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

HOME Implant Home 

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.

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