1. Late, Early and Immediate loading

2. Functional and Non-functional loading

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Concepts and Principles

• Trise and del Fabbro. Biology and Biomechanics in Immediate Loading (CH 2) pp 18-45. Immediate Loading: A New Era in Oral Implantology. Testori, Galli, del Fabbro. 2011. Quintessence.

• Del Fabbro and Taschieri. A Systematic Review of the Literature (CH 4) pp 66-91. Immediate Loading: A New Era in Oral Implantology. Testori, Galli, del Fabbro. 2011. Quintessence.

1. Becker CM, Wilson TG Jr, Jensen OT. Minimum criteria for immediate provisionalization of single-tooth dental implants in extraction sites: a 1-year retrospective study of 100 consecutive cases. J Oral Maxillofac Surg. 2011 Feb;69(2):491-7

2. Ghoul WE, Chidiac JJ. Prosthetic requirements for immediate implant loading: a review. J Prosthodont. 2012 Feb;21(2):141-54.

3. Suarez F, Chan HL, Monje A, Galindo-Moreno P, Wang HL. Effect of the timing of restoration on implant marginal bone loss: a systematic review. J Periodontol. 2013 Feb;84(2):159-69.

4. Chrcanovic BR, Albrektsson T, Wennerberg A. Immediate nonfunctional versus immediate functional loading and dental implant failure rates: a systematic review and meta-analysis.J Dent. 2014 Sep;42(9):1052-9.

5. Sanz-Sánchez I, Sanz-Martín I, Figuero E, Sanz M. Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review.Clin Oral Implants Res. 2015 Aug;26(8):964-82. doi: 10.1111/clr.12428. Epub 2014 Jun 11.

6. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013 Mar 28;3:CD003878.

7. Atieh MA, Alsabeeha NH, Payne AG, et al. The prognostic accuracy of resonance frequency analysis in predicting failure risk of immediately restored implants. Clin Oral Implants Res. 2014 Jan;25(1):29-35. doi: 10.1111/clr.12057. Epub 2012 Oct 31.

8. Barewal RM, Stanford C, Weesner TC A randomized controlled clinical trial comparing the effects of three loading protocols on dental implant stability. Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):945-56.

9. Pozzi A, Mura PImmediate Loading of Conical Connection Implants: Up-to-2-Year Retrospective Clinical and Radiologic Study.Int J Oral Maxillofac Implants.2016 Jan-Feb;31(1):142-52. doi: 10.11607/jomi.4061.

10. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C, Testori T. Immediate Loading of Postextraction Implants in the Esthetic Area: Systematic Review of the Literature. Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.

11. Mijiritsky E, Mardinger O, Mazor Z, Chaushu G. Immediate provisionalization of single-tooth implants in fresh-extraction sites at the maxillary esthetic zone: up to 6 years of follow-up. Implant Dent. 2009 Aug;18(4):326-33.

12. Anitua E, Piñas L, Alkhraisat MH. Long-Term Outcomes of Immediate Implant Placement Into Infected Sockets in Association With Immediate Loading: A Retrospective Cohort Study.J Periodontol. 2016 May 13:1-15. [Epub ahead of print]

13. Vogl S, Stopper M, Hof M, et a. Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized Clinical Pilot Study. Clin Implant Dent Relat Res. 2013 Sep 30. [Epub ahead of print]

14. Benic GI, Mir-Mari J, Hammerle CHF, Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):222-238.

15. Kolerman R, et al. Radiological and Biological Assessment of Immediately Restored Anterior Maxillary Implants Combined with GBR and Free Connective Tissue Graft.Clin Implant Dent Relat Res.2016 Mar 20. doi: 10.1111/cid.12417. [Epub ahead of print]

16. Papaspyridakos et al. Implant Loading Protocols for Edentulous Patients with Fixed Prostheses: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):256-270.

17. Schrott A, Riggi-Heiniger M, Maruo K, Gallucci GO. Implant loading protocols for partially edentulous patients with extended edentulous sites–a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2014;29 Suppl:239-55.

18. Heinemann F, et al. Immediate occluding definitive partial fixed prosthesis versus non-occluding provisional restorations – 4-month post-loading results from a pragmatic multicenter randomised controlled trial.Eur J Oral Implantol. 2016 Spring;9(1):47-56.

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Topic: immediate provisionalization

Authors:Becker CM, Wilson TG Jr, Jensen OT

Title: Minimum criteria for immediate provisionalization of single-tooth dental implants in extraction sites: a 1-year retrospective study of 100 consecutive cases.

Source: J Oral Maxillofac Surg. 2011 Feb;69(2):491-
Type:Retrospective study

Rating: Good

Keywords:

Purpose:Minimum criteria were used in the placement of 100 consecutive provisional restorations on single-tooth dental implants placed into extraction sites within 3 days of surgery.

Materials and Methods:

• Provisional restorations were placed on 4.1- and 4.8-mm diameter standard ITI (Straumann, Waltham, MA) implants in the anterior mandible and maxilla in 100 treatment sites over a 3-year period.

• Provisionals were placed despite low insertion torque values of 15 N-cm or 50 implant stability quotient using radiofrequency analysis. Minimum 3 mm of apical circumferential bone for implant fixation of implant 5.8 mm or longer, and Implant placement at least 1 mm inside facial plate.

• Implants had final impressions for definitive restorations done 8 to 12 weeks after implant placement.

• All patients were recalled 1 year after restoration and evaluated. Routine maintenance appointments continued over a 4- to 6-year follow-up period.

Results:

Eighty implants were placed in the anterior maxilla and 20 in the anterior mandible. The implants were standard platform 4.1- or 4.8-mm-diam- eter sandblasted acid-etched surface implants. All implants were placed in single tooth sites bordered by adjacent teeth

One implant was not osseointegrated. The remaining implants were judged successful at the 1-year recall appointment.

Conclusion:immediate provisional restoration can be done using even minimal quantitative criteria with implants placed at relatively low torque and ISQ val- ues simultaneous to dental extractions. However, cri- teria used for this study suggest that successful pro- visionalization must include primary stability and at least 3 mm of circumferential bone at the apex in an occlusally protected scheme.

Topic: Immediate loading

AuthorsGhoul WE, Chidiac JJ

Title:Prosthetic requirements for immediate implant loading: a review.

Source: J Prosthodont. 2012 Feb;21(2):141-54.

Type:Systematic review

Rating: Good

Keywords: prosthetic considerations, Immediate loading

Purpose: The aim of this article is to review the current literature with regard to prosthetic considerations and their influence on the outcome of immediately loaded implants.


Method: A broad search of the published literature was performed using MEDLINE and PubMed to identify pertinent articles.

Results:One hundred fifty six references were selected. They were mainly descriptive, prospective, follow-up studies. They were reviewed and were categorized with respect to 6 factors that influence immediate loading:

1- Cross-arch stability and micromovements: Cross-arch stabilization by splinting (full arch) or by good interproximal contacts (single implant) provides the necessary stability to minimize micromotion and stimulate bone growth (osseointegration). 


2. Interim prostheses: is fabricated with resin or metalframe- work is important for long-term success. It is an effective method to reduce deleterious mechanical stresses on immediately loaded implants. 


3. Definitive restorations inserted immediately: It is advised to usea CAD/CAM system to predict the vital structures and the position of implants, with the possibility of slightly modifying the implant position and placement. The main advantage is to reduce the postoperative sequelae. It is a reliable procedure when a temporary prosthesis is used and later replaced by a definitive prosthesis after complete osseointegration. 


4- Screw- or cement- retained prostheses: crew-retained restorations seem to have a superior out- come compared with the cement-retained restorations as it is easier to follow up during the healing period. 


5-Occlusion: There is a general disagreement on when and how to provide occlusal contacts, but all authors agree to keep centric contacts only. 


6-Number and distribution of implants in overdentures and fixed prostheses: The number of implants needed when restoring implant cases with fixed prostheses is greater than the number needed for overdentures. In general, at least four implants are needed in the anterior mandible to support a fixed prosthesis, and a greater number of implants are necessary in a maxilla with a good bone quality and high primary stability. The consensus is that micromovements should be controlled by splinting all the implants using a U-shaped bar. To achieve this goal, the distribution of the fixtures is important. 


Conclusion:Immediate loading seems to be a relatively safe procedure. From the prosthodontic point of view, there are specific guidelines to follow.

Topic:Implant marginal bone loss

Authors: Suarez F, Chan HL, Monje A, Galindo-Moreno P, Wang HL.

Title:Effect of the timing of restoration on implant marginal bone loss: a systematic review.

Source:Periodontol. 2013 Feb;84(2):159-69.

Type:Review

Rating:Good

Keywords:alveolar bone loss; dental implantation; dental implants; dental prosthesis design; dental prosethesis; implant-supported

Purpose:To compare the marginal bone loss (MBL) between implants that were restored with the following protocols: 1) immediate restoration/loading (IR/L); 2) early loading (EL); and 3) conventional (CL).

Methods:Electronic literature search (PubMed, Ovid, Cochrane Central) and a hand search in implant related journals were conducted. Inclusion criteria: clinical human studies in English that had reported a comparison of MBL bewtween implants with IR/L, EL, or CL with at least 12 month follow up. Also a minimum number of 10 implants for each group. Immediate placement and delayed placement were included and analyzed separately.

Results:11 studies (eight RCTs, two controlled clinical trials, and one retrospective study) qualified for the study and were split into four groups:

1. IR/L + DP vs CL + DP (6 articles): A meta-analysis showed that the IR/L group had 0.09 mm less mean MBL but this was not significant.

2. IR + DP versus EL + DP (2 articles): NSSD

3. EL + DP versus CL + DP (1 article): NSSD

4. IL + IP versus CL + IP (2 articles): NSSD

The RCTs showed a moderate to high risk of publication bias.

Conclusion:This study does not show that the timing of restorations affects MBL. The selection of restoration protocols should be based on factors other than MBL.

Topic:Immediate loading

Authors:Chrcanovic BR, Albrektsson T, Wennerberg A

Title: Immediate nonfunctional versus immediate functional loading and dental implant failure rates: a systematic review and meta-analysis

Source:J Dent. 2014 Sep;42(9):1052-9.

Type:Systematic Review

Rating: Poor

Keywords:Dental implants; Immediate loading; Nonfunctional loading; Functional loading; Implant failure rate; Marginal bone loss; Meta-analysis

Purpose:To compare the survival rate of dental implants submitted to Immediate Functional Loading (IFL) and Immediate Nonfunctional Loading (INFL) protocols, in order to test the hypothesis that the immediate full occlusal load would compromise or jeopardize the osseointegration process.

Method:An electronic search without time or language restrictions was undertaken in March 2014. Eligibility criteria included clinical human studies, either randomized or not. The exclusion criteria were case reports, technical reports, animal studies, in vitro studies, and reviews papers. The estimates of relative effect were expressed in risk ratio (RR) and mean difference (MD) in millimeters.

Results:1059 studies were identified and 11 studies were included, of which 7 were of high risk of bias, whereas four studies were of low risk of bias. The results showed that the procedure used (nonfunctional vs. functional) did not significantly affect the implant failure rates (P=0.70), with a RR of 0.87 (95% CI 0.44-1.75). The wide CI demonstrates uncertainty about the effect size. The analysis of postoperative infection was not possible due to lack of data. No apparent significant effects of non-occlusal loading on the marginal bone loss (MD 0.01mm, 95% CI -0.04-0.06; P=0.74) were observed.

Conclusion:The results of this study suggest that the differences in occlusal loading between INFL and IFL might not affect the survival of these dental implants and that there is no apparent significant effect on the marginal bone loss.

Topic:Immediate loading

Title: Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review.

Author: Sanz-Sánchez I,Sanz-Martín I,Figuero E,Sanz M.

Source: Clin Oral Implants Res.2015 Aug;26(8):964-82.

Type:Case series/discussion article

Rating:Good

Keywords:immediate loading, delayed loading, implants

Purpose:The aim of this systematic review was to assess whether immediate loading protocols achieve comparable clinical outcomes when compared to conventional loading protocols depending on the type of prosthetic restoration.

Methods and Materials:A protocol was developed aimed to answer the following focused question: “What are the effects of immediate implant loading protocols compared to conventional implant loading, in terms of implant failure, marginal bone levels, and biological and mechanical complications based on the type of restoration?” The next sub-analysis were performed as follows: the extent, type, and material of the restoration and the type of occlusal contact in function. This systematic review only included randomized controlled trials (RCTs) with a follow-up of at least 6 months after implant loading.

Results:Thirty-seven final papers were included. The results from the meta-analyses have shown that the immediately loading implants demonstrated a statistically significant higher risk of implant failure [P = 0.036, a statistically significant lower bone loss [P = 0.000] and a smaller increase in ISQ values [P < 0.001, although both groups attained high survival rates (98.2% in the test and 99.6% in the control). Single teeth implants were greater risk of failure, when compared to immediately loaded full arch restorations, so as the occlusal pattern when compared to non-occlusal.

Conclusions:Immediate loading may impose a greater risk for implant failure when compared to conventional loading, although the survival rates were high for both groups.

Topic:Functional and Non Functional Loading

Authors:  Esposito M, Grusovin MG, Maghaireh H, Worthington HV.

Title: Interventions for replacing missing teeth: different times for loading dental implants. Source: Cochrane Database Syst Rev. 2013 Mar 28;3:CD003878.

Type:Retrospective study

Rating: Fair

Keywords: randomized controlled trial, root form osseointegrated dental implants, immediate occlusal loading, non occlusal loading.

Background:To minimize the risk of implant failures after their placement, dental implants are kept load-free for 3 to 8 months to establish osseointegration (conventional loading). It would be beneficial if the healing period could be shortened without jeopardizing implant success. Nowadays implants are loaded early and even immediately and it would be useful to know whether there is a difference in success rates between immediately and early loaded implants compared with conventionally loaded implants.

Purpose:To evaluate the effects of (1) immediate (within 1 week), early (between 1 week and 2 months), and conventional (after 2 months) loading of osseointegrated implants; (2) immediate occlusal versus non-occlusal loading and early occlusal versus non-occlusal loading; (3) direct loading versus progressive loading immediately, early and conventionally.

Methods: The following electronic databases were searched: Cochrane Oral Health Group’s Trials Register (to 8 June 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012, Issue 4), MEDLINE via OVID (1946 to 8 June 2012) and EMBASE via OVID (1980 to 8 June 2012). Authors of identified trials were contacted to find unpublished randomized controlled trials (RCTs). There were no restrictions regarding language or date of publication.

All RCTs of root-form osseointegrated dental implants, having a follow-up of 4 months to 1 year, comparing the same implant type immediately, early or conventionally loaded, occlusally or non-occlusally loaded, or progressively loaded or not. Outcome measures were: prosthesis and implant failures and radiographic marginal bone level changes.

Data were independently extracted, in duplicate, by at least two review authors. Trial authors were contacted for missing information. Risk of bias was assessed for each trial by at least two review authors, and data were extracted independently, and in duplicate. Results were combined using fixed-effect models with mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). A summary of findings table of the main findings was constructed.

Results:Forty-five RCTs were identified and, from these, 26 trials including a total of 1217 participants and 2120 implants were included. In nine of the included studies there were no prosthetic failures within the first year, with no implant failures in 7 studies and the mean rate of implant failure in all 26 trials was a low 2.5%. From 15 RCTs comparing immediate with conventional loading there was no evidence of a difference in either prosthesis failure (RR 1.87; 95% CI 0.70 to 5.01; 8 trials) or implant failure (RR 1.65; 95% CI 0.68 to 3.98; 10 trials) in the first year, but there is some evidence of a small reduction in bone loss favoring immediate loading (MD -0.10 mm; 95% CI -0.20 to -0.01; P = 0.03; 9 trials), with some heterogeneity (Tau² = 0.01; Chi² = 14.37, df = 8 (P = 0.07); I² = 44%). However, this very small difference may not be clinically important. From three RCTs which compared early loading with conventional loading, there is insufficient evidence to determine whether or not there is a clinically important difference in prosthesis failure, implant failure or bone loss. Six RCTs compared immediate and early loading and found insufficient evidence to determine whether or not there is a clinically important difference in prosthesis failure, implant failure or bone loss. From the two trials which, compared occlusal loading with non-occlusal loading there is insufficient evidence to determine whether there is a clinically important difference in the outcomes of prosthesis failure, implant failure or bone loss.

Conclusion:Overall there was no convincing evidence of a clinically important difference in prosthesis failure, implant failure, or bone loss associated with different loading times of implants. More well-designed RCTs are needed and should be reported according to the CONSORT guidelines.

Topic:implant stability of immediate loaded implants

Authors:Atieh MA, Alsabeeha NH, Payne AG, et al.

Title:The prognostic accuracy of resonance frequency analysis in predicting failure risk of immediately restored implants.

Source:Clin Oral Implants Res. 2014 Jan;25(1):29-35. doi: 10.1111/clr.12057

Type:clinical

Rating: good

Keywords:dental implants, prognosis, ROC curve, sensitivity and specificity.

Purpose: to evaluate the prognostic accuracy of ISQ measurements recorded at implant placement and 8-week post-op, and to determine the optimal threshold value for predicting failure risk of immediately restored/loaded implants.

Methods: on twenty-eight patients, twenty-eight 8 or 9 mm diameter implants were placed in either a fresh molar extraction socket (immediate) or a healed site (delayed) in posterior mandible. The implant stability quotients (ISQs) was measured at implant placement surgery, 8 weeks and 1 year post-op. Acrylic provisional crown was placed out of occlusion within 48 hours. At 8 weeks, the provisional crown was replaced with permanent screw-retained zirconia-ceramic crown. ISQ Receiver operating characteristic (ROC) analysis was used to identify the optimal cut-off level. Sensitivity and specificity were also determined at the selected cut-off value.

Results:Overall implant survival rate after 1 year was 78.6%. Out of the six failed implants: four implants lost their osseointegration within the first 3 months, and the remaining two implants were lost by the end of the 1-year observation period. All the failed implants exhibited signs of mobility without inflammatory signs apart from the one lost after 1 year, which showed tenderness, mobility and signs of peri-implant mucositis. The 1-year implant survival rates for the immediate implants was 71.4% and for delayed placement was 85.7%.The optimum cut-off value for detecting implant stability was 60.5 ISQmeasured at 8 weeks, with sensitivity of 95.2% and specificity of 71.4%. The implant stability measurements after 8 weeks showed a better accuracy in predicting implants that were at risk of failure than those taken at the time of implant placement.

Conclusion:The results show that the RFA measurements (ISQs) taken at the time of surgery were not a significant predictor of the failure riskof immediately restored/loaded single implants in the posterior mandible. In contrast, the RFA measurements at 8 weeks were more effective in detecting the implant failure risk.

Topic:Loading protocols

Author:Barewal RM, Stanford C, Weesner TC

Title:A randomized controlled clinical trial comparing the effects of three loading protocols on dental implant stability.

Source:Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):945-56.

Type:Randomized controlled clinical trial

Rating: Good

Keywords:dental implants; immediate loading; implant stability; randomized controlled clinical trial; resonance frequency analysis; single-tooth replacement

Background: ISQ measures the axial stability of the implant. Insertion Torque Value (ITV) measures the rotational stability of the implant. ITV is a numeric value given to the peak insertion torque reached by the surgical motor during placement. ITV is a more objective, quantifiable assessment of bone density.

Purpose:The purpose of this RCT was to compare the stability of dental implants placed under three different loading regimens during the first 16 weeks of healing following dental implant placement.

Methods: 40 patients (15m, 25f) between the ages of 20 and 82 years old requiring a single implant in the maxilla or mandible were assessed. The insertion torque value (ITV) was the primary determinant of load assignment. Group A=Immediate loading group: ITV >20 Ncm; Group B=Early loading (6wks)=10<ITV<20 Ncm; Group C=Conventional/delayed loading (12 weeks). Resonance Frequency Analysis (RFA) was assessed every 2 weeks for the first 16 weeks, and then at 1,2, and 3 years. Crestal bone height was assessed radiographically at baseline, at 16 weeks, 1, 2, and 3 years (standardized system with bite blocks).

Results:Of the 40 implants placed, one implant was lost in type 4 bone (ITV, 8.1 Ncm) in the delayed group. The cumulative survival rate over the 3-year period for the implants was 97.5%. All implants, when classified by bone and loading type, increased in stability over time, with a minor reduction of 1.3 ISQ units seen at 4 weeks in the immediate loading group. The mean marginal bone loss over 3 years was 0.22mm. The mean ITVs at implant placement for bone types 1 and 2 (grouped together), 3 and 4 were 32, 17 and 10 respectively, and were SS.

Discussion: ITV was a good objective measure of bone type. Using an ITV of 20 Ncm as the determinant for immediate loadingand an ITV of 10 Ncm or greater as a determinant for early loadingprovided long-term success for implants, with no negative changes in tissue response. All bone type groups and loading groups showed no reduction in stability during the first 4 months of healing.

Topic:Immediate implant loading

Authors: Pozzi A, Mura P

Title:Immediate Loading of Conical Connection Implants: Up-to-2-Year Retrospective Clinical and Radiologic Study

Source: Int J Oral Maxillofac Implants. 2016 Jan-Feb;31(1):142-52. doi: 10.11607/jomi.4061

Type:Retrospective study

Rating: Good

Keywords:conical connection, dental implant, immediate loading, platform switching, postextraction

Purpose:To report the clinical and radiologic outcomes of patients treated with a rough oxidized tapered-body implant, with an internal conical connection and built-in platform shifting placed according to immediate loading protocol.

Methods:64 patients were treated with a total of 148 novel tapered body implants with internal conical connections, built in platform shifting, and moderately rough oxidized surfaces were used in this study. Some implants were immediate, post extraction (67 out of 148). Prophylactic antibiotics were administered prior to surgery, as well as chlorhexidine rinse. Implants were placed using a flapless or miniflap approach. Implants were places with an insertion torque of at least 45 Ncm. Provisional or definitive abutments were fixed after implant placement and tightened to 30 Ncm. Light occlusion was used. Periapical radiographs were obtained at the time of surgery and then annually with a positioning jig.

Results:One postextractive, immediately loaded, maxillary implant failed during healing, resulting in a success rate of 99.3%. BOP was detected around 12 implants at follow up. Mean marginal bone loss was 0.71 mm at the 2 year follow up.

Conclusion:The Nobel-Replace Conical Connection implant system, immediately loaded and followed up to 2 years, demonstrated good treatment outcomes with regard to implant and prosthetic survival rate, marginal bone levels, and soft tissue conditions in both postextraction and healed sites.

Topic:Immediate Loading of Post extraction Implants

Authors:Del Fabbro et al.
Title:Immediate Loading of Postextraction Implants in the Esthetic Area: Systematic Review of the Literature

Source: Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.

Type:Systematic Review

Rating: Good

Keywords:dental implants, immediate implants, immediate loading, postextraction socket, systematic review

Purpose:To estimate the survival rate of implants placed in fresh extraction sockets and immediately restored, after at least 1 year of function. Secondary purpose was to compare the clinical outcomes of such protocol with those of standard protocols such as delayed placement in healed ridges and delayed loading, and to assess the influence of various confounding factors on the survival rate of implants immediately placed and restored.

Method:an electronic search was conducted on MEDLINE, EMBASE, and CENTRAL databases to find studies published from 1990 to October 2012. Search terms used were “dental implants,” “extraction socket*,” “immediate implant*,” “immediate loading,” “immediate restoration*,” “immediate placement*,” “immediate installation*,” and “fresh extraction socket*” alone or combined with the Boolean operator “AND”. Also, a hand search of issues from 1995 to October 2012 in the following journals: Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, Implant Dentistry, European Journal of Oral Implantology, International Journal of Oral and Maxillofacial Implants, International Journal of Periodontics and Restorative Dentistry, Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Prosthetic Dentistry. Inclusion Criteria are:
1. RCT, CCT, case-control studies, and prospective case series.
2. At least 10 patients (older than 18 years) treated immediately placed and loaded (within 48 hours of surgery).
3. At least 1 year of follow up after implant placement.
4. Immediate implants placed in the aesthetic zone (anterior maxilla) and studies presenting success and survival data of immediate implants.

Discussion:

1. Type of incision did not affect implant survival.

2. No significant difference in clinical outcome in relation to the graft type, and neither between grafted cases and cases without grafts.

3. Presence of infection did not affect implant survival.

4. Cases restored in centric occlusion displayed significant better results than cases restored without occlusion.

5. Meta-analysis showed that survival rate of immediately loaded implants in fresh post-extraction sockets is excellent; however, it is inferior implants placed in healed ridges.

6. The confounding factors could not be evaluated because they were not systematically reported in the included studies.

7. Conclusion:Based on a sample of nearly 2000 implants, the mean survival rate of immediately placed and restored implants in extraction sites in the aesthetic region is 97.6%; however, the meta-analysis showed that the outcome of immediate implants resulted inferior to that of implants placed in healed ridges. Also, due to the wide range of survival rates observed in this systematic review (78.6%-100%), generalization from the results of the included trials to clinical practice should be made with extreme caution.

Topic:Immediate Provisionalization

Authors:Mijiritsky E, Mardinger O, Mazor Z, Chaushu G.

Title:Immediate Provisionalization of single-tooth implants in fresh extraction sites at the maxillary esthetic zone: Up to 6 years of follow-up

Source:Implant Dentistry 2009.18(4): 326-333.

Type:Clinical Report

Rating:Good

Keywords:immediate provisionalization, immediate implantation, anterior maxilla, nonfunctional immediate loading, single implant.

Purpose:Evaluate the long term survival of single-tooth implants immediately placed in fresh extraction sites at the anterior maxilla with immediate infraocclusion-provisional restorations and nonfunctional immediately loading.

Materials and methods:

A total of 16 patients (7 females and 9 males), ages from 23 to 62 years. Patients included required extraction of a single tooth in the maxillary esthetic zone. All patients were given amoxicillin 1 hour before surgery. Gentle elevation of the tooth root, flaps avoided. Atraumatic extraction and titanium implants were placed with diameters of 3.3 to 5.5 and length from 13 to 16 mm. The platform was set 1.5 to 2 mm below the level of the interseptal bone, and respected the space of 1.5 to 2mm space between adjacent tooth and implant. Implants were positioned palatally and autogenous bone graft obtained from the drill was used to fill space discrepancies of spaces greater than 2mm.

If insertion torque values were 32 N cm greater, they were included in the study. After placement, they were connected to a prefabricated plastic provisional abutment. Fixed provisional restorations cemented to the abutments. Occlusal contacts were avoided. Patients were asked to eat soft food for one month, examined once a week for 3 weeks and then once a month for 6 months. Examiner measured the radiographs to evaluate marginal bone loss.

Results:One implant failed one month after placement due to unscrewing of a temporary abutment that resulted in implant overload. Overall implant survival rate resulted in 95.8%. The mean marginal bone loss increased by 0.9 1mm, starting from implant placement.

Discussion: The soft tissue reaction was described as very favorable due to the provisional crown in the healing phase and preservation of papilla. This provisional should not be removed to prevent jeopardizing osseointegration.The marginal bone loss was of the same magnitude as with conventional approach. Occlusal loads should be eliminated and use of a occlusal splint for 6 to 8 weeks day and night to prevent loading. This technique seems to be beneficial in many ways; there is no need for second stage surgery, and need for transitional removable dentures was avoided.

Conclusion:Nonfunctional immediate loading of single-tooth implants in fresh extraction sites at the anterior maxilla can result in successful implant integration and stable periimplant conditions.

Topic:Immediate loading

Author:Anitua E, et al.

Title: Long-Term Outcomes of Immediate Implant Placement Into Infected Sockets in Association With Immediate Loading: A Retrospective Cohort Study

Source:J Periodontol.2016 May 13:1-15.

Type:Retrospective Cohort study

Rating: Good

Keywords:Dental implants; immediate dental implant loading; infection; tooth extraction; tooth loss.

Background:There is a paucity of studies examining long-term outcomes of immediate loading of dental implants immediately placed into infected sites.

Purpose:This study aims to evaluate long-term outcomes of immediate loading of postextraction implants placed in infected sites.

Methods:Patients were selected if they had postextraction implants in the anterior maxilla that were inserted in the period from December 2006 to June 2015 and immediately loaded. Information collected about patients included: 1) demographic data; 2) implant details; 3) soft tissue stability; 4) prosthodontics data. Marginal bone loss (BL) and implant and prosthesis survival rates were calculated. Recommended insertion torque ranges between 30 and 45 Ncm for a single-unit prosthesis and a minimum of 20 Ncm for multiple prosthses.

Results:Thirty patients (mean age: 56 years) had 43 implants immediately inserted into infected sites and immediately loaded. Implants were inserted at torque >35 Ncm. Mean follow-up time was 6 years (range: 1 to 8 years), and 65% of implants had a follow-up time >5 years. No implant failure occurred, and implant success rate was 93%. Proximal BL was 1.42mm (range: 0.21 to 5.61mm0. Three prosthetic complications (all fracture of veneer material) occurred.

Conclusion:Immediate loading of implants inserted into fresh and infected extraction sockets is not a risk factor for implant survival. However, stability of peri-implant soft and hard tissues indicates the need to take measures that minimize loss. Use of PRGF and placement of dental implants were evaluated for treatment of extraction sockets in the anterior maxilla.

Topic: Immediate Occlusal versus Non-Occlusal Loading

Authors:Vogl S, Stopper M, Hof M, et al

Title: Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized Clinical Pilot Study.

Source: Clin Implant Dent Relat Res. 2013Sep 30. [Epub ahead of print]
Type: A Randomized Clinical Pilot Study.

Rating: Good

Keywords: computer-assisted, immediate loading, marginal bone loss, surgical guides, survival rate

Purpose:This study was performed to compare clinical outcomes of immediate occlusal versus non-occlusal loading of posterior implants.

Materials and Methods:

• N=19 patients with 52 screw-type implants replacing mandibular molars or premolars

  • 9 patients with 21 implants were randomized to a study group that received immediate restorations with occlusal loading

  • 10 patients with 31 implants were randomized to a control group that received provisional restorations without occlusal loading.

• Occlusal loading was defined as full loading in maximum intercuspidation.

• Single-tooth or splinted multiunit restorations were incorporated by screw retention or cementation. Marginal bone defects (MBD) were evlautated by obtaining digital perpendicular longcone radiographs at baseline, 1, 2, 3, 6, and 12 months. Implant survival, and implant success were evaluated 12 months after insertion.

Results:Both groups revealed similar MBD levels consistent with previous reports. No implants were lost (overall survival: 100%) or found to fail (overall success: 100%). No significant intergroup

differences were noted for any of the evaluated parameters.

Conclusions:

No clinically relevant differences in radiographic 12-month results were observed between functionally loaded and nonloaded immediate restorations in partially edentulous posterior mandibles. Both types of restorations yielded 100% success and survival rates over observation periods of 12 months and can therefore be considered a viable treatment concept in selected patients.

Larger long-term prospective studies are needed to confirm the final evidence and predictability of immediate functional loading as a standard treatment concept for partially edentulous jaws.

Topic:Immediate Loading

AuthorsBenic GI, Mir-Mari J, Hammerle CHF,

Title:Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-analysis.

Source: Int J Oral Maxillofac Implants. 2014 Jan-Feb; 29(supplement):222-238.

Type: Systematic Review and Meta-analysis

Rating: Good

Keywords: Loading

Purpose: To test whether or not immediate loading of single-implant crowns renders different results from early and conventional loading with respect to implant survival, marginal bone loss, stability of peri-implant soft tissue, esthetics, and patient satisfaction.

Method: An electronic search of Medline and Embase databases including studies published prior to August 1, 2012, was performed and complemented by a manual search. Randomized controlled trials (RCTs) comparing different loading protocols of single- implant crowns with a follow-up after restoration of at least 1 year were included. A meta-analysis yielded odds ratios (OR) and standardized mean differences (SMD) together with the corresponding 95% confidence intervals (95% CI).

Results:

The search provided 10 RCTs comparing immediate and conventional loading and 1 RCT comparing immediate and early loading.

Implant survival at 1 year of loading: the meta-analysis of 10 studies found NSSDbetween immediate and conventional.

Marginal bone loss during the first year of function: between immediate and conventional loading protocols in 7 was NSSD

Implant survival and marginal bone loss at 2, 3, and 5 years of loading: NSSDbetween immediate and conventional loading

Change of papilla level between immediate and conventional loading: Three RCTs identified NSSD.

Recession of the buccal mucosa after implant placement: One study found significantly inferior soft tissue loss for immediate loading as compared to conventional loading. Two RCTs investigated the recession of the buccal mucosa after insertion of the definitive crown and found NSSD between immediate and conventional loading.

Esthetics and the patient satisfaction: were assessed in one and two RCTs, respectively. There were NSSDbetween immediate and conventional loading.

Conclusion:Immediately and conventionally loaded single-implant crowns are equally successful regarding implant survival and marginal bone loss. This conclusion is primarily derived from studies evaluating implants inserted with a torque ≥ 20 to 45 Ncm or an implant stability quotient (ISQ) ≥ 60 to 65 and with no need for simultaneous bone augmentation. Immediately and conventionally loaded implants do not appear to differently affect the papilla height during the first year of loading. Due to the heterogeneity of the time point of baseline measurements and contradictory findings in the studies, it is difficult to draw clear conclusions regarding the recession of the buccal mucosa. With respect to the assessment of esthetic outcomes and patient satisfaction, the data available remain inconclusive.

Topic:Immediately restored anterior maxilla implants

Authors: Kolerman R, et al.

Title:Radiological and Biological Assessment of Immediately Restored Anterior Maxillary Implants Combined with GBR and Free Connective Tissue Graft.

Source:Clin Implant Dent Relat Res.2016 Mar 20. doi: 10.1111/cid.12417

Type:Retrospective study

Rating:Fair

Keywords:biologic complications, connective tissue, immediate loading, radiographic data, single-tooth implants

Purpose:To assess immediately restored implants combined with guided bone regeneration (GBR) and connective tissue graft.

Methods:34 patients with maxillary immediately restored anterior single implants were included in this study with follow up ranging from 1-4 years. Patient’s alveolar process had to have at least 5 mm of bone apical to the alveolus of the failing tooth to ensure initial implant stability. 32Ncm insertion torque. FDBA was applied to the gap between the implant and buccal bone and a resorbable collagen membrane was placed over this. A CTG was harvested from the palate and placed over the membrane. An abutment was placed and a non-functional acrylic temporary was seated. 6 months later a permanent restoration was fabricated. Patients were assessed for soft tissue dimensions, radiographic bone loss, and biological and prosthetic complications.

Results:Mean follow up was 29 months. Mean mesial and distal bone loss was similar (1.10 mm vs 1.19 mm). Periimplant PD was significantly greater for the implant vs the contralateral tooth (3.49 mm vs 2.35 mm). BOP was present in 29.4% at implant sites vs the contralateral tooth 10.4% (P<0.001.

Conclusion: Using GBR and CTG for anterior maxillary single-tooth replacement (immediate implant placement and non-functional loading) achieves favorable peri-implant soft tissue condition.

Topic:Functional and Non-functional loading

Authors:Papaspyridakos P, Chen CJ, Chuang SK, Weber HP.

Title: Implant Loading Protocols for Edentulous Patients with Fixed Prostheses: A Systematic Review and Meta-analysis.

Source:Int J Oral Maxillofac Implants. 2014;29 Suppl:239-55.

Type:Systematic Review

Rating: Good

Keywords:dental implants, edentulous patients, fixed prosthesis, immediate loading, loading protocols

Purpose:To report on the effect of immediate implant loading with fixed prostheses compared to early and conventional loading on implant and prosthesis survival, failure, and complications.

Method:An electronic and manual search was conducted to identify randomized controlled clinical trials (RCTs) as well as prospective and retrospective studies involving rough surface implants and implant fixed complete dental prostheses for edentulous patients.

 Immediate loading: A prosthesis is connected to the dental implants within 1 week following implant placement.

• Early loading: A prosthesis is connected to the dental implants between 1 week and 2 months following implant placement.

• Conventional loading: Dental implants are allowed to heal for a period greater than 2 months after implant placement without connection of prosthesis.

Results:The 62 studies that fulfilled the inclusion criteria featured 4 RCTs, 2 prospective case-control studies, 34 prospective cohort studies, and 22 retrospective cohort studies. These studies yielded data from 2,695 patients (2,757 edentulous arches) with 13,653 implants. Studies were grouped according to the loading protocol applied; 45 studies reported on immediate loading, 8 on early loading, and 11 on conventional loading. For the immediate loading protocol with flap surgery, the implant and prosthesis survival rates ranged from 90.1% to 100% and 93.75% to 100%, respectively (range of follow-up, 1 to 10 years). When immediate loading was combined with guided flapless impl

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Basic overview of anatomy with special consideration for structures directly related to implant placement

• Surgical and Radiographic Anatomy for Oral Implantology. Al-Faraje, 1^stedition 2013. Quintessence Pub.

• Sharawy and Misch. Applied Anatomy for Dental Implants (CH 22). pp 490-501. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.

• Netter’s Head and Neck Anatomy for Dentistry. Norton. 2007. Saunders.

1. Neiva RF, Gapski R, et al. Morphometric analysis of implant related anatomy in Caucasian skulls. J Periodontol 2004; 75(8): 1061-1067

2. Du Tolt DF, Nortje C. The maxillae: integrated and applied anatomy relevant to dentistry. SADJ 2003; 58(8):325-330.

3. Quirynen M, Mraiwa N, et al. Morphology and dimensions of the mandibular jaw bone in the interforaminal region in patients requiring implants in the distal areas. Clin Oral Implants Res. 2003 Jun;14(3):280-5.

4. Kalpidis CD, Setayesh RM. Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature. J Periodontol. 2004 May;75(5):631-45

5. Mardinger O et al: Lingual perimandibular vessels associated with life – threatening bleeding. An anatomic study. Int J Oral Maxillofac Implants 2007; 22:127-131

6. Chrcanovic BR, Abreu MH, Custódio AL. A morphometric analysis of supraorbital and infraorbital foramina relative to surgical landmarks. Surg Radiol Anat. 2011 May;33(4):329-35.

7. Chrcanovic BR, Custódio AL. Anatomical variation in the position of the greater palatine foramen. J Oral Sci. 2010 Mar;52(1):109-13.

8. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Perio Rest Dent. 1996 Apr;16(2):130-7.

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Topic: Anatomy                            implant related anatomy in skulls

Authors: NeivaRF, Gapski R, et al.

Title: Morphometric analysis of implant related anatomy in Caucasian skulls.

Source: . J Periodontol 2004; 75(8): 1061-1067

Type: Morphometric analysis study

Rating: Good

Keywords: Dental implantation, dental implants, foramen, mental, grafts, bone, jaw anatomy, histology, maxillary sinus augmentation, mandibular symphysis.

BACKGROUND: Sequelae related to implant placement/advanced bone grafting procedures are a result of injury to surrounding anatomic structures. Damage may not necessarily lead to implant failure; however, it is the most common cause of legal action against the practitioner.

PURPOSE: To evaluate the anatomy most commonly associated with implants dentistry and advanced bone grafting procedures, such as symphysis onlay grafts and sinus lifts, and to provide dimensional measurements that could aid the clinician in overall implant treatment planning.

METHODS:

• Morphometric analyses were performed in 22 Caucasian skulls.

• Measurements of the mental foramen (MF) included height (MF-H), width (MF-W), and location in relation to other known anatomical landmarks.

• Presence or absence of anterior loops (AL) of the inferior alveolar nerve (IAN) was determined, and the mesial extent of the loop was measured.

• Additional measurements included height (G-H), width (G-W), thickness (G-T), and volume (G-V) of monocortical onlay grafts harvested from the mandibular symphysis area, and thickness of the lateral wall (T-LW) of the maxillary sinus.

• The independent samples t test, and a two-tailed t test with equal variance were utilized to determine statistical significance to a level of P < 0.05. Multiple regression analyses were performed to determine if each one of these measurements was affected by age and gender.

RESULTS:

• The most common location of the MF in relation to teeth was found to be below the apices of mandibular premolars.

  • The mean MF-H was 3.47 +/- 0.71 mm

  • The mean MF-W was 3.59 +/- 0.8 mm

• The mean distance from the MF to other anatomical landmarks were:

  • MF-CEJ = 15.52 +/- 2.37 mm

  • MF to the most apical portion of the lower cortex of the mandible = 12.0 +/- 1.67 mm

  • MF to the midline = 27.61+/- 2.29 mm

  • MF-MF = 55.23 +/- 5.34 mm.

• A high prevalence of AL was found (88%); symmetric occurrence was a common finding (76.2%), with a mean length of 4.13 +/- 2.04 mm.

• The mean size of symphyseal grafts was:

  • G-H = 9.45 +/- 1.08 mm

  • G-W = 14.5 +/- 3.0 mm

  • G-T = 6.15 +/- 1.04 mm, with an average G-V of 857.55 +/- 283.97 mm3 (range: 352 to 1,200 mm3).

• The mean Thickness-Lateral wall of the maxillary sinus was 0.91 +/- 0.43 mm.

CONCLUSION: Implant-related anatomy must be carefully evaluated before treatment due to considerable variations among individuals, in order to prevent injury to surrounding anatomical structures and possible damage.

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Topic: Anatomy                    applied anatomy

Authors: Du Tolt DF, Nortje C

Tittle: The maxillae: integrated and applied anatomy relevant to dentistry.

Source: SADJ 2003; 58(8):325-330.

Type: Discussion article

Rating: Good

Keywords: maxillae, anatomy, sinus, nerves

Purpose:To address applied anatomy of the maxilla relevant to the practice of dentistry and maxilla-facial surgery.

Discussion:

• The first pharyngeal arch develops to form a cranial maxillary and caudal mandibular process.

• The maxilla presents a body and 4 processes: the frontal, zygomatic, alveolar and palatine processes.

• The ostium drains into the hiatus semilunaris of the middle nasal meatus.

• The infraorbital foramen transmits the infraorbital nerve and vessels. A block to this nerve anesthetizes: Sup labial, nasal and inferior palpebral branches of the infraorbital n. Ant sup alveolar N and Middle sup alv nerve (usually). Teeth: Central, lateral, canine and possible 1^st and 2^nd premolars. The adjacent plate of the labial alveolar bone, vestibular gingiva, alv mucosa, upper lip, lateral aspects of the nose, lower lid skin and conjuctiva together with the anterior aspects of the maxillary sinus are anesthetized.

• The posterior or infratemporal fossa forms the anterior wall of the infratemporal fossa. Visible are the apertures of the 2-3 alveolar canals, that transmit the PSA vessels.

• The superior surface of the maxilla contributes to the formation of the floor of the orbit.

• The palatine process of the maxilla forms the greater part of the floor of the nasal cavity and roof of the mouth.

• The incisive fossa transmits terminal branch of the greater palatine A, and nasopalatine nerve.

• Terminal branches of maxillary artery relevant to the maxilla: PSA, descending palatine A, Infraorbital A, Shenopalatine A, Greater palatine A, Lesser palatine A, Ant sup alv A.

• In some patients orofacial infections may be life threatening, if the abscess or cellulitis spread from one region to another.

• Ludwig’s angina is not a maxillary disease, but arises from a massive infection of the submandibular and sublingual regions.

• Maxillary sinus

1. Pyraminal shape.

2. Lateral wall: infratemporal wall of the maxilla

3. Medial wall: Inferior part of the lateral wall of the nasal cavity

4. Roof: Floor of the orbit

5. Floor: narrow bony plate over premolars and molars.

6. Most often sinuses are of equal and symmetrical size.

________________________________________________________________________

Topic:Interforaminal bone morphology

Authors:Quirynen M, Mraiwa N, van Steenberghe D, Jacobs R

Title:Morphology and dimensions of the mandibular jaw bone in the interforaminal region in patients requiring implants in the distal areas.

Source:Clin Oral Implants Res. 2003 Jun;14(3):280-5.

Type:Clinical study

Rating:Good

Keywords:bone grafting, bone morphology, implant surgery, radiographic evaluation, surgical complications, surgical planning

Purpose: To analyze variations in the mandibular interforaminal morphology in an attempt to identify potential risks or contraindications for surgery, especially implant installation, in this particular region.

Methods: 210 CTs of patients requiring endosseous implants in the lower jaw were re-evaluated to investigate anatomical variations in bone morphology (shape and contour), and to measure parameters concerning height, width, and inclination of the bone. All measurements were performed on the cross-sectional reformatted images mesial to the mental foramina.

Results: Three arbitrary morphologies were created: Type I: with a lingual concavity, Type II: A lingual concavity with a nearly constant width, but a clear lingual slope and Type III: with bone widening in the caudal direction. A lingual concavity (depth 6 ± 2.6 mm) was observed in 2.4% of the jaws with remaining bone height in that area ranging from 4.2 to 11.9 mm. Type II morphology was seen 28.1% of the time and type III 69.5% of the time. A clear lingual tilt/inclined morphology was seen in 28.1% of jaws with a mean angle of 67.6 ± 6.5°, but a relatively constant width (> 8.8 mm). The remaining jaws (69.5%) showed a slight broadening in the caudal direction. Morphology was not affected by age or gender.

Conclusion: Mandibles with a lingual concavity or a severe slope of the lingual cortex might have increased risks of lingual perforations during implant placement. ________________________________________________________________________

Topic: Anatomy                Hemorrhaging

Authors: Kalpidis CD, Setayesh RM.

Title:Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature

Source: J Periodontol. 2004 May;75(5):631-45

Type: Review

Rating: Good

Keywords: Airway obstruction/prevention and control, dental implantation/adverse effects, dental implantation/complications, dental implants/adverse effects, dental implants/complications, emergency care, foramen/anatomy, mouth floor/blood supply, oral hemorrhage/prevention and control

Purpose: 1) To review all available published case reports recording massive bleeding incidents following implant positioning in the anterior segments of the mandible. 2) To bring to the attention of the clinical community this extremely rare but serious and potentially fatal complication. 3) To present a brief but concise regional arterial anatomy and a description of the important anatomical structures related to this life-threatening complication. 4) To provide guidelines for avoiding severe bleeding events and for immediate management should an emergent situation develop during or after surgical implantation.

Discussion: The placement of endosseous dental implants is largely considered a safe surgical procedure. However, upper airway obstruction secondary to severe bleeding in the floor of the mouth has been occasionally reported as a rare but potentially fatal complication of implant surgery. This review presents critical hemorrhagic episodes, related to dental implantation in the anterior segments of the mandible, published to date. Massive internal bleeding in the highly vascularized region of the floor of the mouth is the result of an arterial trauma induced by instrumentation, usually through a perforation of the lingual cortical plate. Depending on the clinical situation, hemorrhage may commence immediately or with some delay after the vascular insult. The progressively expanding lingual, sublingual, submandibular, and submental hematomas have the tendency of displacing the tongue and floor of the mouth to obstruct the airway. Because the course of airway deterioration to complete occlusion may be rapid, ensuring a patent airway is of highest priority. Even though upper airway obstruction is potentially life-threatening, a secure airway was successfully established in all patients without fatal consequences. In most cases, resolution of hemorrhage required a surgical intervention for ligation of the bleeding vessels and hematoma evacuation. To reduce the probability of such a grave complication, preventive and precautionary measures to be taken before, during, and after implant placement in the anterior mandible are presented. Issues related to the level of surgical experience, fine regional arterial anatomy, radiographic and clinical evaluation of the osseous morphology, angulation and length of implants, and timing of hemorrhage onset are discussed. In addition, airway and bleeding management strategies are provided.

Topic: Implant complications

Title: Lingual perimandibular vessels associated with life – threatening bleeding. An anatomic study

Author: Mardinger O et al

Source: Int J Oral Maxillofac Implants 2007; 22:127-131

Type: Discussion

Rating: Good

Keywords: emergency, lingual perforation, implants, floor of mouth hemorrhage

Purpose: To describe the anatomy of the lingual perimandibular vessels and emphasize their distance to the bone.

Methods: 12 human cadavers were dissected. Blood vessels in the floor of the mouth were exposed using sagittal incisions at the canine, mental foramen, and second molar region.

Results: The diameter of the dissected vessels ranged from 0.5 to 3 mm (mean 1.5 mm). Most vessels were found superior to the Mylohyoid muscle in the canine area and inferior to the muscle in the mental and second molar areas. The smallest median vertical distance from blood vessel to bone was in the canine area (14.5 mm), followed by the mental foramen area (15.5 mm) and the second premolar area (19 mm). The median horizontal distance of the  vessels from the lingual plate was 2 mm at the canine and second molar areas and 4 mm at the mental area.

Discussion: Lingual plate perforation, especially anterior to the canine area, can easily injure blood vessels in the floor of the mouth and cause life-threatening hemorrhage following implant placement. Bleeding can occur when the mandibular lingual plate is perforated. Care should be taken to recognize situations where this complication may occur.

Conclusion: Based on the study of human cadavers, it appears that vessels in the floor of the mouth are sometimes in close proximity to the site of implant placement. Caution should be exercised when placing implants in this area.

________________________________________________________________________

Topic: Applied anatomy and physiology for dental implants           foramina

Authors:Chrcanovic BR, Abreu MH, Custódio AL. 

Title: A morphometric analysis of supraorbital and infraorbital foramina relative to surgical landmarks.

Source:Surg Radiol Anat. 2011 May;33(4):329-35.

Type: Review

Rating: Good

Keywords:supraorbital and infraorbital foramina, human dry skulls

Purpose:

To examine the different morphometric variations of the supraorbital and infraorbital foramina of the facial skeleton on human skulls.

Methods:

Eighty adult human dry skulls were studied. Measurements were made to analyze the degree of variability in the location of the supraorbital and infraorbital foramina. All measurements were done bilaterally. Variations were evaluated according to gender and side

Results:

54 females and 26 males crania. Almost all mean measurements were longer in males than in females. A statistically significant difference was observed between the left and the right sides in 4 of 10 measurements. When comparing the morphometric measurements between left and right sides of male and female crania, 6 of 22 measurements were statistically higher in men than in women.

Conclusion:

Gender should be taken into account when the foramina studied here are to be located. The mean location of the infraorbital nerve was about 6.5 mm inferior to the inferior orbital rim (at the point where one can palpate the zygomatico-maxillary suture), about 25 mm from the midline, and about 43 mm below the supraorbital foramen in the same vertical line. Extra care should be taken during surgical dissection in the superior orbital region especially in the middle aspect of the superior orbital rim. In general, there were changes in measurements between the genders, but the ratios of these measurements with the horizontal and vertical measurements chosen remained the same between the genders.

Topic:Anatomical considerations                   greater palatine foramen

Author:Chrcanovic BR, Custódio AL

Title: Anatomical variation in the position of the greater palatine foramen

Source:J Oral Sci. 2010 Mar;52(1):109-13

Type:Cadaver study

Rating: Good

Keywords:greater palatine foramen; hard palate; skull anatomy; local anesthesia methods

Purpose:To define the position of the greater palatine foramen (GPF) in relation to several anatomical landmarks in the maxilla in Brazilian skulls.

Methods:The study was conducted on 80 dry human skulls. The following measurements and observations were made:

1. Location of the foramen in relation to maxillary molar teeth

2. Perpendicular distance from the medial border of GPF to the midline maxillary suture (MMS)

3. Distance from the posterior wall of GPF to the post border of the hard palate (PBHP)

4. Direction of opening of the foramen onto the palate

5. Distance from ant wall of GPF to post border of incisive foramen

6. Angle between the MSS and line from the incisive foramen and the GPF

7. The palatine length

Results:

Location of the foramen in relation to max teeth	-54.87% GPFs were opposite 3rd molar -38.94% GPFs were distal to 3rd molar -6.19% GPFs were b/t 2nd and 3rd molars
Perpendicular distance from the medial border of GPF to the midline maxillary suture (MMS)	-Mean distance was 14.68+1.56mm
Distance from the posterior wall of GPF to the post border of the hard palate (PBHP)	-Mean distance was 3.39+1.11mm
Direction of opening of the foramen onto the palate	-69.38% opened in the Ant direction
Distance from ant wall of GPF to post border of incisive foramen	-Mean distance was 36.21+3.16mm
The palatine length	-Mean length was 52.40+4.63mm

Bottom Line: This study presents valuable clinical information in regards to the location of the GPF. In living subjects, the molar teeth, palatal midline and posterior border of the hard palate are all easily identifiable. That using a combination of the above measurements, the location of the GPF can be plotted with accuracy.

________________________________________________________________________

Topic: Anatomy

Authors: Reiser GM, Bruno JF, Mahan PE, Larkin LH

Title: The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons

Source:Int J Perio Rest Dent. 1996 Apr;16(2):130-7

Type: Cadaver study

Rating: Good

Keywords: Connective tissue graft, palate, anatomy, palatal vault

Purpose: To describe the anatomy of the palatal donor site and to identify structures that could potentially create surgical complications.

Methods:Incisions were made in palates of cadavers, reproducing the palatal incisions needed to obtain donor tissue. The tissue was then elevated and removed from the site. When the procedure was complete, the palatal tissue covering the donor site was removed and the donor tissue replaced to show the distance between the superior edge of the donor tissue and the palatal neurovascular structures.

Results/Conclusions:Knowledge of the anatomy of the soft tissues, hard palate, and neurovascular structures is mandatory to avoid surgical complications when obtaining donor tissue. The thickest tissue can usually be obtained in the premolar region. If this tissue is not sufficient, the other side of the palate can be harvested simultaneously. High palatal vaults have greater tissue availability compared with low palatal vaults. A thick alveolus or exostosis in the molar region can limit the amount of tissue harvested from this area. In the event of serious bleeding complications, 3 steps are recommended: immediate pressure (constant, 5 minutes at least) and injection of local anesthetic with vasoconstrictor, placement of one or more sutures proximal to the bleeding site, and elevation of full thickness flap so that the vessel can be visualized and ligated.

DesignedBy StevenJ. Spindler, DDS LLC

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 Medical History: Effects of Age, Perio compromised patients

Age at Placement (growth);

1. Oesterle LJ, Cronin RJ Jr. Adult growth, aging, and the single-tooth implant. Int J Oral Maxillofac Implants 2000;15(2):252-260.

2. Cronin RJ Jr, Oesterle LJ. Implant use in growing patients. Treatment planning concerns. Dent Clin North Am 1998;42(1):1-34.

3. Cronin RJ Jr, Oesterle LJ, Ranly DM. Mandibular implants and the growing patient. Int J Oral Maxillofac Implants 1994;9(1):55-62.

4. Oesterle LJ, Cronin RJ Jr, Ranly DM. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants 1993;8(4):377-387.

5. Heij D eta al: Facial development, continuous tooth eruption and mesial drift as compromising factors for implant placement. Int J Ora Maxillofac Implants. 2006 Nov-Dec; 21(6)867-78

6. Fudalej P., Kokich V., Leroux B: Determinig the cessation of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants. Am J Orthod Dentofacial Orthop. 2007 Apr; 131 (4 Suppl):S59-67

7. Heuberer S, Dvorak G, Mayer C, Watzek G, Zechner W. Dental implants are a viable alternative for compensating oligodontia in adolescents. Clin Oral Implants Res. 2014 Jan 3. doi: 10.1111/clr.12323. [Epub ahead of print]

Age at placement (outcome):

1. Heij DG, Opdebeeck H, van Steenberghe D, Quirynen M. Age as compromising factor for implant insertion. Periodontol 2000 2003; 33:172-184.

2. Meijer HJ, Batenburg RH, Raghoebar GM. Influence of patient age on the success rate of dental implants supporting an overdenture in an edentulous mandible: a 3-year prospective study. Int J Oral Maxillofac Implants. 2001 Jul-Aug;16(4):522-6.

3. Moy PK, Medina D, Shetty V, Aghaloo TL. Dental implant failure rates and associated risk factors. Int J Oral Maxillofac Implants. 2005 Jul-Aug;20(4):569-77

4. Schwartz-Arad D, Bichacho N. Effect of Age on Single Implant Submersion Rate in the Central Maxillary Incisor Region: A Long-Term Retrospective Study. Clin Implant Dent Relat Res. 2013 Aug 5. doi: 10.1111/cid.12131. [Epub ahead of print]

Periodontal disease

1. Wennstrom, Lang. Treatment planning for Implant Therapy in the Periodontally Compromised Patient. (CH 22). Clinical Periodontology and Implant Dentistry, Lindhe, J.; Lang, K. 5th Edition, 2008, Blackwell Munksgaard (Volume 2).

2. Karoussis IK, Kotsovilis S, Fourmousis I. A comprehensive and critical review of dental implant prognosis in periodontally compromised partially edentulous patients. Clin Oral Implants Res. 2007 Dec;18(6):669-79

3. Karroussis, I et al: A comprehensive and critical review of dental implant prognosis in periodontally compromised partially edentulous patients. Clin Oral Impl. Res 18, 2007; 669-679

4. Ong CT, Ivanovski S, et al. Systematic review of implant outcomes in treated periodontitis subjects. J Clin Periodontol. 2008 May;35(5):438-62.

5. Mengel R, Flores-de-Jacoby L. Implants in patients treated for generalized aggressive and chronic periodontitis: a 3-year prospective longitudinal study. J Periodontol. 2005 Apr;76(4):534-43.

6. Kim KK, Sung HM. Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: a systematic review. J Adv Prosthodont. 2012 Nov;4(4):210-7.

7. Roccuzzo M, Bonino L, Dalmasso P, Aglietta M. Long-term results of a three arms prospective cohort study on implants in periodontally compromised patients: 10-year data around sandblasted and acid-etched (SLA) surface. Clin Oral Implants Res. 2013 Jul 19. doi: 10.1111/clr.12227. [Epub ahead of print]

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Topic:Skeletal growth and implant placement.

Authors: Oesterle LJ, Cronin RJ Jr.

Title:Adult growth, aging, and the single-tooth implant

Source: Int J Oral Maxillofac Implants 2000;15(2):252-260.

Type: Discussion

Rating: Good

PURPOSE: This paper addresses growth of the maxilla and the development of the maxillary dentition in the context of implant treatment

Maxillary Skeletal Growth

• Anteroposterior Skeletal Changes. The midface grows generally in a downward and forward direction (arrow) relative to the anterior cranial base

Maxillary enlargement is variable between individuals and is particularly important to implant behavior. The jaw of patient V132 grew more downward than forward, while the jaw of patient V177 grew more forward than downward

• Transverse Skeletal Changes.As transverse growth of the cranial base occurs, the midface expands in harmony, first at the sagittal sutures that run from the metopic suture of the frontal bone back to the foramen magnum, and later by drift remodeling after the sutures close.

Growth in width of the median suture accelerates at puberty and is the most significant factor in transverse growth of the maxilla.

The average increase in maxillary bone width varies from 5 to 8 mm from 4 years of age to adulthood. The increase in molar width was approximately 1 mm less than the maxillary increase

Transverse maxillary growth changes are not symmetric at the midpalatal suture. The increase in width at the posterior portion of the suture (6.7 mm) is three times the amount of increase at the anterior portion of the palate from 4 years of age to adulthood. This rotation results in the molars growing not only laterally, but also anteriorly, contributing to the decrease in arch length seen during development.

Vertical Skeletal Changes.Vertical growth of the maxilla occurs by sutural lowering (passive displacement) of the maxilla and apposition on the occlusal surfaces of the maxillary alveolus.

Mean growth changes from 4 years to adult:

O = amount of apposition at floor of the orbit.

Su = amount of sutural lowering of maxilla, which would carry an implant downward with the growth.

C = amount of apposition at the infrazygomatic crest, carrying the maxilla downward.

R = amount of resorptive lowering of the nasal floor.

A = the amount of appositional increase in the height of the alveolar process.

Vertical maxillary growth would dramatically affect an implant’s position. An implant placed in the growing maxilla at 4 years of age would behave like an ankylosed tooth. Increases in alveolar height by apposition and resorptive lowering of the nasal floor have the greatest effect on the implant. The osseointegrated implant would remain stationary in the alveolus, being buried by appositional bone growth on its occlusal surface and being exposed on its apical surface by resorptive lowering of the nasal cavity and sinuses. The closer to adulthood the implant is placed, the less the adverse effect.

Maxillary Dental Growth

• Transverse Dental Changes: While dental width changes vary little with the primary dentition, a significant change in arch width occurs with eruption of the permanent teeth. In general, males have a greater increase in the molar areas than females.

Transverse dental changes. The arch width in the lateral incisor area increases 6 mm as the permanent incisors erupt, followed by a 1-mm decrease in width from 9 to 14 years of age but with little

change after 14 years of age, for a net increase of 5 mm

• Anteroposterior Dental Changes.

A significant mesial shift of the teeth is seen relative to the body of the maxilla. Hence, while the maxillary dental arch increases in width, it also decreases anteroposteriorly in length and moves anteriorly as a unit.

Anteroposterior dental changes. Mesial repositioning of the maxillary dentition occurs during growth with 5 mm of change in the incisor area and nearly 4 mm in the permanent molar area reported in some studies. the molars moving mesially 5 mm and maxillary central incisors moving 2.5 mm. The decreased amount of incisor movement results in a “packing” of the incisors against the musculature with possible resultant crowding

• Vertical Dental Changes.

Changes in the height of the palate partially reflect the increase in alveolar height. The results of studies are variable in their findings; however, in general there is an increase in palatal height as seen on dental casts

Much of the increase in total dental height increase is caused by the larger size of the permanent teeth as compared to the primary teeth. Most studies report an increase in posterior palatal height of from 4 to 6 mm, with more growth in males than in females. One study found an increase of only 2.5 mm in height

Maxillary Growth and the Osseointegrated Implant

• As the maxilla moves downward and forward with growth, the alveolar process undergoes considerable remodeling and conformational changes.

• An osseointegrated implant placed in the posterior alveolus of a young, growing maxilla may become significantly buried in bone, and its apical portion may become exposed as the nasal floor remodels occlusally.

• Prostheses that cross the midpalatal suture and arc attached to implants may potentially restrict transverse growth.

• Implants located on opposite sides of the midpalatal suture of a prepubertal child would be carried apart a significant distance by transverse growth.

Recommendations for the Placement of Implants in the Maxilla

• Implants placed before the cessation of growth are unpredictable in their behavior

• Rigid transpalatal prostheses in the prepubertal or early pubertal patient should be avoided to allow unrestricted transverse maxillary growth. Implants placed during the pubertal period have a greater likelihood of success, but still less than the postpubertal or postgrowth implant

• The variation in growth from individual to individual in the amount and direction of change is great

• Careful attention to maxillary growth and development will enable the dental implant team to provide the best possible care to the dentally disadvantaged young patient.

Topic:Age and implant placement

Authors: Cronin RJ Jr, Oesterle LJ

Title: Implant use in growing patients. Treatment planning concerns..

Source: Dent Clin North Am 1998;42(1):1-34.

Type: Discussion article:

Rating: Good

Keywords: age, growth, wrist

Discussion article:

• Maxillary growth: the midface grows in a downward and forward direction relative to the anterior cranial face. Maxillary growth occurs as a result of both passive displacement and enlargement.

• The average size of the dental arches is generally greater in males than in females. Female growth is nearly completed by age 15 and males growing is longer (age 17 to 19) and at a greater rate.

• Tooth eruption and alveolar growth must be viewed as a negative factor in the placement of DI.

• Implants in boys should be delayed longer than in adolescent girls.

• The increase of alveolar height continue with eruption of the permanent incisors

• The mandible grows downward and forward.

• The mandible grows in length by growth at the condyle and ramus.

• To accommodate posterior tooth eruption, the body of the mandible increases in length by resorption on the anterior aspect of the mandible and deposition on its posterior aspect.

• As the mandible increases in length, it also increases in posterior width because of its V shape.

• Girls generally erupt their teeth 2y earlier than boys.

• Generally when the girls start menstruation, their growth is nearly complete. By age 15, most girls have nearly completed their growth, where areas many boys continue to grow into their early 20’s.

• The longer growth period for males results in more prominent lower jaw and straighter profile seen in males.

• There is no totally reliable indicator as to when growth has ceased. In fact long term studies indicate that growth never stops but continuous throughout life in the same direction as in adolescence but at a much reduce rate.

• Long bone growth, particularly in the bones in the hand and wrist, is an indicator commonly used to male an educated guess of the status growth of the pt.

Topic: Mandibular growth and implants

Authors: Cronin RJ Jr, Oesterle LJ, Ranly DM.

Title: Mandibular implants and the growing patient.

Source: Int J Oral Maxillofac Implants 1994;9(1):55-62.

Type:Commentary

Rating: Good

Keywords: dental implants, growth and development, mandibular growth, osseointegration

Purpose:To discuss growth of the mandible and how this can affect implant placement in a growing patient.

Discussion:

Mandibular Growth Changes:

Anteroposterior growth:The mandible lengthens almost exclusively by posterosuperior growth of the condyle and posterior growth of the ramus. Ramus height is increasing 1-2 mm per year. Mandibular anterior width stabilizes relatively early and only increases slightly by appositional growth.

Rotational growth:The mandible exhibits a rotational pattern as it grows. The mandible “rolls” downward and forward. The center of rotation is situated near the incisal region. The goal is to upright the ramus, flatten the mandibular plane, and decrease the gonial angle. Patients can also have little rotational component. Children with a strong rotational pattern, implants would be carried inferior with the rolling pattern of the mandible and buried within the alveolar process. Implants could also be deficient in height and/or positioned at nonesthetic and nonfunctional inclinations.

Transverse changes:Changes in arch width vary greatly from individual to individual. It is impossible to predict intercanine width at age 15 based on intercanine mesaurements taken at 4-5 years old.

Dental height changes:From years 9—15 there is a steady increase in height of both incisors and molars. Measurements from the mandibular plane to the menton increases 12 mm in males and almost 7 mm in females between he ages of 6 and 16.

Arch length changes:Arch length changes occur as the mandible grows, the amount of cange varies with the direction of growth.

Mandibular changes and the Osseointegrated implant: Mandibular midline implants have a better prognosis in a young patient than those placed in other areas of the mandible. Prosthesis design must allow for the average increase in dental height of 5-6 mm and for the anteroposterior variation caused by different directions of growth. The burying of an implant because of occlusal alveolar bone apposition is possible in both the posterior and anterior segments. This can be exacerbated by an unfavorable rotational growth pattern. Girls grow actively until 14-15 years of age while boys grow longer and more abundantly until 17-18 years old.

Recommendations:

Whenever possible implant placement should be delayed until after age 15 for girls and age 18 for boys. The parents and patient should have informed consent that implants placed at an early age may not be “permanent” and may have to be reimplanted. If an implant is adversely affected by growth or causing adverse growth, it should be removed while the surgery is still uncomplicated.

Conclusion:When placed in the growing patient, dental implants should be closely monitored and carefully restored with implant prosthesis designed to accommodate growth and development. Implants placed after age 15 in girls and 18 in boys have the most predictable prognosis.

Topic:Age of Placement

Authors: Oesterle LJ, Cronin RJ Jr, Ranly DM

Title:Maxillary implants and the growing patient.

Source:Int J Oral Maxillofac Implants 1993;8(4):377-387.

Type:Review

Rating: Good

Keywords:dental implants, maxillary growth, osseointegration

Purpose: To addresses growth of the maxilla and the development of the maxillary dentition in the context of implant treatment.

Discussion:Maxillary skeletal and dental growth results in dramatic changes in all three dimensions during active growth. Experimental evidence and the behavior of ankylosed teeth suggest that an osseointegrated object remains stationary in the bone surrounding it and does not move or adapt to bone remodeling. Growth changes may result in the burying or loss of implants depending on the placement site. Hence, implants placed in the early mixed dentition have a poor prognosis of continued usefulness through puberty. When placed early, implants may disturb growth or have to be replaced. Implants placed during late puberty or early adulthood have the best change for long-term usefulness.

Conclusion: Osseointegrated implants in the maxilla of growing patients must be undertaken with a great deal of caution. Implants placed before the cessation of growth are unpredictable in their behavior.

Topic:Implants in younger individuals/children

Author:Heij D eta al

Title:Facial development, continuous tooth eruption and mesial drift as compromisisng factors for implant placement.

Source:Int J Ora Maxillofac Implants. 2006 Nov-Dec; 21(6)867-

Type:Discussion article

Rating:Good

Keywords:Implants, growing skeleton, implants in children

Discussion:

The replacement of teeth lost by children can be an important indication for early implant therapy. Osseointegrated dental implants, like ankylosed teeth, alter position as growth-related changes occur within the jawbones (displacement, remodeling, mesial drift). It has been shown that implants do not follow the growth/change of the alveolar process such as natural teeth. Skeletal growth in the close vicinity around implants are slowed, whereas they continue as normal pace elsewhere. Thus bony defects, occlusal scheme dysfunctions and adjacent tooth complications are seen. 

Facial growth of the child and even of the adolescent, as well as the continuous eruption of the adjacent anterior teeth, create significant risk of a less favorable esthetic and/or functional outcome. Jaw bone growth: Both the mandible and the axilla follow a distinct chronology: growth is first completed in the transversal plane, then in the sagittal plane, and finally, only at a later stage, in the coronal plane. The growth of the mandible is closely associated with growth in stature, whereas growth for the maxilla is more associated with growth of the cranial structures. Maxilla: intercanine arch width increases minimally after 10 years (0.9mm average), sagittal growth of maxilla typically is resorptive therefore implants placed in the anterior maxilla can come across the complication of buccal plate resorption and implant dehiscence, vertical growth of maxilla persists to 17-18 years of age in females, perhaps longer for males therefore until the age of 18 (approx.) there may be vertical plane issues. Mandible: transverse growth completes early in anterior region whereas continue substantially in premolar and molar region, therefore if implants are placed in that region before growth cease implants could result lingually, vertical growth is substantial for mandible and is therefore can be affected by presence of dental implants. For patients with a normal facial profile, the placement of an implant should be postponed until skeletal growth is complete. For patients with a short or long face type, further growth, especially the continuous eruption of adjacent teeth, creates a serious risk even after the age of 25 years. 

In order to determine proper timing for implant placement in adolescents/young adults it was suggested to examine:

Topic:  Treatment planning- Skeletal growth

Authors:Fudalej P., Kokich V., Leroux B:

Title: Determining the cessation of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants.

Source: Am J Orthod Dentofacial Orthop. 2007 Apr; 131 (4 Suppl):S59-67

Type: Retrospective study

Rating: Good

Keywords: dental implant, cephalograms, puberty, facial skeleton growth

Background: Single-tooth implants are commonly used to replace congenitally missing teeth in adolescent orthodontic patients. However, if implants are placed before cessation of facial growth, they will submerge relative to the adjacent erupting teeth. Therefore, it is important to know when facial growth is complete in postpubertal orthodontic patients.

Purpose: To determine and quantify the amount of vertical growth of the facial skeleton and the amount of eruption of the central incisors and the maxillary first molars after puberty.

Methods:

Two or 3 lateral cephalograms taken at pretreatment, posttreatment, and 10 years post retention of 142 males and 159 females were evaluated. Linear regression models were used to determine changes in the parameters with increasing age.

Results:

The findings indicate that

(1) the growth of the facial skeleton continues after puberty

(2) there is a difference in the amount of growth between the sexes during the second decade of life, and after age 20 the intergender difference is substantially diminished

(3) the rate of eruption of the maxillary central incisors in females seems to be greater than in males.

Conclusion:

The growth of the facial skeleton continues after puberty, but the amount of growth decreases steadily and after the second decade of life seems to be clinically insignificant.

Topic:implants in young pts

Authors:HeubererS, Dvorak G, Mayer C, Watzek G, Zechner W

Title:Dental implants are a viable alternative for compensating oligodontia in adolescents.

Source: Clin Oral Implants Res. Jan 3. doi: 10.1111/clr.12323.

Type:clinical

Rating: good

Keywords:children, growth, young dentition

Purpose: To clinically and radiographically evaluate dental implant treatment in adolescents

with extensive oligodontia.

Methods: Patients with more than nine permanent teeth congenitally missing and implant

treatment before the age of 16 years were included. Clinical follow-ups involved bleeding on

probing, plaque index and peri-implant probing value. The peri-implant bone level was analyzed on panoramic radiographs at time of implant treatment and at follow-up. Characteristics of the dental implants and patients (gender, smoking status, position of the missing teeth and age at the time of implant placement) were gathered. The implant positions during maturation was evaluated measuring the center of the implant-abutment interface to a reference line.

Results: This study involved 18 patients (9 m/9 f) having 71 dental implants. 3 were smokers. Youngest patient was 6 yrs old. Number of missing teeth ranged from 10-26. 4 pts received overdentures and the rest, crowns. The tooth predominantly missing was lower left second premolar. Implants used were Nobel Biocare and Dentsply Friadent.

• Mean age at the time of dental implant treatment was 12.5 years.

• BOP was negative on 44% of the implants and positive in 32%. Mean PD was 3.6 mm.

• The peri-implant bone level correlated significantly negative with the age at time of implant placement.

• There were no SSD between bone loss and implant diameter, surface, length, PI, the region, and smoking habits.

• Dental implant treatment in adolescents resulted in a survival rate of 89% (63/71) with a mean loading time of 11 years.

• Thesuccess rate of the dental implants (criteria: peri-implant probing value ≤5 mm, bleeding on probing (BoP) negative, bone loss <0.2 mm) was evaluated on 54 dental implants and calculated as 17% (9/54, 5 patients).

• 54% of the implant crowns (nine of 18 patients, 38 of 71 crowns) had to be renewed after a period of 7.8 years

Conclusion: The results demonstrate long-term survival of DIs in adolescents. However, more long-term studies are needed to further enhance dental implant treatment in maturing individuals with extensive oligodontia.

Topic:Age

Author:Heij DG, Opdebeeck H, van Steenberghe D, Quirynen M.

Title: Age as compromising factor for implant insertion.

Source:Periodontol 2000 2003; 33:172-184

Type: Review

Rating: Good

Keywords:Dental implants; age; maxilla growth/development; mandible growth/development

Purpose:The purpose of this review was to present the age considerations that need to be taken into account during the planning of dental implants.

Discussion:

• Because of osseointegration, which resembles ankylosis, implants do not follow the spontaneous and continuous eruption of the natural dentition. Such implants may even disturb a normal development of the jawbones.

• Installation of an implant should generally be postponed on average until after puberty or after the so-called growth spurt of the child.

• Implants do not follow the formation and development of the alveolar process. At some distance from the implants, the tissues developed normally, but in the immediate vicinity of the implants, further development was slowed down. This can lead to unesthetic and non-functional situations (loss of occlusal contact) together with periodontal complications.

Recommendations by Area

• Anterior Maxilla

  • Most risky site for early implant placement due to the amount, the direction, and the unpredictability of growth in this area

  • Premature implant placement can necessitate a repeated lengthening of the transgingival or transmucosal part of the implants

  • On a long-term basis, early placement can even adversely affect adjacent natural teeth.

  • Best strategy is to delay implant insertion until after skeletal growth has completed.

• Posterior Maxilla

  • Large variations exist in the amount and direction of both sagittal and vertical growth, and the unpredictability of the growth pattern.

  • Since the vertical growth occurs by apposition on the alveolar aspect and resorption on the nasal or maxillary sinus area, an early inserted implant can become submerged occlusally and exposed apically.

  • Recommend delaying an implant placement until after cessation of growth.

• Anterior Mandible

  • Transverse and sagittal growth are completed relatively early in this area.

  • Area seems to hold the greatest potential for early use of an implant supported prosthesis

  • Should avoid use of early implants in combination with natural teeth in that area.

• Posterior Mandible

  • As the mandible undergoes rotational growth, significant changes occur in both the alveolus and the mandibular border, largely influence by the facial growth type.

  • Progressive Infraocclusion of the implant and harm to adjacent teeth preclude the early placement of dental implants in this area.

Topic:Implant patient age

Authors: Meijer HJ, Batenburg RH, Raghoebar GM

Title:Influence of patient age on the success rate of dental implants supporting an overdenture in an edentulous mandible: a 3-year prospective study

Source:Int J Oral Maxillofac Implants. 2001 Jul-Aug;16(4):522-6.

Type:Prospective study

Rating: Good

Keywords: Aging, dental implants, geriatric dentistry

Purpose: To compare selected clinical parameters in older and younger edentulous patients with an implant supported mandibular overdenture during a 3-year evaluation period.

Methods:Inclusion criteria included an edentulous period of at least 2 years and severe resorption of the mandibular ridge. All patients were treated with implants in the right and left canine region of the lower mandible. Implants were restored after 3 months with an overdenture supported by a round bar and clip attachment. The patients were divided into 2 groups based on age: the “younger” patient group (50 and below and the “older” age group (60 and above). Bone height and quality was measured at baseline when denture was placed, at 12 months after placement, and 36 months after placement with standardized intraoral radiographs and lateral cephalometric radiographs. Implant loss, plaque/calculus, inflammation, PD, and BOP were recorded.

Results: One implant was lost in the patient of the older group. The implant appeared to be mobile 3 months after placement. Another implant was successfully placed after 6 months. The only significant difference in clinical parameters noted in between groups was seen in plaque levels, with higher plaque levels observed in the older group.

Discussion: Clinical performance of implant-supported overdentures in the mandible was equally successful in younger and older patients. Increased plaque levels in older patients could be due to increased difficulty in manipulation of devices required to clean I-bars and abutments, however age should not be used as a reason to exclude patients from implant treatment.

Topic:Implant VI – Treatment Planning           implant failure rates and associated risk factors
Authors: Moy PK et al
Title: Dental implant failure rates and associated risk factors.

Source: Int J Oral Maxillofac Implants. 2005 Jul-Aug;20(4):569-77

Type:Retrospective Cohort

Rating: Very Good

Keywords: dental implants, implant failure, medical risk factors, osseointegration

Purpose: To test the hypothesis that coexisting conditions (such as smoking, diabetes, and radiation therapy) lead to increased rates of implant failure, a retrospective analysis of dental implants placed in a consistent manner by a single surgeon was carried out.

Method: a cohort study of consecutive series of patients who received dental implants by the same surgeon over a 21-year period. Medical history and risk factors including, age, gender, location of implant, smoking history and coexisting medical conditions such as diabetes, HP, coronary artery disease, asthma, steroids, chemotherapy and radiation and post-menopausal hormone replacement therapy were extracted from the records.

All implants were placed in a consistent protocol by the same surgeon. Follow up was up to 20 years by the surgeon or a hygienist, most implants were machined type, and failure was recorded when an implant was removed due to mobility, pain, infection, paresthesia or anesthesia and radiographic bone loss greater than 50%

Results:A total of 4,680 implants were placed in 1,140 patients between 1982 and 2003. Patients’ age ranged from 12 to 94 years and females were 59.4% of the study sample. 68% of patients had 1 or more coexisting condition and 6% had 3 or more conditions. 74% of patients had 1 to 5 implants, 26% had 6 or more implants and 1 patient had 24 implants. 85.1% of patients had successful implants; however, 14.9% experienced at least 1 implant failure.

Implants in the maxilla had twice the failure rate of those placed in the mandible. Failure rate in the maxilla is 8.16%, and failure rate in the mandible was 4.93%.

Diabetes, smoking, and head and neck radiation were significant predictors of implant failures. More implants failed in diabetics and those with previous head and neck radiation than in smokers. In smokers, most failures ocured within the first year. Diabetics had failures that continued over the following 10 years and radiation patients experienced most failures within the first 2 years but had fewer failures after 5 or 10 years.

Conclusion:some medical risk factors such as asthma, hypertension and chronic steroid therapy are not correlated with significant increase of dental implant failure. Only smoking, diabetes, head and neck radiation and postmenopausal hormone replacement therapy were associated with significant increase in implant failure. The study did not report any contraindications.

Topic: Biological Principles                   patient age on single implant submersion

Authors:Scwartz-Arad D, Bichacho N

Title:Effect of age on single implant submersion rate in the central maxillary incisor region: A long-term retrospective study.

Source:Clinical Implant Dentistry 2013; 1-6.

Type:Retrospective Study

Rating:Good

Keywords:age, dental implants, long term, and submersion rate

Background:It is contraindicated to place dental implants before growth and development are completed as they are at a risk of submersion due to growth arrest, creating a potential aesthetic problem.

Purpose:The present study evaluated the effect of age on mean submersion rate of single dental implant in the central maxillary incisor area placed after growth has ceased, as compared with the adjacent incisor natural tooth.

Materials and methods A retrospective study was conducted on 35 patients (mean age 29.3±9.9 years, 21 females) who received a single dental implant replacing a missing maxillary central incisor from 1992 to 2008 with a follow-up of at least 3 years. Clinical photos from last follow-up were digitally analyzed to measure the vertical change between the incisal edge of the implant supported crown and the adjacent natural central incisor.

Results:In the younger age group (30 years), the submersion rate was more than three times higher than in the older age group (>30 years), yielding submersion rates of 1.02 and 0.27% per year, respectively. Accordingly, significantly higher proportion of soft tissue complications was also observed in the younger age group as compared with the older one.

Conclusion:

Whereas implant submersion continues throughout adult life, its rate varies with age. It is evident that this phenomenon is much more conspicuous during the second and third decades of life as compared with the fourth and fifth.

Discussion:

If implants are placed before cessation of facial growth, they will submerge relative to the adjacent erupting teeth. Facial growth of the child or adolescent, as well as the continuous eruption of the adjacent anterior teeth, creates significant risk of a less favorable esthetic and/or functional outcome.

Topic: Treatment planning       Implants in periodontally compromised patients

Authors:Wennstrom & Lang

Title:Treatment planning for Implant Therapy in Periodontally Compromised Patient

Source:

Type:

Rating:Good

Keywords:treatment planning, prognosis, compromised patient

Developments in implant treatment options influence our decisions regarding the preservation of teeth with varying degrees of periodontal destruction

PROGNOSIS OF IMPLANT THERAPY IN PERIO COMPROMISED PATIENTS

Global data on implant survival indicate low incidence of implant loss

Question remains: do implants have better long-term prognosis than teeth?

Data from 5 & 10 year studies on perio patients with regular supportive care that incidence of tooth loss =2-5%; implants NOT BETTER THAN TEETH LONG-TERM in these studies.

Perio patients may have increased susceptibility to bone loss around implants.

STRATEGIES IN TREATMENT PLANNING

Comprehensive clinical and Radiographic exams are the basis for planning

Elimination of periodontal lesions prior to implant placement and establishment of high standard of infection control are decisive factors for successful implant therapy; if this is coupled with regular recall – the long term should be same as for patients without prior periodontal disease

POSTERIOR SEGMENTS-

Usually the most severely affected by PD and tooth loss

Tooth Vs. Implant

Is the tooth a critical tooth, or supporting C&B work (ie what is the functional value of the tooth?)

Could the tooth be saved via Sx or nonsurgical means? GTR?

What are the patient’s esthetic and functional demands?

If the tooth is extracted will sufficient bone exist to install an implant? Will sinus or more extensive grafting procedures be necessary to provide sufficient bone?

AGGRESSIVE PERIODONTITIS

Patients often respond to regenerative therapy. Wide, angular Defects are often present on teeth adjacent ones lost early and can often be saved with such regenerative techniques.

instead of dooming these teeth and initiating more complex implant supported restorations, GTR can often be done then limiting the number and complexity of implants otherwise required.

Success is ultimately attributable to high-quality infection control

FURCATION PROBLEMS

If root section is performed, do the future roots have enough interradicular periodontal support after endodontics to support a restoration?

Single-tooth in Esthetic Zone

Can the tooth be saved? Will inevitable consequences of therapy required to save tooth be acceptable (recession, black triangles)?

Topic:Periodontitis vs implant survival

AuthorsKaroussis IK, Kotsovilis S, Fourmousis I

Title: A comprehensive and critical review of dental implant prognosis in periodontally compromised partially edentulous patients.

Source: Clin Oral Implants Res. 2007 Dec;18(6):669-79

Type: Clinical study

Rating: Poor

Objectives: To examine the short-term (<5 years) and long-term ( >5 years) prognosis of osseointegrated implants placed in periodontally compromised partially edentulous patients.


Material and methods: Using the National Library Of Medicine and Cochrane Oral Health Group databases, a literature search for articles published up to and including August 2006 was performed. Out of 2987 potentially abstracts/ 15 prospective studies were selected, including 7 short-term and 8 long-term studies. Because of considerable discrepancies among these studies, meta-analysis was not performed.

Results:

• Short-term survival rates in pt with history of chronic periodontitis: 90-100%

• Long-term survival rate in pts with history of chronic periodontitis up to 97.32%

• Two long term studies reported survival rates <90%, both of them included hollow implants many of which had a short length

• 95% short-term and 88.8% 5-year survival rates in patients treated for aggressive periodontitis

• In conclusion, the long-term survival rates of implants placed in partially edentulous patients with a history of chronic periodontitis are comparable to the mean implant survival rates reported for the general population

Conclusion:

• Short-term survival rates comparable to periodontally healthy individuals, stability of PPD, CAL and peri-implant marginal bone loss

• Long-term survival rates may exceed 90%

• PDs and the proportion of deep pockets tend to increase throughout a long-term period

• Effect on long-term marginal bone loss around implants is not yet clarified

• Although surviving, implants in patients with history of periodontitis may demonstrate higher incidence of peri-implantitis

• Insufficient data for patients with aggressive periodontitis at that time

Critics: Absence of universally accepted definition for “periodontally compromised” patients and criteria for implant success. According to these studies, the ‘periodontally compromised’ patients have a history of periodontitis (chronic or aggressive), but no active disease at the time of implant placement. Certain studies included a relatively limited number of patients. Several studies included smokers. Implant ‘success’ was defined in some cases only. In certain cases, sinus membrane elevation.

Topic: Periodontitis history

Authors:Karroussis, I

Title: A comprehensive and critical review of dental implant prognosis in peridontally compromised partially edentulous patients.

Source: Clin Oral Impl. Res 18, 2007; 669-679

Type: Systematic review

Rating: Good

Keywords: prognosis, periodontally compro

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Medical History: medical conditions + drugs that may affect implant and surgical outcome; Risk factors

1. Misch and Resnik. Medical Evaluation of the Dental Implant Patient (CH 20). pp 406-420. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.

2. Rose L and Mealey B. Implant complications associated with systemic disorders and medications. (CH 2) pp 9-45.

3. Sugerman, P., Barber, M.: Patient selection for endossous dental implants; Oral and systemic considerations. Int J Oral Maxillofac Implants. 2002 Mar-Apr; 17(2):191-201

4. Ong, C et al: Systematic Review of Implant Outcomes in Treated Periodontitis Subjects. J Clin Periodontol 2008; 35:438

5. RasperiniG, Siciliano VI, et al. Crestal bone changes at teeth and implants in periodontally healthy and periodontally compromised patients. A 10-year comparative case-series study. J Periodontol. 2013 Nov 11. [Epub ahead of print]

6. KlokkevoldP, Han T: How do smoking, diabetes and periodontits affect outcomes of implant treatment? Int J Oral Maxillofac Implants. 2007; 22 (suppl)173-202

7. Dowel, S et al: Implant success in people with type 2 diabetes mellitus with varying glycemic control. A pilot study. JADA: 138:2007:355-361

8. StrietzelFP, Reichart PA, et al. Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis. J Clin Periodontol. 2007 Jun;34(6):523-44. Review.

9. BainCA Implant installation in the smoking patient. Periodontol 2000. 2003;33:185-93. Review.

10. Fugazzotto, P et al: Implant Placement with or without Simultaneous Tooth Extraction in Patients Taking Oral Bisphosphonates: Postoperative Healing, Early Follow up and Incidence of Complications in Two Private Practices. J Periodontol 2007; 78:1664-1669

11. Colella, Cannavale, Pentenero, Gandolfo: Oral implants in radiated patients: A systematic review. Int J Orla Maxillofac Implants 2007; 22(4):616-623

12. Holahan, C et al: Effect of osteoporotic status on the survival of titanium dental implants. Int J Oral Maxillofac Implants. 2008:Sep-Oct; 23(5)905-10

13. ClaudyMP, Miguens SA Jr, et al Time Interval after Radiotherapy and Dental Implant Failure: Systematic Review of Observational Studies and Meta-Analysis. Clin Implant Dent Relat Res. 2013 Jun 7. [Epub ahead of print]

14. SharafB, Dodson TB. Does the use of prophylactic antibiotics decrease implant failure? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):547-50

15. AhmadN, Saad N. Effects of antibiotics on dental implants: a review. J Clin Med Res. 2012 Feb;4(1):1-6.

16. EspositoM, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev. 2013 Jul 31;7:CD004152.

17. Ata-AliJ, Ata-Ali F, Ata-Ali F. Do antibiotics decrease implant failure and postoperative infections? A systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2013 Jun 25. pii: S0901-5027(13)00258-0. doi: 10.1016/j.ijom.2013.05.019. [Epub ahead of print]

18. Alissa R, Sakka S, Oliver R, et al. Influence of ibuprofen on bone healing around dental implants: a randomised double-blind placebo-controlled clinical study. Eur J Oral Implantol. 2009 Autumn;2(3):185-99.

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Topic:Patient selection

Author:Sugerman, P., Barber, M

Title:Patient selection for endossous dental implants; Oral and systemic considerations.

Source:J Oral Maxillofac Implants. 2002 Mar-Apr; 17(2):191-201

Type:Discussion

Rating: Good

Keywords:patient selection, endossous dental implant, oral, systemic consideration

Purpose:The aims of this article were to define “reasonable health” for dental implant treatment and to provide a systematic approach to the selection of dental implant patients.

Discussion:

TITANIUM TOXICOLOGY The survival or success of endosseous dental implants may be influenced by a number of local and systemic conditions. Some of these conditions affect the process of osseointegration directly. The following are noted in particular.

• PHYSICAL STATUS

  • The American Society for Anesthesiology (ASA) has defined a 6-point scale of physical status

• AGE

  • Younger patients may show greater crestal bone resorption around dental implants.It is therefore recommended that implant placement be delayed until growth and development have ceased or are minimal

  • However, implant failure does not correlate with age or sex. Increasing age has no effect on osseointegration or the rate of crestal bone resorption around dental implants.

• PATIENT EXPECTATION

  • Although dental implants can enhance esthetics, phonetics, and bite force, it is important to identify unrealistic expectationsthat patients may have about implants and implant- retained prostheses.

• HYPOHIDROTIC ECTODERMAL DYSPLASIA is characterized by hypodontia, hypotrichosis, and hypohidrosis. Dental implants have been used successfully in patients with severe hypodontia associated with ectodermal dysplasia.In a recent prospective study, implant placement and prosthetic rehabilitation in young children with ectodermal dysplasia did not restrict transverse or sagittal growth. However, vertical alveolar growth resulted in the occasional submergence of endosseous implants, necessitating revision and the placement of longer abutments.

• SMOKING:Many studies have shown that smoking interferes with osseointegrationand accelerates bone resorption around dental implants

• OSTEOPOROSIS:osteoporosis appears not to influence implant survival.Moreover,endosseous dental implants may actually stimulate mandibular bone formation in a load-dependent manner.

• DIABETES MELLITUS: endosseous dental implants are usually successful in patients with diabetes, although uncontrolled diabetes contraindicates dental implant placement. Consideration should be given to antibiotic prophylaxis for surgical procedures in diabetic patients.

• SCLERODERMA:little is known about dental implants in patients with scleroderma.Endosseous dental implants may improve prosthesis function and comfort in scleroderma patients, although access for implant surgery and for oral hygiene may be compromised.

• SJÖGREN SYNDROME: Implant-supported prostheses were shown to considerably increase prosthetic comfort and function in patients with Sjögren syndrome,preferable to soft tissue-supported prostheses.

• MULTIPLE MYELOMA: Implant success has been reported in a patient with multiple myeloma.Unmanaged malignant disease in general must be considered a contraindication for the placement of endosseous dental implants.

• PARKINSON’S DISEASE: Implant- supported prostheses should be considered in patients with Parkinson’s diseaseand other diseases affecting orofacial motor function.

• BONE MARROW TRANSPLANTATION: Implant placement should be delayeduntil cytotoxic chemotherapy has ended and the mar- row graft has taken. Bone marrow transplant patients may develop oral graft-versus-host disease that is clinically similar to oral lichen planus

• HIV: endosseous dental implants have been placed successfully in HIV-positive patients

• SYSTEMIC DRUGS: Consultation with the patient’s physicianprior to dental implant placement is desirable for patients on anticoagulants or long-term systemic corticosteroids.

• CHRONICALLY INFECTED IMPLANT SITES: Periodontitis and periapical lesions should be diagnosed and treated prior to dental implant placement.

• ORAL LICHEN PLANUS Endosseous dental implants may be used in patients with nonerosive forms of OLP, although patients should be warned of possible lesion exacerbation related to surgery and possible implant failure if gingival lesions become erosive

• HEAD AND NECK RADIOTHERAPY: Implant placement following head and neck radiotherapy is associated with a significant risk of osteoradionecrosis, especially with irradiation above 50 Gy. Recommended a 6- to 12-month recovery period after irradiation prior to dental implant placement

Presurgical hyperbaric oxygen may reduce the dental implant failure rate in irradiated jawbone from 60% to 5%

• TARDIVE DYSKINESIAS Tardive dyskinesia may complicate dental implant therapy.Alternatives to endosseous dental implants should be considered for patients with neurologic disorders including orofacial dyskinesia, trigeminal neuralgia, or orofacial dysesthesia.

Topic: Implants in patients with periodontitis

Authors: Ong, C et al:

Tittle:Systematic Review of Implant Outcomes in Treated Periodontitis Subjects.

Source: J Clin Periodontol 2008; 35:438

Type: Systematic Review

Rating: Good

Keywords:periimplantitis, failure

Purpose:To determine implant outcomes in partially dentate patients who have been treated for periodontitis compared with periodontally healthy patients.

Methods:

All longitudinal studies (until March 2006) of endosseous dental implants of at least 6 months of loading were searched. Studies presented with one or more of the outcome measures (implant survival, success, bone-level change, peri-implantitis) were included. Screening, data abstraction and quality assessment were conducted independently and in duplicate.

Results:

From 4448 citations, 546 full-text papers were screened and nine studies were included. Overall, the non-periodontitis patients demonstrated better outcomes than treated periodontitis patients. However, the strength of evidence showed that the studies included were at a medium to high risk of bias, with lack of appropriate reporting and analysis of outcomes plus lack of accounting for confounders, especially smoking. Furthermore, the studies showed variability in the definitions of treated and non-periodontitis, outcome criteria and quality of supportive periodontal therapy. Meta-analysis could not be performed due to heterogeneity of the chief study characteristics.

Conclusion:

There is some evidence that patients treated for periodontitis may experience more implant loss and complications around implantsthan non-periodontitis patients. Evidence is stronger for implant survival than implant success; methodological issues limit the potential to draw robust conclusions.

Topic:crestal bone height change

Authors:Rasperini G, Siciliano VI

Title:Crestal bone changes at teeth and implants in periodontally healthy and periodontally compromised patients. A 10-year comparative case-series study.

Source:J Periodontol. 2013 Nov 11.

Type:Comparative case-series

Rating:Good

Keywords:alveolar bone loss, peri-implantitis, periodontitis, smoking

Purpose:To compare the 10 year radiographic crestal bone changes around teeth and implants in periodontally compromised and periodontally healthy patients.

Methods:120 patients (60 with prev hx of perio, 60 healthy) were followed for 10 years post loading for radiographic crestal bone height of dental implants and adjacent teeth. 10 patients were smokers. Digital films were calibrated. Radiographic crestal bone change was calculated by subtracting the creatl BL at baseline from the crestal BL at the 10 year follow up.

Results:After 10 years, implant survival was 80-95% and 100% for teeth. In all categories evaluated, natural teeth were significantly more stable radiographically compared to implants. Adjacent teeth did not seem to be influenced by the presence or absence of bone loss ≥3mm at adjacent implants.

Conclusion:Long-term results show that natural teeth have greater survival and less marginal bone loss compared to dental implants. This was still true when looking at teeth with reduced periodontal attachment (treated and maintained). The decision to extract teeth in favor of dental implants should be carefully considered in partially edentulous patients.

Topic:Risk factors for implants

Authors: Klokkevold P, Han T

Title:How do smoking, diabetes and periodontits affect outcomes of implant treatment?

Source:Int J Oral Maxillofac Implants. 2007; 22 (suppl)173-202

Type:Review

Rating: Good

Keywords:dental implants, dental implant survival, diabetes, periodontitis, smoking, tobacco

Purpose: To evaluate the available literature to assess whether smoking, diabetes, and periodontitis have an adverse effect on the outcomes of implants placed in patients with these conditions.

Method: The dental literature was searched using the MEDLINE, Cochrane Collaboration, and EMBASE databases. Using specific inclusion and exclusion criteria, 2 reviewers evaluated titles, abstracts, and full articles to identify articles relevant to this review. All searches were conducted for articles published through May 2005. Data from included articles for each of the risk factor groups, smoking, diabetes, and periodontitis, were abstracted and analyzed.

Results: A detailed search of the literature and evaluation of relevant articles identified 35 articles for inclusion in this systematic review. Nineteen articles were identified for smoking, 4 articles were identified for diabetes, and 13 articles were identified for periodontitis. One article met the criteria for both smoking and periodontitis. Implant survival and success rates were reported for smokers versus nonsmokers; diabetic patients versus nondiabetic patients; and patients with a history of treated periodontitis versus patients with no history of periodontitis. The findings revealed statistically significant differences in survival and success rates for smokers (better for nonsmokers), with greater differences observed when the data were analyzed according to bone quality (less for loose trabecular bone). No difference in implant survival rate was found between patients with and without diabetes. Likewise, no difference in implant survival rates was found between patients with a history of treated periodontitis compared to patients with no history of periodontitis.

Conclusion: The results of this systematic review of the literature demonstrated that smoking has an adverse effect on implant survival and success. The effect of smoking on implant survival appeared to be more pronounced in areas of loose trabecular bone. Type 2 diabetes may have an adverse effect on implant survival rates, but the limited number of studies included in this review do not permit a definitive conclusion. A history of treated periodontitis does not appear to adversely affect implant survival rates but it may have a negative influence on implant success rates, particularly over longer periods.

Topic:Diabetes

Author:Dowel, S et al

Title:Implant success in people with type 2 diabetes mellitus with varying glycemic control. A pilot study.

Source:JADA: 138:2007:355-361

Type:Cohort study

Rating:Good

Keywords:Diabetes, dental implants, implant success

Purpose:The authors conducted a prospective cohort study to explore the relationship between implant success and glycemic control in patients with type 2 diabetes mellitus.

Methods:The authors used a two-phased enrollment, stratified by glycated hemoglobin (HbA1c) levels, to evaluate 50 implants in 35 subjects. The authors assessed nonsubmerged, nonrestored implants after placement, during healing and at abutment placement (35 newton centimeters) for restoration after four months. Outcomes assessed included implant success or failure, clinical complications and adverse events.

Results:The HbA1c levels of the subjects ranged from 4.5 to 13.8 percent. All 50 implants were integrated clinically. The authors identified three minor complications in three patients having HbA1c levels ranging from 7.4 to 8.3 percent. None of these complications affected the clinical management of the cases, and the authors did not identify any adverse events.

Conclusion:There was no evidence of diminished clinical success or significant early healing complications associated with implant therapy based on the glycemic control levels of subjects with type 2 diabetes mellitus. These findings support the continued investigation of the effects of glycemic control on implant therapy toward the development of therapeutic guidelines that will optimize implant therapy in patients with diabetes.

Topic:smoking and implant

Authors:Strietzel FP, Reichart PA, et al.

Title: Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis.

Source:J Clin Periodontol. 2007 Jun;34(6):523-44. Review.

Type: Retrospective Study

Rating: Good

Keywords:dental implants; meta-analysis;odds ratio; smoking; success rate; survival rate

P: To investigate if smoking interferes with the prognosis of implants with and without accompanying augmentation procedures compared with non-smokers.

M&M:A systematic electronic and handsearch (1989 and 2005; English and German language; search terms “dental or oral implants and smoking”; “dental or oral implants and tobacco”) was performed to identify publications providing numbers of failed implants, related to the numbers of smokers and non-smokers for meta-analysis. Publications providing statistically examined data of implant failures or biologic complications among smokers compared with non-smokers were included for systematic review.

R: Of 139 publications identified, 29 were considered for meta-analysis and 35 for systematic review. Meta-analysis revealed a significantly enhanced risk for implant failure among smokers [implant-related odds ratio (OR) 2.25, confidence interval (CI(95%)) 1.96-2.59; patient-related OR 2.64; CI(95%) 1.70-4.09] compared with non-smokers, and for smokers receiving implants with accompanying augmentation procedures (OR 3.61; CI(95%) 2.26-5.77, implant related). The systematic review indicated significantly enhanced risks of biologic complications among smokers. Five studies revealed no significant impact of smoking on prognosis of implants with particle-blasted, acid-etched or anodic oxidized surfaces.

C:Smoking is a significant risk factor for dental implant therapy and augmentation procedures accompanying implantations.

Topic:smoking and implant

Authors: Bain CA

Title:Implant installation in the smoking patient.

Source:Periodontol 2000. 2003;33:185-93.

Type:Review.

Rating: good

Keywords:implant, failure, smoking,

Purpose:to review the association between smoking and implant failure; potential mechanisms, and benefits of smoking cessation.

Discussion:

• Effects of smoking on general health:smoking has been shown to affect health in many ways such as; cancers especially lung cancer, chronic lung disease, myocardial infarctions, strokes and ischemic heart disease. Research show that 50% of smokers die from a smoking related disease, and life expectancy of smokers is reduced by 7.5 years. Smoking also has been shown to have an adverse effect on bone density.

• Effects of smoking on wound healing: smoking is a complicating factor in post-surgical wound healing. Smokers show less reduction in PD after SRP, poorer healing after mucogingival surgeries, less favorable healing following OFD, greater loss of bone height, reduction in post-ext socket fill and more painful ext socket. Smoking compromises healing of duodenal ulcers. Also, in a study about healing after orthopedic surgery, it was shown than there are more delayed union or non-unions in smokers.

• Influence of smoking on the actions of polymorphonuclear leukocyte, macrophages, circulation and blood flow:Several studies have shown that smoking causes reduced phagocytosis, delayed margination and diapedesis as well as compromised aggregation and adhesion of leukocytes to the endothelium in venules and arteries. Peripheral endothelial dysfunction, vessel wall injury and capillary loss is common in smokers, also reactive hyperemia and sequestration of blood cells in the microcirculation. Coronary flow reserve is also decreases after smoking high-nicotine cigarettes.

• Smoking and implant failure:

  • Smoking and particularly heavy smoking increases the failure rates for machined titanium implants, likely due to a compromise of the blood supply in bone during early healing

  • This increased failure rate clusters largely in the maxilla, with much smaller differences between smokers and non-smokers for implant in the mandible.

  • Smoking is associated with a particularly high failure rate for implants placed into grafted maxillary sinuses.Some operators may consider this to be too great a risk to take, if the patient is unable or unwilling to stop smoking.

• What happens if the potential implant patient stops smoking:Smoking cessation has been demonstrated to improve success rates in machined implant patients. In fact, implant placement may well be an effective motivator in assisting a smoker with cessation.

• Bone density, smoking and implant success: There appears to be a relationship between heavy smoking and reduced bone density. This is seen in various areas of medicine, as well as in implant surgery and might explain high failure rates in Type 4 bone

• Do different materials and surfaces make a difference:There is early evidence that rough surface implants, prepared with a double acid etched technique, have a high success rate in smokers. With success rates around 10% better overall (98.7% vs. 88.7%) and 15% better in the maxilla (97.3% vs. 82.1%) than our original results with machined Branemark implants in smokers, these are at present considered to be the implant of choice in smokers who cannot or will not stop smoking for implant placement.

Topic:Oral Bisphosphonates

Author: Fugazzotto P

Title:Implant Placement with or without Simultaneous Tooth Extraction in Patients Taking Oral Bisphosphonates: Postoperative Healing, Early Follow up and Incidence of Complications in Two Private Practices

Source:J Periodontol 2007; 78:1664-1669

Type:Retrospective study

Rating: Good

Keywords:Bisphosphonates; dental implants; osteonecrosis

Purpose:The purpose of this article was to document the results of treatment of patients with a history of oral bisphosphonate therapy in two private periodontal practices.

Methods:61 female patients were treated in two private offices. All patients were receiving oral bisphosphonate therapy in the form of alendronate or risedronate, 35 or 70 mg/week. All these participants were treated with implant placement and restoration or tooth extraction, immediate placement, and restoration. These patients were then followed for 12 to 24 months after implant placement. The incidence of hard and soft tissue complications, including the development of osteonecrosis were noted.

Results:There were no reported cases of osteonecrosis immediately postoperatively during the follow-up period in any of the 61 patients. One patient demonstrated a small tissue dehiscence at the 1-week postoperative exam. No other complications occurred. All implants were functioning successfully by the Albrektsson criteria 12 to 24 months post-insertion.

Discussion: While the concern with BON is very much real with IV bisphosphonate. A history of oral bisphosphonate use for a mean period of 3.3 years was not found to be a contributing factor to the development of osteonecrosis following implant placement. Due to the size of the patient population, larger controlled studies and retrospective studies are needed.

Topic:Radiation

Authors: Colella, Cannavale, Pentenero, Gandolfo:

Title:Oral implants in radiated patients: A systematic review

Source:Int J Orla Maxillofac Implants 2007; 22(4):616-623

Type:Systematic review

Rating: Good

Keywords: Dental implants, oral cancer, radiation therapy

Purpose:To evaluate and compare the effects of pre- and post-implant radiation therapy. Incidence of implant failure was linked to multiple variables and assessed.

Methods:A thorough review of the relevant literature was performed. Studies were original studies based in humans from 1990- 2006. The man outcome considered was implant failure, defined as implant mobility, implant removal necessitated by progressive marginal bone loss or infection (biologic failure). Restorative status was not considered a determinate of success (sleeping implants were considered a positive outcome). Overall implant failure rate was compared for pre-implantation radiation therapy vs. post-implantation. Four variables were considered: implant location (maxilla vs. mandible), dose of radiation, delay from radiation to implant placement, and timing of implant failure.

Results:18 articles were considered eligible for inclusion in the review.Implant failure in post-implantation radiation therapy: 6 studies overall reported 124 implants with 4 failures (3.2%). Implant failure in pre-implantation radiation therapy: An overall failure rate of 5.4% was reported, which was not significantly different from post-implantation. 22/46 failures reported the cause of failure, with 9 due to lack of osseointegration, 12 due to marginal bone loss, and 1 due to biting trauma. Implant failure in the maxilla was 17.5% and 4.4% in the mandible, a difference that was significant. Vascularized free flaps were associated with the lowest rate of implant failure. Radiation dose: Radiation doses lower than 45 Gy were associated with the lowest rate of implant failure, with 5% being reported at higher doses. Delay of radiation treatment to implant placement: All implant failures occurred within 36 months after treatment. Timing of implant failure: No failures occurred within one month, 3.1% failed within the first month and 0.8% failed after 1 year.

Discussion:Based on this study, the timing of implant placement (pre- or post-therapy)is not linked to a significant difference in implant failure rate, however significantly better outcomes were noted in the mandible.

Topic:osteoporosis
Authors:Holahan, C et al
Title:Effect of osteoporotic status on the survival of titanium dental implants.

Source: Int J Oral Maxillofac Implants. 2008:Sep-Oct; 23(5)905-10

Type:

Rating: Good

Keywords: dental implants, implant survival, osteoporosis

Purpose:Primary Objective is to perform a retrospective chart review to determine the effect of osteoporotic status on survival of dental implants in postmenopausal women. Secondary Objectives included assessing the effects of smoking status, age, and arch location on implant survival as a function of osteoporotic status.

Method: a retrospective chart review was completed on all women who were 50 years of age or older at the time of dental implant placement at the Mayo Clinic between Oct 1, 1983 and Dec 31, 2004. The medical and dental charts were evaluated to collect the following:

1. BMD T-score within 3 years of implant placement

2. Osteoporotic diagnosis based on BMD T-score

3. Arch location of the implants

4. Smoking status at time of implant placement

5. Any implant failures (implant removal due to any reason other than infection or manufacturing defects)

The review resulted in 192 patients (646 implants). Implant survival was estimated using the Kaplan-Meier method. Follow up duration was calculated from date of implant placement to date of failure or last follow up.

Results:

• The Kaplan-Meier t- and 10-year survival rates for the 64 implants in 192 patients were 93.8% and 92.5% respectively. The mean follow up was 5.4 years (range 11 days to 20.4 years). Mean age of women studied was 63.4 years (range 50.3 to 84.9 years)

• Osteoporotic diagnosis of patients based on BMD T-score was: 49% diagnosed as non-OP, 29.7% had osteopenia and 21.4% had osteoporosis. 37 implant failures were found: 10 implant failures in the osteoporosis group, 10 implant failures in the osteopenia group and the other 17 failures occurred in patients with non-OP diagnosis.

• No significant association between arch location and implant failure was identified.

• 12.5% of patients were smoking at the time of implant placement. Smoking had a significant effect on implant failure. Implants in smokers were 2.6 times more likely to fail (5- and 10- year implant survival rate for smokers was 87.3%). Non-smokers had 94.6% and 93.1% survival rates.

Conclusion:

• Dental implant survival rates in this group of patients were encouraging with a 10-year survival rate of 92.5%.

• Implants placed in smokers were 2.6 times more likely to fail than those placed in nonsmokers. The difference between those were most evident in the first year after implant placement.

• A diagnosis of osteoporosis or osteopenia is not a contraindication to dental implant therapy.

Topic: Biological Principles

Authors:Claudy et al

Title:Time interval after radiotherapy and dental implant failure: systematic review of observational studies and meta-analysis

Source:Clinical implant dentistry 2013;1-10

Type:Systematic Review

Rating:Good

Keywords:dental implants, meta-analysis, osseointegration, osteoradionecrosis, radiotherapy

Purpose: To compare the risk of failure of dental implants placed within 6 and 12 months after the end of radiotherapy versus the risk of those implants placed after 12 months from the end of radiotherapy.

Materials and method

Four electronic databases were searched for articles published until February 2013 without language restriction: Lilacs, Medline, Scopus and the Cochrane Central Register of Controlled Trials. Two reviewers independently assessed the eligibility criteria and extracted data. Meta-analysis was performed.

Results:Overall 3,749 observational studies were identified. After the screening of titles and abstracts, 236 publications were selected, and finally 10 articles were included in the analysis. The Relative Risk of failure (1.34) was higher in individuals who had dental implants installed between 6 and 12 months after receiving radiotherapy.

Discussion:The main finding was that placement of dental implants between 6 and 12 months postradiotherapy was associated with 34% higher risk of failure. This is statistically significant and clinically relevant. Literature suggests that patients treated with radiation doses exceeding 50 Gray Units (Gy) are at increased risk of failure of osseointegration because of the loss of ability to repair and neovascularize the irradiated bone. Hyperbaric Oxygen therapy (HBO) reduces the risk of failure of the implant because it increases the number of capillaries and fibroblasts. However, this was not observed in this review which agrees with results of Esposito who found that HBO is not essential.

Conclusion:

Minimum waiting period of 6 months postradiotherapy prior to dental implant placement is unlikely to be the most suitable, and healing periods with duration over 1 year may be beneficial.

Topic:prophylactic antibiotics

Authors:Sharaf B, Dodson TB.

Title:Does the use of prophylactic antibiotics decrease implant failure?

Source:Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):547-50

Type:literature review

Rating:high quality evidence used

Keywords: antibiotic use, implant failure

Background:Despite the high success rate, implant failures do occur. Failure can attributable to implant-related, patient-related, and surgical technique-related factors. Bacterial colonization of the implant surface and surgical site infection have be implicated in early implant failure. Once an infection ensues at the implant site, its eradication is usually difficult, and may lead to removal of the implant. For this reason, various regimens have been suggested to minimize early infections after implant placement. However routine use of antibiotics is not without risk.

Purpose: to answer the question, “in patients receiving dental implants, does the administration of prophylactic antibiotics reduce early implant failure?”

Materials and Methods:The authors searched using the following Medical Subject Headings (MeSH): antimicrobial agents, antibiotics or prophylactic antibiotics, and dental implants. Inclusion criteria:1) randomized controlled clinical trials, (2) meta-analysis or systematic review. The primary predictor variable was antibiotic therapy, classified as a preoperative dose of antibiotics, preoperative and postoperative antibiotic treatment, and no antibiotics. The primary outcome variable was implant failure. The secondary outcome variable was post- operative infection. Each article was reviewed and data summarized for the following variables: sample size, antibiotic use, implant failure, and postoperative infections. The treatment effect was measured using absolute risk reduction (ARR), which is defined as the absolute difference in failure rates between the intervention and control groups. The number needed to treat (NNT), calculated as the reciprocal of ARR, is defined as the number of implants that must be placed with antibiotic use to prevent 1 implant failure. Five articles were selected for review.Four studies were randomized controlled trials.

 

Results:a meta-analysis of the 4 RCTs included 1007 patients receiving a total of 2020 implants showed more implant failures in the groups not receiving antibiotics, with a statistically significant difference. The number of patients that needed to be treated with antibiotics to prevent 1 patient from having implant failure was 33.

Bottom Line: in the authors opinion, based on their review – significant reduction in implant failure was observed when patients received 2g Amoxicillin 1 hr preoperatively or 1 g amoxicillin 1 hr preoperatively followed by 500mg 4 times daily for 2 days postoperatively.

Critique:There are some drawbacks to the RCTs reviewed. The follow-up time varied from 3 months in 1 trialand 4 months in 2 trials to 5 months in 1 trial.Decreasing the follow-up period may decrease the number of failed implants and may overestimate the effect of antibiotics on the primary outcome variable: implant failure. Another drawback is the use of bone substitutes and other bone-regenerative procedures at the time of implant placement, which may affect implant healing and failure rates. The use of bone-regenerative procedures was reported in 2 studies.In addition, the effect of timing of implant placement (delayed or immediately after extraction) may potentially increase implant failure rates. Esposito and colleaguesdemonstrated in a logistic regression analysis that patients in the RCT who received immediate post-extraction implants had a 9% failure rate versus 2% in the delayed group, regardless of antibiotic use (P<.001).

Topic:Antibiotics

Author: Ahmad N, Saad N.

Title:Effects of antibiotics on dental implants: a review.

Source:J Clin Med Res. 2012 Feb;4(1):1-6.

Type:Systematic review

Rating: Good

Keywords:antibiotic, success rate, dental implants.

Purpose:to review the current literature and information on dental implants and prophylaxis. Our objectives are to ask whether or not antibiotics are beneficial to implants, and in what instances pre- and/or postoperative antibiotic regimes should be prescribed.

Material and methods: The systematic literature review was completed using the electronic databases, Pubmed, Medpilot and Medline. Retrospective or prospective controlled studies which met the inclusion criterion, were English studies conducted between 1955 to January 2009. Administrations of various prophylactic antibiotics regimens were accepted. An unsuccessful dental implant was characterized by any implant which failed within the first 3 months, and studies with follow ups within the first 5 months were included. Studies with loading were not included and only studies using low risk patients were included.

Results:Out of 853 studies, only 6 studies were included in this systematic review that met the criteria. 11406 implants used in this literature review, cases with no antibiotics had a 92 % success rate, cases with pre-op antibiotic alone had a 96% success rate, cases with post-op antibiotic alone had a 97% success

Conclusion:The cost-benefit ratio of any therapy, including all potential adverse effects, must be determined. The negative effects associated with use of antibiotic therapy must be assessed in comparison to the costs and morbidity related to treating infective endocarditis or infected prosthetic materials.

Critics:many studies were excluded because they did not include comparisons between no antibiotics, pre-op, post-op antibiotic use.

Topic: Antibiotics

Authors: Esposito M, Grusovin MG, Worthington HV

Tittle:Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications.

Source: Cochrane Database Syst Rev. 2013 Jul 31;7:CD004152.

Type: Systematic Review

Rating: Good

Keywords:antibiotics, failure, survival

Purpose:To assess the beneficial or harmful effects of systemic prophylactic antibiotics at dental implant placement versus no antibiotic or placebo administration and, if antibiotics are beneficial, to determine which type, dosage and duration is the most effective.

Methods:

Cochrane Oral Health Group’s Trials Register (to 17 June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 5), MEDLINE via OVID (1946 to 17 June 2013) and EMBASE via OVID (1980 to 17 June 2013). Selection criteria: RCTs with a follow-up of at least three months, that compared the administration of various prophylactic antibiotic regimens versus no antibiotics to people undergoing dental implant placement. Outcome measures included prosthesis failures, implant failures, postoperative infections and adverse events.

Results:

Six RCTs with 1162 participants were included:

• 3 trials compared 2 g of preoperative amoxicillin versus placebo (927 participants)

• 1 compared 3 g of preoperative amoxicillin versus placebo (55 participants),

• 1 compared 1 g of preoperative amoxicillin plus 500 mg four times a day for two days versus no antibiotics (80 participants), and

• 1 compared four groups: (1) 2 g of preoperative amoxicillin; (2) 2 g of preoperative amoxicillin plus 1 g twice a day for seven days; (3) 1 g of postoperative amoxicillin twice a day for seven days, and (4) no antibiotics (100 participants).

• The overall evidence was considered to be of moderate quality.

• The meta- analyses of the six trials showed a statistically significant higher number of participants experiencing implant failures in the group not receiving antibiotics. The number needed to treat for one additional beneficial outcome (NNTB) to prevent one person having an implant failure is 25, based on an implant failure rate of 6% in participants not receiving antibiotics. There was borderline statistical significance for prosthesis failures, with no statistically significant differences for infections, or adverse events. No conclusive information can be derived from the only trial that compared three different durations of antibiotic prophylaxis since no event (implant/prosthesis failures, infections or adverse events) occurred in any of the 25 participants included in each study group.

Conclusion:

Scientific evidence suggests that antibiotics are beneficial for reducing failure of dental implants. Specifically 2 g or 3 g of amoxicillin given orally, as a single administration, one hour preoperatively significantly reduces failure of dental implants. It might be sensible to suggest the use of a single dose of 2 g prophylactic amoxicillin prior to dental implant placement. It is still unknown whether postoperative antibiotics are beneficial, and which antibiotic is the most effective.

Topic:antibiotics and implant failures/infections

Authors:Ata-Ali J, Ata-Ali F, Ata-Ali F.

Title:Do antibiotics decrease implant failure and postoperative infections? A systematic review and meta-analysis.

Source:Int J Oral Maxillofac Surg. 2013 Jun 25.

Type:Systematic review and meta-analysis

Rating:Good

Keywords:dental implants, infection, disease, antibiotic, meta-analysis, implant surgery

Purpose:To systematically review and perform a meta-analysis to determine does the use of antibiotics reduce the frequency of implant failure and postoperative infection.

Methods:A manual and PubMed electronic search was conducted for RCTs that met the inclusion criteria with a control group that did not receive antibiotics. Four RCTs were included in the final review.

Results:Four RCTs included had a total of 2063 implants in a total of 1002 patients. Antibiotic use significantly lowered implant failure rate with an OR 0.331. One needs to treat 48 patients in order to prevent one patient from having an implant failure. In contrast, antibiotic use did not significantly reduce the incidence of post op infection. The meta-analysis found that there is evidence in favor of systemic antibiotic use in patients receiving dental implants.

Conclusion: