Implants - Treatment Planning II                                 

HOME           Implant Home  

 Medical History: Effects of Age, Perio compromised patients

Age at Placement (growth);

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

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

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

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

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

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

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

Age at placement (outcome):

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

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

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

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

Periodontal disease

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

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

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

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

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

17. 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.

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

Topic: Skeletal growth and implant placement.

Authors: Oesterle LJ, Cronin RJ Jr.

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

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

Type: Discussion

Rating: Good

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

Maxillary Skeletal Growth

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

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

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

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

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

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

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

Mean growth changes from 4 years to adult:

O = amount of apposition at floor of the orbit.

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

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

R = amount of resorptive lowering of the nasal floor.

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

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

Maxillary Dental Growth

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

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

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

• Anteroposterior Dental Changes.

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

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

• Vertical Dental Changes.

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

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

Maxillary Growth and the Osseointegrated Implant

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

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

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

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

Recommendations for the Placement of Implants in the Maxilla

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

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

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

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

Topic: Age and implant placement

Authors: Cronin RJ Jr, Oesterle LJ

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

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

Type: Discussion article:

Rating: Good

Keywords: age, growth, wrist

Discussion article:

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

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

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

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

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

• The mandible grows downward and forward.

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

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

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

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

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

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

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

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

Topic: Mandibular growth and implants

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

Title: Mandibular implants and the growing patient.

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

Type: Commentary

Rating: Good

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

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

Discussion:

Mandibular Growth Changes:

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

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

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

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

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

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

Recommendations:

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

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

Topic: Age of Placement

Authors: Oesterle LJ, Cronin RJ Jr, Ranly DM

Title: Maxillary implants and the growing patient.

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

Type: Review

Rating: Good

Keywords: dental implants, maxillary growth, osseointegration

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

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

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

Topic: Implants in younger individuals/children

Author: Heij D eta al

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

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

Type: Discussion article

Rating: Good

Keywords: Implants, growing skeleton, implants in children

Discussion:

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

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

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

Topic:  Treatment planning- Skeletal growth

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

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

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

Type: Retrospective study

Rating: Good

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

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

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

Methods:

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

Results:

The findings indicate that

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

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

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

Conclusion:

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

Topic: implants in young pts

Authors: Heuberer S, Dvorak G, Mayer C, Watzek G, Zechner W

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

Source: Clin Oral Implants Res. 2014 Jan 3. doi: 10.1111/clr.12323.

Type: clinical

Rating: good

Keywords: children, growth, young dentition

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

with extensive oligodontia.

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

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

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

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

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

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

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

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

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

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

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

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

Topic: Age

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

Title: Age as compromising factor for implant insertion.

Source: Periodontol 2000 2003; 33:172-184

Type: Review

Rating: Good

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

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

Discussion:

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

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

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

Recommendations by Area

• Anterior Maxilla

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

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

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

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

• Posterior Maxilla

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

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

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

• Anterior Mandible

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

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

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

• Posterior Mandible

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

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

Topic: Implant patient age

Authors: Meijer HJ, Batenburg RH, Raghoebar GM

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

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

Type: Prospective study

Rating: Good

Keywords: Aging, dental implants, geriatric dentistry

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

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

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

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

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

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

Type: Retrospective Cohort

Rating: Very Good

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

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

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

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

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

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

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

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

Topic: Biological Principles                    patient age on single implant submersion

Authors: Scwartz-Arad D, Bichacho N

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

Source: Clinical Implant Dentistry 2013; 1-6.

Type: Retrospective Study

Rating: Good

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

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

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

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

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

Conclusion:

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

Discussion:

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

Topic: Treatment planning        Implants in periodontally compromised patients

Authors: Wennstrom & Lang

Title: Treatment planning for Implant Therapy in Periodontally Compromised Patient

Source:

Type:

Rating: Good

Keywords: treatment planning, prognosis, compromised patient

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

PROGNOSIS OF IMPLANT THERAPY IN PERIO COMPROMISED PATIENTS

Global data on implant survival indicate low incidence of implant loss

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

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

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

STRATEGIES IN TREATMENT PLANNING

Comprehensive clinical and Radiographic exams are the basis for planning

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

POSTERIOR SEGMENTS-

Usually the most severely affected by PD and tooth loss

Tooth Vs. Implant

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

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

What are the patient’s esthetic and functional demands?

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

AGGRESSIVE PERIODONTITIS

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

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

Success is ultimately attributable to high-quality infection control

FURCATION PROBLEMS

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

Single-tooth in Esthetic Zone

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

Topic: Periodontitis vs implant survival

Authors Karoussis IK, Kotsovilis S, Fourmousis I

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

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

Type: Clinical study

Rating: Poor

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


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

Results:

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

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

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

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

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

Conclusion:

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

• Long-term survival rates may exceed 90%

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

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

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

• Insufficient data for patients with aggressive periodontitis at that time

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

Topic: Periodontitis history

Authors: Karroussis, I

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

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

Type: Systematic review

Rating: Good

Keywords: prognosis, periodontally compromised, partially edentulous.

Purpose: to perform a comprehensive and critical review regarding the short-term (<5 years) and the long-term (> 5 years) prognosis of implants placed in periodontally compromised partially edentulous patients.

Methods: Using The National Library Of Medicine and Cochrane Oral Health Group databases, a literature search for articles published up to and including August 2006 was performed. Full papers were screened independently by the three reviewers. The inclusion criteria were as follows: Clinical studies only, Prospective design, Placement of DI in periodontally compromised partially edentulous patients, Completion of periodontal therapy before DI, Follow-up more than 1 year, Report of data revealing implant survival (or success) rate in periodontally compromised partially edentulous pa
tients.


Results: The search provided 2987 potentially relevant titles and abstracts. At the second phase, The full text of the remaining 31 publications was retrieved for more detailed evaluation

Definition of ‘periodontally compromised’ patients: These patients have a history of periodontitis (chronic or aggressive), but no active disease at the time of implant placement.

Implant survival rates

Short-term studies/patients with a history of chronic periodontitis: The implant survival rates was well above 90%, reaching 100% in certain cases. These survival rates are comparable to the mean implant survival rates reported for the general population.

Long-term studies/patients with a history of chronic periodontitis: Implant survival rates are well above 90%, reaching up to 97.32%. Only two studies have reported implant survival rates <90%. In conclusion, the long-term survival rates of implants are comparable to the mean implant survival rates reported for the general population.

Short-term implant survival rates in aggressive periodontitis: It was well above 95%, reaching up to 100%. However, the only available long- term study reported a 5-year implant survival rate of 88.8%. Therefore, the long-term survival of implants in patients treated for aggressive periodontitis still remains open to question and more studies are required.

PD and CAL:

A stability of PPD and CAL (clinical parameters) and peri-implant marginal bone loss (radiographic parameter) around implants has been demonstrated on a short-term basis.

Patients with a history of chronic periodontitis may exhibit significantly greater long-term probing pocket depth, peri-implant marginal bone loss and incidence of peri-implantitis compared with periodontally healthy subjects.

Conclusion: NSSD in both short-term and long-term implant survival exist between patients with a history of chronic periodontitis and periodontally healthy individuals.

Topic: Implants in periodontitis patients

Authors: Ong CT, Ivanovski S

Title: Systematic review of implant outcomes in treated periodontitis subjects.

Source: J Clin Periodontol. 2008 May;35(5):438-62.

Type: Systematic review

Reviewer: Evan Santiago

Rating: Good

Keywords: implants, implant outcomes, periodontal disease, systematic review, treated periodontitis

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

Methods: All longitudinal studies to March 2006 of dental implants in at least 6 months of loading were searched (Med-LINE and EMBASE). Individual case reports were excluded.

Results: Nine studies were included after screening. Periodontally healthy patients overall demonstrated better outcomes than treated periodontitis patients. However the strength of evidence shows that the included studies had a medium to high risk of bias. There was a lack of accounting for confounders, particularly smoking. Studies showed variability in definitions of treated and non-periodontitis, outcome criteria, and SPT. A meta-analysis could not be performed.

Conclusion: Some evidence suggests that patients treated for periodontitis may experience more implant loss and complications around implants than those who were periodontally healthy. Evidence is stronger for implant survival than implant success. Adequate consent should be obtained prior to implant therapy. Systematic and continuous monitoring of the periodontal and peri-implant tissue conditions is suggested to prevent recurrence of periodontal disease and allow early diagnosis and treatment of peri-implant diseases.

Topic: Periodontal Disease

Authors: Mengel R, Flores-de-Jacoby L

Title: Implants in patients treated for generalized aggressive and chronic periodontitis: a 3-year prospective longitudinal study

Source: J Periodontol. 2005 Apr;76(4):534-43.

Type: Clinical

Rating: Good

Keywords: Dental implants; follow-up studies; jaw, edentulous, partially; mouth rehabilitation; osseointegration; outcome assessment; periodontitis, aggressive/therapy; periodontitis/therapy; tooth

Purpose: The aim of the present prospective longitudinal study of periodontally diseased and periodontally healthy patients was a clinical, microbiological, and radiographic comparison of teeth and implants and an assessment of the implant success rate.

Method: 39 partially edentulous patients provided with a total of 150 implants were enrolled in the study. Oral rehabilitation was undertaken in 15 patients treated for generalized aggressive periodontitis (GAP), 12 patients treated for generalized chronic periodontitis (GCP), and 12 periodontally healthy patients. The examinations of the teeth and implants were carried out within the framework of a 3-month recall schedule over a 3-year period. At each session, clinical parameters for probing depth (PD), gingival recession, attachment level (AL), gingival index (GI), and plaque index (PI) were recorded, and the composition of the subgingival microflora determined by dark-field microscopy. In the periodontally diseased patients, Actinobacillus actinomycetemcomitans (A.a.), Porphyromonas gingivalis (P.g.), and Prevotella intermedia (P.i.) were detected at teeth and implants by DNA analysis in the first and third years after insertion of the superstructure. Intraoral radiographs of the teeth and implants were taken at baseline, immediately after insertion of the superstructure, and then 1 and 3 years later.

Results: At the implants and teeth, a slight increase in PD and a continuous attachment loss was recorded in the GAP patients. The attachment loss was greater at the implants than at the teeth in all groups. The morphological distribution of the microorganisms revealed virtually healthy conditions in all groups. A.a. was detected in two GAP patients, whereas P.g. and P.i. were found more frequently both in the GAP and in the GCP patients. Radiographically detected bone loss was higher after 3 years at implants and teeth in the GAP patients than in the other two groups. The implant success rates recorded were 100% in the periodontally healthy and GCP patients, and 95.7% in the maxilla and 100% in the mandible of the GAP patients.

Conclusion: The results show that oral rehabilitation can be performed with implants in patients treated for generalized aggressive and chronic periodontitis. However, slight attachment loss and bone loss were registered at the implants and teeth in the patients with aggressive periodontitis.

Topic: Implants in aggressive periodontitis

Author: Kim KK, Sung HM.

Title: Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: a systematic review.

Source: J Adv Prosthodont. 2012 Nov;4(4):210-7.

Type: Systematic review

Rating: Good

Keywords: Implants, aggressive periodontitis

Purpose: The purpose of this study was to analyze the current literatures and assess outcomes of implant treatment in patients with generalized aggressive periodontitis.

Methods: Studies considered were searched in Pub-Med. The literature search for studies published between 2000 and 2012. Findings included literature assessing implant treatment in patients with a history of generalized aggressive periodontitis. The outcome measures were survival rate of restorations, marginal bone loss around implant and survival rate of implants. All studies were divided into two follow-up period: short term study (< 5 years) and long term study (≥ 5 years).

Results: Seven prospective studies were selected, including four short-term and three long-term studies. The survival rates of the restorations were generally high in patients with generalized aggressive periodontitis (95.9 - 100%). Marginal bone loss around implant in patients with generalized aggressive periodontitis as compared with implants in patients with chronic periodontitis or periodontally healthy patients was not significantly greater in short term studies but was significantly greater in long term studies. In short term studies, the survival rates of implants were between 97.4% and 100% in patients with generalized aggressive periodontitis-associated tooth loss, except one study. The survival rates of implants were between 83.3% and 96% in patients with generalized aggressive periodontitis in long term studies.

Conclusion: Implant treatment in patients with generalized aggressive periodontitis is not contraindicated provided that adequate infection control and an individualized maintenance program are assured.

Topic:  Treatment planning

Authors:  Roccuzzo M, Bonino L, Dalmasso P, Aglietta M.

Title: Long-term results of a three arms prospective cohort study on implants in periodontally compromised patients: 10-year data around sandblasted and acid-etched (SLA) surface.

Source: Clin Oral Implants Res. 2013 Jul 19. doi: 10.1111/clr.12227. [Epub ahead of print] 

Type: Prospective Cohort study

Rating: Good

Keywords: biological complications, CIST, dental implants, implant failure, peri-implantitis, periodontally compromised patients, periodontitis, SLA surface, supportive periodontal therapy, survival, tooth loss

Purpose: To compare the long-term outcomes of sandblasted and acid etched (SLA) implants in patients previously treated for periodontitis and in periodontally healthy patients (PHP).

Methods: 149 partially edentulous patients were consecutively enrolled in private specialist practice and divided into three groups according to their periodontal condition: PHP, moderately periodontally compromised patients (PCP) and severely PCP. Implants were placed to support fixed prostheses, after successful completion of initial periodontal therapy. At the end of active periodontal treatment (APT), patients were asked to follow an individualized supportive periodontal therapy (SPT) program. Diagnosis and treatment of peri-implant biological complications were performed according to cumulative interceptive supportive therapy (CIST). At 10 years, clinical and radiographic measures were recorded by two calibrated operators, blind to the initial patient classification, on 123 patients, as 26 were lost to follow up. The number of sites treated according to therapy modalities C and D (antibiotics and/or surgery) during the 10 years was registered.

Results: Six implants were removed for biological complications. The implant survival rate was 100% for PHP, 96.9% for moderate PCP and 97.1% for severe PCP. Antibiotic and/or surgical therapy was performed in 18.8% of cases in PHP, in 52.2% of cases in moderate PCP and in 66.7% cases in severe PCP, with a statistically significant differences between PHP and both PCP groups. At 10 years, the percentage of implants, with at least one site that presented a PD ≥ 6 mm, was, respectively, 0% for PHP, 9.4% for moderate PCP and 10.8% for severe PCP, with a statistically significant difference between PHP and both PCP groups.

Clinical parameters around implants at 10 years follow up irt SPT

Conclusion: This study shows that SLA implants, placed under a strict periodontal control, offer predictable long-term results. Nevertheless, patients with a history of periodontitis, who did not fully adhere to the SPT, presented a statistically significant higher number of sites that required additional surgical and/or antibiotic treatment. Therefore, patients should be informed, from the beginning, of the value of the SPT in enhancing long-term outcomes of implant therapy, particularly those affected by periodontitis.