Implant 5 – Treatment Planning I
Basic overview of anatomy
Medical History: systemic conditions + drugs that may affect implant and surgical outcome;
Risk factors: Smoking, Age, Periodontal disease, Parafunction
Rapid Search Terms
- Medical Overview
- Osteoporosis and/or Bisphosphonates
- Radiation Therapy
- Other Disorders involving Bone
- Other medications
- Periodontal disease
- Age at Placement (growth)
- Age at placement (outcome)
Medical History: medical conditions + drugs that may affect implant and surgical outcome; Risk factors
- Misch and Resnik. Medical Evaluation of the Dental Implant Patient (CH 20). pp 406-420. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.
- Rose L and Mealey B. Implant complications associated with systemic disorders and medications. (CH 2) pp 9-45.
- Neiva RF, Gapski R, et al. Morphometric analysis of implant related anatomy in Caucasian skulls. J Periodontol 2004; 75(8): 1061-1067
- Du Tolt DF, Nortje C. The maxillae: integrated and applied anatomy relevant to dentistry. SADJ 2003; 58(8):325-330.
- 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.
- Chrcanovic BR, Custódio AL. Anatomical variation in the position of the greater palatine foramen. J Oral Sci. 2010 Mar;52(1):109-13.
- Galluci GO et al. Influence of the Posterior Mandible Ridge Morphology on Virtual Implant Planning. Int J Oral Maxillafac Implants 2017 Jul/Aug; 32(4): 801-806
- Urban IA, et al. Mandibular Regional Anatomical Landmarks and Clinical Implications for Ridge Augmentation. Int J Periodontics Restorative Dent. 2017 May/Jun;37(3):347-353.
- 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.
- 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
- Mardinger O et al: Lingual perimandibular vessels associated with life – threatening bleeding. An anatomic study. Int J Oral Maxillofac Implants 2007; 22:127-131
- Nilsun B et al. Cone-Beam Computed Tomography Evaluation of the Submandibular Fossa in a group of dental implant patients. Implant Dent 2019 Aug;28(4):329-339.
- Carr AB, Revuru VS, Lohse CM. Association of Systemic Conditions with Dental Implant Failures in 6,384 Patients During a 31-Year Follow-up Period. Int J Oral Maxillofac Implants. 2017 Sept/Oct;32(5):1153-1161
- Clementi M et al. Systemic risk factors for peri-implant bone loss: a systematic review and meta-analysis. Int J Oral Maxillofac Surgery. 2014; 43:323-334.
- Sugerman, P., Barber, M.: Patient selection for endossous dental implants; Oral and systemic considerations. Int J Oral Maxillofac Implants. 2002 Mar-Apr; 17(2):191-201
- Klokkevold P, Han T: How do smoking, diabetes and periodontits affect outcomes of implant treatment? Int J Oral Maxillofac Implants. 2007; 22 (suppl)173-202
- Strietzel FP, Reichart PA, et al. Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis. J Clin Periodontol. 2007 Jun;34(6):523-44. Review.
- Moraschini V, Barboza ED. Success of dental implants in smokers and non-smokers: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2015 Sep 15.
- Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and dental implants: A systematic review and meta-analysis. J Dent. 2015 May;43(5):487-498
- Bain CA, et al. Implant installation in the smoking patient. Periodontol 2000. 2003;33:185-93.
- Nobre Mde A, Maló P, Gonçalves Y, Sabas A, Salvado F. Outcome of dental implants in diabetic patients with and without cardiovascular disease: A 5-year post-loading retrospective study. Eur J Oral Implantol. 2016 Spring;9(1):87-95.
- Naujokat H, Kunzendorf B, Wiltfang J. Dental Implants and diabetes mellitus-a systematic review. Int J Implant Dent. 2016 Dec;2(1):5
- Monje A, Catena A, Borngakke WS. Association between diabetes mellitus/hyperglycemia and peri-implant disease: systematic review and meta-analysis. J Clin Periodontol. 2017 Jun;44(6):636648.
Osteoporosis and/or Bisphosphonates
- Holahan, C et al: Effect of osteoporotic status on the survival of titanium dental implants. Int J Oral Maxillofac Implants. 2008:Sep-Oct; 23(5)905-10
- Temmerman A, et al. A Prospective, Controlled, Multicenter Study to Evaluate the Clinical Outcome of Implant Treatment in Women with Osteoporosis/Osteopenia: 5 year results. J Dent Res. 2019 Jan;98(1):84-90.
- Kwon TG et al. Osteonecrosis associated with dental implants in patients undergoing bisphosphonate treatment. Clin Oral Implants Res. 2014 May;25(5):632-640
- Stavropoulos A, et al. The effect of antiresorptive drugs on implant therapy: systematic review and meta-analysis. Clin Oral Implants Res. 2018 Oct;29 suppl 18:54-92.
- Colella, Cannavale, Pentenero, Gandolfo: Oral implants in radiated patients: A systematic review. Int J Orla Maxillofac Implants 2007; 22(4):616-623
- Claudy MP, Miguens SA Jr, et al Time Interval after Radiotherapy and Dental Implant Failure: Systematic Review of Observational Studies and Meta-Analysis. Clin Implant Dent Relat Res. 2013 Jun 7. [Epub ahead of print]
Other disorders involving bone or soft tissue
- Gerlach RC et al. Case presentation of florid cemento-osseous dysplasia with concomitant cemento-ossifying fibroma discovered during implant explantation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Mar;115(3): e44-52
- Friberg B. Brånemark System Implants and Rare Disorders: A Report of Six Cases. Int J Perio Rest Dent 2013; (33):139-48.
- Strietzel FP, et al. Implants in patients with oral manifestations of autoimmune of mucocutaneous diseases-a systematic review. Med Oral Patol Cir Bucal 2019 Mar 1;24(2):e217-30.
- Madrid C, Sanz M. What influence do anticoagulants have on oral implant therapy? A systemic review. Clin Oral Impl Res (Suppl 4) 2009; 10: 96-106.
- Broekema FI, et al. Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants. Br J Oral Maxillofac Implants 2014; 52:e15-e19.
- Gomez-Morena G, et al. Dental implant surgery in patients in treatment with the anticoagulant oral rivaroxaban. Clin Oral Imp Res. 2016; 27:730-733
- Chrcanovic BR et al. Intake of Proton Pump Inhibitors is Associated with an Increased Risk of Dental Implant Failure. Int J Oral Maxillofac Implants 2017 Sept/Oct;32(5): 1097-1102.
- Chrcanovic BR et al. Is the intake of selective serotonin reuptake inhibitors associated with an increased risk of dental implant failure? Int J Oral Maxillofac Surg. 2017 June;46(6):782-788
- Chappius V, et al. Medication-related dental implant failure: systematic review and meta-analysis. Clin Oral Implants Res. 2018 Oct;29 Suppl 16:55-68.
- Radzewski R, Osmola K. Osseointegration of Dental Implants in organ transplant patients undergoing chronic immunosuppressive therapy. Implant Dent. 2019 Jul 12 epub ahead of print
- Wen X, et al. History of periodontitis as a risk factor for long-term survival of dental implants: a meta-analysis. Int J Oral Maxillofac Implants. 2014 Nov-Dec;29(6):1271-80.
- Zagrando MS et al. Long-term evaluation of periodontal parameters and implant outcomes in periodontally compromised patients: a systematic review. J Periodontol. 2015 Feb;86(2):201-21.
- Swierkot K et al. Mucositis, peri-implantitis, implant success, and survival of implants in patients with treated generalized aggressive periodontitis:3- to 16-year results of a prospective long-term cohort study. J Periodontol 2012 Oct;83(10):1213-25.
- Kim KK, Sung HM. Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: a systematic review. J Adv Prosthodont. 2012 Nov;4(4):210-7.
- Monje A et al. Generalized aggressive periodontitis as a risk factor for dental implant failure: a systematic review and meta-analysis. J Periodontol. 2014 Oct;85(10):1398-1407.
- RasperiniG, Siciliano VI, et al. Crestal bone changes at teeth and implants in periodontally healthy and periodontally compromised patients. A 10-year comparative case-series study. J Periodontol. 2013 Nov 11. [Epub ahead of print]
- Chitumalla R, et al. Assessment of Survival Rate of Dental Implants in patients with bruxism: a 5 year retrospective study. Contemp Clin Dent. 2018 Sept;9(suppl 2):S278-S282.
- Chrcanovic BR, Albrektsson T, Wennerberg A. Bruxism and Dental Implants: A Meta-Analysis. Implant Dent. 2015 Oct;24(5):505-16
- Merin RL. Repair of peri-implant bone loss after occlusal adjustment: a case report. J Am Dent Assoc. 2014 Oct;145(10):1058-62
Age at Placement (growth)
- Cronin RJ Jr, Oesterle LJ. Implant use in growing patients. Treatment planning concerns. Dent Clin North Am 1998;42(1):1-34.
- Mankani N et al. Osseointegrated dental implants in growing children: a literature review. J Oral Implantol 2014. Oct;40(5):627-31.
- Heijl D eta al: Facial development, continuous tooth eruption and mesial drift as compromisisng factors for implant placement. Int J Ora Maxillofac Implants. 2006 Nov-Dec; 21(6)867-78
- Fudalej P., Kokich V., Leroux B: Determing the cessation of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants. Am J Orthod Dentofacial Orthop. 2007 Apr; 131 (4 Suppl):S59-67
- Oesterle LJ, Cronin RJ Jr. Adult growth, aging, and the single-tooth implant. Int J Oral Maxillofac Implants 2000;15(2):252-260.
- Schwartz-Arad D, Bichacho N. Effect of Age on Single Implant Submersion Rate in the Central Maxillary Incisor Region: A Long-Term Retrospective Study. Clin Implant Dent Relat Res. 2015 Jun;17(3):509-514.
Age at placement (outcome)
- Chvartszaid D, et al. Thematic Abstract Review: Implants and the Spectrum of Aging. Int J Oral Maxillofac Implants 2017 Sep/Oct;32(5):965-968
- Hoeksema AR, Visser A, Raghoebar GM, Vissink A, Meijer HJ. Influence of Age on Clinical Performance of Mandibular Two-Implant Overdentures: A 10-Year Prospective Comparative Study. Clin Implant Dent Relat Res. 2016 Aug;18(4):745-51.
- Becker W, Hujoel P, Becker BE, Wohrle P. Dental Implants in an Aged Population: Evaluation of Periodontal Health, Bone Loss, Implant Survival, and Quality of Life. Clin Implant Dent Relat Res. 2015 Jun 17.
- Schimmel M, et al. Effect of advanced age and/or systemic medical conditions on dental implant survival: a systematic review and meta-analysis. Clin Oral Implants Res. 2018 Oct;29 suppl 16:311330.
Topic: Anatomy implant related anatomy in skulls
Title: Morphometric analysis of implant related anatomy in Caucasian skulls.
Source: J Periodontol 2004; 75(8): 1061-1067
Type: Morphometric analysis study
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.
- Morphometric analyses were performed in 22 Caucasian skulls.
- Measurements of themental 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 theinferior alveolar nerve (IAN) was determined, and the mesial extent of the loop was measured.
- 2 onlay block grafts, 3 mm apaty, were harvested from the symphysis area respecting the 5x5x5 rule described by Hund (from MF, from apeces of the teeth and from the cortex of the mandible).
- Additional measurements includedheight (G-H), width (G-W), thickness (G-T), and volume (G-V) of monocortical onlay grafts harvested from the mandibular symphysis area. Thickness determined by immediate drop to the marrow space.
- Thickness of the lateral wall (T-LW) of the maxillary sinus was also measured.
- Theindependent 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.
- Themost common location of the MF in relation to teeth was found to be below the apices of mandibular premolars.
- Themean MF-H was 3.47 mm
- Themean MF-W was 3.59 mm
- Themean distance from the MF to other anatomical landmarks were:
- MF-CEJ = 15.52 mm
- MF to themost apical portion of thelower cortex of the mandible = 12.0 mm
- MF to themidline = 27.61 mm
- MF-MF = 55.23 mm.
- A high prevalence of AL was found (88%); symmetric occurrence was a common finding (76.2%), with a mean length of 4.13 mm.
“the MF is most commonly located apically between ﬁrst and second premolars, followed by apical to the mandibular second premolar.”
Important to remember the numbers quoted are just the means. Look at the incidence of the anterior loop. At 88% you must assume that it is likely there so you must account for it in your case workup. Pano films may provide a hint, but your best tool is obviously the cbct scan. “variation of the length of the mesial extension of these loops, ranging from 1.2 mm to 6.95 mm”
- Themean size of symphyseal grafts was:
- G-H = 9.45 mm
- G-W = 14.5 mm
- G-T = 6.15 mm, with an average G-V of 857.55 mm3 (range: 352 to 1,200 mm3).
- Themean Thickness-Lateral wall of the maxillary sinus was 0.91 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.
Topic: Anatomy applied anatomy
Tittle: The maxillae: integrated and applied anatomy relevant to dentistry.
Source: SADJ 2003; 58(8):325-330.
Type: Discussion article
Keywords: maxillae, anatomy, sinus, nerves
Purpose: To address applied anatomy of the maxilla relevant to the practice of dentistry and maxilla-facial surgery.
- 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 1st and 2nd 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:
- Pyraminal shape.
- Lateral wall: infratemporal wall of the maxilla
- Medial wall: Inferior part of the lateral wall of the nasal cavity
- Roof: Floor of the orbit
- Floor: narrow bony plate over premolars and molars.
- Most often sinuses are of equal and symmetrical size.
This is a great little review article from a trade journal. Pay particular to the tables, especially # 3 which highlights most of the possible pathologies of the maxillary sinus.
Also, one thing it did not review that you may remember from head and neck anatomy is The danger triangle of the face consists of the area from the anterior maxialla to the bridge of the nose, including the nose and maxilla. Infections may retrograde due to the venous communication (via the ophthalmic veins) between the facial vein and the cavernous sinus. Therefore it is possible, albeit unlikely, for retrograde infection from thisl area to spread to the brain, causing cavernous sinus thrombosis, meningitis or brain abscess.
Title: A morphometric analysis of supraorbital and infraorbital foramina relative to surgical landmarks
Source: Surg Radiol Anat. 2011 May;33(4):329-35.
Type: Cadaver skull study
Keywords: Human facial skeleton, morphometric measurements, reference points, supraorbital foramen, infraorbital foramen
Purpose: To analyze the degree of variability in the location of the supraorbital foramen (SOF) and infraorbital foramen (IOF) in cadaveric dry skulls relative to the frequently encountered surgical landmarks and according to gender and side.
Methods: 80 dry skulls (Brazil) were studied and gender determined using anatomical landmarks. Measurements were done bilaterally with a stainless-steel metric digital caliper with 0.01 mm precision. Measurements were made relative to readily identifiable skeletal landmarks and statistically analyzed.
Results: 54 female and 26 male skulls were analyzed. Measurements were statistically significantly higher in males. The IOF was on the sagittal plane passing through the SOF in 52.50% of the cases, lateral to the plane in 28.75%, and medial in 18.75%. While the SOF was not present in all specimens, IOF was found in all crania. Single IOF was seen in all cases. Significant differences were noted in the right and left side in some measurements as well.
Discussion: The best site for local anesthetic block for the infraorbital nerve would be 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 SON/F in the same vertical line. Distances may be longer in males than females.
Title: Anatomical variation in the position of the greater palatine foramen
Source: J Oral Sci. 2010 52(1):109-13
Type: cadaver study
Keywords: cadaver study, dry human skulls, anatomy, greater palatine foramen, maxilla
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:
- Location of the foramen in relation to maxillary molar teeth
- Perpendicular distance from the medial border of GPF to the midline maxillary suture (MMS)
- Distance from the posterior wall of GPF to the post border of the hard palate (PBHP)
- Direction of opening of the foramen onto the palate
- Distance from ant wall of GPF to post border of incisive foramen
- Angle between the MSS and line from the incisive foramen and the GPF
- The palatine length
|Location of the foramen in relation to max teeth||54.87% GPFs were opposite 3rd molar
38.94% GPFs were distal to 3rd molar
(about 94% above 3rd M or distal)
-6.19% GPFs were between 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 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 distance was 52.40 + 4.63mm
Conclusion: This study presents valuable clinical information in regard 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. Using a combination of the above measurements, the location of the GPF can be plotted with accuracy.
Title: Influence of the Posterior Mandible Ridge Morphology on Virtual Implant Planning
Source: Int J Oral Maxillafac Implants 2017 Jul/Aug; 32(4): 801-806
Purpose: To examine the anatomy of the mandibular posterior region to develop an anatomical categorization for implant-prosthodontic planning.
Materials and methods:
- 313 consecutive CBCT scans of patients with at least one missing posterior mandibular tooth.
- Posterior edentulous sites were categorized as
- Group A: consisted of a posterior edentulous space delimited by a mesial tooth only
- Group B: consisted of a posterior edentulous space delimited by a mesial and a distal tooth.
- When no posterior teeth were present, the mental foramen was used as the reference point to delimit the anterior boundary.
- Virtual implant planning was per- formed, and the need for bone grafting was assessed. Generic implants, 4.1 mm in diameter and 8 mm in length, were virtually planned in the edentulous sites.
- After the implants were virtually planned, the need for and extent of bone grafting procedures (horizontal and/or vertical) was assessed and used to categorize the level of complexity of planning implants in the positions selected. Sites were classified as follows:
- Straightforward: no horizontal or vertical bone augmentation needed
- Advanced: there was a need for up to 2mm of horizontal or vertical bone augmentation.
- Complex: The selected implant sizes could not be placed, even with 2mm horizontal/vertical bone augmentation.
Based on visual observation of the cross sectional mandibular ridge morphology, five well-defined configurations emerged:
- Straight: the basal bone and alveolar process were perpendicular to the occlusal plane, and no lingual concavity was observed (53.6%)
- Oblique: the alveolar process was lingually angled with respect to the basal bone and the occlusal plane. There may have been a slight buccal concavity present. 26.2%
- S-shape: the alveolar process and the basal bone depicted an S-shape. There was a marked lingual concavity, and the alveolar process was lingually inclined with respect to the occlusal plane. 7.4%
- Hourglass: there was a constriction between the alveolar process and the basal bone resulting from a buccal and a lingual concavity. 1.9%
- Basal Bone: only basal bone was present. 10.8%
When the distribution of cross-sectional ridge shape was assessed by the characteristics of the edentulous space, a homogeneous distribution was observed be- tween group A and B (edentulous space) for the straight, oblique, s-shape, and hourglass configurations, whereas in the basal bone morphology group. Group A edentulous spaces predominated.
There was a statistically significant association between the ridge shape and the feasibility of placing an implant with or without simultaneous horizontal and/ or vertical bone grafting and the inability to place an implant. When the need for bone grafting at the implant planning phase was correlated with the ridge morphology, the straight and oblique ridge shapes were more likely to be associated with a favorable anatomy for implant placement.
Conclusion: The ridge shape significantly influenced the ease or difficulty of placing an implant. The s-shape, hourglass, and basal bone posterior mandibular cross-sectional shapes were associated with a higher degree of difficulty. Due to the challenges posed by the more difficult jaw shapes, 3D imaging is highly desirable for implant planning in the posterior mandible to identify these shapes as part of treatment planning
Title: Mandibular Regional Anatomical Landmarks and Clinical Implications for Ridge Augmentation.
Source: Int J Periodontics Restorative Dent. 2017 May/Jun;37(3):347-353.
Keywords: anatomical landmarks; anatomy; ridge augmentation
Purpose : to describe anatomical features of the posterior mandibular region necessary to safely perform regenerative procedures in the atrophic mandibular ridges.
Methods: 10 cadaver heads with intact soft tissue were used. 5 of the specimens were irrigated with saline and perfused with Thiel solution followed by red-colored Creato Latexmilch and immersed in Thiel solution for 1 year. The other 5 specimens were fixed in 10% neutral formalin solution.
- Musculature of Floor of the Mouth and the Tongue
- Mylohyoid creates diaphrahmaoris (diaphragm of the mouth). Originates inner surface of mandible running oblique and inserts into body of hyoid bone. Most superior at molar region and deepens at first premolar. Functions in swallowing and mouth opening.
- Movement of tongue muscles: genioglossus, hyoglossus, styloglossus, and palatoglossus.
- Digastric muscle anterior and posterior belly held to hyoid bone. The posterior belly originates from the mastoid notch of temporal bone and anterior belly from digastric notch at mandibular symphysis. Function in mouth opening and lowering of mandible as well as elevating hyoid bone.
- Digastric muscle and body of mandible form submandibular triangle.
- Vascular supply
- Severe bleeding and hematoma have been reported related to implant surgery. Branches of external carotid artery provide arterial supply mainly the lingual and facial arteries (2nd and 3rd branches).
- Lingual artery: usually arises superior to hyoid bone then runs anteriorly between hyoglossus and middle pharyngeal constrictor being anterior to genioglossus. Runs superiorly branching into hyoid and dorsal lingual arteries. Branches anteriorly and becomes the deep lingual artery and sublingual artery. Sublingual artery runs between mylohyoid and genioglossus; provides branches to sublingual gland, muscles, and gingiva.
- Facial artery: runs anteriorly superiorly medial to digastric and stylohyoideus muscles. Branches into submental artery before reaches mandible which anastomoses with sublingual artery. Then, facial artery curves up to face in front of masseter muscle.
- 63% sublingual artery supplying sublingual space.
- 6% sublingual artery did not exist and sublingual space supplied by branch of submental artery
- 6% sublingual and submental artery anastomoses supplying together the floor of the mouth
- 8% sublingual and deep lingual artery are missing from lingual artery and FOM. Tongue supplied by submental artery from facial artery
- Innervation: major nerves to be aware of lingual and hypoglossal.
- Lingual: branch of mandibular nerve V3. starts after mandibular nerve exits foramen ovale of skull running down between medial and lateral pterygoids until reaches ramus of mandible. Distances of 9.6, 13, and 14.8mm at 2nd molar, 1st molar, and 2nd premolar from lingual artery. Innervates anterior ⅔ of tongue. The chorda tympani (branch of facial nerve) connects to lingual nerve and is responsible for taste sensation anterior ⅔ tongue and salivary production of sublingual and submandibular glands.
- Hypoglossal nerve CN XII responsible for motor function of tongue. Exits skull and runs between the internal carotid and internal jugular vein. Breaks into terminal branches when reaches hyoglossus muscle.
- Salivary glands
- Submandibular protrudes into lateral lingual groove. Excretory duct is submandibular duct AKA Wharton duct and opens into sublingual caruncle
- Sublingual gland located anterior to lateral lingual groove and is covered by oral mucosa directly. Anterior lobe opens with major sublingual duct of Bartholin into Wharton duct.
- Connective Tissue
- Dense CT surrounded anatomical landmarks such as lingual nerve, sublingual artery, sublingual gland and Wharton duct. Collagen fibers dominate in this dense CT
- Common surgical complications:
- Hemorrhage, nerve damage, accidental injury to neighboring anatomical structures. Proximity of nerves and blood vessels in mandible, the area must be thoroughly understood and explored presurgically. Knowing vascularity to the inner aspect of mandible is supplied by facial artery and its branch, the submental artery, and the lingual artery and its branch, the sublingual artery are critical as penetrating the mandibular lingual plate may induce excessive hemorrhage. Most common presentation is the artery running medial to sublingual gland 92% and 45% of cases the artery lies further from lingual plate.
- Clinical implications:
Use of dull instrument for blunt dissection when reflecting lingual flaps. In the anterior region reflection should not go beyond genial foramina to prevent hemorrhagic/neurosensory alteration.
Discussion: Understanding of and knowledge about key anatomical landmarks of mandibular region is imperative to safely perform ridge augmentation when releasing the lingual flap.
Dr. Urban is a world renowned master in the area of ridge augmentation. He has devised methods that he teaches for vertical ridge augmentation. He has authored a very good book on this subject. Some of the cases he presents show 8 to 10 mm of vertically augmented bone. To achieve this, his method relies on very serious flap relaxation where the dissection to mobilize tissue to close the flaps without tension goes way farther than the immediate surgical field. It is for this reason he makes everyone aware in this article, just how important accurate knowledge of anatomy is.
Topic: Bone morphology
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: Radiographic study
Keywords: bone grafting, bone morphology, implant surgery, radiographic evaluation, surgical complications, surgical planning
To evaluate a large series of available CT images of mandibles from patients in need of oral implants in order to describe morphological variations in the mental interforaminal region.
210 spiral CT scans from consecutive patients requiring implant supported rehabilitation in the lower jaw were evaluated. Patients consisted of 135 females and 75 males, aged 18-80. The numbers of fully edentulous, partially edentulous, and fully dentate patients were 3, 186, and 21, respectively. The CT scans protocol included 39 axial slices of 1mm in thickness. The CT scans and panoramic images were used to examine the mandibles and divided into 3 morphological categories: type I, with a lingual concavity, type II, with a nearly constant width but a clear lingual slope, and type III, with bone widening in the caudal direction. Cross-sectional reformatted images mesial to the mental foramina were used to measure parameters such as height, width, angulation of jaw bone, and arch size. In addition to the descriptive statistics, the possibility of an effect of gen- der or age on the occurrence of mandibular jaw bone morphology was investigated using the chi-square test
- Type I: 2.4% of the jaws, with a lingual concavity depth of 6 ± 2.6mm and remaining bone height of 4.2 – 11.9mm
- Type II: 28.1% of the jaws, with a mean lingual inclination of 67.6 ± 6.5°, and a constant width of >8.8mm
- Type III: 69.5% of the jaws
- No gender or age influence was found on the morphologic parameters. T
- The mean distance between the two mental foramina was 43.2mm for Type I, 46.9mm for Type II, and 46.9mm for Type III.
Discussion: A lingual concavity or severe lingual inclination in mandibles present increased risks for lingual perforation and fenestration during trepanation surgery, graft harvesting, or implant insertion, especially when wider implants under specific conditions (parallel to each other and in between the mental foramina) are necessary. The authors recommended reflecting the mucoperiosteum at the lingual side up to the mandibular base during the surgery. In order to prevent postsurgical complications, additional radiographs and cross-sectional radiography should be considered instead of panoramic radiograph alone.
Topic: Anatomy, Hemorrhaging
Title: Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature
Source: J Perio. 2004 May;75(5):631-45
Type: Review/Case Report
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
1) review all available published case reports recording massive bleeding incidents following implant positioning in the anterior segments of the mandible.
2) To bring attention to 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.
- Lingual artery arises at hyoid bone level, comes anteriorly, then disappears near the posterior of the hyoglossus muscle and continues antero-superiorly to enter the tongue.
- Lingual artery gives rise to sublingual artery at anterior border of hyoglossus muscle
- Facial artery arises below posterior belly of digastric muscle and enters submandibular triangle while coursing anteroinferiorly to lower border of mandible
- Submental artery is a branch of facial artery and courses along inferior surface pf mylohyoid muscle with mylohyoid nerve
- in 53% of cadavers sublingual artery was small or absent and a larger submental artery was seen in 60% of those cadavers
- Many common accessory anterior lingual mandibular foramina patterns
– most common one is located at midline and superior to genial tubercle (frequency 85-99%)
-diameter of foramen .54mm
-distance to alveolar border averages 10-13.7mm
- Residual ridge reduction is normally a horizontal, predictable pattern
-resorption pattern + protruding mental tubercle results in lingually angulated anterior mandible
- 11 reference/case reports with a total of 12 patients with severe hemorrhage during or after implant placement in the anterior mandible
-Mean average of patients was 60 years; 2:1 female to male ratio
-34 endosseous implants were placed in 7 completely and 3 partially edentulous mandible
-majority of hemorrhaging occurred in mandibular canine site and >15mm implant length
-most were a consequence of arterial trauma during implant placement
-airways were maintained in patients through intubation or tracheostomy before
hemorrhages were controlled
- expanding lingual, sublingual, submandibular, and submental hematomas have the tendency of displacing the tongue and floor of the mouth to obstruct the airway
- extensive hemorrhage can occur immediately or with some delay
- constriction and retraction of the transected artery along with the vasoconstriction effect of epinephrine via anesthetic may help cease bleeding
- airway loss is manifested by tachypnea, dyspnea, employment of accessory muscles of respiration, stridor, stertor, cyanosis, decreased phonation, etc
- hemorrhage may be controlled by: tamponage, hemostatic agent, cauterization, digital compression
- To reduce the probability, measures must be taken before, during, and after implant placement in the anterior mandible
-medical history is important: aspirin, warfarin, heparin, coumadin all affect
- If swelling occurs:
-compression both extra and intraorally (apply at perforation and posterior if injury is at the facial artery, put pressure over antegonial notch -when tongue is pulled out, lingual artery is compressed -be prepared to insert flexible nasal airway.
Conclusion: Surgeons must be aware of possible medical emergencies when placing mandibular anterior implants. 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 all important.
Topic: Implant Anatomy
Title: Lingual Perimandibular Vessels Associated with Life-Threatening Bleeding: An anatomic study
Source: Int J Oral Maxillofac Implants 2007; 22:127-131
Type: Anatomic Study
Keywords: dental implants, lingual perimandibular vessels, sublingual artery, submental artery
Purpose: Characterize anatomy of lingual perimandibular vessels with special focus to the distance to the bone.
Methods: 12 human cadavers, equal gender distribution 58-86 years. Mandible was sectioned at canine, mental foramen and second molar areas including buccal perimandibular soft tissue, submandibular floor of mouth, tongue, and mandibular bone. The type of vessel, diameter, relation with mylohyoid muscle, distance from lingual plate and alveolar crest were recorded. Each mandible was classified following system by Lekholm and Zarb.
Results: 6 of 12 mandibles were edentulous, 3 were Type A, 2 Type B, 2 Type C. Five ridges considered combination of A, B and C. The diameter of the selected vessels had a mean of 1.5mm. Submental vessels were seen in all premolar and molar areas where vessels were identified.
|# mandible with identifiable vessels||12/12||10/12||9/12|
|Arteries and Veins||5||2||5|
|Alveolar Crest to Vessels (mm)|
|Lingual Plate to Vessels (mm)|
|Vessels in Relation to Mylohyoid|
Discussion: Sublingual and submental arteries run above and below the mylohyoid respectively before anastomosing, both giving rise to a variety of vessels in the floor of mouth near the lingual plate of the mandible. When the mandible atrophies, the ridge deteriorates at an angle causing a vertical drill position to approximate the lingual plate. Due to the narrow range of space between the cortical plate and vessels, even a small perforation can cause a vascular injury.
Topic: CBCT and submandibular fossa
Title: Cone-Beam Computed Tomography Evaluation of the Submandibular Fossa in a group of dental implant patients
Source: Implant Dent 2019 Aug;28(4):329-339.
Type: retrospective study
Background: In the posterior mandibular region, the location of the mandibular canal and the submandibular fossa are the most important anatomical structures to be avoided during surgery to prevent any damage to the inferior alveolar nerve and the submental and sublingual arteries.
The submandibular fossa is a depression on the medial surface of the mandible inferior that extends to the mylohyoid line and contains the submandibular gland.
Purpose: retrospective study is to evaluate submandibular fossa anatomy in the posterior mandible using CBCT scans of patients on a group of dental implant patients.
- 132 preimplant CBCT examinations
- only those who had a history of at least 5+ years after extraction and minimum 5 years after the removable of partial dentures were included in this study
- patients defined by Kennedy classification
- The deepest concavity at the submandibular fossa was in all the 1st and 2nd molars for all
Kennedy Class groups-class I group showed a depth between 2.90 and 3.12 mm, class II showed 1.63- to 2.08-mm depth, class III group showed 1.84- to 2.30-mm depth, class IV showed 1.64- to 1.85-mm depth
- concavity depth was statistically higher in class I group for 1st and 2nd molars than the other
Kennedy Class groups-class IV group showed less depth than the other groups
- SSD found among the Kennedy Class groups in terms of the distance of the concavities to the alveolar bone, alveolar crest, and root apex
- in the class II group, a significant difference was found between the left and right sides (dentate and edentulous sites)
- male patients show larger distances than the female patients for all measurements with a significant difference from the others
- patients older than 35 years showed SS higher measurements than the patients younger than 35 years
- results show that class I patients, which indicated patients who were edentulous on both sides, had the maximum concavity depth and higher measurements than the other types
- in class II patients, whose one site is edentulous and the other is dentate, a significant difference was found between the left and right sides
- male patients’ dimensions are greater than those of the female patients
- patients older than 35 years showed higher measurements than the patients younger than 35 years
- a significantly reduced bone was observed in the molar region when compared with the premolar region horizontally in class I and class II patients.
Topic: Medical Overview
Title Association of Systemic Conditions with Dental Implant Failures in 6,384 Patients During a 31-Year Follow-up Period.
Source: Int J Oral Maxillofac Implants. 2017 Sept/Oct;32(5):1153-1161
Type: Retrospective Cohort Study
Keywords: association, implant failure, patient-based, systemic condition, systemic disease
Purpose: identify associations between implant failure and system conditions or disease in a consecutive series of patients who received dental implants from October1, 1983, to December 31, 2014, in the Department of Dental Specialties at Mayo Clinic in Rochester, Minnesota.
Methods: Data were imported from a prospective clinical database and electronic health records for patients’ demographic, implant-specific, and medical profiles to deterimine time to first implant failure. Survival free of implant failure at the patient level was estimated using the Kaplan-Meier method. Association of demographic and systemic characteristics with impant failure were evaluated by using Cox proportional hazards regression models and summarized with hazard ratios and 95% confidence intervals.
Results: The study consisted of 6,358 patients with a median age of 53 years at placement of the first implant. A total of 713 patients experienced implant failure at a median of 0.6 years. Among the 5,645 patients who did not experience implant failure, the median duration of follow-up was 5.8 years. 21 systemic conditions or systemic diseases were identified for assessment and 50% of the population had neither and served as a robust control. However, only 15 comprised more than 50 patients and 5 comprised more than 500 patients. The results had been adjusted for age, sex, and era of implant due to the influence of such factors on failure. The study main result is that no systemic disease or condition shown to increase the risk for implant failure in the population and settings studied.
Discussion: The study had adjustments for the risk models that would include variables affecting implant survival. This adjustment prevents assignment of risk due to confounding and may explain differences in risk estimates compared with those in other publications. However, after adjustment only the presence of coronary artery disease at the first implant was significantly associated with implant failure, and the association favored implant survival.
Conclusion: The study provides practice-based estimates for implant-failure risk that are related to the demographic, systemic disease or condition profiles of patients. The main finding was that no systemic disease or condition increased the risk of implant failure.
Topic: Medical Overview
Title: Systemic risk factors for peri-implant bone loss: a systematic review and meta-analysis.
Source: Int J Oral Maxillofac Surgery. 2014; 43:323-334.
Type: Systematic Review
Keywords: bone loss; dental implants; meta-analysis; risk factors; smoking; systemic diseases
- The aim of this study was to determine the influence of patient-related systemic risk factors (systemic disease, genetic traits, chronic drug or alcohol consumption, and smoking status) on peri-implant bone loss at least 1 year after implant installation and prosthetic loading.
- An electronic search was performed of MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials up to January 2012. One thousand seven hundred and sixty-three studies were identified. After applying a three-stage screening process, 17 articles were included in the qualitative analysis, but only 13 in the quantitative analysis, since smoking was a common exposure.
- A total of 1883 patients and 5730 implants were analyzed.
- Cigarette and tobacco smoking were the most prevalent exposures (identified as single factors in 11 studies). The others were osteoporosis, IL-1 gene polymorphisms, diabetes, endocrine diseases, cardiac diseases, and arthritis, and Sjogren’s syndrome.
- Radiographic bone loss was evaluated by means of intraoral apical X- rays in 11 studies, panoramic X- rays in four studies, and both methods were used in two studies.
- Only a few studies reported soft tissue outcomes (bleeding on probing, plaque index, gingival recession, and width of keratinized tissues
- No study reported data for peri-implant gingival recession or width of keratinized tissues.
- The meta-analysis of these 13 studies (478 smokers and 1207 non-smokers) revealed a high level of heterogeneity and that smoking increases the annual rate of bone loss by 0.164 mm/year.
- Exposure to smoking had a harmful effect on peri-implant bone loss. However, the level of evidence for oral implant therapy in patients with systemic conditions is very low. Future studies should be improved in order to provide more robust data for clinical application.
Title:Patient selection for endossous dental implants; Oral and systemic considerations.
Source:J Oral Maxillofac Implants. 2002 Mar-Apr; 17(2):191-201
Keywords:patient selection, endossous dental implant, oral, systemic consideration
Purpose:The aims of this article were to define “reasonable health” for dental implant treatment and to provide a systematic approach to the selection of dental implant patients.
TITANIUM TOXICOLOGY The survival or success of endosseous dental implants may be influenced by a number of local and systemic conditions. Some of these conditions affect the process of osseointegration directly. The following are noted in particular.
- PHYSICAL STATUS
- The American Society for Anesthesiology (ASA) has defined a 6-point scale of physical status
- Younger patients may show greater crestal bone resorption around dental implants.It is therefore recommended that implant placement be delayed until growth and development have ceased or are minimal
- However, implant failure does not correlate with age or sex. Increasing age has no effect on osseointegration or the rate of crestal bone resorption around dental implants.
- PATIENT EXPECTATION
- Although dental implants can enhance esthetics, phonetics, and bite force, it is important to identify unrealistic expectationsthat patients may have about implants and implant- retained prostheses.
- HYPOHIDROTIC ECTODERMAL DYSPLASIA is characterized by hypodontia, hypotrichosis, and hypohidrosis. Dental implants have been used successfully in patients with severe hypodontia associated with ectodermal dysplasia.In a recent prospective study, implant placement and prosthetic rehabilitation in young children with ectodermal dysplasia did not restrict transverse or sagittal growth. However, vertical alveolar growth resulted in the occasional submergence of endosseous implants, necessitating revision and the placement of longer abutments.
- SMOKING:Many studies have shown that smoking interferes with osseointegrationand accelerates bone resorption around dental implants
- OSTEOPOROSIS:osteoporosis appears not to influence implant survival.Moreover,endosseous dental implants may actually stimulate mandibular bone formation in a load-dependent manner.
- DIABETES MELLITUS: endosseous dental implants are usually successful in patients with diabetes, although uncontrolled diabetes contraindicates dental implant placement. Consideration should be given to antibiotic prophylaxis for surgical procedures in diabetic patients.
- SCLERODERMA:little is known about dental implants in patients with scleroderma.Endosseous dental implants may improve prosthesis function and comfort in scleroderma patients, although access for implant surgery and for oral hygiene may be compromised.
- SJÖGREN SYNDROME: Implant-supported prostheses were shown to considerably increase prosthetic comfort and function in patients with Sjögren syndrome,preferable to soft tissue-supported prostheses.
- MULTIPLE MYELOMA: Implant success has been reported in a patient with multiple myeloma.Unmanaged malignant disease in general must be considered a contraindication for the placement of endosseous dental implants.
- PARKINSON’S DISEASE: Implant- supported prostheses should be considered in patients with Parkinson’s diseaseand other diseases affecting orofacial motor function.
- BONE MARROW TRANSPLANTATION: Implant placement should be delayeduntil cytotoxic chemotherapy has ended and the mar- row graft has taken. Bone marrow transplant patients may develop oral graft-versus-host disease that is clinically similar to oral lichen planus
- HIV: endosseous dental implants have been placed successfully in HIV-positive patients
- SYSTEMIC DRUGS: Consultation with the patient’s physicianprior to dental implant placement is desirable for patients on anticoagulants or long-term systemic corticosteroids.
- CHRONICALLY INFECTED IMPLANT SITES: Periodontitis and periapical lesions should be diagnosed and treated prior to dental implant placement.
- ORAL LICHEN PLANUS Endosseous dental implants may be used in patients with nonerosive forms of OLP, although patients should be warned of possible lesion exacerbation related to surgery and possible implant failure if gingival lesions become erosive
- HEAD AND NECK RADIOTHERAPY: Implant placement following head and neck radiotherapy is associated with a significant risk of osteoradionecrosis, especially with irradiation above 50 Gy. Recommended a 6- to 12-month recovery period after irradiation prior to dental implant placement
Presurgical hyperbaric oxygen may reduce the dental implant failure rate in irradiated jawbone from 60% to 5%
- TARDIVE DYSKINESIAS Tardive dyskinesia may complicate dental implant therapy.Alternatives to endosseous dental implants should be considered for patients with neurologic disorders including orofacial dyskinesia, trigeminal neuralgia, or orofacial dysesthesia.
Topic:Risk factors for implants
Title:How do smoking, diabetes and periodontits affect outcomes of implant treatment?
Source:Int J Oral Maxillofac Implants. 2007; 22 (suppl)173-202
Keywords:dental implants, dental implant survival, diabetes, periodontitis, smoking, tobacco
Purpose: To evaluate the available literature to assess whether smoking, diabetes, and periodontitis have an adverse effect on the outcomes of implants placed in patients with these conditions.
Method: The dental literature was searched using the MEDLINE, Cochrane Collaboration, and EMBASE databases. Using specific inclusion and exclusion criteria, 2 reviewers evaluated titles, abstracts, and full articles to identify articles relevant to this review. All searches were conducted for articles published through May 2005. Data from included articles for each of the risk factor groups, smoking, diabetes, and periodontitis, were abstracted and analyzed.
Results: A detailed search of the literature and evaluation of relevant articles identified 35 articles for inclusion in this systematic review. Nineteen articles were identified for smoking, 4 articles were identified for diabetes, and 13 articles were identified for periodontitis. One article met the criteria for both smoking and periodontitis. Implant survival and success rates were reported for smokers versus nonsmokers; diabetic patients versus nondiabetic patients; and patients with a history of treated periodontitis versus patients with no history of periodontitis. The findings revealed statistically significant differences in survival and success rates for smokers (better for nonsmokers), with greater differences observed when the data were analyzed according to bone quality (less for loose trabecular bone). No difference in implant survival rate was found between patients with and without diabetes. Likewise, no difference in implant survival rates was found between patients with a history of treated periodontitis compared to patients with no history of periodontitis.
Conclusion: The results of this systematic review of the literature demonstrated that smoking has an adverse effect on implant survival and success. The effect of smoking on implant survival appeared to be more pronounced in areas of loose trabecular bone. Type 2 diabetes may have an adverse effect on implant survival rates, but the limited number of studies included in this review do not permit a definitive conclusion. A history of treated periodontitis does not appear to adversely affect implant survival rates but it may have a negative influence on implant success rates, particularly over longer periods.
Topic:smoking and implant
Title: Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis.
Source:J Clin Periodontol. 2007 Jun;34(6):523-44. Review.
Type: Retrospective Study
Keywords:dental implants; meta-analysis;odds ratio; smoking; success rate; survival rate
P: To investigate if smoking interferes with the prognosis of implants with and without accompanying augmentation procedures compared with non-smokers.
A systematic electronic and handsearch (1989 and 2005; English and German language; search terms “dental or oral implants and smoking”; “dental or oral implants and tobacco”) was performed to identify publications providing numbers of failed implants, related to the numbers of smokers and non-smokers for meta-analysis. Publications providing statistically examined data of implant failures or biologic complications among smokers compared with non-smokers were included for systematic review.
R: Of 139 publications identified, 29 were considered for meta-analysis and 35 for systematic review. Meta-analysis revealed a significantly enhanced risk for implant failure among smokers [implant-related odds ratio (OR) 2.25, confidence interval (CI(95%)) 1.96-2.59; patient-related OR 2.64; CI(95%) 1.70-4.09] compared with non-smokers, and for smokers receiving implants with accompanying augmentation procedures (OR 3.61; CI(95%) 2.26-5.77, implant related). The systematic review indicated significantly enhanced risks of biologic complications among smokers. Five studies revealed no significant impact of smoking on prognosis of implants with particle-blasted, acid-etched or anodic oxidized surfaces.
C: Smoking is a significant risk factor for dental implant therapy and augmentation procedures accompanying implantations.
Topic: Patient Factors ( smoking)
Title: Success of dental implants in smokers and non-smokers: a systematic review and meta- analysis Source: Int. J. Oral Maxillofac. Surg. 2016; 45: 205–215
Type: Systematic Review
Keywords: dental implants; smoking; tobacco; implant survival; marginal bone loss; meta- analysis.
Purpose: Thepurposeofthisreviewwastotestthenullhypothesisofnodifferencein marginal bone loss and implant failure rates between smokers and non-smokers with respect to the follow-up period.
Methods An extensive electronic search was performed in PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials to identify relevant articles published up to February 2015. The eligibility criteria included randomized and non-randomized clinical studies. After an exhaustive selection process, 15 articles were included. The meta-analysis was expressed in terms of the odds ratio (OR) or standardized mean difference (SMD) with a confidence interval (CI) of 95%.
Results: There was a statistically significant difference in marginal bone loss favouring the non-smoking group (SMD 0.49, 95% CI 0.07– 0.90; P = 0.02). Independent analysis revealed an increase in marginal bone loss in the maxilla of smokers, compared to the mandible (SMD 0.40, 95% CI 0.24–0.55; P < 0.00001). A statistically significant difference in implant failure in favour of the non-smoking group was also observed (OR 1.96, 95% CI 1.68–2.30; P < 0.00001). However, the subgroup analysis for follow-up time revealed no significant increase in implant failure proportional to the increase in follow-up time (P = 0.26).
Discussion: This review attempted to identify studies comparing the marginal bone loss and rate of implant failure between smokers and non-smokers.
Tobacco smoking is an accepted potenttial risk factor for oral health. Several clinical studies have shown that the sur- vival of implants can be affected by to- bacco usage. However, the quantity and frequency of cigarettes consumed (or packs per year) can be a key factor in determining the predictability of the implants.
Conclusion- a statistically significant difference in marginal bone loss was found between the smoking group and the non-smoking group, in favour of the non-smoking group (SMD 0.49, 95% CI 0.07–0.90; P = 0.02).
Topic: Smoking and dental implants
Title: Smoking and dental implants: A systematic review and meta-analysis
Source: Elsevier Journal of Dentistry
Type: Systematic review and Meta analysis
Keywords: Dental implants, smoking, systematic review, meta-analysis, implant failure rate, postoperative infection, marginal bone loss.
Purpose:To test the null hypothesis of no difference in the implant failure rates, postoperative infection, and MBL for smokers or non-smokers, against the alternative hypothesis of a difference.
Methods:For this review, patients smoking minimum of one cigarette per day were classified as smokers. Definitions:Implant failure = complete loss of the implant. Exclusion: Case reports, technical reports, biomechanical studies, finite element analysis, animal studies, in vitro and review papers.
Results: Search resulted in 1432, after duplicates and paper that met exclusion a total of 107 publications were included in the review. 4 Randomized Clinical trials, 16 prospective studies, 71 retrospective analyses.
From 104 studies comparing implant failure rates: A total of 19,836 implants were placed in smokers, with 1,259 failures (6.35%), 60,464 implants were placed in non-smokers, with 1923 failures (3.18%)., 44 studies informed there was a statistically significant difference between failure rates amd 17 did not find statistically significant difference.
- The insertion of dental implants in smokers statistically affected the implant failure rates; implying that it is 2.23 (123%) times more likely to fail.
- Statistically affected incidence of postoperative infections (RR=2.01) and marginal bone loss.
After a sensitivity analysis was performed:
- When placed in the maxilla statistically affects implant failure rates
- When placed in the mandible, no statistically difference.
- Significant difference when using turned implants with sandblasted and acid etch surfaces.
- The study suggests that insertion of implants in smokers affects failure rates, risk of postoperative infection and marginal bone loss, mainly because the effect of smoking in osteogenesis and angiogenesis.
- Nicotine inhibits gene expression of several enzymes that regulate osteoblast proliferation, differentiation and, apoptosis; which affects bone formation and remodeling.
- Nicotine has local and systemic effects on blood vessels, producing vasoconstriction, resulting in decreased blood perfusion and causing ischemia.
- There is evidence to suggest that smoking may have dose-related effect on osseointegration, however, few studies reported quantity of cigarettes and reported the number of years smoking.
- A 60 month follow-up success rate for non smokers was 82.7% and for smokers was 65.3%.
Conclusion: Results should be interpreted with caution due to the presence of uncontrolled factors. Present study suggest that smoking affect implant failure rates, post-operative infection.
Topic:smoking and implant
Title:Implant installation in the smoking patient.
Source:Periodontol 2000. 2003;33:185-93.
Keywords:implant, failure, smoking,
Purpose:to review the association between smoking and implant failure; potential mechanisms, and benefits of smoking cessation.
- Effects of smoking on general health:smoking has been shown to affect health in many ways such as; cancers especially lung cancer, chronic lung disease, myocardial infarctions, strokes and ischemic heart disease. Research show that 50% of smokers die from a smoking related disease, and life expectancy of smokers is reduced by 7.5 years. Smoking also has been shown to have an adverse effect on bone density.
- Effects of smoking on wound healing: smoking is a complicating factor in post-surgical wound healing. Smokers show less reduction in PD after SRP, poorer healing after mucogingival surgeries, less favorable healing following OFD, greater loss of bone height, reduction in post-ext socket fill and more painful ext socket. Smoking compromises healing of duodenal ulcers. Also, in a study about healing after orthopedic surgery, it was shown than there are more delayed union or non-unions in smokers.
- Influence of smoking on the actions of polymorphonuclear leukocyte, macrophages, circulation and blood flow:Several studies have shown that smoking causes reduced phagocytosis, delayed margination and diapedesis as well as compromised aggregation and adhesion of leukocytes to the endothelium in venules and arteries. Peripheral endothelial dysfunction, vessel wall injury and capillary loss is common in smokers, also reactive hyperemia and sequestration of blood cells in the microcirculation. Coronary flow reserve is also decreases after smoking high-nicotine cigarettes.
- Smoking and implant failure:
- Smoking and particularly heavy smoking increases the failure rates for machined titanium implants, likely due to a compromise of the blood supply in bone during early healing
- This increased failure rate clusters largely in the maxilla, with much smaller differences between smokers and non-smokers for implant in the mandible.
- Smoking is associated with a particularly high failure rate for implants placed into grafted maxillary sinuses.Some operators may consider this to be too great a risk to take, if the patient is unable or unwilling to stop smoking.
- What happens if the potential implant patient stops smoking:Smoking cessation has been demonstrated to improve success rates in machined implant patients. In fact, implant placement may well be an effective motivator in assisting a smoker with cessation.
- Bone density, smoking and implant success: There appears to be a relationship between heavy smoking and reduced bone density. This is seen in various areas of medicine, as well as in implant surgery and might explain high failure rates in Type 4 bone
- Do different materials and surfaces make a difference:There is early evidence that rough surface implants, prepared with a double acid etched technique, have a high success rate in smokers. With success rates around 10% better overall (98.7% vs. 88.7%) and 15% better in the maxilla (97.3% vs. 82.1%) than our original results with machined Branemark implants in smokers, these are at present considered to be the implant of choice in smokers who cannot or will not stop smoking for implant placement.
Topic: implants and diabetics and CVD
Title: Outcome of dental implants in diabetic patients with and without cardiovascular disease: a 5-year post-loading retrospective study.
Source: Eur J Oral Implantol. 2016; 9(1): 87-95
Type: Retrospective clinical study
Keywords: dental implant, diabetes, cardiovascular disease, risk factor, marginal bone loss
Purpose: To look at the outcomes of immediately loaded implants in diabetic patients with or without coexisting cardiovascular disease at 5 years.
Methods: Retrospective study of private practice patients in Portugal. 70 patients with diabetes who were treated between 1999-2007 were included. Patients were divided into 2 groups:
- Diabetes and coexisting CVD
- Diabetes without coexisting CVD
Clinical and radiographic examinations were done to plan the implants. Standard surgical procedures were followed to place NobelSpeedy implants. Sites were underprepared to achieve insertion torque of 30Ncm. For single teeth, final abutments were placed the day of surgery and temporary screw retained crowns were delivered into immediate function. Full arch patients received full-arch acrylic resin prosthesis at the day of surgery. Typically, final restorations were delivered after 6 months. Follow-ups were performed at 10days, 2, 4, and 6months after surgery and every 6 months thereafter. Radiographs were taken in order to measure MBL at baseline, first year and fifth year.
Results: 70 diabetic patients (38 with CVD and 32 without CVD) were included in the study. The groups included some smokers, bruxers and those with history of periodontitis.
- Diabetics with CVD: received 183 dental implants
- Diabetics without CVD: received 169 dental implants
Cumulative Prosthesis and implant survival rates:
- Diabetics with CVD:
- Prosthesis survival: 100%
- Implant survival: 8%
- Diabetics without CVD
- Prosthesis survival: 97.4%
- Implant Survival: 86.7%
Marginal Bone Loss and Complications: Average MBL at 1 and 5 years was 0.88mm and 1.56mm respectively. NSSD was seen between groups.
1) Diabetics with CVD:
- MBL 1 year: 0.95mm
- MBL 5 years: 1.52mm 2) Diabetics without CVD:
- MBL 1 year: 0.78mm
- MBL 5 years: 1.54mm
Complications occurred in 38 patients. 7 patients experienced biologic complications being primarily periimplant pathology and were treated either non-surgically or surgically. Mechanical complications occurred in 33 patients and included temporary prosthesis fracture, definitive prosthesis fracture, and prosthesis loosening. No significant differences were seen with complications between groups.
Discussion: The authors concluded that NSSD were found between diabetics with and without CVD in regard to dental implant therapy with immediate load. They concluded there is a favorable risk-benefit ratio for treatment at 5 years.
Title: Dental Implants and diabetes mellitus-a systematic review.
Source: Int J Implant Dent. 2016 Dec;2(1):5
Type: systematic review
Keywords: Dental implants; Diabetes mellitus; Glycemic control; Implant survival; Peri-implantitis; Risk factor; Systemic disease
Purpose: To determine if diabetic patients with dental implants have a higher complication rate in comparison to healthy controls.
Methods: an online search in the literature was conducted. 22 studies out of a total of 327 were included in this review. Because of too few studies, heterogenic study design, and incompletely reported data like type of diabetes therapy, quality of glycemic control, and duration of disease, the quantitative data synthesis could not be performed in the way necessary for meta-analysis. In most of the studies, patients were divided into: well-controlled (HbA1c 6.1– 8 %), moderately controlled (HbA1c 8.1– 10 %), and poorly controlled (HbA1c ≥ 10 %). The healthy control had HbA1c ≤ 6 %.
- Dental implants are safe and predictable procedures for dental rehabilitation in diabetics.
- The survival rate of implants in diabetics does not differ from the survival rate in healthy patients within the first 6 years, but in the long-term observation up to 20 years, a reduced implant survival can be found in diabetic patients.
- Patients with poorly controlled diabetes seem to have delayed osseointegration following implantation. After 1 year, there is no difference between diabetic and healthy individuals, not even to the poorly controlled HbA1c. Therefore, authors recommend avoiding immediate loading of the implants.
- In the first years after implant insertion, there seems to be no elevated risk of peri-implantitis; but in the long-term observation, peri-implant inflammation seems to be increased in diabetic patients. Therefore, a risk-adapted dental recall is helpful to detect early signs of gingivitis, which can easily be treated by dental/implant cleanings to avoid serious peri-implant infection.
- Authors found some hints that good glycemic control improves osseointegration and implant survival. Therefore, and to avoid other long-term side effects, the practitioner should ask for the HbA1c and if necessary improvement of antidiabetic therapy should be aimed.
- In the literature, there was no evidence that bone augmentation procedures like guided bone regeneration and sinus lifts have a higher complication and failure rate in patients with well- to fairly well-controlled diabetes. To improve implant survival and reduce postoperative complications, supportive therapy consisting of prophylactic antibiotics and chlorhexidine mouth rinse is recommended.
Conclusion: patients with poorly controlled diabetes suffer from impaired osseointegration, elevated risk of peri-implantitis, and higher level of implant failure. The influence of duration of the disease is not fully clear. The supportive administration of antibiotics and chlorhexidine seems to improve implant success. When diabetes is under well control, implant procedures are safe and predictable with a complication rate similar to that of healthy patients.
Title: Association between diabetes mellitus/hyperglycemia and peri-implant disease: systematic review and meta-analysis.
Source: J Clin Periodontol. 2017 Jun;44(6):636-648.
Keywords: dental implants; diabetes complications; epidemiology; gestational diabetes
Purpose: to identify and assess the existing scientific evidence from epidemiologic, non-experimental, observational studies of associations between hyperglycemia/ diabetes mellitus and peri-implant disease through systematic review.
Methods: electronic and manual literature searches were conducted independently by 2 authors. Inclusion criteria included: humans whose peri-implantitis or peri-implant mucositis was clinically diagnosed. Cases were defined by hyperglycemia and a normoglycemic comparison group. Results needed to include at least one parameter related to hyperglycemia and report presence of peri-implant mucositis or peri-implantitis. Other inclusion criteria included overall enrollment of atleast 10 subjects, duration of atleast 6 months, and rough surface screw-shaped implants.
Results: 12 studies out of 401 titles were included. 5 were prospective cohort studies, 1 retrospective cohort study, and 6 cross-sectional studies. These studies included 1,955 participants; 12 with pre-diabetes, 468 with diabetes, and 1,487 with no diabetes. 2, 892 implants were assessed. 3 of the prospective studies were eliminated due to heterogenicity compared to the rest of the reported data. 7 out of the 9 remaining studies could be synthesized by meta-analysis to assess the association between hyperglycemia/ diabetes and peri-implantitis.
Peri-implant mucositis did not have OR or RR between hyperglycemia vs. normoglycemia. However, Periimplantitis had both OR and RR statistically significantly higher in hyperglycemia than in normoglycemia.
|The risk of peri-implantitis in hyperglycemia is between 1.21 and 2.46 fold statistically significantly higher|
|than in normoglycemia.|
No study reported prevalence of peri-implant diseases in hyperglycemia vs otherwise healthy subjects without other confounder factors (smoking, history of periodontitis, or poor plaque control). 3 studies among non-smokers exclusively report consistent results as they all find subjects with hyperglycemia to have about 3x greater risk of peri-implantitis compared to normoglycemia.
Conclusion: Similar mechanisms are activated in peri-implant tissues as around natural dentition in periodontitis. Limitations of conducting this review is the heterogenicity of peri-implantitis definition. The patient should be made aware of risk involved in implant therapy with hyperglycemia.
Keywords: dental implants, implant survival, osteoporosis
Purpose:Primary Objective is to perform a retrospective chart review to determine the effect of osteoporotic status on survival of dental implants in postmenopausal women. Secondary Objectives included assessing the effects of smoking status, age, and arch location on implant survival as a function of osteoporotic status.
Method: a retrospective chart review was completed on all women who were 50 years of age or older at the time of dental implant placement at the Mayo Clinic between Oct 1, 1983 and Dec 31, 2004. The medical and dental charts were evaluated to collect the following:
- BMD T-score within 3 years of implant placement
- Osteoporotic diagnosis based on BMD T-score
- Arch location of the implants
- Smoking status at time of implant placement
- Any implant failures (implant removal due to any reason other than infection or manufacturing defects)
The review resulted in 192 patients (646 implants). Implant survival was estimated using the Kaplan-Meier method. Follow up duration was calculated from date of implant placement to date of failure or last follow up.
- The Kaplan-Meier t- and 10-year survival rates for the 64 implants in 192 patients were 93.8% and 92.5% respectively. The mean follow up was 5.4 years (range 11 days to 20.4 years). Mean age of women studied was 63.4 years (range 50.3 to 84.9 years)
- Osteoporotic diagnosis of patients based on BMD T-score was: 49% diagnosed as non-OP, 29.7% had osteopenia and 21.4% had osteoporosis. 37 implant failures were found: 10 implant failures in the osteoporosis group, 10 implant failures in the osteopenia group and the other 17 failures occurred in patients with non-OP diagnosis.
- No significant association between arch location and implant failure was identified.
- 12.5% of patients were smoking at the time of implant placement. Smoking had a significant effect on implant failure. Implants in smokers were 2.6 times more likely to fail (5- and 10- year implant survival rate for smokers was 87.3%). Non-smokers had 94.6% and 93.1% survival rates.
- Dental implant survival rates in this group of patients were encouraging with a 10-year survival rate of 92.5%.
- Implants placed in smokers were 2.6 times more likely to fail than those placed in nonsmokers. The difference between those were most evident in the first year after implant placement.
- A diagnosis of osteoporosis or osteopenia is not a contraindication to dental implant therapy.
Title: A prospective, controlled, multicenter study to evaluate the clinical outcome of implant treatment in women with osteoporosis/osteopenia: 5-year results
Source: J Dent Research 2019, Vol. 98(1) 84–90
Keywords: dental implants, marginal bone loss, postmenopausal, long-term outcome, survival rates, bone mineral density
Purpose: to provide long-term information on the clinical performance of oral implants in patients with diagnosed systemic primary osteoporosis/ osteopenia.
- Osteoporosis is defined as a skeletal disease, characterized by a low density of bone tissues
- Primary osteoporosis can be divided into 2 groups: post- menopausal osteoporosis and senile osteoporosis.
- Dual X-ray absorptiometry (DXA) is the gold standard in the diagnosis of osteoporosis/osteopenia. DXA scans assess the bone mineral density (BMD) and report a Tscore.
- T-score compares the BMD with the mean peak BMD for an individual of the same sex (healthy, 30-year-old individual).
- A T-score of 0 to −1.0 is considered nor- mal. A T-score of −2.5 or less will result in the diagnosis of osteoporosis, whereas T-scores of −1.0 to −2.5 are diagnosed as osteopenia. Methods:
- This study was performed at 4 centers: Leuven (Belgium), Gothenburg (Sweden), Würzburg (Germany), and Uppsala (Sweden)
- Patients were divided into 3 groups:
Group O (osteoporosis/osteopenia): patients with a T-score ≤ -2 o
Group C (healthy – control): patients with a T-score ≥ -1
- Inclusion: provision of informed consent, postmenopausal women aged ≥60 years, in need of 2- 8 implants in the maxilla, a history of edentulism in the area of oral implant therapy of ≥3 months, BMD suitable for group O or C (A: T-score ≥2 SD in g/cm3 and B: T-score ≥ -1 g/cm3)
- 2 – 8 implants (OsseoSpeed TX, Astra Tech Implant System; DentsplySirona) placed via 2-stage approach and Implants Stability Quotient (ISQ) were measured.
- PA radiographs taken immediately post-op and at 12 weeks when healing abutments were connected to the implants
- At 13 weeks, abutment level impression taken, and permanent restorations (bar-attached overdenture or screw-retained fixed partial denture [FDP]) was delivered 4 to 8 weeks after abutment surgery, and the implants were functionally loaded
- oral examination and implant follow- up were performed at 6 months after loading and then yearly up to 5 years. At every recall, intraoral PA radiographs were taken.
- Marginal bone levels (MBLs) were measured from a reference point (junction of the roughened and machined beveled surface) to the most coronal point of the bone-to-implant contact, both mesially and distally.
- The MBL at loading was regarded as baseline. Alterations were defined as the difference between MBL at base- line and each follow-up appointment
- Parameters (plaque scores, probing depth – PPD, bleeding on probing – BOP, clinical attachment levels CAL) of the peri-implant mucosa were recorded at every follow-up appointment and written down in the file of the patient
- Analysis was performed at implant level and patient level. Results:
- 148 implants placed in 48 patients (mean age: 67)
- 64 implants placed in group O (20 patients), 85 implants placed in group C (28 patients)
- 117 implants in 37 patients assessed at 5-year follow up
- The cumulative survival rate for all patients, after 5 y, on an implant level was 96.5% (group O:
91.5%; group C: 100.0%) and 95.7% (group O: 89.2%; group C: 100.0%) on a patient level.
- There was a significant difference in implant survival between groups O and C on an implant level (P = 0.004) but no significant difference on a patient level (P = 0.29).
- After 5 y of loading, 5 mechanical complications occurred (abutment screw fractures and connecting bar fractures), and 3 patients were treated for peri-implantitis.
- The overall MBL alterations on an implant level were −0.09 ± 0.78 mm (group O: −0.15 ± 0.50 mm; group C: −0.06 ± 0.89 mm).
- The overall MBL alterations on a patient level were −0.09 ± 0.54 mm (group O: −0.18 ± 0.43 mm; group C: −0.06 ± 0.58 mm)
- No significant difference in MBL alterations between loading and loading + 5 y between group O and group C, neither on an implant level (P = 0.31) nor on a patient level (P = 0.54)
- Smoking and type of restorations did not affect MBL alterations after 5 years of loading
- No statistically significant difference in plaque score, BOP, PPD, or CAL was found after 5 years of loading
- Oral implant therapy is a reliable treatment option in patients with osteoporosis, with survival rates and MBL alteration values comparable to the healthy control group. 50 vs 8.5% failure rate
Topic: osteonecrosis & bisphosphonates
Title: Osteonecrosis associated with dental implants in patients undergoing bisphosphonate treatment Source: Clin Oral Implants Res. 2014 May;25(5):632-640
Type: case study
Keywords: bisphosphonates, dental implants, jaw, osteonecrosis
Purpose: To verify clinical and pathological characteristics of BRONJ around dental implants, the present study analyzed clinical, radiographic and histopathological findings of these lesions.
- 19 study subjects who were implant-treated patients, and developed BRONJ of the maxilla or mandible and were followed up for > 3 months o The demographic data, prior medical and dental history, duration, type, route of administration of BP were recorded.
- Surgical treatments related to implant placement and progress after the BRONJ treatment were analyzed.
- After confirming the diagnosis, the BRONJ patients were recommended to stop the BP treatment
- Surgery was performed when no change in BRONJ status was noted o Surgical curettage of necrotic bone was carried out for most of the patients. o implants were extracted when the necrotic bone surrounded more than half of the implant surface or the implant lost stability after curettage or sequestrectomy of the necrotic bone
- primary treatment outcomes were divided according to the condition of the lesion after primary treatment and were classified as follows:
- (i) Complete cover of mucosa over the lesion site;
- (ii) Mostly covered by mucosa but still had some part of asymptomatic exposed bone;
- (iii) Partial healing, exposed bone with symptoms such as pain, swelling, or pus discharge that requires further treatment
- Biopsy of all specimens taken
- primary treatment outcomes were divided according to the condition of the lesion after primary treatment and were classified as follows:
- Oral BP users were most common (79%) compared with IV BP.
- Alendronate was the most commonly related drug.
- The lesion was located in mandible (n=9), maxilla (n=8) or both (n=2).
- BP initiation before surgery was documented in 16 people and after implant surgery in 3 people
- NSSD in period of drug administration, drug holiday, or location of the lesion in terms of sequestrum formation o extended bone resorption accompanying the bacterial colonies, as well as acute and chronic inflammatory cells were observed at the implant-surrounding bone tissue
- Only three patients developed osteonecrosis within 6 months after implant surgery, which suggests that the surgical process during the dental implant procedure is a contributing factor.
- Many patients (58%) developed BRONJ without any relation to surgical trauma from insertion or removal of the dental implant.
- could not find definitive relation between the BP duration and underlying disease and treatment outcomes.
- Most patients (68% of the cases) exhibited complete cover of mucosa after the first treatment using surgical curettage of necrotic bone or sequestrectomy.
Already osseointegrated dental implant also can show the osteonecrosis around the implant after BP administration.
Title: The effect of antiresorptive drugs on implant therapy: systematic review and meta-analysis. Source: Clin Oral Implants Res. 2018 Oct;29 suppl 18:54-92.
Keywords: antiresorptive drugs, bisphosphonates, dental implants, hormone replacement therapy, medication-related osteonecrosis of the jaw, systematic review
Purpose: To answer the question “In patients with systemic intake of ARDs, what is the outcome of implant therapy in terms of rates of implant loss, failure of grafting procedures, peri-implant marginal bone loss, MRONJ, and periodontitis compared to patients without systemic intake of ARDs?”
Methods: Electronic search including studies that were English or German, case series, cohort studies, case control studies, controlled and randomized clinical trials, retrospective design, greater than 10 patients with systemic intake of ARDs, clearly reported relevant clinical data.
- 36 articles were included in the study after all exclusions and grouped into studies on BP intake, studies on HRT intake, and studies on MRONJ associated with implants.
- Bisphosphonate Intake:
- No significant differences were observed regarding implant loss between cases and controls and success rates renaged from 85.7% to 100%.
- One study found an OR of 2.7 for implant loss with bisphosphonate intake o More implant losses were found in posterior maxilla, a short time from installation. o No SSD for marginal bone loss, one study reports an OR 3.3. for thread exposure o Several studies report no association with MRONJ and implants or grafting, but one study of 16,000 cases showed only 5 cases with complications.
- Hormone Replacement Therapy:
- Higher implant loss rate 9.1%-27.3% compared to conrols, a relative risk of 2.55 o 25% versus 15% of implant length bone loss comparing HRT with controls
- MRONJ Associated with Implants o Associated with bisphosphonate therapy in all studies except one o 84 in posterior mandible, 34 in maxilla
- 20 cases showed that implant installation or explantation as the trigger for MRONJ, and
41 cases showed the presence of the implant causing MRONJ o IV bisphosphonates were present in 61 cases, and oral in 44 cases.
- Meta Analysis:
- NSSD were observed in terms of implant loss between cases and controls in bisphosphonate studies.
- Hormone replacement therapy however, showed a marginally significant negative effect regarding implant survival on the patient level.
- MRONJ in patients on bisphosphonates for osteoporosis appeared >36 months after start of drug intake, while those on bisphosphonates for cancer had MRONJ <36 months after drug intake.
Discussion: Low-dose oral bisphosphonate intake for osteoporosis does not compromise implant therapy, they do not lose more implants or develop more complications compared to those not taking the drug. No relevant information exists on the effect of implnlat therapy on high-dose bisphosphates. Hormone replacement therapy has no negative effect on the implant level but may exert a marginally negative effect on implant survival and marginal bone levels. There is too little evidence to draw conclusions on grafting in conjunction with implants. There are valid reasons to consider as high-risk patients for MRONJ, those patients with high dose ARD intake for managing malignancies, patients on long term oral BP, and patients with comorbidities.
Authors: Colella, Cannavale, Pentenero, Gandolfo:
Title:Oral implants in radiated patients: A systematic review
Source:Int J Orla Maxillofac Implants 2007; 22(4):616-623
Keywords: Dental implants, oral cancer, radiation therapy
Purpose:To evaluate and compare the effects of pre- and post-implant radiation therapy. Incidence of implant failure was linked to multiple variables and assessed.
Methods:A thorough review of the relevant literature was performed. Studies were original studies based in humans from 1990- 2006. The man outcome considered was implant failure, defined as implant mobility, implant removal necessitated by progressive marginal bone loss or infection (biologic failure). Restorative status was not considered a determinate of success (sleeping implants were considered a positive outcome). Overall implant failure rate was compared for pre-implantation radiation therapy vs. post-implantation. Four variables were considered: implant location (maxilla vs. mandible), dose of radiation, delay from radiation to implant placement, and timing of implant failure.
Results:18 articles were considered eligible for inclusion in the review.Implant failure in post-implantation radiation therapy: 6 studies overall reported 124 implants with 4 failures (3.2%). Implant failure in pre-implantation radiation therapy: An overall failure rate of 5.4% was reported, which was not significantly different from post-implantation. 22/46 failures reported the cause of failure, with 9 due to lack of osseointegration, 12 due to marginal bone loss, and 1 due to biting trauma. Implant failure in the maxilla was 17.5% and 4.4% in the mandible, a difference that was significant. Vascularized free flaps were associated with the lowest rate of implant failure. Radiation dose: Radiation doses lower than 45 Gy were associated with the lowest rate of implant failure, with 5% being reported at higher doses. Delay of radiation treatment to implant placement: All implant failures occurred within 36 months after treatment. Timing of implant failure: No failures occurred within one month, 3.1% failed within the first month and 0.8% failed after 1 year.
Discussion:Based on this study, the timing of implant placement (pre- or post-therapy)is not linked to a significant difference in implant failure rate, however significantly better outcomes were noted in the mandible.
Title:Time interval after radiotherapy and dental implant failure: systematic review of observational studies and meta-analysis
Source:Clinical implant dentistry 2013;1-10
Keywords:dental implants, meta-analysis, osseointegration, osteoradionecrosis, radiotherapy
Purpose: To compare the risk of failure of dental implants placed within 6 and 12 months after the end of radiotherapy versus the risk of those implants placed after 12 months from the end of radiotherapy.
Materials and method
Four electronic databases were searched for articles published until February 2013 without language restriction: Lilacs, Medline, Scopus and the Cochrane Central Register of Controlled Trials. Two reviewers independently assessed the eligibility criteria and extracted data. Meta-analysis was performed.
Results:Overall 3,749 observational studies were identified. After the screening of titles and abstracts, 236 publications were selected, and finally 10 articles were included in the analysis. The Relative Risk of failure (1.34) was higher in individuals who had dental implants installed between 6 and 12 months after receiving radiotherapy.
Discussion:The main finding was that placement of dental implants between 6 and 12 months postradiotherapy was associated with 34% higher risk of failure. This is statistically significant and clinically relevant. Literature suggests that patients treated with radiation doses exceeding 50 Gray Units (Gy) are at increased risk of failure of osseointegration because of the loss of ability to repair and neovascularize the irradiated bone. Hyperbaric Oxygen therapy (HBO) reduces the risk of failure of the implant because it increases the number of capillaries and fibroblasts. However, this was not observed in this review which agrees with results of Esposito who found that HBO is not essential.
Minimum waiting period of 6 months postradiotherapy prior to dental implant placement is unlikely to be the most suitable, and healing periods with duration over 1 year may be beneficial.
Topic: cemento-osseous dysplasia, cemento-ossifying fibroma
Title: Case presentation of florid cemento-osseous dysplasia with concomitant cemento-ossifying fibroma discovered during implant explantation
Source: Oral Surg Oral Med Oral Pathol Oral Radiol 2013 Mar;115(3):e44-52
Type: Case report
Keywords: implant explantation, florid cemento-osseous dysplasia, cemento-ossifying fibroma
Purpose: This case report details a unique manifestation of florid cemento-osseous dysplasia (FCOD) and cemento-ossifying fibroma (COF) associated with implant failure within the same patient
Methods: 39-year-old African American female whose medical history was positive for diabetes, hypertension, anxiety, and NKDA. Symptomatic mandibular right first molar with a large periapical radiolucency. Initial endodontic therapy attempted, and when symptoms were not relieved, tooth was extracted with ridge preservation. After 6 months, #30 extraction sited demonstrated irregular radiopaque progression within the previous radiolucent lesion but was interpreted as a “healing phase”. Implant of 5×13 mm was placed in site #30 and restored.
After 26 months of function, patient returned with mobility on #30 implant, along with a buccal inflammation (of 1×2 cm) and tenderness adjacent to the implant. Radiographs showed multiple, mixed radiolucent/radiopaque lesions circumscribed around the apices of the mandibular anterior and posterior teeth. The lesions were evident on a series of panoramic radiographs dating back to 2007. From the panorex in 2007, a large periapical radiolucency can be seen at the apices of #30, which persisted after the extraction. It progressively increased in radiopacity and became a circumscribed, mixed radiolucent/radiopaque. CBCT scan from 2010 showed a buccal expansile lesion with an inner radiolucent core surrounded by a thin sclerotic border adjacent to irregular, dense, radiopaque bone surrounding implant #30. Other small regions of mixed radiolucent/radiopaque can also be seen in proximity to the implant. The inferior alveolar nerve canal has been displaced to the lingual aspect of the body of the mandible. Patient was scheduled for surgery to enucleate the lesion and remove the implant with differential diagnosis of FCOD, COF, giant-cell lesion, and odontogenic tumor. All specimens were submitted to pathology for histological examination for final diagnosis.
Results: This case report details a diagnosis of 2 distinct disease entities associated with the implant site, FCOD and COF of the mandibles. Based on radiographic evidence and surgical gross examination, a definitive diagnosis of FLCOD was made. A more recent, rapidly expansile, osseous lesion was also diagnosed as COD based on clinical, surgical, radiographic, and histologic evidence. Both diagnoses were verified after biopsy and removal of the previously osseointergrated implant following postinsertion failure by fibrous encapsulation.
Discussion: Before implant therapy, it is essential to conduct a thorough radiographic evaluation of any dental arch with suspected bony lesions to prevent implant failure, as a diagnosis of any COD lesion is considered a contraindication. Any radiolucent lesion should be suspected as a possible early lesion of FLCOD if accompanied by other mixed radiolucent/radiopaque lesions within either dental arch (primarily the mandibular arch). Once diagnosed, treatment considerations include frequent follow-ups, annual radiographic surveys, and aggressive preventive measures to prevent further tooth loss or need for surgery. Tooth-borne prostheses such as a fixed or removable partial denture that are the recommended procedures instead of implant therapy.
Topic: Treatment planning
Title: Branemark System Implants and Rare Disorders: a Report of Six Cases
Source: Int J Perio Rest Dent. 2013; 33:139-48
Type: Case Report
Reviewer: Maggie Weber
Keywords: dental implant; rare disorders; langerhan; hypophosphatemia; osteogenesis; dentinogenesis
Purpose: to describe the outcome of oral implant treatment in patients suffering from rare disorders.
- X linked hypophosphatemia (XLH)
- X linked dominant osteomalacia effecting 1:20,000
- Clinical features: growth retardation, limb deformities, joint pain, osteoarthritis
- Oral manifestations: loss of teeth due to abscess without evident caries
- Langerhans Cell Histiocytosis
- Common term for: eosinophilic granuloma, Hand-Shuller-Christian disease, Letterer-Siwe disease effecting 9:1,000,000
- Oral manifestations: soft tissue ulcers, gingival bleeding, pain, periodontal damage, tooth mobility and loss
- Osteogenesis Imperfecta/Brittle Bone Disease
- Genetic disorder effecting 1:20,000
- Clinical features: bone fractures without trauma, hearing loss
- Oral manifestations: worn enamel, defective dentin, small/calcified pulp chambers2
X linked hypophosphatemia (XLH) case reports
- Patient 1: generalized tooth loss
- 4 implants placed (2 anterior mandible and two central maxillary) and follow up of 50 months
- After implant placement healing time was 1 year before abutments connected due to mobility
- 3 unit fixed prosthesis was received 2 years after initial implant placement
- Bone response at 50 months followup in all 4 implants was unremarkable
- Patient 2: generalized tooth loss
- 4 implants placed (maxillary anterior) and followup of 20 months
- After implant placement healing time was 1 year prior to abutment connection
- Fixed prosthesis was delivered a year after implant placement
- Bone response was unremarkable 20 months followup
- Patient 3: complete edentulism
- 6 implants placed in maxilla and 4 implants placed in mandible
- After implants healing time of 1 year in maxilla and 10 months in mandible, abutments were connected and prosthesis delivered
- Bone response around all 10 implants was unremarkable at 19 and 22 month followup
Langerhans Cell Histiocytosis case reports
- Patient 1: generalized tooth loss
- 4 implants placed in mandible
- Healing period of 2.5 months prior to abutment connection with 2, 3-unit fixed prostheses
- Bone response at 5 years was unremarkable
- Patient 2: complete edentulism (minus wisdom teeth)
- 4 implants placed in maxilla and 4 in mandible, wisdom teeth extracted
- 6 months of healing time prior to abutment connection and 8-unit fixed prostheses
- Bone response at 15 years was unremarkable
- Patient 1: edentulous
- 6 implants placed in mandible
- After 5.5 months of healing, abutments connected
- Bone response at 4 years was not stable
In X-lined hypophosphatemia patients, all 18 implants place were successfully in function after 5 years with good bone response although healing time was longer than normal. Results were similar in patients with Langerhans cell histiocytosis.
In osteogenesis imperfecta, bone resorption was seen at follow-up appointments which may or may not be a result of the disease.
Topic: Other disorders involving bone or soft tissue
Author:Strietzel, FP., et al.
Title: Implants in patients with oral manifestations of autoimmune or muco-cutaneous diseases – A systematic review
Source: Journal section: Medically compromised patients in Dentistry doi:10.4317/medoral.22786
Purpose: To study implant survival rates in patients with oral manifestations of systemic autoimmune (oral Lichen planus (oLp), Pemphigus (Pe)), muco-cutaneous (Epidermolysis bullosa (EB)), autoimmune multisystemic rheumatic diseases (Sjögren ́s syndrome (SjS), systemic Lupus erythematosus (sLE), or systemic Sclerosis (sSc)).
Methods: Systematic literature review of studies published between 1980 and August 2018 in English language using (PubMed/Medline, Embase) using MESH and search term combinations, reporting on dental implant prosthetic rehabilitation of patients with oLp, Pe, EB, SjS, sLE, sSc, study design, age, gender, follow-up period (≥ 12 months), implant survival rate. Implant-related weighed mean values of implant survival rate (wmSR) were calculated.
Results: After a mean follow-up period (mfp) of 44.6 months, a wmSR of 98.3 % was calculated from data published for patients with oLp (100 patients with 302 implants). Data of 27 patients (152 implants) with EB revealed wmSR of 98.7 % following mfp of 32.6 months. For 71 patients (272 implants) with SjS, wmSR was 94.2 % follow- ing a mfp of 45.2 months, and for 6 patients (44 implants) with sSc, wmSR was 97.7 % after mfp of 37.5 months. One case report on one patient each with Pe (two implants) as well as sLE (6 implants) showed 100 % SR following at least 24 months.
Discussion: Gingiva and other oral tissues may exhibit several pathologic phenomena as symptoms or manifestations of systemic diseases, requiring further diagnostic and interdisciplinary treatment. Guidelines regarding implant treatment of patients with oLp, Pe, EB, SjS, sLE or sSc do not exist . Implant survival rates of patients affected are comparable to those of healthy patients.
Title: What influence do anticoagulants have on oral implant therapy? A systematic review
Source: Clin Oral Implants Res. 2009 Sep;20 Suppl 4:96-106
Type: Systematic Review
keywords: anticoagulant therapy, bisphosphonates, coated implants, oral implants, osteonecrosis
- Assess the risks (both thromboembolic and bleeding) of an Oral Anticoagulation Therapy (OAT) patient undergoing implant therapy
- Provide a management protocol to patients under OAT undergoing implant therapy.
- PICO question
- In patients with OAT what is the risk of bleeding complications when dental implants are placed, and OAT is not discontinued?
- In patients with OAT what is the risk of a thromboembolic even when dental implants are placed in and OAT is discontinued?
- Final selection was based on clinical trials, prospective and retrospective studies only
- 19 studies identified that reported outcomes of oral surgery procedures, 9 RCTs, 9 prospective studies.
- In all studies the INR was in the therapeutic range
- In 8 studies: Two protocols are compared: Discontinuation of OAT 2-4 days before surgery and Continuation of therapy. Results from these showed no difference between the two groups and all bleeding events were controlled with local hemostatic measures and no thrombolytic events reported.
- 8 studies where different hemostatic treatments were implemented. Tranexamic acid mouthwashes, gelatin sponges and cellulose gauzes were effective in controlling postoperative bleeding.
- 3 case reports describing INR and bleeding risks, the OAT medication was not altered, and hemostatic agents were used, but no correlation was found with INR ranges.
- The only evidence-based recommendation was from the American College of Chest Physicians and Guidelines from Oral Medicine that were similar:
- Patients within therapeutic INR range less than 3.5 warfarin should not be modified for simple extractions or minor surgical procedures.
- If INR is on the high end of the scale, then more complicated surgeries may present an exception to the previous rule
- Greater than 3.5 should be sent to physician for adjustment before any invasive procedures.
Discussion: This study does not suggest a higher occurrence of perioperative bleeding when appropriate hemostatic measurements were taken or when different hemostatic agents were used. The placement of implants should be considered comparable or less traumatic than the extraction of three teeth assuming no harvesting of autogenous bone grafts are necessary or needing preparation outside of the bony envelope; and OAT is not a contraindication for dental implants.
Topic: Medical Overview
Title: Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants
Source: British Journal of Oral and Maxillofacial Surgery 52 (2014) e15–e19
Type: Retrospective Study
Keywords: Haemorrhage; Tooth extraction; Apicectomy; Dental implantation; Aspirin; Acenocoumarol
Purpose: Academic Centre for Dentistry Amsterdam (ACTA) guidelines were evaluated to find out whether these procedures led to increased postoperative bleeding. The study compared the incidence in patients taking anticoagulants with that in a group of patients who were not taking them.
Methods: The study involved 206 patients who were referred to the Department of Oral and Maxillofacial Surgery of the University Medical Center Groningen, the Netherlands, for dentoalveolar operations that met the ACTA guidelines – which are:
- Maximum of 3 extractions, apicectomies, or placement of implants at the same time.
The type of surgery required were divided into 4 categories: surgical extractions, non-surgical extractions, apicectomies, and placement of implants. 103 patients were taking oral anticoagulants and 103 were not.
Patients were given a local anesthetic (4% articaine with 1/100 000 epinephrine). Procedures were as atraumatic as possible, and wounds were sutured. Post-op instructions were given verbally and in a written format to apply compression with gauze for 30 min immediately post-op. no patient was allowed to leave the hospital until bleeding stopped and instructions to call the OMFS dept. if bleeding did not stop after 30 min were given.
Two types of post-op bleeding were defined. If patient came to the hospital because bleeding could not be stopped at home, it was scored as severe. During a one-week interval patients had follow ups and were asked if they had bleeding that stopped by compression with gauze and scored as mild.
- Episodes of bleeding were most common in patients who had had surgical extractions while they were taking anticoagulants, but no significant difference was found between this group and the control.
- No patient had a severe postoperative bleeding.
- Control group had fewer mild bleeds than the anticoagulant group.
Conclusion: The study concluded that that dentoalveolar surgery is safe in patients being treated with anticoagulants provided that the conditions described in the ACTA guidelines are met.
Title: Gomez-Moreno G, et al. Dental implant surgery in patients in treatment with the anticoagulant oral rivaroxaban. (xarelto)
Source: Clin Oral Imp Res. 2016; 27:730-733
Keywords: bleeding; dental implants; rivaroxaban; tranexamic acid
Purpose:The purpose of this study was to evaluate the incidence of bleeding complications after dental implant placement in patients in treatment by the anticoagulant oral rivaroxaban without interrupting its administration or modifying dosage.
- 57 patients were divided into two groups: 18 had been in treatment by rivaroxaban for over 6 months before implant surgery and a control group consisted of 39 healthy subjects.
- All subjects received dental implants in different positions, without interrupting or modifying rivaroxaban dosage.
- Patients were treated in an outpatient setting. Non-absorbable sutures were used, and all patients were given gauze impregnated with tranexamic acid 5% (Lysteda), to bite on for 30–60 min. Afterward, the patient was examined again to ensure that hemorrhaging had stopped. When this had been established, the patient was given a packet of sterile gauzes and an ampoule of tranexamic acid and sent home.
- All patients were instructed to apply external ice packs to the surgical area for 6–8 h post- operatively. Avoid mouthwashes for the first 24 h after surgery, avoid aspiration movement, manipulation of the surgical area and to avoid tongue contact with the area.
- Patients carrying RPD not to wear their dentures for 2–3 weeks after implant surgery.
- One rivaroxaban patient presented moderate bleeding the day after surgery
- Two control patients presented moderate bleeding the day after and on the second day.
- Bleeding was managed with gauzes impregnated with tranexamic acid.
- No statistically significant differences
(P = 0.688) were found in relation to bleeding episodes between the groups, with a relative risk = 0.919 based on the pooled groups and 95% confidence interval of 0.078–10.844
- In the present study, implant surgery was performed in patients with normal renal function without interrupting or modifying rivaroxaban doses, applying local hemostasis that consisted of non-absorbable sutures, and compression with sterile gauzes soaked in 5% tranexamic acid in the surgical area for 30– 60 min; no significant differences were found between rivaroxaban patients and healthy control subjects.
- Only one rivaroxaban patient presented moderate bleeding the day after surgery, which was brought under control by applying gauze soaked in tranexamic acid solution; in this case, the patient reported that he had played some sport that morning that had coincided with the bleeding episode.
- The local application of tranexamic acid has been shown to stabilize clot formation in various oral surgical settings.
Conclusion: The present study found no statistically significant difference in the number of bleeding complications between rivaroxaban patients and a systemically healthy control group. Although the study had a small patient sample, this suggests that dental implant surgery in patients in treatment by the anticoagulant oral rivaroxaban can be performed safely in an outpatient setting applying local hemostatic measures; there is no need to interrupt or modify the coagulant dose.
Topic: Other medications
Title: Intake of Proton Pump Inhibitors is Associated with an Increased Risk of Dental Implant Failure
Source: Int J Oral Maxillofac Implants 2017 Sept/Oct;32(5): 1097-1102
Type: retrospective cohort study, consecutively treated between 1980 and 2014
Keywords:Meds and dental implant failure
Purpose: To investigate the association between the intake of proton pump inhibitors (PPIs) and the risk of dental implant failure.
Methods: Modern endosseous dental implants with cylindrical or conical design were included, and only complete cases were considered; ie, only those implants with information available for all variables measured were included in the regression model analysis. Zygomatic implants and implants detected in radiographies but without basic information about them in the patients’ files were excluded from the study. Implant- and patient-related data were collected. Multilevel mixed-effects parametric survival analysis was used to test the association between PPI exposure (predictor variable) and risk of implant failure (outcome variable), adjusting for several potential confounders.
Results: A total of 3,559 implants were placed in 999 patients, with 178 implants reported as failures. The implant failure rates were 12.0% (30/250) for PPI users and 4.5% (148/3,309) for nonusers. A total of 45 out of 178 (25.3%) failed implants were lost up to abutment connection (6 in PPI users, 39 in nonusers), with an early-to-late failure ratio of 0.34:1. The intake of PPIs was shown to have a statistically significant negative effect for implant survival rate (HR 2.811; 95% CI: 1.139 to 6.937; P = .025). Bruxism, smoking, implant length, prophylactic antibiotic regimen, and implant location were also identified as factors with a statistically significant effect on the implant survival rate.
Discussion: This study suggests that the intake of PPIs may be associated with an increased risk of dental implant failure.
Topic: Implant failure associated with intake of SSRI
Title: Is the intake of selective serotonin reuptake inhibitors associated with an increased risk of dental implant failure?
Source: International Association of Oral and Maxillofacial Surgeons. Volume 46, Issue 6, June 2017, Pages 782-788.
Keywords: dental implant; implant failure; multilevel mixed-effects parametric survival analysis; multivariate generalized estimating equation analysis; selective serotonin reuptake inhibitors.
Purpose: To investigate the association between the intake of SSRIs and the risk of dental implant failure.
- Retrospective cohort study.
- Patients treated with implant-supported prostheses between 1980 and 2014 at one specialist clinic.
- Included patients taking only SSRIs and no other medication and not present any other systemic condition.
- All patients had to have taken prophylactic antibiotics for implant surgery.
- All modern endosseous dental implants with a cylindrical or conical design only.
- Zygomatic implants were not included in the study, nor were implants detected in radiographs without basic information about them in the patient’s files.
- An implant was considered a failure in the presence of signs and symptoms that led to implant removal, lack or loss of osseointegration, implant mobility, continuous pain, advanced marginal bone loss, and refractory infection.
- Total of 931 implants placed in 300 patients were included in the study.
- 460 implants were placed in 145 men.
- 471 implants were placed in 155 women
- All implants were inserted with open flap surgery
Data analyses: Differences between implants placed in SSRI users and SSRI non-users were compared with:
- Student t-test or Mann–Whitney test for continuous variables.
- Wald x 2 test was used to analyze the statistical significance of each parameter within the model .
- The Akaike information criterion (AIC) was used to choose the best fit survival model .
- 35 implant failures were reported. Combined 3.75% failure rate.
- 48 implants were placed in 18 SSRI users.
- 883 implants were placed in 282 non-users.
- Follow-up from 1578 to 1717 days (SSRI users).
- Follow-up from 2804 to 2267 days (SSRI non-users).
- SSRI users implant failure was 12.5 % (6/ 48)
- SSRI non-users implant failure was 3.3% (29/883)
- Fewer implants were placed in the mandible in relation to the anterior maxilla, and fewer patients were followed up for longer periods in the SSRI user group than in the non-user group, and these differences were statistically significant.
- Table 1 screenshot.
- Intake of SSRIs, age, sex, implant diameter, or bone augmentation did not have statistically significant influence on implant failure. However, longer implants failed less than shorter implants.
4 different statistical methods were used.
- Fisher’s exact test showed a statistically significant association between the intake of SSRIs and an increased risk of implant failure. However, this test does not take into consideration the other confounders.
- Kaplan–Meier analysis showed a statistically significant difference in the cumulative survival rate between SSRI users and non-users. Although this test considers the factor time, it does not consider the influence of the other variables .
- The multivariate GEE method did not find a statistically significant association between the intake of SSRIs and an increased risk of implant failure.
- The multilevel mixed-effects parametric survival analysis showed no statistically significant association between the intake of SSRIs and a higher risk of dental implant failure.
- Influence of the follow-up time on the failure rate.
- Lower risk of failure with a longer follow-up, may be connected to that 31.4% of the implants were lost prior to the abutment connection procedure and 51.4% up to 1 year after surgery.
- This study showed no statistically significant association between the intake of SSRIs and a higher risk of dental implant failure.
Conclusion- the intake of SSRIs may not be associated with an increased risk of dental implant failure.
Topic: Effect of medications on implants
Title: Medication-related dental implant failure: Systematic review and meta-analysis Source: Clinical oral implants research. 2018 Oct; 29:55-68.
Type: Systematic review and meta-analysis
Keywords: Dental implant, failure, Medication, biologic complications.
Purpose: Evaluate the effect of the intake of different systemic drugs on implant failure rate.
- The review was conducted according to the guidelines of the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) statement.
- The primary outcome was implant failure (IF) while the secondary outcomes were biological and mechanical causes associated with IF.
- PECO questions were P: Human adults receiving implant supported prosthesis, E: regular intake of systemic drugs that may affect bone metabolism, C: Individuals not taking relevant medications, O: Dental implant failure (primary) biological and mechanical complication (secondary).
- The study included relative Prospective or retrospective cohort, case–control, cross-sectional, or randomized controlled trials in any language.
- Electronic and manual literature searches were conducted by two independent authors in multiple databases for all relevant studies published up to May 2017.
- Initial search of databases yielded 430 articles out of which 40 full text articles were assessed the 17 articles were selected for qualitative assessment. Five studies evaluated the use of nonsteroidal anti-inflammatory drugs (NSAIDs), two on proton pump inhibitors (PPIs), seven on oral bisphosphonates (BPs), one on anti-hypertensives (AHTNs) and two on selective serotonin reuptake inhibitors (SSRIs).
- Patients receiving PPIs and SSRIs showed higher incidence of IF compared to control groups while no meta-analysis could be conducted for AHTNs as only one study was included, and it showed increased survival rate of implants in patients receiving AHTNs.
- NSAIDs and BPs showed no significant results.
- The results from this study should be interpreted with caution and only an association relationship can be concluded, and no cause-effect relationship can be established.
- Bisphosphonate therapy could cause increased risk of osteonecrosis of the jaw as a consequence of dental extraction and other oral surgeries thus care should be taken when utilizing the results in this study and remember that the intake of intra-venous BPs is considered an absolute contraindication for implant therapy.
- A more prospective manner of investigation is recommended to control other contributing cofactors.
- Timing of implant failure is another important factor that needs to be better reported.
Topic: Implants and medical conditions
Title: Osseointegration of Dental Implants in Organ Transplant Patients Undergoing Chronic Immunosuppressive Therapy
Source: Implant Dentistry / Volume 00, Number 00 2019
Type: Clinical study
Keywords: crestal bone level, solid- organ transplantation, endosseous implant, immunosuppression
Purpose: to evaluate the effect in terms of function and esthetics, that implanto- prosthetic treatment has on patients who are subject to immunosuppressive treatment after organ transplants.
Methods: 21 patients received altogether 24 implants. The control group=15 people with 15 implants in place. The inclusion criteria were:>25 years of age, at least 1 year after organ transplant, in need of a single missing tooth replacement with titanium implant, at least one tooth missing with neighboring teeth present, suitable bone condition for implantation procedure without the need of guided bone regeneration (GBR). The exclusion criteria were: active periodontal disease, occlusion disorders, bone diseases, blood coagulation disorders, untreated dyslipidemia and smoking. An additional exclusion parameter for control group was immunosuppressive medication. After 4 months, a single crown was placed. The parameter that they evaluated was crestal bone level (CBL), using radiological and mechanical means.They measured the torque to locate the implant and the implant stability quotient. The time devoted to osseointegration was extended to 4 to 6 months. Measurements were performed twice: on the day of implantation and after the integration period.
Results: The basic measured parameter of CBL median revealed lack of significant differences between the experimental group and the control group. The only statistically significant difference in CBL was found between patients taking 1 or 2 medications.
Discussion: The results of this study showed that there is no difference in the effects of dental implant treatment between patients in the course of immunosuppressive therapy after organ transplantation and the control group of healthy people, and successful osseointegration concerned 100% implants. Contemporary medications exert considerably lower influence on osseointegration and are less toxic to bone and solid organs of the patient.
Conclusion: Patients with organ transplants can safely and effectively undergo dental implant treatment.
Topic: Periodontal Disease and DI survival
Title: History of periodontitis as a risk factor for long-term survival of dental implants: a meta-analysis Source: Int J Oral Maxillofac Implants 2014; 29(6): 1271-80
Keywords: implant survival, implants, meta-analysis, periodontitis, risk factors
Purpose: To conduct a meta-analysis to determine the effect of a history of periodontitis on the longterm survival or success of dental implants and to determine if a history of periodontitis can be considered a significant risk factor.
Methods: A literature search was conducted for articles through March 2013. Titles were screened and potential abstracts were selected. Then two-reviewers assessed the papers to determine inclusion. The primary outcome was dental implant survival rate and/or success rates.
Implant Success was defined as probing depth </= to 5mm, no BOP, and annual bone loss <0.2mm. Implant survival included all implants that remained osseointegrated at the time of last report. Data from studies was pooled and meta-analysis was performed.
Results: After finding 367 papers, 57 were screened, 20 underwent full-text review and 13 articles were included. The included studies came from 7 different countries. Follow up varied from 24months to
192months. There were a total of 2,011 patients and 6,802 implants were included in the meta-analysis.
- 2,309 implants were plaed in 847 healthy individuals
- 4,493 implants were placed in 1,164 individuals with periodontal disease
Overall, the authors identified a statistically significant increased risk for a history of periodontal disease to lower implant survival but did not seem to affect implant success. Aggressive periodontitis had the most significant impact on implant survival (risk ratio [RR] = 1.03, 95% confidence interval [CI] = 1.02 to 1.04).
Analysis of a subgroup showed that a history of periodontitis had no statistically significant effect on implant survival up to 100 months of follow-up (RR = 1.03, 95% CI = 0.99 to 1.06); however, it did significantly affect implant survival within a period of 101 to 200 months (RR = 1.03, 95% CI = 1.02 to
1.04). Some implant systems also significantly influenced the correlation between a history of periodontitis and implant survival.
Conclusion: This meta-analysis demonstrated that the risk of periodontitis for implant survival are significantly influenced by the type of periodontal disease, the duration of follow-up, and the implant system. The authors conclude that a history of periodontitis should be considered a risk factor for the long-term survival of dental implants. However, further studies are needed.
Topic: Periodntal Disease
Title: . Long-term evaluation of periodontal parameters and implant outcomes in periodontally compromised patients: a systematic review.
Source: J Periodontol. 2015 Feb;86(2):201-21.
Type: systematic review
Purpose: To evaluate he long-term (‡5 years) clinical/radiographic outcomes of patients with periodontitis submitted to periodontal therapy and implant placement
- Review performed according to the PRISMA systematic review guidelines.
- MEDLINE, EMBASE and Central databases were searched.
- 959 papers originally reviewed.
- 10 papers included in final review and no meta analysis was performed
- A total of 748 patients and 1,403 implants were evaluated, and of these, 556 patients were classified as having some degree of periodontal disease.
- All papers reported that periodontal treatment was performed and maintenance and/or therapy had been performed for more than 5 years. Although the type and extent of treatment was not clearly reported
- Implant survival rate of patients with periodontal disease after 10 years of follow up was 92.1% but 50% of the patients in one of the papers were positive for plaque and presented BOP at 35.3% of teeth and 6.1% of implant sites.
- Mean bone loss around implants was 1.7mm and 0.8mm around teeth. Mean BOP was 42% for implants and 30.2% for teeth.
- Overall patients with residual pockets and or high levels of BOP around teeth were directly associated with higher PD, CAL, and BL around implants.
- Periodontally compromised smokers presented inferior outcomes related to mean BL and survival implant rate.
Conclusion: Implant therapy can be successfully used in patients with a diagnosis of periodontitis, as long as the periodontitis is properly treated and the patient adheres to the periodontal maintenance program. The original periodontal diagnosis is important for implant prognosis, but the presence of RPs and non-attendance to periodontal maintenance observed during the follow-up period and smoking habit can be considered negative factors for implant outcomes.
Topic: Periodontal Disease
Title: Mucositis, peri-implantitis, implant success, and survival of implants in patients with treated generalized aggressive periodontitis:3- to 16-year results of a prospective long-term cohort study
Source: J Periodontol 2012 Oct;83(10):1213-25
Type: Prospective cohort
Keywords: aggressive periodontitis; peri-implantitis;
Purpose: to evaluate the prevalence of mucosisits, peri-implantitis, implant success, and survival in partially edentulous patients treated for generalized aggressive periodontitis and in periodontally healthy individuals.
Methods: 35 patients (15 male, 20 female) age 27-56 years were treated for generalized aggressive periodontitis and 18 healthy patients (9 male, 9 female) were included that had dental implants placed. 7 of the GAgP patients, guided bone regeneration was done in the anterior region and implants placed after 6 months. In both groups, 2nd stage surgery was done after 6 mo in the maxilla and 3 mo in the mandible. 4 weeks after abutments were placed, crowns were inserted. GAgP group: 18 single implant crowns, 20 fixed implant supported bridges, 18 removable implant supported suprastructures. In healthy subjects, 22 single crowns, 4 fixed implant supported bridges. Initially, they were examined 2-4 weeks prior to extraction of hopeless teeth (baseline), and 3 weeks after placement of final abutments. Additional examinations were done during a 3 month recall schedule over 5-16 years. Clinical parameters were taken at each exam: 1, 3,5,10, 5 years and microbiological and radiographic examination performed.
Results: Implant survival rate of 100% in periodontally healthy patients vs. 96% in generalized aggressive periodontitis patients. Implant success rate was 33% in generalized aggressive vs. 50% in periodontally healthy patients. In GAgP, mucositis was present 56% and peri-implantitis 26% of implants. Healthy patients showed 40% mucositis and 10% peri-implantitis in contrast. In addition, GAgP had 5x greater risk of implant failure and 3x greater risk of mucositis, and 14x greater risk of peri-implantitis.
Conclusion: The results suggest that patients with treated GAgP are more susceptible to mucositis and peri-implantitis, with lower implant survival and success rates even with a strict recall schedule (3 months).
Topic: Periodontal disease.
Title: Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: a systematic review.
Source: J Adv Prosthodont 2012;4:210-7
Type: Systematic Review
Keywords: Aggressive periodontitis, Dental Implants, Dental Implantation, Systematic Review.
Purpose: Evaluating the marginal bone loss around implant and the survival rates of implants in patients with generalized aggressive periodontitis
Methods: seven articles were included. The reason the others were excluded was: less the 5 patients, follow up period <1 year and no cumulative survival/success rate for implant. These studies included 4 short-term and 3 long-term studies.
Marginal bone loss around implant
- Short-term studies: 1.14 to 1.78 mm in the GAP, 0.86mm in CP, 0.70 to 1.4 mm in PH, with a 3 years observation period. No significant differences between these groups.
- Long-term studies: 0.88 to 3.37mm in the GAP patients, while it was 0.19 to 1.24 mm in the PH and CP patients
- Marginal bone loss at the implant of the GAP patients was significantly greater than in PH subjects.
- The marginal bone loss at implants in patients with GAP as compared with implants in PH patients or CP patients was not significantly greater in short terms but was significantly greater in long-term studies.
Survival rates of implants
- Short-term studies: 100% in the PH and CP patients and 97.4% of GAP patients.
- No significant differences were seen in the results between the groups.
- 100% in CP patients and 83.3 to 88.8% in GAP patients. So in the GAP patients there was a significantly lower implant survival rate.
- However, the implant success rate was 33% in GAP patients, and 50% in PH subjects. GAP patients had 5 times greater risk of implant failure.
Conclusion: There is a controversy about whether implant treatment in patients with previous tooth loss due to GAP is characterized by an increased incidence of peri-implantitis and implant loss. Implant treatment in patients with GAP is not contraindicated provided that adequate infection control and an individualized maintenance program are assured.
Topic: aggressive periodontitis
Title: Generalized aggressive periodontitis as a risk factor for dental implant failure: a systematic review and meta-analysis
Source: J Periodontol. 2014 Oct;85(10):1398-1407
Purpose: The present study aims at assessing whether patients who suffered from generalized aggressive periodontitis (GAgP) have a higher implant failure rate and MBL in implant prostheses when compared with patients with chronic periodontitis (CP) and/or healthy patients (HPs).
Methods: Electronic literature review consisted of reviewing articles written in English from the year 2000 to November 2013 using several databases. Cases reports, systematic reviews, implants followed up for less than 12 months and studies with no control groups are excluded.
PICO question: Do edentulous patients restored with implant‐supported prostheses have a higher or similar implant survival rate (SR) and/or MBL among patients with a history of GAgP and/or HPs and/or patients with CP?
Results: Only 6 articles were analyzed in this meta-analysis, 5 of which were developed by the same group. All 6 articles are prospective studies, which compare implant treatment outcomes between patients with generalized aggressive periodontitis, and/or chronic periodontitis with healthy patients.
The survival rates for the GAgP group ranged from 83.3% to 100%, 96.4% to 100% for the CP group, and 96.9% to 100% for the HP group. The risk ratio is 0.96 for the comparison between AgP and HP and 0.94 for the comparison of SR between AgP and CP.
This Meta‐analysis presented an overall risk ratio of 4 when the “failure rate” was evaluated for the comparison among patients with AgP and HPs and 3.97 for comparison between patients with AgP and CP.
The weight mean difference (WMD) in marginal bone loss (MBL) is 0.15mm, -0.28 and -0.43 for HP versus CP, HP versus GAgP and CP versus GAgP respectively.
Discussion: when Evaluating SR of implants, patients with a history of GAgP had similar SRs when compared with the CP and HP groups. However, a high risk ratio was found when examining failure rate. larger and longer follow‐up studies are needed to validate the current findings.
Topic:crestal bone height change
Title: Crestal bone changes at teeth and implants in periodontally healthy and periodontally compromised patients. A 10-year comparative case-series study.
Source: J Periodontol. 2013 Nov 11.
Type: Comparative case series
Keywords: alveolar bone loss, peri-implantitis, periodontitis, smoking
Purpose: To compare the 10-year radiographic crestal bone changes around teeth and implants in periodontally compromised and periodontally healthy patients.
- 120 patients (60 with previous history of perio – PCP and 60 healthy -PHP) were followed for 10 years post loading for radiographic crestal bone height of dental implants and adjacent teeth.
- 10 patients were smokers.
- Digital films were calibrated. Radiographic crestal bone change was calculated by subtracting the crestal BL at baseline from the crestal BL at the 10 year follow up.
- After 10 years, implant survival was 80-95% and 100% for teeth.
- In all categories evaluated, natural teeth were significantly more stable radiographically compared to implants.
- Bone loss around teeth was 0.44 mm and bone loss around implants was measured as 2.28 mm in average.
- Adjacent teeth did not seem to be influenced by the presence or absence of bone loss ≥3mm at adjacent implants.
- The bone loss around teeth paralleled the findings at implants.
- Teeth in PCPs demonstrated a statistically higher mean bone loss compared with PHPs after 10 years of follow-up.
- Despite being included in a regular, individually tailored periodontal maintenance protocol, nonsmoking patients with a history of periodontitis displayed a mean crestal bone loss at the examined teeth that ranged from 0.49 to 0.65 mm, whereas in smoking PCPs, this value ranged from 0.78 to 0.85 mm.
Conclusion: Long-term results show that natural teeth have greater survival and less marginal bone loss compared to dental implants. This was still true when looking at teeth with reduced periodontal attachment (treated and maintained). The decision to extract teeth in favor of dental implants should be carefully considered in partially edentulous patients.
Title: Assessment of Survival Rate of Dental Implants in Patients with Bruxism: A 5-year Retrospective Study
Source: Contemp Clin Dent. 2018 Sep; 9(Suppl 2): S278–S282.
Type: retrospective study
Keywords: Bruxism, decementation, dental implant
Purpose: To assess complications in dental implants in bruxism patients.
- 5-year study including 450 patients with a total of 640 implants Ø 24 patients had bruxism habits:
- complaints of tooth grinding or tapping sound at night
- confirmation of masseter muscle hypertrophy on voluntary contraction during clinical examination
- hypersensitivity of teeth to cold air
- clicking sound in temporomandibular joint movements
- presence of masticatory muscle fatigue or stiffness in the morning
- radiographs or patients’ records were evaluated for the presence of complications such as fracture of implant, fracture of ceramic, screw loosening, screw fracture, and decementation of unit Results:
- NSSD between cement or screw retained restorations o complications were seen in 145 screw-type and 130 cemented-type fixations o absent in 260 screw-type and 242 cemented-type fixations
- in cemented type of fixation, common complications were: fracture of ceramic > decementation > fracture of implant > screw loosening > screw fracture
- common complications in screw-type fixation were: fracture of implant fracture of ceramic > decementation > screw loosening > screw fracture > fracture of implant
- SSD between complications in types of prostheses o complications were seen in 45 single crowns, 125 partial prostheses, and 105 complete prostheses
- absent in 112 single crowns, 210 partial prostheses, and 180 complete prostheses
- Survival rate of dental implants with bruxism habit was 90%-92% after 1 year, 87%-90% after 2 years, 85% after 3 years, 75% after 4 years, and 70-72% after 5 years o Survival rates were slightly higher in females, but NSSD Conclusions:
- found that the common complications were fracture of implant, fracture of ceramic/porcelain, screw loosening, screw fracture, and decementation.
- the most common complication was fracture of porcelain
- overload caused by bruxism may result in failure of implant-supported prostheses
Title: Bruxism and Dental Implants: A Meta-Analysis.
Source: Implant Dent. 2015 Oct;24(5):505-16
Keywords: dental implants, bruxism, implant failure rate, meta-analysis
Purpose: To compare the survival rates of dental implants, postoperative infection, and marginal bone loss of dental implants inserted in bruxers and non-bruxing patients.
- Implant failure was defined as the complete loss of an implant
- They were able to extract the following data: days of antibiotic prophylaxis, mouth rinse, implant healing, failed and placed implants, post-op infection, marginal bone loss, bruxism definitions, implant surfaces, jaws, type or restoration, opposing dentition.
- 10 publications in total were used for this systematic review.
- 760 implants were inserted in bruxers with 49 failures, a 6.45% failure rate
- 2989 implants were placed in non-bruxers with 109 failures, a 3.65% failure rate
- Meta-analysis- the insertion of dental implants in patients being diagnosed with bruxism affected implant failure rates, a relative risk of 2.93 was found. The insertion of implants in bruxers increases the risk of implant failure by 193% compared to non-bruxers.
- No meta-analysis was available for post-op infection, or marginal bone loss.
Discussion: Due to the limited number of published studies, this study cannot suggest that implant therapy in bruxers will affect implant failure rate. The real effect of bruxing habits on osseointegration and survival of implants is not well established.
Topic: occlusal adjustments
Title: Repair of peri-implant bone loss after occlusal adjustment: a case report
Source: J Am Dent Assoc. 2014 Oct;145(10):1058-62
Type: Case report
Keywords: Peri-implantitis, peri-implant bone loss, occlusion and dental implants, bruxism and dental implants, occlusal overload and dental implants, occlusal adjustment and dental implants
Purpose: To review a case were bone loss around an implant was treated non-surgically with occlusal adjustments. Case Report:Straumann implant placed at site #30 in 2009. patient was female, 60 years old and had a history of bruxism. 1 year later clinically and radiographically appeared good and stable. 2 years later in 2011, #29 was extracted, the site healed and then a 2nd implant was placed at #29. 1 year after #29 implant was placed radiographic findings found #30 implant had increase in pocket depth by 1mm to a PD of 4mm. Signs of bleeding on probing were absent and the gingival margin was at the level of implant crown and no excess cement. Blue occlusal paper revealed a heavy occlusion on #30 working and nonworking inclines. once occlusal adjustments were made, patient returned 5 months later. radiographs showed bone repair and clinically 1.5mm recession on lingual and 1 mm recession on buccal.
Conclusion: Radiographic evidence of bone repair once occlusal adjustments is made to an implant with heavy occlusion and marginal bone loss. Although the case does not present peri-implantitis with traditional symptoms such as bleeding on probing and deep pockets.
Title: Implant use in growing patients. Treatment planning concerns..
Source: Dent Clin North Am 1998;42(1):1-34.
Type: Discussion article:
Keywords: age, growth, wrist
- Maxillary growth: the midface grows in a downward and forward direction relative to the anterior cranial face. Maxillary growth occurs as a result of both passive displacement and enlargement.
- The average size of the dental arches is generally greater in males than in females. Female growth is nearly completed by age 15 and males growing is longer (age 17 to 19) and at a greater rate.
- Tooth eruption and alveolar growth must be viewed as a negative factor in the placement of DI.
- Implants in boys should be delayed longer than in adolescent girls.
- The increase of alveolar height continue with eruption of the permanent incisors
- The mandible grows downward and forward.
- The mandible grows in length by growth at the condyle and ramus.
- To accommodate posterior tooth eruption, the body of the mandible increases in length by resorption on the anterior aspect of the mandible and deposition on its posterior aspect.
- As the mandible increases in length, it also increases in posterior width because of its V shape.
- Girls generally erupt their teeth 2y earlier than boys.
- Generally when the girls start menstruation, their growth is nearly complete. By age 15, most girls have nearly completed their growth, where areas many boys continue to grow into their early 20’s.
- The longer growth period for males results in more prominent lower jaw and straighter profile seen in males.
- There is no totally reliable indicator as to when growth has ceased. In fact long term studies indicate that growth never stops but continuous throughout life in the same direction as in adolescence but at a much reduce rate.
- Long bone growth, particularly in the bones in the hand and wrist, is an indicator commonly used to male an educated guess of the status growth of the pt.
Topic: Dental implants and children
Title: Osseointegrated dental implants in growing children: a literature review.
Source:. J Oral Implantol 2014. Oct;40(5):627-31.
Keywords: osseointegration; dental implants; children
Purpose : to review current literature of placing dental implants in young patients and discuss potential risks involved placing implants in jaws that are still developing.
Discussion: Two primary concerns: If implants are present during several years of facial growth, do they face a danger of becoming embedded, relocated, or displaced as the jaws grow? Second concern is the effect of prosthesis on growth. Implants cannot participate in maxillary growth due to behaving similar to ankylosed teeth leading to unpredictable implant dislocations or maxillary growth disturbances. The maxilla resorbs at the nasal floor and the anterior surface leading to implant dislocations in the vertical and anteroposterior direction. In the mandible, transversal and skeletal changes are less dramatic. Posteriorly, changes occur in late childhood with anteroposterior, transverse, and vertical growth. Rotational growth also occurs causing vertical alterations. The anterior mandible however seems to have smaller alveolar growth. Patients with severe hypodontia, the anterior mandible may be the most suitable site of implant placement.
Timing of dental implant placement seems to be safest during declining adolescent growth curve or near adulthood. Other aspects to consider include individual status of existing dentition, functional status, phonetics, and esthetics.
Survival rates show higher for mandibular (91-92%) vs. maxilla (71-86%). Anterior maxillary implants were 2.8 times greater chance to fail than those placed in the anterior mandible.
Conclusion: Implant location, sex of patient, and skeletal maturation level are the most important factors in the final decision of when to place implants. It is still recommended to wait for the completion of dental and skeletal growth except for severe cases of ectodermal dysplasia.
Topic: Implant placement in young individuals
Title: Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement
Source: Int J Oral Maxillofac Implants 2006 Nov-Dec;21(6):867-78
Keywords: alveolar process, dental esthetics, dental implants, facial growth, jawbone, orthodontics, puberty
Purpose: Osseointergrated implants do not follow changes in the alveolar processes caused by displacement, remodeling, mesial drift of the jawbones, and continues eruption of adjacent teeth. This results in a significant risk of a less favorable esthetic and/or functional outcome. This review aims to explain these phenomena and provides some guidelines for timely implant placement.
Discussion: The replacement of teeth lost in children can be an important indication for early implant therapy. Osseointergrated dental implants behave like ankylosed teeth. Skeletal growth in the close vicinity around implants are slowed down, whereas they continue at normal pace elsewhere, leading to an observation of bony defects, occlusal scheme dysfunctions, and adjacent tooth complications.
Facial growth of the child and even of the adolescent, as well as the continuous eruption of the adjacent anterior teeth, create significant risk of a less favorable esthetic and/or functional outcome.
Jaw bone growth: Both the mandible and the axilla follow a distinct chronology: growth is first completed in the transversal plane, then in the sagittal plane, and finally, only at a later stage, in the coronal plane. The growth of the mandible is closely associated with growth in stature, whereas growth for the maxilla is more associated with growth of the cranial structures.
Maxilla: intercanine arch width increases minimally after 10 years (0.9mm average), sagittal growth of maxilla typically is resorptive therefore implants placed in the anterior maxilla can come across the complication of buccal plate resorption and implant dehiscence, vertical growth of maxilla persists to 17-18 years of age in females, perhaps longer for males therefore until the age of 18 (approx.) there may be vertical plane issues.
Mandible: transverse growth completes early in anterior region whereas continue substantially in premolar and molar region, therefore if implants are placed in that region before growth cease implants could result lingually, vertical growth is substantial for mandible and is therefore can be affected by presence of dental implants. For patients with a normal facial profile, the placement of an implant should be postponed until skeletal growth is complete. For patients with a short or long face type, further growth, especially the continuous eruption of adjacent teeth, creates a serious risk even after the age of 25 years.
Conclusion: In order to determine proper timing for implant placement in adolescents/young adults it was suggested to examine:
- Continuous eruption should be considered and evaluated not only in adolescences but also adulthood when implant therapy is treatment planned.
- Lack of proper occlusion due to jaw growth may compromise oral rehabilitation using implant supported protheses and unesthetic situations can occur, especially in the anterior region.
- timeframe for the development of the alveolar process can vary widely, especially in the case of long or short facial types.
- For patients with a normal facial profile, the placement of an implant should be postponed until growth is complete.
- For patients with a short or long face type, further growth, especially the continuous eruption of adjacent teeth, creates a serious risk even after the age of 20 years.
Topic: Treatment planning- Skeletal growth
Title: Determining the cessation of vertical growth of the craniofacial structures to facilitate placement of single-tooth implants.
Source: Am J Orthod Dentofacial Orthop. 2007 Apr; 131 (4 Suppl):S59-67
Type: Retrospective study
Keywords: dental implant; cephalograms; puberty; facial skeleton growth
Purpose: To determine and quantify the amount of vertical growth of the facial skeleton and the amount of eruption of the central incisors and the maxillary first molars after puberty
- 301 of 645 subjects selected: each subject had pretreatment, end of treatment, at least 10 year post treatment
- Patients divided into 2 samples: males (142) and females (159)
- Two or 3 lateral cephalograms taken at pretreatment, posttreatment, and 10 years post retention
- landmarks were identified on the lateral ceph and two planes were created: palatal and mandibular
- total change in anterior face height was assessed (distance from nasion to menton) along with the amount of eruption between maxillary and mandibular central incisors and molars (distance from incisal edge to palatal plane or mandibular plane)
- chi square test performed to evaluate differences in distribution of Angle classification and extraction treatment alternative
- Linear regression models were used to determine changes in the parameters with increasing age
- In males, anterior facial height increased 9.4mm during the observation time
- 50% of the increase occurred before age 15
- In females, anterior facial height increased 4.3mm during the observation time
- 40% of the increase occurred before age 15
- For both sexes, 60-70% of anterior facial height increase occurred in the lower anterior facial height
- In males, the total eruption of maxillary incisors was 2.0mm
- 50% of the eruption occurred before age 15
- In males, the total eruption of the mandibular incisors was 5.0mm
- 46% of the eruption occurred before age 15
- In females, the total eruption of the maxillary incisors was 2.7mm
- 44% of the eruption occurred before age 15
- In females, the total eruption of the mandibular incisors was 2.4mm
- 33% of the eruption occurred before age 15
- In males, the total eruption of maxillary molars was 4.0mm
- 5mm of the eruption occurred before age 15
- In females, the total eruption of the maxillary molars was 1.7mm
- 65% of the eruption occurred before age 15
- The growth of the facial skeleton is a continuous process which increases around puberty but then decreases with time – especially after 20 years old
- increase in anterior facial height due to vertical growth is rapid during the teens
- there is a difference in the amount of growth between the sexes during the second decade of life
- the rate of eruption of the maxillary central incisors in females is greater than in males.
Topic: Implant age
Title: Adult Growth, Aging, and the Single-Tooth Implant
Source: Int J Oral Maxillofac Implants 2000 Mar-Apr;15(2):252-260.
Keywords: adult growth, aging, single tooth implant
Purpose: Review the research on changes due to growth and aging in the adult face, arches, and dentition and relate these to the effect of those changes on a single tooth implant prosthesis.
- Soft Tissue Changes: Cranium is nearly the young adult size by 7 or 8 years. Most of the changes that occur in the face happen due to the downward and forward growth of mandible relative to the maxilla as well as the increased size of the frontal sinuses and nose. The face will continue to grow throughout adulthood due to age (sagging and wrinkling), physical, and environmental (smoking, sun exposure) factors. For soft tissue the ears grow, eyebrows become lower and more prominent, and the nose becomes longer and more angulated. The upper and lower lips with increase in length, decreasing maxillary incisor exposure, increasing mandibular incisor exposure and decreasing vermillion lip exposure.
- Bony Changes: Bony changes associated with soft tissue changes are due to remodeling because sutures are fused earlier in life. There is growth in the anterior and posterior direction with most growth occurring in the lower face. Males show a greater increase in posterior height than females, who have equal growth posterior and anteriorly. Tooth loss will affect facial growth, but only with multiple teeth. The chin in males grows more horizontally, while in females it grows more vertically. No changes seen in glenoid fossa.
- Dentition Changes Maxillary incisors upright themselves pushing their roots more labially by around 2-3 degrees. Maxillary molars upright, as do mandibular molars in males but show mesial tipping in females. The arch depth and shape will decrease over time about 0.6-1.6mm causing crowding and an increase in the Curve of Spee forming a squarer arch shape.
- Implant Consideration Males should be considered questionable implant candidates until the age of 25, and females should be considered questionable until at least age 17 keeping in mind the potential for growth during childbearing years long term. The movement of maxillary anterior teeth could show a change in implant position compared to natural teeth after 2 decades or more. The mandible will show the greatest change in implant position compared to natural teeth due to movement of the teeth in a protrusive and vertical direction as well as crowding that occurs over time. The vertical growth seen in natural teeth in the posterior could lead to an implant crown being out of occlusion after several decades but wear of natural dentition could reverse these effects and possibly damage the implant itself.
Conclusion: Effects of growth and aging are normally subtle and occur very slowly but can be substantial in highly growing patients. Pretreatment counseling may be needed to explain implant crown modifications or replacements after 2 or more decades due to these changes in growth.
Title: Effect of Age on Single Implant Submersion Rate in the Central Maxillary Incisor Region: A Long-Term Retrospective Study
Source: Clinical Implant Dentistry and Related Research, Volume 17, Number 3, 2015
Type: Retrospective Study
Keywords: age, dental implants, long term, submersion rate
Purpose: to evaluate the effect of age on the mean submersion rate of single dental implant, replacing a central maxillary incisor, placed after growth has ceased, as compared with the adjacent incisor natural tooth.
Methods: the retrospective study was conducted on patient’s files who received a single implant to replace a missing maxillary anterior tooth from 1992 to 2008. The study included 35 patients with a mean age of 29 years at implant placement, 14 of which were females. Criteria of patient selection:
- Missing maxillary central incisor between two natural teeth
- With clinical and radiographic follow-up of at least 3 years.
Most of implants were placed by one operator whereas 10 implant placements were placed by various others. Mean follow up time was 7.5 years and patients were divided into two groups according to the age at time of implant placement: <30 and >30 years old. Photos from the last follow-up were used to assess the change in the vertical dimension between the incisal edges of the implant supported crown of the missing central and the adjacent natural central incisor, considering that the restoration was performed at the same incisal level. Images were digitally analyzed using Image J software and due to the lack of scaling and uniformity of the photos, the mean submersion rate was defined in terms of percent of crown occlusal-gingival length per year.
Results: Implant submersion rates were o.48 for males and 0.82 for females. Results were not SSD (p=.087).
Discussion: The results of the present research suggest that whereas implant submersion continues throughout adult life its mean rate varies with age. It is evident that this phenomenon is much more conspicuous during the second and third decades of life as compared with the fourth and fifth.
Conclusion: The continuous submersion of the implant crown would result in pocketing and inflammation due to the continuous eruption of the adjacent teeth leading to shifting of the bacterial population and dominance of anaerobic bacteria. Changing the implant crown may not be biological efficient but will be esthetically important. Free gingival grafts to correct the problem can be beneficial.
Topic: Age at placement
Title: Thematic Abstract Review: Implants and the Spectrum of Aging.
Source: Int J Oral Maxillofac Implants 2017 Sep/Oct;32(5):965-968
- Oral health care needs of the elderly, continue to be seen as being largely unmet.
- No consistent definition of “elderly” exists, but 65 years of age is a common cutoff in the literature
- Subclassifying into three groups: functionally independent, functionally dependent, and institutionalized.
- With advanced age, ability to perform tasks of daily living declines. Need for assistance rises. Within a dental context, poor oral health status due to limited ability to perform oral self-care or to access professional dental services.
- The increasing need to rely on substitute decision makers and restricted wheelchair access are also factors that may become barriers to the access of qualified dental care services.
- Mean age of patients receiving implants appears to be rising. Researchers found that the overall age- at-treatment distribution is shifting to the right. Elderly patients (defined in this study as older than 70 years of age) constituted 7.7% of the treated patients in 2002 to 2004 time period, 11.0% of the treated patients in the 2008 to 2010 time period, and 21.0% of the treated patients in 2014.
- Compared with an average person, bone quality and quantity are likely compromised in the elderly, while implants and prostheses in elderly people are likely subjected to increased plaque burden but decreased masticatory forces.
- Systematic review (Srinivasan et al): The elderly cohort was defined as ≥ 65 years of age. After a thorough search, 11 studies were included in the analysis. The mean age of patients in most studies was 65 to 70 years. Only two studies focused on those older than 80 years of age. The random effects model revealed that 1-year, 3-year, 5-year, and 10-year postloading implant survival rates were 97.7%, 96.3%, 96.2%, and 91.2%, respectfully.
- Hoeksema et al: elderly patients with implant-supported overdentures and those with remaining teeth performed better on a range of survey parameters than completely edentulous elderly patients with conventional prostheses.
- Removable implant-supported restorations need to be designed so that retention can be lessened to account for decreased hand strength and dexterity.
- Fixed implant-supported restorations need to be designed so that, if necessary, they can be converted to removable alternatives later in life.
- A recent randomized controlled trial (RCT) (Merz et al) examined attitudes toward dental implant treatment in a geriatric institutionalized: Overall, approximately 20% to 25% expressed willingness to receive implants. Not ready to undergo dental implant treatment, cost (78.4%) and fear of surgery (43.1%) were found to be the primary reasons for their decision.
- Research focusing on dental implant care in the elderly is challenging, especially in the very elderly. Enrollment in intervention studies can be complicated by significant health compromise. Duration of follow-up can be significantly limited by a high dropout rate due to loss of independence and mobility, heath decline, and mortality.
- The overall impression is that the success of implant therapy per se is unaffected by aging and that the elderly can and do greatly benefit from the support and retention provided by the osseointegrated implants. However, access to qualified dental care providers who are experienced in delivering dental care services -including dental implant services- to the elderly cohort may be limited.
- Educational and research efforts should focus on reducing barriers to dental treatment in this vulnerable population group. The elderly with functional, cognitive, and health compromises are particularly likely to benefit from effective treatment approaches that are expedited, minimally invasive, and economic.
Topic: AGE AT PLACEMENT
Title: Influence of Age on Clinical Performance of Mandibular Two‐Implant Overdentures: A 10‐Year Prospective Comparative Study
Source: Clin Implant Dent Relat Res. 2016 Aug;18(4):745-51.
Type:10 yr prospective comparative study
Purpose: The aim of this prospective comparative study was to assess whether age has influence on peri‐implant health in patients treated with mandibular two‐implant overdentures during a 10‐year evaluation perio
Methods: A prospective study was carried out with two groups of edentulous patients, viz a younger (n = 52; mean age 45 years, 35–50 years) and an older (n = 53; mean age 68 years, 60–80 years) group. In all patients, two dental implants were placed in the interforaminal region of the mandible and after a 3‐month healing period overdentures were fabricated. Clinical and radiographic parameters were evaluated immediately after completion of the prosthetic treatment, and after 1, 5 and 10 years. Implant loss, plaque index, gingival index, bleeding index, and probing depth were assessed as clinical parameters. Peri‐implant bone loss was assessed on dental radiographs made with a standardized long‐cone technique with a direction device.
Results: Implant survival after 10 years was 97.1% and 93.4% in the younger and older group, respectively. Ten‐year scores of plaque, gingiva, and bleeding were between 0 and 1 for both groups (possible scores 0–3), and mean probing depth was 3 mm in both groups. Mean peri‐implant bone loss after 10 years was 1.2 and 1.4 mm in the younger and older patients, respectively. No significant differences were observed between the groups.
Discussion: Clinical performance of mandibular two‐implant overdentures is equally successful in younger and older patients.
Topic: Evaluation of dental implants in an aged population.
Title: Dental Implants in an Aged Population: Evaluation of Periodontal Health, Bone Loss, Implant Survival, and Quality of Life.
Source: Clin Implant Dent Relat Res. 2015
Keywords: bone changes; elderly patients; implant survival; medications; periodontal health; quality of life
Purpose: To evaluate aged partially and fully edentulous patients who received dental implants and were maintained over time.
- Patients from 66 and 93 years of age.
- Bone grafting or sinus lifting were not performed.
- 15 males from 78 and 89 years old.
- 16 females from 66 to 93 years old.
- All implants were manufactured by Nobel Biocare.
- Thirty implants were placed using a flapless approach.
- 35 placed with a flapped two-stage approach.
- 19 were placed with a flapless immediate implant protocol.
- 54 implants were placed in maxilla with a loss of two.
- 30 implants were in mandibles with loss of two.
- Of the 31 patients, 3 have deceased, 2 are in living nursing homes, and 2 patients could not be located.
- 25 patients were evaluated in this study.
- The radiographic measurements were taken at the second stage appointment, prior to implant restoration and at the longest follow-up evaluation.
- Non-standardized parallel long cone periapical radiograph was taken.
- Mesial and distal bone levels were measured using Image J.
- Periodontal evaluation was based on Periodontal Disease Index
- For natural teeth, probing depth, plaque, bleeding on probing, and mobility were evaluated.
- Blinded 7 question quality of life questionnaire was sent to all patients.
- Descriptive statistics were used to compare changes in clinical measurements.
- Kaplan–Meier survival probabilities were used to determine the implant survival.
- The mean probing depth for 25 examined were statistically insignificant.
- Comparison of measured bone levels between a previously reported control group was made with the aged group for implant length and width, crestal bone levels at implant insertion, and longest follow-up and change in bone height.
- Changes between control and aged groups were significant only for implant diameter .
- Most patients classified themselves as having a good quality of life with minimal distress from eating, relaxing, and socially engaging.
- 15 patients did not perceive a change in quality of life.
- 8 had improvement oral health.
- 8 out of 33 of the patients were lost to follow-up.
- 6 to 7-year follow-up the implant survival rate was 94.6%. (Assumes patients lost to follow-up have not lost implants).
- Implants placed in an aged population have excellent clinical outcomes in terms of implant survival and maintenance of periodontal health with minimal long-term loss of interproximal bone levels.
- With careful diagnosis and treatment planning, aged patients are excellent candidates for dental implants.
- Caution must be exercised, as many of these patients are taking multiple medications.
Topic: Implants in aged patients
Title: Effect of advanced age and/or systemic medical conditions on dental implant survival: A systematic review and meta‐analysis
Source: Clin Oral Implants Res. 2018 Oct;29 suppl 16:311-330.
Background: In the scope of this review, geriatric patients were defined as patients with an age of 75 years and above.
Objective: The aim of this systematic review was to screen and pool the available evidence to establish: 1. The dental implant survival rate in geriatric patients. 2. The potential impacts of the most common systemic medical conditions (WHO, 2015) and their treatments on implant survival.
The focused question set for this systematic review was “In patients undergoing dental implant therapy, what is the effect of advanced age (≥75 years) and/or common systemic medical conditions on the implant survival, biological complication, and technical complication rates?” Dental implants that satisfied inclusion criteria were included in the first part of this systematic review, which analyzed implant survival.
Therefore, outcomes in healthy aged people were also sought. Exclusion criteria:
- Age <75
- years One‐piece implants, Zygomatic implants, and pterygoid implants
- Post-loading follow‐up <12 months
- Narrow diameter implants or mini dental implants (implants with diameter <3 mm)
- Implants with turned or machined surface
For the second part of this search, no age limit was applied, as a preliminary screening of the literature did not identify any studies in relation to the most common medical conditions in the elderly (WHO, 2015) if the exclusion criteria included those aged 75 years or older.
Articles sources were MEDLINE (PubMed), online internet search engines (e.g., Google and Yahoo), research community websites on the internet, reference cross‐checks, personal communications, and hand searches. Hand searches in dental journals were only performed for records not available electronically or without an electronic abstract
Results: 46 relevant articles were shortlisted for inclusion in the review. After subsequent hand searches, reference cross‐checks, and information from other sources and authors, an additional 16 articles were identified.
First part: Patients who are 75 years and older showed high implant survival rates.
Second part: Medical conditions and their treatment:
Cardiovascular disease (including ischemic heart disease, stroke, hypertensive heart disease): Implant survival in relation to CVD or associated treatment was reported in two studies. In particular, one article reported a higher survival rate of implants in patients treated with antihypertensive therapy. In contrast, a second article did not find an influence of hypertensive heart disease on implant survival.
Seventeen studies were identified which met the inclusion and exclusion criteria, most investigators reported a time lapse between radiotherapy and implant placement of more than 12 months; however, some utilized a shorter delay.
Antiresorptive therapy (ART) may be associated with medication‐related osteonecrosis of the jaw (MRONJ), however, in studies of osteoporotic patients managed with ART, reported implant survival rates were predominately high. The prevalence of MRONJ in these patient cohorts was rarely specified.
Calculated survival rates were reported to range from 86.3% (24‐month observation period) to 100% (12 months). Poor control (HbA1c ≥ 8.0%) may have an influence.
Neurocognitive impairment (unipolar depression, Alzheimer’s disease and other dementias, and Parkinson’s disease)
One study reported higher implant failure rates in patients taking selective serotonin reuptake inhibitors for depression compared to nonusers of SSRIs, Case reports and case series with a limited number of participants reported on patients with Parkinson’s disease with calculated survival rates ranging between 82.1% and 100%.
No articles reporting on implant survival in patients with Osteoarthritis, Cirrhosis of the liver, Respiratory diseases (chronic obstructive pulmonary disease COPD and lower respiratory infections).
This review identified high implant survival rates in geriatric patients aged 75 years and older. Cardiovascular disease:
the current review identified one study that reported the positive impact of antihypertensive drugs on implant survival (Wu et al., 2016). The authors hypothesize that this may be related to the positive effect of such drugs including beta‐blockers, thiazide diuretics, ACE inhibitors, and ARBs on bone metabolism.
The use of head and neck radiotherapy has been associated with a reduced survival rate of implants Antiresorptive therapy and osteoporosis
Dental implant treatment is often contraindicated in these patients because of the strongly increased risk of MRONJ Diabetes:
HbA1c levels above 8% may result in reduced implant survival compared to lower levels.
Conclusion: Implant prostheses in geriatric subjects are a predictable treatment option with a very high rate of implant survival. The functional and psychosocial benefits of such intervention should outweigh the associated risks to common medical conditions.