immediate, medium and late term implant failures                                 

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• Part II Intraoperative Complications in Implant Placement. pp 20-89. Surgical complications in oral implantology: etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.

• Part III Postoperative Complications (complications 30-33). pp 96-105. Surgical complications in oral implantology: etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.

• Froum, Klokkevold, et al. Implant-Related Complications and Failures. (CH 77). pp 723- Carranza’s Clinical Periodontology; Newman, Takei et al., 2012, 11th edition, Elsevier.

1. Jemt, T: Failures and complications in 391 consecutively inserted fixed prostheses supported by Branemard implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual check – up. Int J Oral Maxillofac Impls. 6:270-276, 1991

2. Berglundh, T et al: A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2002; 29 suppl 3:197-212

3. Devine M, Taylor S, Renton T. Chronic post-surgical pain following the placement of dental implants in the maxilla: A case series.Eur J Oral Implantol. 2016;9(2):179-86.

4. Esposito, M et al: Differential diagnosis and treatment strategies for biologic complications and failing oral implants: A review of the literature. Int J Oral Maxillofac Impls 14:473-490, 1999

5. Biglioli F, Chiapasco M. An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique. Clin Oral Implants Res. 2013 Sep 30. [Epub ahead of print]

6. Levine RA. Soft Tissue Augmentation Procedures for Mucogingival Defects in Esthetic Sites. Int J Oral Maxillofac Impls 29 (supplement) 155-185.

7. Tal, H: Spontaneous early exposure of submerged implants I Classification and clinical observations. J Periodotnol 7o: 213-219, 1999

8. Asshe, N et al: Correlation between early perforation of cover screws and marginal bone loss: A retrospective study: J Clini Periodontol 2007:35: 76-79

9. Kim A, Kar K, et al. Subapical osteotomy to correct dental implant malpositioning and vertical ridge deficiency: a clinical report. J Prosthet Dent. 2012 Oct;108(4):204-8.

10. McCrea SJ. Nasopalatine Duct Cyst, a delayed complication to successful dental implant placement: Diagnosis and surgical management. J Oral Implantol. 2012 Mar 12. [Epub ahead of print]

11. Givol N, Peleg O, et al. Inferior alveolar neurosensory deficiency associated with placement of dental implants. J Periodontol. 2013 Apr;84(4):495-501.

12. Walia MS, Arora S, Luthra R, Walia PK. Removal of fractured dental implant screw using a new technique: a case report. J Oral Implantol. 2012 Dec;38(6):747-50.

13. Boffano P1, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: a review of the literature of the last two decades. Dent Traumatol. 2013 Jun;29(3):185-96.

Implant Failures

1. Rosenberg E, Evian C, et al. Implant failure: prevalence, risk factors, management and prevention. (CH 6) pp 110-118. Dental Implant Complications: Etiology, Prevention, and Treatment. Froum, SJ. 2010. Wiley-Blackwell.

2. Li CH, Chou CT Bone sparing implant removal without trephine via internal separation of the titanium body with a carbide bur. Int J Oral Maxillofac Surg. 2014 Feb;43(2):248-50. Epub 2013 Oct 28.

3. Marini E, Cisterna V, Messina AM. The removal of a malpositioned implant in the anterior mandible using piezosurgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 May;115(5):e1-5.

4. Machtei EE. What do we do after an implant fails? A review of treatment alternatives for failed implants. Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):e111-9. doi: 10.11607/prd.1505.

5. Grossman, Y., Levin, L: Success and survival of single dental implants placed in sites of previously failed implants. J Periodontol 2007; 78:1670-1674

6. Machtei, E et al: Dental implants placed at previously failed sites: Survival rate and factors affecting the outcome. Clin Oral Implants Res 2008:19(3):259-64

7. Mardinger O, Oubaid S, et al. Factors affecting the decision to replace failed implants: a retrospective study. J Periodontol. 2008 Dec;79(12):2262-6.

8. Machtei EE, Horwitz J, Mahler D, Grossmann Y, Levin L. Third attempt to place implants in sites where previous surgeries have failed. J Clin Periodontol. 2011 Feb;38(2):195-8

9. Mardinger O, Ben Zvi Y, et al. A retrospective analysis of replacing dental implants in previously failed sites. Oral Surg Oral Med Oral Path Oral Radiol. 2012 Sep;114(3):290-3.

10. Vervaeke S, Collaert B, et al. A Multifactorial Analysis to Identify Predictors of Implant Failure and Peri-Implant Bone Loss. Clin Implant Dent Relat Res. 2013 Sep 4. doi: 10.1111/cid.12149.

11. Froum S, Yamanaka T, Cho SC, Kelly R, St James S, Elian N. Techniques to remove a failed integrated implant. Compend Contin Educ Dent. 2011 Sep;32(7):22-6, 28-30

12. Implant removal tools: Straumann (explantation tool), Nobel (implant retrieval tool) and Neobiotech (fixture removal kit)—please look up protocols and summarize include pictures if necessary

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IMPLANT COMPLICATIONS

Topic: Failures of fixed implant prostheses

Authors: Jemt, T

Title: Failures and complications in 391 consecutively inserted fixed prostheses supported by Branemark implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual check – up

Source: Int J Oral Maxillofac Impls. 6:270-276, 1991

Type: Retrospective study

Rating: Good

Keywords: Failure, complication, fixed prostheses, Branemark implants

P: The purpose of the present study was to identify problems and complications related to the prosthetic treatment and the first year of post insertion experience in a large number of edentulous patients provided with fixed prostheses supported by implants.
M&M: A total of 391 edentulous maxillae and mandibles was consecutively treated with routine fixed prostheses, supported by 2,199 implants. The patients were followed for 1 year

Treatment: The edentulous patients were provided with Branemark implants. The mucosa was allowed to heal approximately 10 to 14 days after the second surgical procedure before the final prosthetic treatment was started. Healing caps were delivered.

R: the overall success rate was 99.5% and 98.1% for the prostheses and implants, respectively. The number of severe complications was low, but it was possible to identify a significantly higher ratio of problems in the maxillae throughout the observation period than for the mandibles. While many problems occurred in both the maxillae and mandibles, there were also problems more typical for each jaw. Diction and fractures of resin teeth were more common problems in maxillae; cheek and lip biting was a more frequent post insertion complication in the treatment of mandibles. Most problems were easily resolved, and the retrievability of the prostheses was of great advantage.

C: Most of the problems have been observed in maxillae, but few of the problems have jeopardized the continuous stability of the fixed prostheses. Most problems were easy to resolve, and their relatively simple management was facilitated by the retrievability of the implant system.

Topic: Dental implant complications

Authors: Berglundh, T

Tittle: A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years.

Source: J Clin Periodontol. 2002; 29 suppl 3:197-212

Type: Systemic review

Rating: Good

Keywords: Complications, survical, success

Purpose: To systematically review the incidence of biological and technical complications in implant therapy reported in prospective longitudinal studies of at least 5 years.

Methods: A MEDLINE search was conducted for prospective longitudinal studies with follow-up periods of at least 5 years. Screening and data abstraction were performed independently by multiple reviewers. The types of complications assessed were as follows: implant loss, sensory disturbance, soft tissue complications, peri-implantitis, bone loss >or=2.5 mm, implant fracture and technical complications related to implant components and suprastructures.

Results: The search provided 1310 titles and abstracts, out of which 159 were selected for full-text analysis. Finally, 51 studies were included. Meta analysis of these studies indicated that implant loss prior to functional loading is to be expected to occur in about 2.5% of all implants placed in implant therapy including more than one implant and when routine procedures are used. Implant loss during function occurs in about 2-3% of implants supporting fixed reconstructions, while in overdenture therapy >5% of the implants can be expected to be lost during a 5-year period. Few studies (41% of those included) reported data on the incidence of persisting sensory disturbance >1 year following implant surgery. Most of the studies that provided such data reported on the absence or a low incidence (1-2%) of this complication beyond this interval. A higher incidence of soft tissue complications was reported for patients treated with implants supporting overdentures. There is limited information regarding the occurrence of peri-implantitis and implants exhibiting bone loss >or=2.5 mm. Implant fracture is a rare complication and occurs in <1% of all implants during a 5-year period. The incidence of technical complications related to implant components and suprastructures was higher in overdentures than in fixed reconstructions.

Conclusion: Implant loss was most frequently described (reported in about 100% of studies), while biological complications were considered in only 40-60% and technical complications in only 60-80% of the studies. This observation indicates that data on the incidence of biological and technical complications may be underestimated and should be interpreted with caution.

Topic: Chronic pain from dental implants

Authors: Devine M, Taylor S, Renton T.

Title: Chronic post-surgical pain following the placement of dental implants in the maxilla: A case series

Source: Eur J Oral Implantol. 2016;9(2):179-86.

Type: Case review

Rating: Fair

Keywords: chronic pain, dental implant, neuropathic pain, postoperative complications

Purpose: Present 10 cases of post-surgical neuropathic pain after placement of maxillary dental implants

Methods: Data collected from patients presenting to orofacial pain clinic, with neuropathic pain arising

after placement of maxillary dental implants

Results: 9/10 patients were female with avg age 55. Six patients had significant medical history including depression, peripheral neuropathic pain, irritable bowel syndrome, and fibromyalgia). Four of the patients had experienced pain during the implant placement. Nine of the patients had immediate pain post-surgery. Average pain on 1-10 scale was 5.6. Pain was constant in all patients. Potentially exacerbating factors were stress, tiredness, low mood, and cold weather. Two patients had implants removed but the pain persisted. Pain management varied and included medication (anti-epileptics and TCAs), botox, and cognitive behavioral therapy. Pain still remained in 9 of the patients despite therapy.

Conclusion: Chronic pain following dental implant placement may occur in patients with no apparent cause and without neurosensory deficits. Practitioners must be aware of chronic post-surgical neuropathic pain as a complication. Certain patients may be more susceptible to this based on medical history and should be considered whether they are suitable for implants. Patients reporting severe and prolonged postoperative pain following surgery should be considered high risk patients for post-surgical neuropathic pain and referred to a specialist in orofacial pain.

Topic: Implant Complications

Authors: Esposito, M et al

Title: Differential diagnosis and treatment strategies for biologic complications and failing oral implants: A review of the literature

Source: Int J Oral Maxillofac Impls 14:473-490, 1999

Type: Discussion

Rating: Good

Keywords: complication, dental implant, evidence-based treatment, failing implants, guided bone regeneration, infection, peri-implantitis, therapy

Purpose: The aim of this article was to review the literature on differential diagnosis and treatment of biologic complications and failing implants.

Method: All types of publications, with the exception of abstracts, published in English up to December 1998, were included. A multi-layered search strategy was used. Controlled clinical trials (CCTs) were searched in the Cochrane Oral Health Group’s Specialized Register of Trials. This database contains all CCTs identified in MEDLINE and EMBASE. PubMed was searched using various key words and the “related articles” feature. All identified publications were obtained and none were excluded.

Result: Infection, impaired healing, and overload are considered the major etiologic factors for the loss of oral implants. Only a few clinical and animal investigations were found that tested the validity of the proposed therapeutic approaches. The treatment of failing implants is still based mainly on empirical considerations, often derived from periodontal research, from data extrapolated from in vitro findings, or from anecdotal case reports performed on a trial-and-error basis.

Conclusion: The treatment strategy for complications and failing implants is influenced by the identification of the possible etiologic factors. In particular, the therapy of infected failing implants should be immediate, aggressive, and combined (prolonged systemic or local antibiotics and surgical debridement). Antibiotic administration alone is unlikely to be successful because of the difficulties in eradicating bacterial colonies from surfaces of biomaterials. If no improvement occurs, removal of the implant is indicated.

Topic: Iatrogenic complications

Authors: Biglioli F, Chiapasco M.

Title: An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique.

Source: Clin Oral Implants Res. 2013 Sep 30

Type: Discussion

Rating: Good

Keywords:lateral window, maxillary sinus, displaced implants

Purpose:To present the authors’ experience concerning the removal of dental implants displaced in the maxillary sinus via an intraoral approach consisting of the creation of a bony window pedicled to the maxillary sinus membrane.

Methods and Materials: Thirty-six systemically healthy patients, presenting with oral implants displaced into the maxillary sinus, but with no signs of acute or chronic sinusitis, were consecutively treated between 2002 and 2012 via an intraoral approach with the bony window technique.

Results:Removal of oral implants from the maxillary sinus was achieved in all patients, and postoperative recovery was uneventful in all of them. Computed tomographies performed after surgery showed no signs of residual sinus infection in all patients and a complete ossification of the bony window margins. Twelve of the 36 treated patients were treated with a sinus grafting procedure 12-18 months after in the same areas previously treated with the bone lid technique. Seventeen implants were placed in the grafted areas 6-9 months later and, after a further waiting period needed for osseointegration, the treated patients were rehabilitated with implant-supported prostheses. The survival rate of implants was 100%, and no complications related to the sinuses and implants were recorded.

Conclusion: Results from this study seem to demonstrate that the bony window technique is a safe and easy way to remove oral implants from the maxillary sinus under local anesthesia. The surgical access is hardly visible 6-12 months after surgery, and maxillary sinuses appeared free from residual pathology in all treated patients. Finally, this procedure allows a second-stage sinus grafting procedure via a lateral approach as in a previously untreated maxillary sinus, thus allowing an implant-supported prosthetic restoration.

Topic: Post Surgical Management

Authors: Levine RA.

Title: Soft Tissue Augmentation Procedures for Mucogingival Defects in Esthetic Sites.

Source: Int J Oral Maxillofac Impls 29 (supplement) 155-185.

Type: Systematic Review

Rating: Fair

Keywords: soft tissue deficiencies, maxillary anterior implants

P: This systematic review was performed to address the focus question: “In adult patients with soft tissue deficiencies around maxillary anterior implants, what is the effect on esthetic outcomes when a soft tissue procedure is performed?” In addition, this paper reviews the importance of presurgical esthetic risk assessment (ERA) starting with comprehensive team case planning prior to surgical intervention and a restorative-driven approach.

M&M: A thorough Medline database search performed on related MeSH terms yielded 1,532 titles and selected abstracts that were independently screened. Out of the 351 abstracts selected, 123 full-text articles were obtained for further evaluation. At each level, any disagreements were discussed until a consensus was reached.

R: 18 studies were included. A preliminary analysis of the included studies showed that the vast majority were case series studies with most not providing objective outcomes of their results. Moreover, only one randomized controlled trial was identified. Therefore, quantitative data analysis and subsequent meta-analysis could not be performed. The included studies were grouped according to the intervention on the peri-implant soft tissue performed and six groups were identified. The periodontal procedures performed around dental implants gave initial good results from the inflammation involved in wound healing, but in virtually all cases significant recession occurred as healing resolved and the tissues matured.

C: Although success of implant therapy is similar in the anterior maxilla and other areas of the mouth, the majority of studies evaluating this therapy in the esthetic zone are lacking literature support, few in number, devoid of long-term follow-up and number of patients, and are subject to inclusion bias. The use of the ERA tool for all esthetic zone cases can benefit both the clinician and the patient to avoid any miscommunication and problems of expectation upon completion. All the available knowledge on this topic, including the approaches described in this paper, is based on a very limited literature support and thus should be addressed with caution. These concerns should encourage long-term good clinical trials for better assessment of those issues.

Topic: spontaneous early exposure

Authors: Tal H,

Title:Spontaneous early exposure of submerged implants: I. Classification and clinical observations.

Source: J Periodontol. 1999 Feb;70(2):213-9. DOI:10.1902/jop.1999.70.2.213

Type: case series

Rating: good

Keywords: Dental implants; classification; infection; prevention and control; osseointegration.

Background: It is believed that complete mucosal coverage and isolation of the implant from the oral cavity avoids trauma and infection and establishes favorable conditions for osseointegration.

Purpose:Toclinically classify spontaneous early exposure and to describe and analyze this complication.

Methods:a group of 148 patients treated with 372 submerged implants: 216 in the mandible and 156 in the maxilla. Edentulous sites were exposed by mid-crestal incisions and full thickness gingival flaps. Implants’ shoulder leveled with the bone crest. Incisions were closed in an attempt to achieve complete closure and healing by primary intention. Measurements were taken to avoid mechanical trauma to the mucosa over the implants. Patients were followed up weekly and examined to identify early exposures. At Perforations were classified according to the degree of exposure from 0 (no perforations) to 4 (complete exposure). At 8-10 weeks post-op, implants were exposed with a biopsy punch.

Results:Of the implants, 51 (13.7%) presented spontaneous early exposure, 28 (13%) in the mandible

and 23 (14.7%) in the maxilla. Class 2 perforation was the most frequent, followed by Class 3, Class 1 and Class 4. nine implants (17.6%) were associated with loose cover screws (P value <0.01). Inflammation at the mucosal orifices of the perforations was minimal, but no objective index (bleeding, probing) was taken in order to avoid morphological changes of the lesions that were biopsied for histological examination.

Conclusion: spontaneous early exposure can be due to:

• Failure of the mucosal incision to heal by primary intention due to tension in the flaps.

• Acute mechanical trauma or continuous pressure

• Loosening of the cover screw

• Bone debris from the osteotomy

Early perforation and partial exposure of the implant’s covering device are a focus for plaque accumulation which, if left untreated, may result in inflammation, damage to the peri-implant mucosa, and possible peri-implant loss.

Topic: Cover screws

Author: Asshe N, et al.

Title: Correlation between early perforation of cover screws and marginal bone loss: A retrospective study

Source: J Clini Periodontol 2007:35: 76-79

Type: Retrospective study

Rating: Good

Keywords: bone loss; cover screw; exposure; implant; perforation

Purpose: The purpose of this retrospective study was to determine the consequence of early screw exposure on peri-implant marginal bone level.

Methods: 60 Astra Tech MicroThread implants were placed in 34 patients with partially edentulous jaws. 20 implants were placed following a two-stag procedure and were unintentionally exposed to the oral cavity (two-stage exposed), 20 implants were placed following a two-stage procedure and were surgically exposed after a subgingival healing time of 3-6 months (two-stage submerged), and 20 implants were placed following a one-stage surgical protocol (one-stage). Digital radiographs were taken at time of implant placement for all implants, and after abutment surgery (for two staged groups) and at 3 months for the one-stage group. Bone loss was measured on the mesial and distal of implants with an on-screen cursor.

Results: The mean bone re-modelling around each protocol was recorded

Group	Mean bone re-modeling (range)
Two-stage submerged	0.01mm (0.0-0.3 mm)
Two-stage exposed	1.96 mm (0.2-3.2 mm)
One stage	0.14mm (0.0-1.2mm)

This amount of bone loss was significantly higher in the two-stage exposed group compared with the other two groups.

Discussion: This study indicates that when soft tissue integrity isn’t maintained during the healing of two stage implants, there will be significantly more bone loss. Bone loss after unintentionally exposed implants in the oral cavity could be explained by a bacterial infection that arises almost instantly.

Conclusion: The unintentional perforation of two-stage implants resulted in significant bone destruction.

Topic: implant repositioning

Authors: Kim A, Kar K, Noxzari H, Kang-Min A, Cha H

Title: Subapical osteotomy to correct dental implant malpositioning and vertical ridge deficiency: a clinical report

Source: J Prosthet Dent. 2012 Oct;108(4):204-8

Type: Case report

Rating: Good

Keywords: osteotomy, reposition, implants, malpositioning

Purpose: The technique of subapical osteotomy involves separating the teeth containing bone segment and repositioning it. This report describes using this technique to simultaneously correct a vertical ridge deficiency and reposition the implants with a segmental down fracture.

Method: A patient presented with definitive implant prosthesis with gingiva-colored porcelain to mask a vertical ridge deficiency of approximately 7 mm. The patient was not pleased with the esthetics due to a high smile line. Subapical osteotomy was performed under general anesthesia. A mucosal vestibular incision was made approximately 5-8 mm apical to the MGJ. Subapical osteotomy was performed with small carbide round burs and microsaws. The bone segment containing the implants was down fractured with chisels. Bone block graft was used for stabilization.

Results: Healing was uneventful. Implants were successfully repositioned and remained stable for 3 years.

Conclusion:Subapical osteotomy is a viable treatment option than can be considered for select patients requiring correction of implant position.

Topic: Nasopalatine Duct
Authors: Shane Josef McCrea
Title: Nasopalatine Duct Cyst, a Delayed Complication to Successful Dental Implant Placement: Diagnosis and Surgical Management
Source: Clin Implant Dent Relat Res. 2013 Apr 22. doi: 10.1111/cid.12074.
Type: Case Report
Rating: Good

Keywords:implantology, nasopalatine duct cyst, symphyseal graft

Purpose: To report a case history of the late manifestation of a nasopalatine duct cyst (NPDC) in close proximity to a dental implant and its subsequent surgical management.

Method:62-year old white man presented to private practice for implants on asymptomatic fractured teeth #4 and #5. However, he had successful rehabilitation of tooth #9 with dental implants three years ago. The clinical exam revealed a grey-blue soft/fluctuant translucent mucosal 1 cm swelling on the palatal aspect of the implant. The mass was depressible without bony resistance. Also, a fluctuant swelling was noted at tooth #8.

Conclusion:The presence of the nasopalatine cyst remains a chance finding due to its largely asymptomatic nature. Its unchecked expansion will result in destruction of the palatal and/or buccal cortical walls and sometimes even the nasal floor. The presence of dental implants in the direction of expansion will certainly endanger those implants. The annual review of dental implants in the anterior maxilla (4^th to 6^th decade of age) must be strongly reinforced to allow the early diagnosis of the NPDC and its ease of excision.

Topic: Implant Complications –paresthesia

Authors: Givol N, Peleg O, Yarom N, Blinder D, Lazarovici T

Title:Inferior alveolar neurosensory deficiency associated with placement of dental implants

Source: Journal of Periodontology, 2013.84: 495-501.

Type: Case Series

Rating: Good

Keywords:Chin, dental implants, legal liability, mandibular nerve, trigeminal neuropathy.

Background:This study reports and analyzes a large series of patients with neurosensory deficiency related to the placement of dental implants (Dis) resulting in liability claims (LCs) in an Israeli population.

Materials and methods:

From 1998 to 2009 a total of 92 LCs associated with persistent altered sensation following placement of DIs was reported to Medical Consultants International Company (MCI). The data were analyzed according to patient demographics, year of LC report to MCI, source of report (patient, practitioner or legal representative), interval between the operation that resulted in a neurosensory deficiency and reporting MCI, qualifications of the practitioner, preoperative imaging modality, DI placement site, DI length, whether DI ws placed immediately after tooth extraction or after the socket had healed, treatment administered after neurosensory deficiency was detected.

Results: Study cohort consisted of 92 patients who fulfilled inclusion criteria of permanent damage to inferior alveolar nerve due to placement of dental implants (58 LCs submitted by females). There were 21 cases during first 5 years of the study and 63 cases over the following 5 years. Most LCs involved procedures that were planes according to radiographs and computes tomography. 65% of LCs was performed by general dental practitioners, and 35% by specialists. More than one DI was performed during surgery that resulted in a neurosensory deficiency in 73 LCs (79.3%) and the DI was greater than 10mm in 55 (59.8%) cases.

Conclusion: Liability claims for DIs that result in a neurosensory deficiency pose a legal risk t the practitioner long after the injury has occurred.

Topic:Post surgical management, screw loosening, prosthetic complications               Fractured Dental Implant Screw

Authors: Manpreet S. Walia, Saryu Arora, Reena Luthra, Prabhjot Kaur Walia

Title: Removal of Fractured Dental Implant Screw Using a New Technique: A Case Report

Source:Journal of Oral Implantology. 2012;38(6):747-750.

Type:clinical case report

Rating:low level evidence; Potentially high clinical value

Keywords:dental implant, screw loosening, osseointegration

Background: Many methods have been reported for retrieving screw fragments within the implant. Two common approaches are the use of a self-made screwdriver or the use of a service set available for the specific implant system. If the fragment is not jammed, an attempt to unscrew it using an explorer or a straight probe might be successful. The tip of the instrument is moved carefully in a counterclockwise direction over the surface of the screw segment until it loosens.

An implant repair kit (ITI Dental Implant System, Institut Straumann, Waldenburg, Switzerland) is also available and consists of drills, 2 drill guides, and 6 manual tapping instruments. One drill is 1.6 mm in diameter and is used counterclockwise at a speed of at least 600 rpm, together with the respective drill guide. Once the fragment has been perforated, the 6 manual tapping instruments are used successively with the second drill guide in a clockwise direction to remove the retained fragment and to section the threads. This procedure will not unscrew the fractured fragment. It will cut it into splinters while cutting the threads at the same time, leading to the misfit of the new abutment screw. The method is complex for routine application and involves the risk of damaging the internal threads of the implant. The use of the repair system may not be successful in different situations.

Screwing out the fragment is a better method as it will leave the implant threads intact. It is essential not only to retrieve the fractured screw but also to determine the reason for failure and to modify the prosthesis if necessary.

Purpose: procedure used for removal of the fractured screw portion is described.

Materials and Methods: One clinical case presented of single implant crown in molar region. Previously Been in function for 6 years. Presented with chipped porcelain, and marginal bone loss. Access hole was made through occlusal of crown; it and abutment were removed leaving the screw fragment in the screw access of the fixture. Explorer tip and US tip in CCW direction were unsuccessfully attempted. Screw was notched notched, off-center, taking care not to damage the screw channel threads. US tip on low power placed in notch and rotated in CCW direction until removed.

Results: screw successfully removed

Conclusions: Screw loosening and fracture can happen for a number of reasons and is one of the most common reported implant complications. Several screw removal systems are available but are expensive, have many components, are complex for routine application, and can damage screw channel threads impeding use of another abutment. A simpler method for screw fragment retrieval is presented. Morse taper systems (Ankylos) eliminate the need for screws for retention.

Critique: we did this and it worked level evidence. But is a good trick to have in our belts. Dr. Aljohani successfully removed a fractured screw using this technique 11/3/16. His results confirm those found by these authors.

IMPLANT FAILURES

Topic: Mandibular Fractures

Authors: Boffano P1, Roccia F, Gallesio C, Berrone S.

Title: Pathological mandibular fractures: a review of the literature of the last two decades.

Source: Dent Traumatol. 2013 Jun;29(3):185-96.

Type: Review

Rating: Good

Keywords: Mandibular fractures, pathology

Intro: Pathological mandibular fractures are rare, accounting for fewer than 2% of all fractures of the mandible. They could be defined as fractures that occur in regions where bone has been weakened by an underlying pathological process. Treatment of pathological can be challenging, and it should differ according to presented etiology;

Mandibular fractures following tooth removal

• A rare event with a reported incidence between 0.0034% and 0.0075%

• Several risk factors can be associated with this type of pathological fracture, such as age (over 40 years of age), gender, types of impaction, existing infection or bony lesions, surgical technique, and patient’s compliance (in particular, chewing of hard foods after extraction).

• 71% of postoperative pathological occurred during chewing. A soft diet should be recommended for 4 weeks postoperatively, especially in patients with full dentition

Mandibular fractures following implant placement

• This rare event is most likely to occur in severely resorbed mandibles with an anterior mandibular bone lower than 12 mm, when the ratio between implant length and the distance to the occlusal plane is compromised, resulting in unfavorable biomechanics

• Marginal bone loss around a dental implant may be an area of stress concentration and weakness, thus representing a predisposing factor for a fracture in the atrophic mandible too

• it should be remembered that both the use of wide-diameter implants and bicortical penetration may jeopardize the integrity of severely atrophic mandibles, as inadequate remaining bone volume after placement of implants may increase stress concentration from functional loading

Mandibular fractures associated with benign cystic pathology

• Very rarely reported

• Different benign cystic lesions were involved in pathological mandibular fractures, such as aneurismal bone cysts, follicular cysts, residual cysts, radicular cysts, and odontogenic keratocysts

Mandibular fractures associated with a malignant pathology/benign tumors

• The treatment of pathological mandibular fractures associated with malignant or benign neoplasms has to be directed toward the disease process that must be considered the first priority

• Pathological fractures are more frequently associated with metastatic tumors or primary oral squamous cell carcinoma

• The aim of the treatment is the maintenance of oral function and pain control to maintain quality of life

• Primary radical surgery (with segmental resection of the mandible and selective or radical neck dissection) is the gold standard treatment if the tumor is resectable.

• For secondary metastatis, treatment depends on the tumor type and patient’s general condition: frequently radiation therapy or chemotherapy is administered as palliation

Mandibular fractures associated with osteomyelitis

• Osteomyelitis of the mandible may develop if a primary infection is not eliminated by proper treatment or if concurrent immunodeficiencies are present.

• The first step of treatment is antibiotic therapy, a minimum of 6 weeks of intravenous therapy is recommended.

• Treatment of the fracture should depend on how much viable bone is present following sequestrectomy or resection, on a case-by case-basis

Mandibular fractures associated with ORN and BRONJ

• Often are elderly and they may frequently present comorbidities or swallowing and nutritional problems because of previous surgery and/or radiotherapy

• First of all, surgeons should deal with the patient’s systemic problems, ruling out recurrent cancer and nutritional issues before managing the fracture.

• In such patients, the aim of the treatment is to restore the function of the mandible, allowing food processing, swallowing and speech production, and if possible to restore the appearance of the lower face

Topic: Implant removal

Authors: Li CH, Chou CT

Title: Bone sparing implant removal without trephine via internal separation of the titanium body with a carbide bur.

Source: Int J Oral Maxillofac Surg. 2014 Feb;43(2):248-50. Epub 2013 Oct 28.

Type: Case study

Rating: Fair

Keywords: osseointegrated, implant removal, immediate replacement

Purpose: To describe a novel technique to remove osseointegrated implants without enlarging the bony socket and immediately replacing it with an implant of the same size.

Methods: A 42 year old healthy male patient with a betel nut chewing habit and a heavy bruxer had to have an osseointegrated implant removed after being loaded for 13 months. Bone covering the implant shoulder was removed using a diamond coated fissure bur creating a 2-3 mm gap in depth around implant shoulder. A carbide surgical round bur was used to perforate both buccal and lingual titanium walls to split the implant into two. Cutting was relatively easy on the hollow 2/3 of the implant however the apical third was solid and vibrations made it difficult to section. Next and was wedged into the distal space created and forced away from the socket wall. Forceps were then used to flex and fatigue the metal until the section separated and was removed. The elevator was then used on the other side of the socket and was removed with forceps. This took approximately 45 min. The osteotomy was reangulated in order to place a straight abutment and the same size implant was placed with good stability and healing was uneventful.

Results: Six months later, at second stage, new bone was found to have grown over the shoulder and a restoration was placed. Good bone stability was observed for 12 months.

Conclusion: Compared to the socket before drilling, the size was almost unchanged after implant removal with this new technique. The surrounding bone was not significantly compromised and a larger implant as not necessary for immediate replacement.

Topic: Implant Failures

Authors: Marini E, Cisterna V, Messina AM

Title: The removal of a malpositioned implant in the anterior mandible using piezosurgery.

Source: Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 May;115(5):e1-5

Type: Case Report

Rating: Good

Keywords:

Purpose: To report the removal by means of piezosurgery of a malpositioned osseointegrated implant that had previously caused a sublingual hematoma during its insertion.

Method: 85-year-old woman with a significant medical history for cerebral ischemia presented at the office of her dentist for placement of dental implants in the anterior region of the mandible. Four 1-piece implants were placed with ball attachments to attach to removable prosthesis. 5 hours after the implant surgery, the patient’s tongue began to swell, protrude, and become elevated. The patient began to have difficulty in swallowing and breathing, so she called her dentist and was then referred to a nearby local hospital. The upper-airway obstruction was caused by the development of a delayed hematoma within the floor of the mouth. Oral intubation was performed, and prophylactic antibiotics and steroids were administered. The swelling began to steadily resolve during the next 4 days and the patient was discharged from the hospital 1 week after implant surgery.

3-months later the patient presented for implant removal. The radiological study included a panoramic X-ray and computed tomography (CT) to assess the position of the 4 implants and their relationship to neighboring structures. A circumferential osteotomy was performed with piezosurgery. The insert was use working at the bone-implant interface so as to break it down by means of the ultrasonic waves. After removal of the implant, attention was focused on hemostasis, the residual perforation was sealed with fibrin glue, then the site was reconstructed using hydroxyapatite plus fibrin glue. The flap was closed using a 4-0 polyester suture with an interrupted suturing technique. Patient was given antibiotics and pain meds.

Result: Clinical evaluation was carried out 2 days, 7 days, 4 weeks, and 12 weeks after implant removal to assess complications at the surgical site, hematoma formation, and the integration and resorption of the graft. The postoperative course was uneventful, no bleeding, infection, or hematoma formation was noted and the patient reported 100% resolution of all symptoms.

Conclusion: Recommend CT or cone-beam examination to visualize the mandibular lingual foramina before the implant removal; furthermore, piezosurgery may reduce the risk of postsurgical life-threatening complications.

Topic: Implant Failures

Authors: Machtei EE.

Title: What do we do after an implant fails? A review of treatment alternatives for failed implants.

Source: Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):e111-9. doi: 10.11607/prd.1505.

Type: Discussion

Rating: Good

Keywords:alternative treatment, implant failure, treatment planning

Purpose: The purpose of this paper is to explore treatment alternatives for failed implants and their strengths and shortcomings.

Methods and Materials: A comprehensive literature search was performed using PubMed and a manual search. Only five studies were identified that explored treatment in sites where implants had failed. In all five studies, the treatment alternative tested was the placement of a new implant in the failed site.

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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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