of available bone between them fairly accurately. Palpation for areas of
depression or sharp contour changes at the buccal/labial of the maxilla and the buccal/labial and
lingual of the mandible in the vicinity of the root of the candidate tooth reveals whether all of the
available bone observed on the radiograph can be used. In cases in which an undercut or
unusual contour is detected, measurement of the usable depth of available bone needs to be
exact to ensure that cortical bone is not penetrated. Final confirmation of available bone depth
occurs during the procedure when a measurement radio-graph is taken with a millimeter
measuring rod positioned within the osteotomy that is being prepared. In this way, the
practitioner can accurately count each millimeter, thereby avoiding error that can be introduced by
distortion or elongation of the radiographic image.

Figure 19-17  Radiograph with millimeter grid to aid measurement.

Figure 19-17 Radiograph with millimeter grid to aid measurement

Determine Whether to Use Unified Post-Core/Endodontic Stabilizer

Combination
When a tooth has been targeted for endodontic stabilization, consider whether a unified post-
core/stabilizer combination is required for the restorative phase. Such treatment is considered
mainstream. Cases in which the coronal portion of the tooth is of inadequate size to support the
planned restoration are suitable for treatment using a post-core/stabilizer combination, which
provides an abutment. Both sizes of endodontic stabilizer are available as unified post-
core/stabilizer combinations.

Sterilize Implant

Endodontic stabilizer implants are supplied sealed in two pouches. The outer pouch details the
product information required by U.S. Food and Drug Administration (FDA) regulations and the
U.S. Good Manufacturing Practices Act. Remove the inner pouch, which contains the stabilizer
implant, but do not remove the implant from the pouch. Sterilize the implant in the conventional
manner. Guidelines for gravity air displacement steam sterilization are for an exposure time of 30
minutes at 250° F (121° C) or 15 minutes at 270° F (132° C). For prevacuum steam sterilization,
an exposure time of 4 minutes is required at 270° F (132° C). Once sterilized, the pouch is
transferred to the surgical tray setup. If desired, stabilizer implants can be resterilized following
cleansing.

Prescribe Preoperative Medication

The preoperative prescription of medication described for the abutment-providing modalities in

Chapter 9 is also followed for endodontic stabilization cases. Preoperative administration of anti-
edema medication is generally not required for mainstream cases, unless the patient’s history
suggests that edema may be greater than normal. Nor is preoperative sedation recommended.
Patients who take prophylactic aspirin daily are advised to discontinue doing so for at least 3
weeks preoperatively, to allow for normal clotting at the insertion visit

ENDODONTIC STABILIZER IMPLANT INSERTION VISIT

The steps that are performed during the one-visit endodontic stabilizer insertion procedure are
shown in Box 19-2 .

Box 19-2
ONE-VISIT ENDODONTIC STABILIZER IMPLANT INSERTION PROTOCOL

   Confirm use of prophylactic antibiotic

   Administer local anesthetic
   Enlarge canal with tapered reamer
   Parallel dentinal walls at apical 4 mm of canal
   Prepare implant osteotomy to its final depth
   Tap apical 4 mm of canal and osteotomy beyond apex
   Insert millimeter measuring rod into osteotomy
Take periapical radiograph to evaluate whether depth of oste-otomy can be increased,
  
and to determine location of apex
   Flush, sterilize, and dry canal to apex
Apply endodontic cement to portion of stabilizer that will be located within paralleled
  
dentinal walls at apical 4 mm of root following seating
Apply crown and bridge cement to portion of stabilizer that will be coronal to paralleled
  
dentinal walls
   Seat endodontic stabilizer implant
   Trim excess stabilizer length in oral cavity
   Prescribe postoperative medication
   Provide home care instruction
Confirm That Preoperative Medication Has Been Taken

It is not necessary to postpone the case if the patient has not taken his or her preoperative
prophylactic antibiotic medication. The practitioner should have antibiotics on hand for
preoperative administration in such cases. If a patient on an aspirin regimen has not discontinued
its use, insertion may nonetheless be performed, with delayed clotting expected.

Instrumentation Setup—The Armamentarium

The sterile tray setup should include local anesthetic and syringes with appropriate needles; a
mirror; an explorer; suction tips; a plastic instrument; a syringe with canal sterilization flush; a
selection of large cotton points; a set of graduated hand and/or engine-driven reamers up to size
No. 90 or No. 120 for the No. 3 or No. 4 stabilizers, respectively; rubber stoppers; an endodontic
contra angle; an endodontic millimeter rule; locking college pliers; a titanium seating wrench (for
post-core stabilizers); millimeter x-ray grid; peri-apical radiograph films; endodontic cement; slow-
setting crown and bridge cement; setup to isolate the tooth under treatment; low-speed contra
angle; the selected sterilized stabilizer implant; and its coordinated bone drill and millimeter
measuring rod ( Figs. 19-18 and 19-19 ).

Figure 19-18  Hand and engine reamers, bone drill, millimeter measuring rod, and stabilizer (No. 3
left, No. 4 right).

Figure 19-18 Hand and engine reamers, bone drill, millimeter measuring rod, and
stabilizer (No. 3 left, No. 4 right

Figure 19-19  Post-core/stabilizer combination armamentarium.

Figure 19-19 Post-core/stabilizer combination armamentarium

Sterilization is performed as with all dental treatment instrumentation.

Local Anesthetic and Promotion of Comfort

In the absence of allergic conditions or medical contraindication, local anesthetic with 1:100,000
vasoconstrictor is administered as for conventional endodontic therapy. A loaded syringe is kept
available for supplemental administration or to help control bleeding, if necessary.

Expose the Canal for Treatment

The endodontic stabilization protocol for mainstream cases begins when all endodontic therapy
has been completed to the point at which the canal is measured for depth and ready for
obturation. Isolate the tooth, expose the canal, and flush with sterilizing solution ( Fig. 19-20 ).

Figure 19-20  Canal ready for obturation at start of stabilization protocol.

Figure 19-20 Canal ready for obturation at start of stabilization protocol

Enlarge the Canal

If a No. 3 stabilizer is chosen, progressively enlarge the canal to a No. 90 reamer inserted 2 mm
beyond the apex. For the No. 4 stabilizer, enlarge to a No. 120 reamer to the same point 2 mm
beyond the apex ( Fig. 19-21 ).

.
 Figure 19-21 Coordinated reamer penetrating 2 mm beyond apex

   At all times during this phase, exert reaming pressure toward the lingual to
enlarge at the expense of lingual bone and preserve the thinner buccal/labial plate. It
is advised that only hand instrumentation be used through the No. 25 reamer.
Starting with the No. 30 reamer, one may switch to engine instrumentation, if desired.

Flush and cleanse often as the series of reamers is used to enlarge the canal to its coordinated
final size.

Parallel the Dentinal Walls of the Apical Area

Place the bone drill that coordinates with the size of the stabilizer to be used (in the teaching case
a No. 3 for a mandibular incisor) into a low-speed contra angle. Before the endodontic
stabilization protocol is begun, at the time of canal instrumentation, a radiograph is taken with a
file or reamer in position to determine the distance from the apex to the chosen measuring point
on the clinical crown. A rubber stopper is now placed on the bone drill at that distance plus 2 mm,
as measured from the tip of the drill. With external coolant, the drill is passed into the canal at low
speed until the rubber stopper comes into contact with the measuring point on the crown. This will
parallel the apical 4 mm of dentin lining the canal ( Fig. 19-22 ). This also initiates the drilling of
the stabilizer osteotomy to a depth of 2 mm beyond the apex.

Figure 19-22  Parallel-sided bone drill penetrating 2 mm be-yond apex.

 Figure 19-22 Parallel-sided bone drill penetrating 2 mm be-yond apex

   Because of the standardized taper of the final reamer used to enlarge the
canal (No. 90 in the teaching case), the coordinated bone drill first contacts the
dentin approximately 4 to 5 mm from the apex. Use gentle, intermittent pressure to
pass the drill apically until the rubber stopper contacts the measuring point on the
crown. Because the drill is parallel sided, the facing dentinal walls in the apical area
are paralleled. The diameter of the drill is slightly wider than the minor diameter of
the stabilizer, and narrower than its major diameter.
Prepare the Stabilizer Implant Osteotomy

Withdraw the drill and cleanse it. Using the preoperative radiograph taken with the millimeter grid
as a guide, estimate the number of millimeters of bone from the apex to the cortical plate, and
move the rubber stopper coronally to the point that corresponds to that distance from the drill tip,
to limit the depth of bone drill insertion in creating the final osteotomy.

   The osteotomy is prepared to the opposite cortical plate, unless the presence
of an undercut prevents this.

Apply intermittent force apically to prepare the osteotomy to its estimated final depth ( Fig. 19-
23 ). Use water spray, and drill at low speed until the rubber stopper comes into contact with the
measuring point on the crown of the tooth.

Figure 19-23  Parallel-sided bone drill preparing osteotomy to planned depth.

 Figure 19-23 Parallel-sided bone drill preparing osteotomy to planned depth

   During this procedure, place one finger gently against the labial surface of
the bone to confirm by palpation that, as the bone drill prepares the osteotomy, bone
perforation does not occur. If a perforation is felt, stop drilling, withdraw the drill
approximately 2 mm and move the rubber stopper down to the coronal measuring
point on the tooth.

Remove the drill, and record in millimeters the distance from the coronal measuring point to the
base of the osteotomy.

   Three key measurements have now been recorded: the total distance from
the position of the rubber stopper against the coronal portion of the tooth to the base
of the osteotomy, the distance to the apex of the root, and by subtracting, the
distance from the apex to the base of the osteotomy.
Tap the Parallel Dentinal Walls and Osteotomy to Its Base

Remove the endodontic stabilizer implant from its pouch. The stabilizer is first used as its own
tap, to internally thread the dentinal and osteotomy walls ( Fig. 19-24 ). By hand, begin tapping by
gently inserting the stabilizer while slowly turning it clockwise. If binding occurs, turn
counterclockwise to remove and cleanse the stabilizer, reinsert it, and repeat the process until the
osteotomy has been tapped to its final depth. After the final depth has been achieved, remove,
cleanse, and dry the stabilizer.

Figure 19-24  Endodontic stabilizer tapping dentinal walls (A), and threaded dentin (B).

Figure 19-24 Endodontic stabilizer tapping dentinal walls (A), and threaded dentin
(B).

   The stabilizer, when being used as a tap, may bind because of accumulated
cut dentin and bone chips clogging the threads. Frequent removal and cleansing of
the stabilizer during tapping corrects this.

While tapping, keep a finger on the labial plate of bone to detect a penetration in the unlikely
event that tapping progresses out of line with the prepared osteotomy.

   Because the diameter of the osteotomy falls between the major and minor
diameters of the stabilizer, only the outer half of the threads taps the dentinal walls.
This allows space between the dentinal walls and shaft of the stabilizer to guide any
endodontic cement expression coronally rather than apically.
Confirm and Adjust Final Depth in Millimeters From Root Apex to
Osteotomy Base

Insert the coordinated millimeter measuring rod (No. 3 in the teaching case) to the base of the
osteotomy. Set the rubber stopper at the coronal measuring point.

   The millimeter measuring rod has a groove at every millimeter of depth. The
diameter of the rod is smaller than the diameter of the bone drill to avoid damage to
or widening of the prepared and tapped dentinal and osteotomy walls.

With the millimeter measuring rod in position, take a periapical radiograph ( Fig. 19-25 ). The
marks on the millimeter measuring rod appear clearly on the radiograph, and allow for precise
measurement regardless of any image distortion. Measure and record the distance from the base
of the osteotomy to the apex of the tooth by counting the millimeter marks visible on the
radiograph. Extraorally measure and record the distance from the stopper to the base of the
millimeter measuring rod.

Figure 19-25  Radiograph (A) of millimeter measuring rod passing through apex (B).

Figure 19-25 Radiograph (A) of millimeter measuring rod passing through apex (B).
    These measurements are not estimates. They are accurate, and are used for
the next steps in the procedure. If the radiograph indicates available bone depth
beyond the base of the osteotomy, it is possible to deepen the osteotomy to improve
the crown/root ratio further when the stabilizer is seated.

Set the bone drill into its low-speed contra angle. Place the rubber stopper at the position on the
drill that represents the depth from the measuring point on the crown to the base of the osteotomy
plus the additional number of millimeters of available bone according to the millimeter measuring
rod radiograph. Drill until the rubber stopper comes into contact with the coronal measuring point
according to the protocol previously described. When the osteotomy has been deepened to its
planned extent, thread the newly deepened portion using the stabilizer, as previously described.

Flush, Resterilize, and Dry Canal

The root canal is now flushed and dried as is conventionally done according to one’s favored
endodontic therapy protocol in preparation for final placement of the endodontic stabilizer implant
( Fig. 19-26 ).

Figure 19-26  Flushing (A) and drying (B) of canal.

Figure 19-26 Flushing (A) and drying (B) of canal

    Flush gently to limit the presence of solution beyond the apex.

If bleeding from the osteotomy persists, deposit local anesthetic containing 1:100,000
vasoconstrictor directly into the osteotomy by passing the needle into the canal and through the
apex. Do so slowly and without undue pressure. Next, with a series of extra-large cotton points,
dry the canal up to and approximately 2 mm beyond the apex. If seepage continues, press one to
three cotton points into the canal and maintain pressure until the bleeding stops. Gently remove
them, and insert a few clean cotton points up to but not past the apex.

   The canal is now dry and sterile.

Apply Conventional Endodontic Cement to Apical Portion of
Stabilizer

Place a rubber stopper on the stabilizer implant. Note the thread that corresponds to the distance
from the base of the osteotomy to the apex of the root as recorded on the millimeter measuring
rod radiograph ( Fig. 19-27 ). Also note the number of millimeters recorded from the base of the
measuring rod to the coronal measuring point, as indicated by the position of the rubber stopper
on the millimeter measuring rod, and move the rubber stopper to the corresponding position on
the stabilizer.

Figure 19-27  Determination of which stabilizer thread will be at root apex after seating.

Figure 19-27 Determination of which stabilizer thread will be at root apex after
seating

   The stabilizer seats to the base of the osteotomy. This is equal to the depth
to which the millimeter measuring rod was inserted when the measurement
radiograph was taken.
Place one’s favored endodontic cement for conventional endodontic regimens at the noted apical
thread, and cover 4 to 5 mm of stabilizer between that point and the handle ( Fig. 19-28 ).

Figure 19-28  Endodontic cement (arrows) at apex area (A) and crown and bridge cement coronally (B).

Figure 19-28 Endodontic cement (arrows) at apex area (A) and crown and bridge
cement coronally (B).

   This endodontic cement seals the apex and fills the threaded dentinal walls.
Recall that a space exists between the minor diameter of the stabilizer and the
dentinal walls, permitting the expression of excess endodontic cement coronally, and
not through the apex when the stabilizer is turned clockwise into position.
Apply Crown and Bridge Cement to the Portion of the Stabilizer
Coronal to the Paralleled Dentinal Walls

Apply one’s preferred conventional crown and bridge cement to the portion of the stabilizer
coronal to the stabilizer area covered with the endodontic cement. The setting time should be
slow enough to allow full insertion of the stabilizer at a measured pace.
    The portion of the stabilizer covered with crown and bridge cement will not
touch the paralleled dentinal walls. Coronal to the apical 4 mm, the tapered walls
widen in conformity with the contours of the reamer used to widen the canal (No. 90
in the teaching case). This portion of the prepared canal is wider than the No. 3
stabilizer chosen for the teaching case.
Seat Endodontic Stabilizer Implant to Osteotomy Base

Holding the stabilizer by the handle, gently insert it into the canal. When it meets resistance to
vertical seating approximately 4 mm from the apex, turn the stabilizer clockwise slowly and
deliberately to engage the threaded dentinal walls.

   The tip of the stabilizer, which engages the dentinal threading, is bare. The
portion covered with endodontic cement is not yet near the apex of the tooth, and
never approaches the osteotomy beyond the apex.

Turn the stabilizer clockwise with gentle apical pressure until it reaches the base of the
osteotomy. The endodontic cement is now at the apex, where it creates a seal together with the
stabilizer implant threading within dentin ( Fig. 19-29 ).

Figure 19-29 

Figure 19-29 Seated stabilizer trimmed to support coronal tooth structure (A),
 radiograph of stabilizer seated to cortical plate (B), and post-core/stabilizer seated
with hand wrench (C)

   In cases in which the stabilizer base is close to a cortical plate, the rubber
stopper signals to prevent overseating. In most cases in which perforation is not an
imminent risk, it is common to seat the stabilizer until it can no longer be turned,
when it reaches the osteotomy base.
Postinsertion Radiography

A postoperative periapical radiograph is taken for the patient record ( Fig. 19-30 ).

Figure 19-30 

Figure 19-30 Postoperative periapical radiograph of seated stabilizer

   Note the depth of the stabilizer, the number of millimeters of added length
beyond the apex of the root, the area of the apical seal, and the absence of cement
beyond the apex.

If the radiograph reveals that the stabilizer was overseated into a landmark, back it out a few
turns, and take another radiograph to confirm that the overseating has been corrected.

Remove Excess Coronal Portion of Stabilizer and Cement, and Check

Occlusion

Allow the crown and bridge cement to harden. Remove excess coronal length of stabilizer and its
handle using a small, tapered diamond. Remove excess cement. Adjust the tooth to be slightly
shy of full occlusion, if necessary.
    If the coronal portion of the tooth above the gingival crest is to be maintained,
reduce to approximately 2 mm below the occlusal surface to provide room for a
restoration. If restoration with a full crown follows, the stabilizer serves to reinforce
the remaining coronal portion of the tooth, and is flush with the completed full crown
preparation.
Postinsertion Home Care Instruction
Trauma.

No medication is needed for postoperative trauma. Postoperative edema is almost never clinically
evident.

Prophylactic Antibiotics.

Antibiotic medication prescribed preoperatively may be continued for an additional 3 to 4 days

after stabilizer insertion, although doing so is not mandatory. One’s office policy for antibiotic
administration after routine endodontic treatment may be followed.

Comfort Medication.

One’s office policy for prescribing pain medication after a routine endodontic procedure should be
followed. Generally, analgesics are taken only if required.

Diet/Function.

The patient is placed on a soft diet and instructed not to chew for approximately 4 weeks on the
tooth that was treated. Then, slowly increasing function for 2 more weeks may be followed by full
function.

Applied pressure on the treated tooth may reveal tenderness for 3 to 4 days postoperatively. In
such cases, which are uncommon, comfort medication should be taken as directed. Transient
tenderness of a treated tooth is not a cause for alarm.

Postinsertion Follow-Up Visit

In the absence of complaints, a follow-up visit is usually scheduled 7 to 10 days postoperatively.

Asymptomatic cases may be scheduled for restorative procedures at any time following this visit.
Restoration should be delayed in the rare cases in which slight tenderness to pressure persists.
Prescribing an additional antibiotic regimen now may or may not be indicated, but is usually not
required. Tenderness to pressure, in the rare cases in which it persists, usually resolves within 1
or 2 weeks.

Treatment Codes

In conventional stabilizer cases, for purposes of office records and insurance reports, separate
the recorded treatment on the patient record into two parts. Record the endodontic therapy, and
then record the endodontic stabilizer implant treatment separately. For cases using the unified
endodontic stabilizer/post-core combination, record the post-core procedure separately. Thus,
either two or three distinct, separate services have been performed.
PROSTHODONTIC RESTORATION

All common options for prosthodontic restoration are now available for the tooth treated with the
endodontic stabilizer implant, with an enhanced prognosis. Because the tooth was originally
compromised, it is good practice to splint the tooth to an adjacent tooth or include it within a
restoration of greater scope, if possible. Occlusal adjustment is a must.

AFTERCARE AND MAINTENANCE

Special aftercare or maintenance is not required following endodontic stabilization. Commonly

recommended general home care and professional maintenance for the completed restorative
treatment should be followed. Examination of the stabilizer should be included in all follow-up
radiography

COMPLICATING AND ATYPICAL CONDITIONS

General Frequency of Occurrence

Complications are rare. Success and survival rates of endodontic stabilizers are very high.

Inflammation, Infection, and Periodontal and Endodontic

Complications

Inflammation, infection, and periodontal and endodontic complications are treated in the same
manner as those related to conventional endodontic therapy. The tooth generally responds more
favorably and rapidly to such treatment than if it were not stabilized.

Stabilizer Perforation of Cortical Bone

If it is discovered that the stabilizer extends slightly through a cortical plate postoperatively, and
the case is asymptomatic, no treatment is required. If symptoms of tenderness, infection, or
swelling occur, expose the area with a gingival flap, and smooth the exposed portion of the
stabilizer with a diamond at high speed using coolant. Bone augmentation may be considered.

Root Fracture at the Apex

Because of the precise and coordinated dimensions of the bone drill and endodontic stabilizer,
which is used as a tap, root fracture at the apex is very rare. Following the protocol previously
described, performing steps slowly and deliberately, and frequently withdrawing and cleansing
bone chips from the cutting threads of the stabilizer during tapping prevent this complication. This
is a precise, controlled procedure.

The most common cause of root fracture at the apex is an unexpectedly friable root tip, or the use
of a No. 4 stabilizer when a No. 3 stabilizer is indicated. If root fracture is noted radiographically
and no clinical symptoms are observed, monitor the apex radiographically. If a periapical
radiolucency develops, flap the tissue, approach the apex, and curette carefully to remove all soft
tissue and possible root fragments from the area. Avoid disturbing the stabilizer, which remains in
position during this procedure. Augment if indicated. Prescriptions related to this procedure are
the same as those for an apicoectomy.
Paresthesia

No cases of paresthesia have been reported in the literature, and the authors know of none in
practice. If a paresthesia were to occur, it would result from overseating a stabilizer that was used
in a tooth that should have been avoided in any event. Stabilizers generally are not
recommended for teeth in the mandible over the inferior alveolar canal. The possibility of
paresthesia in the maxilla is minimal.

VARIATIONS AND ALTERNATIVES

Unified Post-Core/Endodontic Stabilizer Combination

Use of the unified post-core/endodontic stabilizer is appropriate in cases in which the crown of the
tooth is compromised to the extent that a post-core is required to aid in restoration. The post-
core/stabilizer combination is available in both the No. 3 and No. 4 sizes. Its abutment seats
against the faced-off root at or near the height of the surrounding gingival cuff. The case
sequencing using the post-core/ stabilizer combination is shown in Box 19-3 . Departures from
the standard stabilizer procedure appear in italicized type.

Box 19-3
ONE-VISIT POST-CORE/STABILIZER COMBINATION INSERTION PROTOCOL

   Confirm use of prophylactic antibiotic

   Administer local anesthetic
   Enlarge canal with tapered reamer
   Parallel dentinal walls at apical 4 mm of canal
   Prepare implant osteotomy to its final depth
   Tap apical 4 mm of canal and osteotomy beyond apex
   Insert millimeter measuring rod into osteotomy
Take periapical radiograph to evaluate whether depth of osteotomy can be increased,
  
and to determine location of apex
Remove apical portion of post-core/stabilizer implant at point that corresponds to depth
  
of osteotomy
   Flush, sterilize, and dry canal to apex
Apply endodontic cement to portion of post-core/stabilizer combination that will be
  
located within paralleled dentinal walls at apical 4 mm of root following seating
Apply crown and bridge cement to portion of post-core/ stabilizer combination that will be
  
coronal to paralleled dentinal walls
   Seat endodontic stabilizer implant until base of abutment is at surface of faced-off root
   Prepare abutment if necessary for better parallelism and interocclusal clearance
Creation of an Additional Tooth Root Equivalent

Although the creation of an additional tooth root equivalent is not considered a mainstream
procedure, it can be readily accomplished by practitioners who have experience in several
mainstream cases. The practitioner penetrates the coronal portion of the tooth root, carefully
directing the long axis of drilling to pierce the side of the root at a level a few millimeters apical to
the crest of bone, passing into the available bone beyond ( Fig. 19-31 ). This is often done in
maxillary second molars to create the equivalent of a new additional tooth root distal to the sinus,
high into the tuberosity area. It can also be performed in the last mandibular molar in position to
create a new tooth root equivalent under the ascending ramus. This procedure may be performed
using available bone in an edentulous area adjacent to any appropriate tooth intended for use as
a natural abutment for a conventional fixed bridge, as long as no landmark is impinged upon. The
piercing of the tooth root a few millimeters apical to the crest of bone is well accepted
physiologically.

Figure 19-31  Additional tooth root in tuberosity (A), and distal to third molar in mandible (B).

Figure 19-31 Additional tooth root in tuberosity (A), and distal to third molar in
mandible (B)

Endodontic Stabilization of a Fractured Root

Endodontic stabilizers have been used to splint intraosseous root fractures. This improves the
prognosis of the tooth, which otherwise would have been extracted. [10] Although this procedure is
not considered mainstream, it can and should be attempted after experience with several
mainstream cases.

Smooth, Unthreaded, Parallel-Sided Stabilizer

Experience has shown that the smooth, unthreaded, parallel-sided variation of stabilizer design is
contraindicated. Because it is impossible to create a perfect circular hole at the apex during
osteotomy preparation, this configuration cannot seal the apex, and tends to cause cement
expression beyond the apex during final seating. In addition, the collagen fibers surrounding the
stabilizer cannot be stimulated, resulting in an ever-widening fibrous zone around the stabilizer as
shown in Fig. 19-4 , rather than the osteostimulatory peri-implant ligament that maintains bone
close to the interface that forms around a threaded stabilizer.
Tapered Stabilizer

Tapered stabilizers are contraindicated, whether they are threaded or smooth. When smooth, the
problems just discussed for smooth, parallel-sided stabilizers all apply. Moreover, tapered
stabilizers do not always engage the root at the apex. Most often they bind at a point in the canal
that is coronal to the apex, resulting in lack of apical seal. They exert significant lateral force at
the point of binding, resulting in a higher incidence of root fracture

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