Oreste Iocca


Implant Dentistry


Evidence-Based Implant Dentistry

Oreste Iocca

Evidence-Based Implant

Oreste Iocca
International Medical School
Sapienza University of Rome
Rome, Italy

Private Practice Limited to Oral Surgery
Periodontology and Implant Dentistry
Rome, Italy

ISBN 978-3-319-26870-5 ISBN 978-3-319-26872-9 (eBook)
DOI 10.1007/978-3-319-26872-9

Library of Congress Control Number: 2016954323

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and the implant specialists who wish to have an update on various implantology topics. treatment algorithms are drawn in order to facili- tate the decision-making process. the processes of osseointegration. Chapter 10 covers the topic of pre-implant surgery. The materials and designs of abutments and prostheses are analyzed in a way to facilitate the clinical decision-making. The first two chapters are intended to describe the bibliographic tools used for literature searches and the most common statistical concepts necessary to fully understand the medical and dental literature. bone remodeling after dental extraction and subsequent implant placement. A schematic approach is adopted in the analysis of the various clinical scenarios. Chapter 4 focuses on bone response to implant surfaces. implant length. A review of the outcomes of implants placed in infected sites is also provided. and platform configurations in an attempt to establish their impacts on clinical outcomes. Careful review of all the possible surgical options for the edentulous patient is performed and is accompanied by a rich iconography. Chapters 8 and 9 examine the various prosthetic solutions for implant res- toration. and proposed treatment options for the most worrisome long-term complica- tion of the implant treatment: periimplantitis.Preface The information provided in this book are the result of an evidence-based approach to the dental implant literature with the aim to analyze the most common dilemmas faced by the clinicians who adopt dental implants in their practice. Chapter 11 is intended as a review of the pathogenesis. the general practitioners. Chapters 6 and 7 give an organized classification of implant designs. and the definition of implant stability and its clinical impli- cations. Our work is directed to the students. Chapter 5 provides a description of the various placement and loading protocols in order to establish if any difference exists in terms of survival and success rates between the various protocols. Acknowledging that a consen- v . clinical aspects. Chapter 3 analyzes the old dilemma in regard to extraction or implant placement. Finally.

DDS . an analysis of the proposed management strategies and results is attempted. Italy Oreste Iocca. Rome. I hope that our work will be useful for the colleagues in search of evidence- based answers to their questions and also as a refresh to the most frequent topics in current implantology practice.vi Preface sus on this topic is far to be reached.

vii . José Pardiñas Arias and Dr. which contributed enormously to enrich the iconography of the book. Carmen López Prieto for sharing some of their clinical cases. to Rekha Udaiyar and Selvaraj Suganya at SPi Technologies for their attention in bringing this book to publication.Acknowledgments The Editor is grateful to Tanja Maihoefer at Springer. The Editor also expresses his deep appreciation to Dr.


. . . . . . . 59 Oreste Iocca 5 Implant Placement and Loading Time . and Mohammad H. . . . . . . . . . . . . . . . . . . Giuseppe Bianco. . . . . . 125 Oreste Iocca 9 Implant Prosthodontics . . . . . . Giuseppe Bianco. . . 33 Oreste Iocca. . . . . . . . . . . . . . . . . . . .Contents 1 Introduction to Evidence-Based Implant Dentistry. . . Eduardo Anitua. . . . . and Simón Pardiñas López 10 Pre-Implant Reconstructive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Oreste Iocca. . . . . 229 Oreste Iocca and Giuseppe Bianco ix . . . . . . . . . . . . . . . . . . . . . and Simón Pardiñas López 4 Bone Response to Implants . . . . . . . . . . . . . . . . . . . . . . . 171 Simón Pardiñas López. 83 Oreste Iocca and Simón Pardiñas López 6 Implant Design and Implant Length . . . . . . . . . . . . . . . . . . . . 97 Nicholas Quong Sing 7 Platform Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Giovanni Molina Rojas and David Montalvo Arias 8 Implant Abutments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Oreste Iocca 2 Basics of Biostatistics . . . . . . . 19 Oreste Iocca 3 Teeth or Implants? . . . . . Alkhraisat 11 Peri-implantitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


DDS. PhD Division of Clinical Dentistry. Apa Aesthetic and Cosmetic Center. Galicia. Dubai. Apa Aesthetic and Cosmetic Dental Centre. DDS International Medical School. Biotechnology Institute. MD. DDS. PhD Center Polispecialistico Fisioeuropa. Trinidad and Tobago xi . Implant and Cosmetic Dentistry. Carenage. Dubai. Sapienza University of Rome. Clinica Eduardo Anitua. Rome. Periodontology and Implantology. DDS. cert OSOM Dental Smiles Ltd. Clínica Pardiñas. Alkharaisat. FFD OSOM. Vitoria-Gasteiz. Spain Eduardo Anitua. BDS. A Coruña. DDS Prosthodontics. Victoria-Gasteiz. Periodontology and Implant Dentistry. PhD Oral Surgery and Implantology. Spain David Montalvo Arias. Implant Dentistry. United Arab Emirates Giuseppe Bianco. Rome. DDS Periodontics. MS. DDS. MFD. United Arab Emirates Nicholas Quong Sing. Italy Oreste Iocca. Viale dell’Umanesimo. LLC. Rome.Contributors Mohammad H. Spain Giovanni Molina Rojas. MS Oral Surgery. Italy Private Practice Limited to Oral Surgery. Italy Simón Pardiñas López.

Basic knowledge of the methodologies used in observational and experimental studies will allow to perform a critical appraisal of the available evidence. the three main components of (EBM) comes from the influential work of Prof. DDS • Appraising the evidence means to possess the International Medical School. O. Viale Regina Elena 324. Evidence-Based Implant Dentistry. Finally. the application of the evidence-based information to the clinical scenario needs a quality assessment of the studies and is possible only when internal and external validity are high. Italy the collected evidence is applied to a specific e-mail: oi243@nyu. • Getting the evidence involves the knowledge of all the instruments available to answer the original question. Introduction to Evidence-Based Implant Dentistry 1 Oreste Iocca Abstract Evidence-based dentistry (EBD) concepts are of extraordinary importance for a good clinical practice. Private Practice Limited to Oral Surgery. The definition of evidence-based medicine Therefore. the scientific evidence. © Springer International Publishing Switzerland 2016 1 O. DOI 10.1007/978-3-319-26872-9_1 . David Sackett who stated that “EBM constitutes and the patient. Rome.1 Evidence-Based Dentistry evidence available. Sapienza University instruments to critically analyze the available of Rome. Evidence-based information comes from electronic databases and hand searches with the use of appropriate bibliographic techniques. 1. EBM are the clinician. 00161 Rome. and the scientific evidence are the three main components of EBD.edu clinical scenario. The clinician.). • Formulating a question means to translate a clin- explicit and judicious use of the best scientific ical doubt into a searchable question format. Good EBM practice articulates in four steps: ical decisions derive from the integration of the doctor’s experience with the conscientious. all of this mediated by the preferences of the patient” [1. a new approach to clinical practice in which clin. Iocca. appraising the evidence. Italy scientific literature. the patient. Iocca (ed. getting the evidence. whose integration involves the application of four steps: formulating of a question. • Applying the evidence is the process by which Periodontology and Implant Dentistry. 2]. and applying the evidence.

and Fig. Usually two additional reviewers (normally experts in their given scientific area) receive Meta Reviews the manuscript at this point. ture). For example. the term evidence-based dentistry (EBD) group of patients that had the implant fracture is now of common use among dental practitio. designed to graphically categorize the quality of The peer-review process ensures quality con- various study designs. highest [4]. including dentistry and its subspecialties. a RCT is not always feasible or indicated. a manuscript which is received by the editor of cation like implant fracture is studied. Cohort Studies Many journals have their own checklists for assessing quality of the manuscript. to measure the odds of exposure among cases cine.). It is evident that a able today. On the contrary. In fact. discussion. particular study design is indicated to answer a The evidence pyramid (Fig. in other words. 1. it should be understood that performing peer review. An author submits ies are preferable. group (implant patients without implant frac- mentioned principles [3]. This process is similar in the majority of the there are situations in which observational stud. If the manuscript is considered for publication.2 O. must be able to understand the extent to which a ing or countering a scientific hypothesis.1) has been specific question. Usually the Meta-Analysis reviewers are unaware of the names of the Systematic authors in order to ensure integrity of the Reviews review process. It can be should be considered useless. we analyze the two groups Nevertheless. retrospectively in order to understand why the cian may encounter difficulties in staying updated rare adverse event occurred in the case group in with the overwhelming amount of evidence avail. mid because they actually give the best evidence. address all the four steps of the good EBD In summary. Iocca All of these factors apply to all fields of medi. Case series mitted (case report. it would be the journal who assesses if the work is suitable better to adopt a case–control design that allows for publication. the actual peer-review process begins. researchers and readers of the scientific literature erly conducted research or study aimed at prov. Indeed. soundness of the results. it needs to be further reviewed. systematic review. randomized clinical trial. defined as the information derived from a prop. study design and methodology. but a specific Case control studies evaluation depends upon the type of study sub- Case reports. Evaluation focuses on Expert opinions title and abstract. RCT in order to identify a rare outcome would Development of specific sets of knowledge not be indicated because a rare complication/dis- spanning from bibliographic research to statisti. Once the reviewers accept to Randomized Controlled Trials review the manuscript. from the lowest to the trol over the evidence-based knowledge. The definition of best scientific evidence by but this does not mean that observational studies itself may generate some confusion. complication (rare outcome cases) and a control ners who are eager to put in practice the above. versus a control group. medical and dental journals. ease may not occur even with long follow-up cal test interpretation is fundamental in order to periods. respect to the control group. RCTs are at the top of the pyra- practice. . if a rare compli. etc.1 Evidence-based pyramid conclusions. a biomedical research is not usually considered Although it is true that the best study design is worthy of consideration until it is not validate by the RCT. 1. In this way. we select a Luckily. even the most scrupulous clini.

indexed in MEDLINE.2 Getting the Evidence from specific clinical scenarios. Comparison nonplatform-switched implant Although subjectivity and biases in the evalu. be incorporated in the everyday practice by the Medical bibliographic databases have the clinicians. PubMed provides links to bone resorption. the process is repeated. the peer-review mecha. The PICO elements can help in formulating a tor. Moreover. accessible by the PubMed users regard- configurations?” less of the sources. A division of the Intervention of interest. In any case. Although answered. Once the question is clearly stated and deemed important for the clinical practice. in detail the Population of interest. Undoubtedly. and if it can because of non-indexed publications. structured question: revising. or therapeu. prognostic. the next step involves the application of defined criteria for the 1. function of large catalogs that points to informa- Framing a good question. PubMed ness of platform switching in reducing or elimi. . For example. Outcome marginal bone resorption in millimeters nism is still considered the best way of performing measured clinically or radiographically high-quality dissemination of the scientific knowledge. In other order to get studies not retrieved by digital sys- words. available studies of interest are conducted mostly A good question is the one that. Information (NCBI). on various medical and biological when compared to nonplatform-switched topics.1 Formulating a Question Unresolved questions.1 Introduction to Evidence-Based Implant Dentistry 3 The reviewers send their evaluation to the edi. who finally makes the decision of accepting. is the most known and used database elements. the National Center for Biotechnology erence against which we compare the intervention. once through the use of electronic databases. if Population patients undergoing implant treatment revision is required (as it usually happens for Intervention platform-switched implant insertion accepted manuscripts). if it can be may not be present in electronic databases) or generalized to a whole population. a question may be related to Most of the researchers are familiar with platform switching. insertion ation process may occur. was created to allow medi- and the Outcome of the intervention we are cal and biotechnology researchers worldwide an studying. Central is a digital archive of selected free full- nating the marginal bone resorption over time text articles. the Comparison or the ref. although it may seem tion found elsewhere. A well-formulated the National Institute of Health in Bethesda. 1. in order to understand if this MEDLINE which is the searchable citation index particular platform configuration gives an database of the NLM of which PubMed is its advantage in terms of prevention of marginal online search engine.2 EBD in Practice search of relevant evidence from the scientific lit- erature that may help in answering the question. would provide useful and applicable manual searches are still considered important in information for the practicing clinician. it should be established if the question is tems due to the date of publishing (old studies important for the clinical practice.2. automated tool to retrieve scientific information. the United easy. arise 1. diagnostic. Today the strategies adopted for searching for the tic issues. NLM. These can refer to etiologic. The question format should be full-text articles of the scientific publishers something similar to this: “what is the effective. most of the times. requires skills and expertise in order to not States National Library of Medicine (NLM) of get lost in the quest for evidence.2. or refusing the manuscript. the authors are informed of the final decision. question takes into account the so-called PICO Maryland. the for medical research worldwide.

” “dental lar sources of data. two examples dental problems.” and “platform switch. For example. even if answers and accessibility for most of healthcare they can be important in suggesting an associa- professionals is a topic that should be addressed tion or a particular line of research which has not in order to guarantee a wide diffusion of the been investigated yet. these studies is the lack of information about ing” are MeSH terms. this parison group and possible selection bias identi- is not possible for all the practitioners looking for fies these studies as low level of evidence. In dentistry and implantology in and others. that can be used for a literature search on regarded as studies with low level of evidence.2. Understandably. evidence summaries that collect and ficult or not possible due to the difficulties in synthesize the current literature on most medical obtaining meaningful data regarding specific topics are available for clinicians. and the collection of information about possible . these include Embase®. trend over time of a particular condition (e. experimental. impact and applicability of a study to the clinical practice [5]. a search of pub- 1.2.3 Appraising the Evidence lished case reports regarding the rare situation of dislodgement of an implant in the infratemporal Critical appraisal of the available evidence is of fossa can give some clue to the practitioner on utmost importance in order to understand the how to manage this rare situation. Case Reports and Case Series Anyway. particular.gov/mesh). One of the problems of the above resources is Case series are consecutive or nonconsecutive that many of them are not available for free for reports of specific diseases or conditions usually nonsubscribers. the search of EBM/EBD culture. This is a thesaurus of a standard set of terms orga- nized in categorical order.nlm. are Up-To-Date® and Essential Evidence Plus®. “dental implants. for their particular form of presentation or rarity. platform-switched implants. ClinicalTrials. In general it is possible to classify two broad ncbi.g. on how to manage it.4 O.gov/) are facilitated if one uses the so. Instead.3.1 Observational Studies subcategories arranged hierachically. Cochrane Central edentulism) in a given population in a specific Register of Controlled Trials.nlm. efficient access to medical information indexed in These studies use information coming from MEDLINE and appropriateness of literature National Health Service registries or other simi- search. no such best-evidence summaries Case Reports refer essentially to observations of exist specifically for dentistry and its single cases which are considered to be important subspecialties.gov. These are epidemiological studies that are aimed nih. The use of MeSH terms guarantees at evaluating a population rather than individuals. For example. Iocca Searches in MEDLINE/PubMed (http://www. geographic area. case reports in the literature may help the clini- cian. application of ecologic studies is dif- Also. The lack of a com- or institutional subscription.ncbi. elencated in hierarchical single members of the population and are usually order.nih. they can be useful to understand a Other databases are used in literature research. Moreover. each category contains 1. Cross-Sectional Studies The first thing to do is to analyze the type of Cross-sectional studies consist in the individua- studies available and the results emerging from tion of a sample from the population of interest them. they require individual in a small group of patients. sets of clinical studies design: observational and called MeSH terms (Medical Subject Headings). Nevertheless. Each term corresponds to a technical word used for indexing Ecologic Studies biomedical journal articles (http://www. who is facing a very specific situation. The main shortcoming of implant-abutments design.. among others.

Then an in intensity of pain between peri-implant probing allele and genotype analysis from a blood sample and periodontal probing. Studies of this kind allowed the study of the association between spe- allow to take a snapshot of the association of cific IL-1 polymorphisms and early implant increased/decreased pain.). . current diseases. once it was time is required.1 Introduction to Evidence-Based Implant Dentistry 5 etiologic risk factors or association of particular Typically the recruited subjects are those conditions with a given disease. tive design which is prone to biases. but Shortcomings include the difficulty in select- on the other hand. the selection of of peri-implant probing. the evaluation is on the prevalence of having the same disease as the case group. completion of the study because no follow-up Regarding the previous example. same population with the sole exclusion criteria cific time point. frequently. with no follow-up The control subjects are selected randomly by the period. afferent to a hospital or a department but anyway tic of this design is the evaluation of exposure considered representative of an entire population. failure. the association between IL-1 can be aimed at assessing the discomfort or pain gene polymorphisms and early implant failure associated with pocket probing in patients with can be analyzed selecting from the same clinic a peri-implant and periodontal pockets. between the exposure and the condition of Advantages of this design consist in rapid interest. in contrast to random established that pain scores were higher in case selection from the population. gender. it remained difficult to specific cases of interest allows to study even rare ascertain if this was due to the mere presence of cases that in a cohort population would not occur the implant or to confounding factors (age. the of a particular disease and not on the incidence presence of other diseases or conditions does not (which supposes an evaluation of a healthy popu. Also. In the group of patients experiencing early implant loss study by Ringeling and coll [25]. an indicator of previous risk (the presence of spe- On the other hand. a group of patients will be A nested case–control study instead is per- selected for the presence of a disease/condition formed during a cohort or RCT study. All patients matched each group in order to determine any difference for age. a case–control study can be Case–Control Studies performed with a prospective design. In fact. One characteris. con. In this case (case group) and another group will be selected a group of cases part of the original study are for the absence of the same disease/condition compared to a control group from the same study (control group). etc. data is analyzed retrospectively in order to iden- often on diseases and conditions that have a high tify any association between an exposure and the prevalence in the population. ysis in which a biologic sample (blood) is used as form the study rapidly and with less expenses. and smoking habits. and outcome at a point in time. the phenomenon of “hyperselection. examination. For example. a typical cross-sectional study For example. that did not have the outcome of interest. it cific gene polymorphisms) for a given outcome becomes difficult to establish a causality (implant loss). missing the temporality. results were suggestive of the ing a matching control group and the retrospec- association at that point in time. Less commonly. In other words. constitute reason for exclusion in order to avoid lation over time). even if in These studies are characterized by the particular this case there is the necessity to wait until modality of selection of the patients chosen for enough cases have been accumulated. Pain referred by (cases) and a control group of patients with the patient with a VAS score was measured in implants still in place [22]. being conducted at a spe. psychological factors. outcome of interest. basis of the hypothesis that inspires the study. The main advantage of this design is the This is a typical example of retrospective anal- lack of follow-up period which allow to per.” The chosen population is identified on the After selection of case and control groups.

. lack of randomiza. Items (the cohort) are followed longitudinally over a relate to title. the exposure is identified in normal subjects tion characteristics. tion and bias from dropouts (i. It is clear that this control cannot studies (cohort. It has been esti. of which a minority are RCTs ble confounding factors was performed (excluding and the vast majority are observational studies.). the trialist may adjust for outcome. methods. A bias may be due to specific popula- case.1). On the other hand. This an example of prospective evidence. the researcher has control over the entire study. These biases are possibly elapsed. they help to establish intervention by the researcher. bone height. while in the cohort Reduction of possible biases was performed studies it is out of control.) and exposure/ mated that around nine out of ten studies pub. called STROBE (strengthening the report of signifying that one or more groups of patients observational studies in epidemiology) [7]. relation with a given exposure (materials of res.6 O. more homogenous the results.. treatment/exposure on the healthy or diseased Cohort studies can be retrospective – in this population. and finally adjustment of the possi- dentistry studies. establishing inclusion and exclusion criteria regard- Much of clinical research is presented in the ing patient characteristics (e.e. In particu- Advantages of cohort studies are primarily lar. and in this way. etc.2 Experimental Study Design terior dentition. pres- form of observational research. a RCT was aimed at evaluating over the study) limit the strength of the evidence. be performed with the other study designs. same surgical tech- journals come in the form of observational nique according to the assigned group. etc. lowed over time and then the outcome of interest This control allows to eliminate or at least reduce (survival or marginal bone level) is tested for cor. 11 mm implants and sinus lift in the posterior ered of higher quality is that in RCT the exposure atrophic maxilla [26]. and cross-sectional). cohort study. the risk of bias implicit in clinical research [6]. abstract. outcomes of short implant 6 mm long versus indeed. with the control of the exposure/ over time. and when potential an association between the exposure and a given confounders are known. a study [23] evaluated unsplinted implant-supported restorations replacing the pos. Biases are distortions of the true effects of a toration or implant length). one observational research efforts and also render exposed and one not exposed to the risk factor. this is because with this particular design.).2.. in which a cohort of patients is fol. The cohort is free of disease at results. those with uncontrolled systemic To improve the reporting of observational pathologies. reporting the results after 4 years of follow-up. and discussion (Table 1. case–control. Usually this is reporting of outcomes coming from the various accomplished comparing two cohorts. the same research. the main reason why RCTs are consid. a lack of control For example. them in order to reduce their impact [8]. recruitment because the aim of this kind of study It is expected that this checklist would be fully is to evaluate the development of an outcome and applied by researchers in order to improve the identify possible risk factors. This is particularly true for implant materials. Iocca Cohort Studies a group of experts developed a checklist of items These studies are also termed follow-up studies.3.g. ence of antagonist teeth. heavy smokers. intervention control (all patients underwent the lished in peer-reviewed medical and dental same antibiotic prophylaxis. overcome with careful design of RCT. period of time. For example. to a lack of accounting for without the disease – and evaluate if the outcome exposure to a risk factor and to all the other so- of interest occurs after a period of time has called confounders. 1. etc. introduction. is controlled by the researcher. Survival rates and marginal bone Randomized Controlled Trials loss were reported as outcomes of interest and Randomized controlled trials (RCTs) are consid- correlated them with the restoration material and ered to be the studies providing the highest level of implant length. with careful selection of the patients to include due to the possibility of following up the patient in the study.

give matching criteria and the number of controls per case Variables 7 Clearly define all outcomes. predictors. measurement Describe comparability of assessment methods if there is more than one group Bias 9 Describe any efforts to address potential sources of bias Study size 10 Explain how the study size was arrived at Quantitative variables 11 Explain how quantitative variables were handled in the analyses. and data collection Participants 6 (a) Cohort study—give the eligibility criteria. If applicable. describe which groupings were chosen. give sources of data and details of methods of assessment (measurement). and relevant dates. if applicable Data sources/ 8a For each variable of interest. Give the rationale for the choice of cases and controls Cross-sectional study—give the eligibility criteria. locations. give matching criteria and number of exposed and unexposed Introduction to Evidence-Based Implant Dentistry Case–control study—for matched studies. exposures. including those used to control for confounding (b) Describe any methods used to examine subgroups and interactions (c) Explain how missing data were addressed (d) Cohort study—if applicable. potential confounders. and the sources and methods of selection of participants (b) Cohort study—for matched studies. follow-up. explain how matching of cases and controls was addressed Cross-sectional study—if applicable. 1 Table 1. including periods of recruitment. and the sources and methods of selection of participants. and effect modifiers. including any prespecified hypotheses Methods Study design 4 Present key elements of study design early in the paper Selling 5 Describe the setting. exposure. and why Statistical methods 12 (a) Describe all statistical methods. Give diagnostic criteria. and the sources and methods of case ascertainment and control selection. explain how loss to follow-up was addressed Case–control study—if applicable.1 The STROBE statement—checklist of items that should be addressed in reports of observational studies Item number Recommendation Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract (b) Provide in the abstract an informative and balanced summary of what was done and what was found Introduction Background/rational 2 Explain the scientific background and rationale for the investigation being reported Objectives 3 State specific objectives. Describe methods of follow-up Case–control study—give the eligibility criteria. describe analytical methods taking account of sampling strategy (e) Describe any sensitivity analyses (continued) 7 .

. multiplicity of analyses. and. confounder-adjusted estimates and their precision (e.. examined for eligibility. and Epidemiology at http://www.plosmedicine. if applicable. 8 Table 1. Separate versions of the checklist for cohort. for exposed and unexposed groups in cohort and cross-sectional studies.1 (continued) Item number Recommendation Results Participants 13a (a) Report the numbers of individuals at each stage of the study—e. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www. and other relevant evidence Generalizability 21 Discuss the generalizability (external validity) of the study results Other information Funding 22 Give the source of funding and the role of the funders for the present study and. and cross-sectional studies are available on the STROBE Web site at http://www. Iocca .org/.g.g. for the original study on which the present article is based a Give such information separately for cases and controls in case–control studies. included in the study. numbers potentially eligible.annals. clinical..org/ O.com/). taking into account sources of potential bias or imprecision. confirmed eligible.. 95 % confidence interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized (c) If relevant. demographic. case–control. if applicable. completing follow-up. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting.g. if applicable. social) and information on exposures and potential data confounders (b) Indicate the number of participants with missing data for each variable of interest (c) Cohort study—summarize follow-up time (e. average and total amount) Outcome data 15a Cohort study—report numbers of outcome events or summary measures over time Case–control study—report numbers in each exposure category. and analyzed (b) Give reasons for non-participation at each stage (c) Consider use of a flow diagram Descriptive 14a (a) Give characteristics of study participants (e. or summary measures of exposure Cross-sectional study—report numbers of outcome events or summary measures Main results 16 (a) Give unadjusted estimates and.epidem. consider translating estimates of relative risk into absolute risk for a meaningful time period Other analyses 17 Report other analyses done—e. Discuss both direction and magnitude of any potential bias Interpretation 20 Give a cautious overall interpretation of results considering objectives.org/.g.g. and sensitivity analyses Discussion Key results 18 Summarize key results with reference to study objectives Limitations 19 Discuss limitations of the study..strobe-statement. limitations. analyses of subgroups and interactions. Annals of Internal Medicine at http:// www. results from similar studies.

in a RCT group. In summary. ment or placebo. he will be The term allocation concealment refers to the analyzed as having received it. blocked. are at least equally distributed in the two groups (or arms). and in this imbalance (e. the aim of ITT • Single blinding means that one of the catego.1 Introduction to Evidence-Based Implant Dentistry 9 Most importantly. 3:1.). this should result in the greatest prob. Blinding is considered to reduce the biases ability that the intervention is causally related to that may come from knowing the assigned treat- the outcome. analysis is to maintain the two groups as equal ries participating in the study does not know as possible avoiding biases and preventing the what kind of intervention is receiving (treat. in this way. older patients may have worst given group (so there is the intention to admin- outcomes for a given surgical procedures). The answer is that this approach pre- an “external” randomization center which does serves randomization.. This . larly useful in multicenter studies in order to three approaches are usually employed (Fig. loss of randomization process. usually this refers to the patient. because it usually refers to three categories cess of randomization. • As-treated analysis considers only the patient etc. It is clear that awareness of the treatment Three types of randomization are usually per. equal number of subjects. gender. • Simple randomization is the casual allocation Sometimes it is not possible to blind one of the of studied subjects in the control or treated categories in the study. and the assessor. that actually received a given treatment. ment. For example. in case a difference is known between study. an imbalance is created between RCTs is the blinding [8]: the two groups and validity of the results is compromised. way. have matched variables equally distributed in the • Triple blinding is the same of double blinding control and treatment group. if but with the adjunct that a blind data analysis unknown confounders cannot be controlled. Indeed if more patients not know anything about the patients but just drop out from a given arm because of more assigns them to a random group according to the adverse events compared to the other arm. which is particu. 4:1. treatment A or treatment B.). and randomization type.2): maintain an equal ratio between the treatment and control groups (1:1). • Intention-to-treat analysis (ITT) refers to • Stratified randomization allows to randomize counting the patient in its assigned group according to specific strata like age. the investigator.. whether or not he will ever receive the assigned treatment. they is performed. In other words. One may asks fact that those recruiting the patients are not why counting a patient that actually never informed about to which arm the next patient will received a treatment or dropped out from the be allocated.g. In simple terms.. blinding is impossible for him.g. the allocation ratio can be involving the evaluation of short versus long unequal. and stratified): the investigator may influence their behavior and impair the validity of the results. RCTs allow to face the • Double blinding can be a confusing term issue of unknown confounders through the pro. the patient. 1. etc. the clinician performing the surgery random allocation can result in substantial will know which implant is placing. This is important because unaware of the treatment administered: the random distribution of study subjects allows to patient. This is usually performed adopting study. or formed (simple. Regarding the analysis of the results of RCT. especially for small samples a simple implants. ister the treatment). although in • Block randomization refers to the casual allo. regardless of dropouts or death during the etc. once randomized to a groups (e. this case it is probably not important for the cation of patients in small groups including validity of the study. assigned on the part of the dentist. analysis is performed only on patients finish- Another important concept applicable to ing the trial.

it can become difficult in others. trial- Although it may seem an easy task in some situ. in this case. On the other hand. implant survival. death. 2. This is a loss of randomization end point. selection of the outcome to evaluate in In order to improve the quality of performed the trial should be taken into consideration. a group of experts comprising editors. Intention-to-treat analysis reassigned to the control group because he did not receive (ITT) in which the patient assigned to a given group will the experimental treatment. Iocca analysis may be important when patients need RCT aimed at establishing a difference in out- to be switched from one arm to another as it is comes between a particular implant surface and the case for patients assigned to a medical another. Per-protocol analysis eval- be counted in his assigned group regardless of dropout or uates only the patients that complete the trial.2 Schematization of the analytic approaches to received a given treatment. they need gate end points are sometimes used in order to a surgery. Again. and methodologists gathered in Ottawa. the patient was randomized clinical trials. The problem in information regarding the noncompliant this case is that validation of surrogate end points patients does not allow an evaluation of is not always clear and is an argument of debate confounders. Sometimes this is necessary because evalu- with the assigned treatment. the so-called surro- treatment arm. of some and may impair the validity of the analysis. ists. but for some reason. in order to discuss various top- example. 1. and so they are reassigned to the gain conclusions regarding the primary (or true) surgical group. Finally. in this case.10 O. this leads ation of the true end point would require exces- to a loss of randomization. a docu- point. 3. and the loss of sive follow-up or larger samples. in 1993. As-treated analysis considers only patients that the patient dropped out or died and he will not be counted . RCT. For Canada. which is a true end ics about RCTs. This is the case. 1. for example. In subsequent meetings. the blinding is usually compromised in gate end points such as pocket probing depth. this case. clinical attachment level. peri-implantitis treatment studies in which surro- Also. ations. can be considered easy to evaluate in a ment collecting a set of recommendations was Fig. and bleeding on prob- • Per-protocol analysis evaluates only patients ing are used instead of the true outcome (implant that complete the trial and are fully compliant loss). if a study using only surrogate end points gives reliable results.

atic reviews and is called the PRISMA statement ing of a clinical trial. the reviewers to improve the reporting of system- list of items deemed essential for optimal report. appropriate statistical methods. Meta-reviews are performed in a . the introduction.4 Systematic Review searching. Performing a meta- methodological quality assessment in which review may allow to the creation of a summary of ulterior studies of poor quality are excluded. authors in improving the reporting of their trials.2. 1. its objective is to help (Table 1. clear that such analysis is limited by the quality dence may become impossible. of the underlying primary studies. usually performed on the basis of the abstracts.2. When pri- Development of a systematic review. all the relevant studies considered appraising the literature is to encounter multiple for the inclusion pass to the full-text phase in reviews and meta-analysis on the same topic that which the authors of the review perform a come to different results.3) [11]. requires the for. if data is homogenous ods. an The last step in the search of evidence for health- assessment is done regarding the eligibility of care interventions is the systematic review of the studies according to predetermined exclu. Systematic reviews are aimed at identifying Meta-analyses are important because it all the relevant published studies on a given topic. and in this way. it is possible to obtain amount of information is published every year. all the available reviews in a single document. Then at all [13–16]. usually mary studies of good quality are lacking. the results. allows to answer questions that single studies assessing the quality of each. a group of the CONSORT (CONsolidated Standard of experts developed a checklist which should aid Reporting Trials) statement [9]. form of meta-analysis. Systematic review data can be aggregated and The checklist includes recommendation for put in context in order to draw a general conclu- the title and abstract. This is a check.1 Introduction to Evidence-Based Implant Dentistry 11 produced which finally led to the publication of In the same fashion as for RCTs. The findings of the systematic give the possibility of synthesizing a huge amount review and its relative data are combined using of data in a single study. decisions. and this can be cases. further analyzed and manipulated in the mation (Table 1. One of the problems faced by clinicians In this way. and additional infor. in some mulation of a clear question.2). Reviewers can choose to include of Systematic Reviews only RCTs or studies of lower quality as well. top of the evidence pyramid because they collect A good meta-analysis starts with good-quality all the available evidence with scientific rigor and systematic review. may lead to unclear or biased results or. this performed by two reviewers.3 Systematic Reviews allows to combine the evidence coming from and Meta-analysis multiple studies and can help in giving a precise Systematic reviews and meta-analysis are at the estimate of the effects of given intervention [12]. sion on a given topic or. systematic reviews and meta-analyses (meta- sion and inclusion criteria. Finally. enough. and interpreting the are unable to do. impossibility of performing the analysis accomplished with the PICO elements.3. statistically significant results. this selection is reviews) [17]. the meth.3. the published evidence is searched carefully using all the database available and with hand. combining data coming from multiple studies The need of systematically collecting the theoretically is like enlarging the sample popu- available evidence comes from the fact that huge lation. Anyway. This is due to the fact that findings in an impartial way [10]. discussion. and Meta-analyses After collection of all the possible studies. Meta-analysis is a statistical technique that 1. it is and keeping up with the primary research evi. the data of all the studies is extracted This can be helpful in drawing general conclu- and usually graphically represented in a sions and arrive at more informed evidence-based summary table.

who enrolled participants. describing any steps taken to conceal the sequence until interventions were assigned Implementation 10 Who generated the random allocation sequence. those assessing outcomes) and how 11b If relevant. with reasons Sample size 7a How sample size was determined 7b When applicable. such as subgroup analyses and adjusted analyses O. factorial) including allocation ratio 3b Important changes to methods after trial commencement (such as eligibility criteria). participants. explanation of any interim analyses and stopping guidelines Randomization: Sequence generation 8a Method used to generate the random allocation sequence 8b Type of randomization. description of the similarity of interventions Statistical methods 12a Statistical methods used to compare groups for primary and secondary outcomes 12b Methods for additional analyses.2 CONSORT 2010 checklist of information to include when reporting a randomized trial Section/topic Item no Checklist item Reported on page no Title and abstract la Identification as a randomized trial in the title lb Structured summary of trial design. with reasons Participants 4a Eligibility criteria for participants 4b Settings and locations where the data were collected Interventions 5 The interventions for each group with sufficient details to allow replication. who was blinded after assignment to interventions (e. 12 Table 1. care providers. including how and when they were assessed 6b Any changes to trial outcomes after the trial commenced.. and who assigned participants to interventions Blinding 11a If done. including how and when they were actually administered Outcomes 6a Completely defined prespecified primary and secondary outcome measures. results. Iocca . details of any restriction (such as blocking and block size) Allocation concealment 9 Mechanism used to implement the random allocation sequence (such as sequentially numbered mechanism containers). and conclusions (for specific guidance see CONSORT for abstracts45 65) Introduction Background and objectives 2a Scientific background and explanation of rationale 2b Specific objectives or hypotheses Methods Trial design 3a Description of trial design (such as parallel.g. methods.

presentation of both absolute and relative effect sizes is recommended Ancillary analyses 18 Results of any other analyses performed. and were analyzed for the primary outcome 13b For each group. and. and the estimated effect size and its precision (such as 95 % confidence interval) 17b For binary outcomes. balancing benefits and harms. imprecision. applicability) of the trial findings Interpretation 22 Interpretation consistent with results. results for each group. including subgroup analyses and adjusted analyses. together with reasons Recruitment 14a Dates defining the periods of recruitment and follow-up 14b Why the trial ended or was stopped Baseline data 15 A table showing baseline demographic and clinical characteristics for each group Numbers analysed 16 For each group. received intended strongly recommended) treatment. if relevant. if available Funding 25 Sources of funding and other support (such as supply of drugs). 1 Results Participant flow (a diagram is 13a For each group. multiplicity of analyses Generalizability 21 Generalizability (external validity. addressing sources of potential bias. number of participants (denominator) included in each analysis and whether the analysis was by original assigned groups Outcomes and estimation 17a For each primary and secondary outcome. role of funders 13 . and considering other relevant evidence Other information Registration 23 Registration number and name of trial registry Protocol 24 Where the full trial protocol can be accessed. the numbers of participants who were randomly assigned. distinguishing prespecified from exploratory Harms 19 All important harms or unintended effects in each group Discussion Introduction to Evidence-Based Implant Dentistry Limitations 20 Trial limitations. losses and exclusions after randomization.

piloted forms. difference in means) Synthesis of results 14 Describe the methods of handling data and combining results of studies.. included in systematic review. PICOS..g.g. comparisons. limitations. included in the meta-analysis) Data collection process 10 Describe method of data extraction from reports (e. interventions.g. language. and.3 Checklist of items to include when reporting a systematic review (with or without meta-analysis) Section/topic # Checklist item Reported on Page # Title Title 1 Identify the report as a systematic review. and study design (PICOS) Methods Protocol and registration 5 Indicate if a review protocol exists. length of follow-up) and report characteristics (e. or both Abstract Structured summary 2 Provide a structured summary including. study eligibility criteria.g. funding sources) and any assumptions and simplifications made Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was clone at the study or outcome level). risk ratio.. I2) for each meta-analysis Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.. and interventions. if done. objectives.g. study appraisal and synthesis methods. years considered. if and where it can be accessed (e. publication bias. including any limits used. giving rationale Information sources 7 Describe all information sources (e. if applicable. and.g. eligibility. contact with study authors to identify additional studies) in the search and date last searched Search 8 Present full electronic search strategy for at least one database. including measures of consistency (e. participants.. meta-analysis. systematic review registration number Introduction Rationale objectives 3 Describe the rationale for the review in the context of what is already known 4 Provide an explicit statement of questions being addressed with reference to participants.. PICOS. provide registration information including registration number Eligibility criteria 6 Specify study characteristics (e. such that it could be repeated Study selection 9 State the process for selecting studies (i. publication status) used as criteria for eligibility. Web address).. as applicable: background. outcomes.g. independently in duplicate) and any processes for obtaining and confirming data from investigators Data items 11 List and define all variables for which data were sought (e. if available. conclusions and implications of key findings.. data sources.. results.. databases with dates of coverage. screening.g.e. selective reporting within studies) O.g. and how this information is to be used in any data synthesis Summary measures 13 State the principal summary measures (e. 14 Table 1. Iocca .

study size. consider their relevance to key groups (e. 1 Additional analyses 16 Describe methods of additional analyses (e.. and policy makers) Limitations 25 Discuss limitations at study and outcome level (e.g. if done (e. assessed for eligibility. for each study: (a) Simple summary data for each intervention group (b) Effect estimates and confidence intervals.. ideally with a forest plot Synthesis of results 21 Present results of each meta-analysis done.. risk of bias) and at review level (e.. reporting bias) Conclusions 26 Provide a general interpretation of the results in the context of other evidence. meta-regression) Introduction to Evidence-Based Implant Dentistry Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome. incomplete retrieval of identified research. any outcome-level assessment (see Item 12) Results of individual studies 20 For all outcomes considered (benefits or harms). sensitivity or subgroup analyses. ideally with a flow diagram Study characteristics 18 For each study.g.. and implications for future research Funding Funding 27 Describe sources of funding for the systematic review and other support (e. present characteristics for which data were extracted (e.g. indicating which were prespecified Results Study selection 17 Give numbers of studies screened.g.g. if available.. supply of data) and role of funders for the systematic review 15 . with reasons for exclusions at each stage. and included in the review.g. PICOS. healthcare providers. users. sensitivity or subgroup analyses.g. including confidence intervals and measures of consistency Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15) Additional analysis discussion 23 Give results of additional analyses. follow-up period) and provide the citations Risk of bias within studies 19 Present data on risk of bias of each study and. meta- regression). present.. if done.

in particular. and analysis of confounding fac- studies.4 Applying the Evidence CONSORT statement was evaluated. may ask how it is possible to arrive at an applica- analysis allow to understand which statistical bility of study results. As previously stated. researchers to improve the quality of reporting tistry. allocation concealment was not addressed Assessment of the quality of reporting of studies in 62 % of the studies. Industry fund- observational rather than experimental. Results showed that the majority of the trials 1. journals have adopted the CONSORT statement. Iocca similar manner compared to traditional system. eligibility criteria. Moreover. Ulteriorly.2. Common reported problems in the analysis of the thesizing the data in order to draw a general literature included poor reporting of study design.. it is common further research on that specific topic. very few have implanted an active compliance. it was considered important for of reporting of longitudinal data in implant den. the evidence on this topic is sponsorship of implant companies. that dental implant studies do not specify how meta-reviews allow to identify multiple biases as they came to a specific study size with a specific suggested by the different reviews analyzed. tions usually limit the analysis on implant sur- cient in order to draw definitive conclusions on a vival without addressing the issue of restoration given intervention.4. they for the reader to figure out whether a study was allow the appraisal of the general quality of the classified as cohort. case–control. these can lead to encourage survival and complications. mented in routine clinical practice. careful search of the literature these kinds of studies according to the STROBE on a given topic but limiting the research to sys.1 Quality of Reporting of Clinical (64. methodol- understanding the heterogeneity between the ogy of research. i. if consistent discrepancies exist tors were often lacking. In fact. Finally.7 %) lacked a reporting of sample size calcu- Studies in Implant Dentistry lation. way clear that properly performed RCTs and dence and identify which areas of a topic are cohort studies can provide a better evidence and a clear and applicable to clinical practice and quality substrate to improve the quality of sys- which one instead requires further research tematic reviews and meta-analyses as well. this power calculation. the majority between the available reviews. it is any- tool to give a “snapshot” of the available evi. In Pjetursson and coll. Also. ered influential in clinical research results is the For this reason.16 O. Moreover. only evidence coming from good-quality research The authors concluded that even if numerous ensures that results of a study can be imple. such that many times it was considered difficult Meta-reviews have many advantages. or prospective/ available reviews on a given topic. tematic reviews and meta-analyses and then syn. the adherence to the 1. [19] evaluated the quality conclusion. ing and pro-industry results have been considered a . They found that the majority of the studies and for editors to implement more stringent crite- reported for implant-supported restorations are ria for publication of RCTs. efforts [18]. recommendations regarding the reporting of atic reviews. This is a rather disappointing picture and one Lastly. One possibility is to rely tool is the most used and which one best describes on well-performed systematic reviews and meta- the chosen outcome.2. with a clear lack of RCTs. [6] analyzed the quality of RCTs published in prosthodontics and implantol- ogy journals. mainly based on prospective and retrospective Another important factor that may be consid- observational studies.e. statement are unattended by most authors. conclusion. this means that of the studies on implants and implant restora- primary studies are poorly performed or insuffi. meta-reviews are an excellent various outcomes. and blinding was not in implant literature is important mainly because reported in around 37 % of them. Kloukos and coll. They allow retrospective. which can provide cumulative results of In conclusion. gives a sort of larger picture on the selected topic. analysis of different reviews and meta. analysis.

study measures what it is supposed to measure. Reporting quality of randomised controlled the various designs should confer high internal trials published in prosthodontic and implantology validity. Papageorgiou.A.M. Brignardello-Petersen. F.A. periodontology and implant dentistry: a systematic review. this 1524 (2014) does not mean that a good-quality study finds an 8. R. Gray. Moreover. Am. A practical approach tice depends upon the internal validity and exter- to evidence-based dentistry. Azarpazhooh. C. Richardson. (2002). W. Assoc. skills starting from dental school and then in cantly lower in industry-associated trials when postgraduate programs. ological tools for assessing the quality of studies in sidered to have a higher internal validity com. J.S. results showed that funding sources Aseptic application of evidence is avoided. Wasiak. Moher. Altman. the phenomenon of sponsorship bias. S.L. clinician. journals. 42(12). W.F. J. continuing education compared with non-industry. C. Pandis. adherence to the abovementioned checklists for N. 22]. desires should be met whenever possible. experimental References instead of observational design and application of the CONSORT guidelines can aid in avoiding 1. explanation and elaboration. Application of research results to clinical prac. J. Indeed. K. Also. confer. Schulz. 9. Blinding in randomised tri- als: hiding who got what. Rosenburg.. fundamental component of good practice.S. Faggion. and the CONSORT 2010 statement: updated guidelines for . 1997) 3.M.2 Internal Validity and External R. 12. Glick. Huda.B. J. Rosenburg. Am.1 Introduction to Evidence-Based Implant Dentistry 17 problem in medical and dental literature. 41. Guyatt. 71–72 (1996) 2. J. Petridis. Strengthening the Reporting External validity refers to the applicability of of Observational Studies in Epidemiology (STROBE): the evidence in practice. Finally. the dental specialist must develop his/her rates of dental implants. K external validity means that the cost of the inter. Grimes. 1500– ity is the prerequisite for external validity. D. Kloukos. In fact. course trying to reach the common aim of provid- ency of sponsorship is of utmost importance. 145. this was explained by evidence-based decisions about the same proce- the fact that maybe authors that deliberately do dure will constitute the foundation for an not report a funding source did not have the same evidence-based practice rather than a personal- quality control of sponsorship studies and so based one. importance of the disease allow an adoption of ring to the studies of the so-called sponsorship bias. I. may have a significant effect on the annual failure Instead. Periodontol. J. R. etc. orabinejad. Doulis. 696–700 application to the real-world situation.. Surg. ing the highest level of care. 625–631 (2014) pared to designs at the bottom. Carrasco-Labra. 255–265 (2015) This is evaluated hierarchically. Use of method- designs at the top of the evidence pyramid con.2. Vandenbroucke et al. Although internal valid. in simple terms how well a M. H.P. D. Evidence-based med- icine: what it is and it isn’t. 1262–1267 (2014) Internal validity refers essentially to the qual.B. Integration between trials where funding source was not specified had the technical aspects of a given procedure and the an even lower failure rate. Lancet 359. A. the studied intervention on the part of the Popelut and coll. Evidence-based medicine: how to prac- Validity tice and teach EBM New York (Churchill Livingstone. [20] analyzed this topic col. W.G. D. Group. D. lecting data from implant studies and tried to cor. Clin. 4. Dent. A.H. 1. of This analysis clearly pointed out that transpar. Moreover. D. vention. conferences.F. G.N.M. Int. with study 5. Sackett. Richardson. Schulz. 914–925 (2015) 7. Assoc. D. Dent. A practical approach to evidence-based dentistry: VI. when a sponsorship is declared. New York.4. Oral Rehabil. it is the duty of the reader to assess carefully if results are biased in some way. the patient’s preferences and results were more biased. Haynes. MBahjri. relate the presence of a financial sponsorship patient’s preferences and doctor’s expertise are a with annual failure rates. Brignardello-Petersen et al. nal validity of the studies [21. ity of the studies. 146. the ease of implementation. J. Failure rate was signifi.L. R. BMJ 312. J. Sackett. 6. K. Haynes. W. If we go back to the definition of EBD. It also emerged that courses.

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p-value. A new. there is a need generalized to the whole population in a process of using rigorous methods aimed at collection.). 00161 Rome. and data is not assumed to formed on a sample of persons which should be come from a larger population. method of analyses of primary studies is the network meta-analysis for multiple treatment comparisons. It is Periodontology and Implant Dentistry. At the basis of reporting and understanding of The conclusions drawn from the sample are the medical and dental literature. Rome. hypothesis testing. at the basis of Bayesian statistics. Viale Regina Elena 324. This may become an important way of assessing the efficacy of numerous treatments when direct comparison of primary studies is impossible. Evidence-Based Implant Dentistry. Iocca (ed. Italy statistical concepts. Usually. This last one is based on the concepts of distribution of variables.1 Probability O. representative enough of a given population. and interpretation of data. is becoming popular among research- ers and usually opposed to the most commonly used frequentist approach. Basics of Biostatistics 2 Oreste Iocca Abstract Statistical knowledge is at the basis of understanding and reporting the results of scientific research. still unexplored.1007/978-3-319-26872-9_2 . which the analysis of the data is performed on the tistical tools [1]. dom process that gives rise to an outcome. analysis. Systematic reviews and meta-analyses are becoming important tools for synthesis of the available evidence. Conditional probabil- ity. known as inferential statistics. dental research is per. Sapienza University Concepts of probability are at the foundation of of Rome. Iocca. and confidence intervals. DDS International Medical School. Italy always described as a proportion and always e-mail: oi243@nyu. © Springer International Publishing Switzerland 2016 19 O. Basic concepts of probability are the first building blocks for most of the statistical concepts. DOI 10. 2. Probability refers to a ran- Private Practice Limited to Oral Surgery. This can be This is in contrast with descriptive statistics in accomplished with the knowledge of basic sta. sample available.edu takes values between 0 and 1.

55. research. which allows to answer some specific ques- tions given a conditional probability.). Independency refers to the fact that knowing the result of one outcome does not have an influence P ( A |B) * P ( B) P ( B | A) = on the second one. P ( A) For example. the probability of tossing a coin 2. P ( A and B ) P ( A | B) = only one outcome can occur at any toss. P ( H and R ) = P ( H ) * P ( R ) this means that a patient not having peri-­ = 1 / 2 * 1 / 6 = 1 / 12 = 0. a patient with peri-implantitis almost probability of tossing head P(H) and rolling a red certainly will present with bleeding on probing. negative predictive value is estimated to be around 55 % or P(A−|B−) = 0. in In the case of the coin and die outcomes. a probability of Finally the sum of conditional probabilities tossing head or tail includes the totality of the will be possible outcomes.99. From published data it is estimated that The multiplication rule for independent prevalence of peri-implantitis (B+) in the implant processes defines the probability that both patient population is around 22 %. this can be written as follows: P(H) and P(T) are a classical example of dis- joint or mutually exclusive outcomes. indeed. Iocca For example.20 O. for P ( A1 | B ) + P ( A2 | B ) + …+ ( PAn | B ) example.3 % of Now if we want to reverse the question and we tossing a head and rolling a red face.1. observed. This means that there is a probability of 8. P ( B) In this case.083 implantitis will not present bleeding on probing in around 55 % of the cases. knowing the outcome of a coin toss does not have an influence on the outcome of Using this formula in context will help in under- rolling a six-faced colored die (which means that standing the utility of Bayes’ theorem in clinical 1/6 of the die is white. P ( H orT ) = P ( H ) + P (T ) = 1 / 2 + 1 / 2 = 1 P ( A and B ) = P ( A | B ) * P ( B ) It is intuitive that all the possible outcomes are included in this case. Also. In this example. the probability of tossing This is defined as the probability of an outcome head will be written as P(H) and probability of (A) given that a second outcome (B) has been tossing tail as P(T).1 Conditional Probability can randomly produce the outcome of the head and Bayes’ Theorem or tail. the probability that one of this events will occur is given by the addition rule: From this we can derive the general multiplica- tion rule. it was established in observational stud- P ( A and B ) = P ( A) * P ( B ) ies that positive predictive value of bleeding on probing (A) is around 99 % P(A+|B+) = 0. the other terms. from which independent events occur and are calculated in we derive that peri-implant healthy patients (B−) this way: are around 78 %. want to know which is the probability that the . 1/6 is red. These rules are at the basis of the Bayes’ theo- P ( A or B ) = P ( A) + P ( B ) − P ( A and B ) rem. etc. when there is the possibility that A and B events can occur by themselves but exists also where n represents all the possible outcomes for the possibility that they can occur together: a variable. When the two events are not disjoint. on a six-faced die P(R) will be: On the other hand. In fact.

we conditional probabilities.78 than 180 cm. even being taller than ing on probing given that one has peri-implantitis 180 cm. null hypothesis. the probability of playing in the NBA is is almost 100 %. it is almost certain that you are taller 0. this can be expressed as P(180+|NBA+) = 0. is the most com- ing on probing has a probability of having a diag. other diagnostic tools like probing depth and gram in which the probability of having peri-­ x-ray evaluation. To make another example.4 %. therefore.22 States with only around 360 players part of it) are 0. ( ) P A + This may seem to add some subjectivity to the = ( + ) ( ) P A | B+ * P B+ analysis. It is clear that the anterior probabil- the Bayes’ theorem helps us in resolving this ity can differ according to the sources from which question. going back to the previous With the application of the theorem. In this case.569 Frequentist approach.78 ) 0. our results would have changed accordingly if we ( P B + and A+ ) chose another value for the probability of having ( P B |A + + )= peri-implantitis in implant patient population. rem to understand that.384 ( 0 . if you play in 0. confidence intervals. If we reverse the question and we Peri-implantitis no (B-) 0. implantitis is denoted as P(B+).0″).99 Yes (A1+|B+) professional basketball association in the United Peri-implantitis yes (B+) 0.218 that is the strength of Bayesian statistics. of peri-implantitis. = = = 0.99 * 0.22 0. We combine the data of reverse the scenario and check for the probability our prior knowledge (anterior probability) in of having peri-implantitis given that the patient order to calculate a revised probability (posterior has bleeding on probing or P(B+|A+).45 Yes (A2+|B-) the NBA. but at the same time makes it possible to ( P A1 | B+ + ) * P ( B ) + P ( A2 | B ) * P ( B ) + + + + recalculate the results in light of new data (new prior probability) in a process of updating beliefs 0. but in clinical situation we check minimal! for bleeding on probing in order to perform a Bayesian approach is a way of calculating diagnosis of peri-implantitis. monly used in the scientific literature and usually . we found that a patient with bleed. It is important to remember P(A1+|B). probability). we found example.99 * 0 . we understand that P(NBA+|180+). we extract the data.01 No (A1-|B+) taller than 180 cm (6. it is reported that Bleeding on probing around 99 % of players playing in the NBA (the 0. essentially based on p-value. therefore. probability of This may seem counterintuitive because we having bleeding on probing given is (A+). and power (discussed later).2  Basics of Biostatistics 21 patient has peri-implantitis (B+) if we found nosis of peri-implantitis of 38.22 ) ( + 0 . it is better to integrate it with We can represent the situation with a tree dia. In other words.55 No (A2-|B-) want to know which is the probability of playing in the NBA if we are taller than 180 cm or From the tree diagram. we can apply the suggest that. and probability of having bleeding on that we reversed the question and tried to figure probing given that one do not have peri-­ out what would be the probability of having peri-­ implantitis is denoted as P(A2+|B−) implantitis once we found bleeding on probing. various authors report different rates of out that prevalence for peri-implantitis. we don’t need the Bayes’ theo- P(A1+|B+) or simply probability of having bleed.99. In conclusion. although evaluation of bleeding on Bayes’ theorem and use a graphical tool to clarify probing is important in the process of diagnosis how we obtain the results. in par.45 * 0 . stated at the beginning that a patient with peri-­ ticular probability of having bleeding on probing implantitis has a 99 % probability of having given that one has peri-implantitis is denoted as bleeding on probing. This would bleeding on probing (A+).

if in a patient population. 2. the distribution of the mean A random variable is a process or outcome that will be approximated by a normal model. standard deviation is 1.5. which is a precalculated table test result. SE describes the has mean μ = 0 and standard deviation σ = 1. Iocca opposed to the Bayesian one. n bution for a given population and also the stand. delimited by the gray area (Fig. and bell shaped and by definition called the standard error (SE). it is expected that the Bayesian the other patients from the same population.96 standard σ deviations from the mean (Fig. the mean years. unimodal. or a symptom acts in associated with the percentiles for a particular the same way as updating a prior probability. 2. above the mean. periodontal probing depth is higher than 84 % of In the future. a (Fig.2). a clinical sign. the patient is 1 standard deviation statistics. If we know the mean of a given distri.0 mm and the among researchers due to the possibility of add. normal model (Fig.1). z= = = 1. we can calculate the Z-score for a and n the sample size. standard deviation) will tell us that the patient They conclude that clinical decision-making is lies in the 84th percentile.2 Distribution of  Variables least 30 independent observations and data are not strongly skewed. 2. In this regard. terms. SE is calculated as the Z-score. the Z-score for a patient who has a periodontal bility [2]. we may calculate ing knowledge with the update of a prior proba.0 in the sense that they apply Bayesian rule in clini. mean error associated with the estimate. the probing values below the 84th percentile are ical research. σ 1. which is defined as the number of S standard deviations a value falls above or below SEx = the mean. which fits the people in a geographic area. we have 12 random samples each com- random variable can be the number of edentulous posed of at least 30 observations. A probability distribution is the one that includes all the possible numerical values for a given variable. 2. 2. in order in statistics. where s is the standard deviation of the sample ard deviation. All approach will be further incorporated in the med. tion but instead just values of a sample from the A standardization of the normal curve is called population we want to study. For example. probing depth of 7.5 mm.5 cal practice even without knowing Bayesian In this case. Bayesian statistics is gaining popularity periodontal probing depth is 6.5 − 6.1 Confidence Intervals The normal distribution is taken as the refer- ence distribution because it is the most common A plausible range of values for the population and taken as a reference to solve many problems parameter is called confidence interval.22 O.2). it reflects the variability of the statistics mal distribution and are called distribution when we don’t have values of the entire popula- parameters. . But in the last few For example. in simple and standard deviation describe exactly the nor. some authors [3] arrived at the x − µ 7.2. which means that his Bayesian at its core. given X value as: It is known from the Z-score table that 95 % of observations that lie under the normal curve is x−µ z= comprised between −1. The importance of the Z-score and the area under the normal curve is that if we sample at 2. we take into account the Normal distribution is described as symmet.96 and +1.0 conclusion that clinicians are natural Bayesians. standard deviation associated with an estimate ric. In can assume a numerical outcome. to obtain this value. and a normal probability table Their claim is based on the fact interpreting a (also called Z table.3).

3. 3.14 and Confidence intervals display the range of plau. and they always contain the effect estimate in a pre- defined level.2 Hypothesis Testing ples are drawn from a population.0 4.18 ) the formula for a 95 % confidence interval for a point estimate that comes from a normal distribu. All the scores below the 84th percentile are delimited by the gray area 3.2. 2.5 mm and standard hypothesis can be rejected or not.5 6. 95 of them would contain the true population value. it is opposed to the alternative For example.5 9.1.1. or it fails to .96 * 0. a 95 % CI means that if 100 sam. if we take a random sample of hypothesis which goes against the null 50 patients treated with implants in our clinic and hypothesis. 95% CI ( 3.18 standard deviation associated with the estimate.0 Fig. Frequentist approach is based on the formula- tistical terms. 2. with a mean of 3. which represents the skep- fident that the population parameter is in the tical perspective to be tested and called null calculated range.96 * SE ÷ our clinic.18. 95 % of this samples will have values è ø of pocket depths comprised between 3.96 * 0.85 ) tion will be We are 95 % confident that if we take 100 sam- æ point estimate . we measure the pocket depths around the Statistical testing usually evaluates if the null implants.14. a 95 % CI for this sample terms.96 * SE . tion of a hypothesis. hypothesis or H0.3 / Ö 50 = 0.0 7.5 + 1. sible values between or among groups.85 mm. 3. it is said that we can be 95 % con. In sta. point estimate ö ples of 50 patients from the implant population in ç + 1.2  Basics of Biostatistics 23 Fig. = ( 3.2  Random samples each composed of at least 30 observations which fit the normal model -3 -2 -1 0 1 2 3 Given that the standard error represents the SE = 1.3 mm.5 .1  Normal distribution of patients 84% OF THE POPULATION periodontal probing depth. In statistical deviation of 1. 2. a test may lead to reject the null hypothesis will be calculated in this way: in favor of the alternative hypothesis.

Usually it is accepted that a minimum power of 80 % is needed. increases the power. ¹ 4.20 = 0. If we conduct a one-sided hypothesis test. implants to be around 4 mm. a HA : probing depth mean with smooth collar very important concept for the validity of a study. this means H0 : probing depth mean with smooth collar that β should not be higher than 0. way (it is negative because we want to check for Type II error consists in failing to reject H0 when a value less than the hypothesis. now we have a sam- In hypothesis testing. The p-value is defined as the smooth collar with a significance level of α = 0. so that = 4.05.96 -3 -2 -1 0 1 2 3 reject the null hypothesis in the sense that it is not We set a normal probing depth around implausible that H0 is true.20. Calculation of the power goes Instead if we would like to check if probing depth beyond the scopes of this introduction. check for a value greater than the hypothesis. we would say that it is a positive test).3  Normal curve where the gray area 95% of observations lie in the area under the corresponds to 95 % of observations curve comprised between -1. two types or errors are ple of implant patients treated with a smooth col- possible: lar. if we would HA is actually true.0 mm 1−0. in this case.05.0 mm With the p-value we quantify the strength of evidence against the null hypothesis and in favor If we take a sample of 100 patients treated with of the alternative. This would mean that the proba- bility of rejecting the null hypothesis given that it HA : probing depth mean with smooth collar is not true is 80 %.96 standard . for our sample mean (that we suppose comes from a example. Iocca Fig. we perform a two-sided enough to say that increasing the sample size. Statistical power. = 4. Type I error consists in rejecting H0 when it is we set a negative one-sided hypothesis test in this actually true. hypothesis test.0 mm Type II error is symbolized by β and is deter- mined by the sample size. probability of observing the data at least as favor. <0.0 mm. null hypothesis will be rejected with a p-value able to the alternative hypothesis. < 4.24 O. and we assume that this may contribute to reduced probing depth after 1 year. 2. This means that if the null hypothesis is true. A significance level α = 0.96 and +1.05 means that we do not want to commit a type I error more than 5 % H0 : probing depth mean with smooth collar of the times. Here is is different than 4.0 mm is defined as the probability of rejecting the null hypothesis or 1−β. we can formulate the test in this way: normal distribution) will lie into 1.80.

Regarding the previous example.1 mm with a standard deviation of 1. value/SE = 3.11 is less than 0.18 which corresponds to the exists between two or more groups. B = 1.5. can we state that the sample of patients with this probing 2.0/0. A 2. ability between groups (calculated as mean square between groups or MSG) and the variabil- ity within groups (mean square error or MSE).0001 and again allows to reject freedom.2. Analysis of variance (ANOVA) and the associ- cally significant? ated statistical test F are used to check with a sin- We can perform a Z test to test our hypothesis.11 = − 8. the t distribution becomes positive test. instead of the Z-score table. and the test area under the left tail. will terms. If the sam- test or more than 95th percentile for a one-sided ple size is at least 30.36 which corresponds lows an F distribution with two types of degree of to a p-value of <0. The t distribution has the same shape as the nor- mal distribution but with a single parameter. we use the t table in which the area under reject the null hypothesis in favor of the alterna- the curve is calculated according to the degrees tive. If we designed our test as two sided. the larger the sample. D) bution table. .05. B.2  Basics of Biostatistics 25 deviations from the mean for a double-­sided test or from a small sample and in this case is more below the fifth percentile for a one-­sided negative accurate than the normal distribution. This ginal bone level changes (MBL) at 1 year. as with the other tests.1. ANOVA is used in this case to test if a difference In this case. but this time we H0 : m1 = m 2 = m3 = m 4 should multiply the Z-score * 2 because in this HA : at least one mean is different case we are checking for the area under the curve comprised between the lower and the upper tail. the area under the curve or p-value with different surfaces. less than 0.0001 of observing such a large mean The F tests give us the ratio between the vari- for a sample of 100 patients. C. In simple The corresponding F results. we have four groups of patients If we check this z value on the normal distri. this would of freedom. we bution.1–4. and we check for mar- associated with z = 0. we would perform a Z test in the same fashion as before. df1 = k−1 where k are the groups and the null hypothesis.18. For example. We lower tail area provides sufficient strong evidence found that the mean MBL is A = 1.9.3 The t Distribution simplified way to understand the F test is to con- sider it in this way. The t distribution is used when we mean that the mean bone level change at 1 year need to estimate the mean and standard error varies between the four groups. Alternatively stated. there is a probability of from all the groups. once checked. and D = 1. because the normal model statistics used in this case is called F which fol- is symmetric −8.3.2. nearly normal.4 ANOVA and F Test depth mean actually come from a different popu- lation? In statistical terms. If we get a mean probing depth of 3. z =−8. treated with four different implants (A. the Variance between treatments F= degrees of freedom (df).0002. for rejecting the null hypothesis. be used to compute the p-value in the same way bution will resemble the normal distribution. are our results statisti. If p-value is less than our Also. predetermined significance level of 0. which corresponds to Variance within treatments the number of observations −1 (or n−1) and describes the shape of the t distribution. so just We can perform a hypothesis test in this way: checking for HA ≠ H0.1 mm.18*2 = 16. gle hypothesis test whether the mean across which is Z  = mean of the sample – null groups is equal. the more the t distri. if the df2 = n−k where n are the number of subjects null hypothesis is true. for the t distri. C = 0.

complications connection connection Total ally done by a software). C. and for the data the table from which we analyze the data. In this way the expected rate of complication Scope of the analysis is to establish if a lin- for external connection patients would be 177 * ear correlation exists between the two variables.05. x3.6. where r are the rows and c the columns of reject the null hypothesis. .08 and the rate their values goes beyond the scopes of this of no complications 228 * 0.16 = 6. complications connection connection Total Yes 27 38 65 No 150 190 340 2. we can try to check which groups have a statistically k ( Oi − Ei ) 2 ( 27 − 28. Total 177 228 405 In conclusion. A vs.6 65 t-tests will tell us which groups have a statisti. and the expected rate of no complica. etc. there is no difference in the rate of prosthetic complications between internal and Prosthetic External Internal external connection. centages. Of course.16 and the sion analysis and takes into account an explana- rate of no complications over the total of tory variable (x) and a dependent variable (y) patients = 340/405 = 0. it exists with 1 df on the χ2 distribution table will cor- a χ2 distribution with (r−1) (c−1) degrees of free. This is done performing a pair t-test for all the groups. a value of 1.7. introduction). B.84 = 148.2.84 = 159. C.3. In the same way. we compare the means fore drawn in this way. so we dom.1 Linear Regression data (E). If Now applying the chi-square formula there is evidence that some evidence exists. in this case. Linear regression is the simplest form of regres- tions over total of patients = 65/405 = 0. x2.3 Regression Analyses Total 177 228 405 Regression analyses allow to consider the rela- tion existing between one or more explanatory or χ2 = ∑ k (Oi − Ei )2 independent variables (x1. D. available.4 148. respond to the area under the tail >0.01 2.5 340 cally significant difference. the chi-square (χ2) is a common test we have (2−1) (2−1) = 1 df.5 When comparing two or more proportions or per.5) 2 2 + + = 1.01 performed to find the p-value.6 ) (190 − 191. No 148. represented in a scatterplot.84.26 O. The rate of complication or total of complica. B vs.) and a i =1 Ei dependent variable (y). of each group. The results of the single Yes 28. for the 2 × 2 table of the example. Iocca In order to know which of the groups have sta. where b0 is the inter- 0.6 191. 0. and B vs. The equation used for the linear regression tions for the external connection would be 177 * analysis is y = b0 + b1*x. In this case.4 36.5 ( 38 − 36. The table for the expected values can be there- tistically different means. A Prosthetic External Internal vs.5 191. In this example we have the observed data (O) and we want to compare them with the expected 2.3.16 = 28. the expected rate cept of the line and b1 is coefficient calculated of complications for the internal connection according to the variable values (calculation of patients would be 228 * 0. ANOVA examines the big pic- ture considering all the groups simultaneously.5 Chi-Square Test 36. A vs. c2 = ∑ = + i =1 Ei 28. D (this is usu.4 ) 2 (150 − 148) 2 significant difference between each other.

039x + 62.354 straight: y = 0.4  Scatter diagrams and correlations lines with the corresponding r values (Reproduced with permission from Howashi and coll) . The reported r values for straight implants were A value of r closer to −1 means that a linear rela. but in means that a high positive correlation was this case when one increases. and 0. tells us the amount of variabil. the implant Another value.038 10 straight: y = 0. a study [4] evaluated the rela- ear relationship.084x .858 in (B).052x .3.933 5 (C) tapered: y = 0.083x + 44.084x + 11. ues and the insertion torque values. 2. This tionship exists between the two variables. ticular a strong correlation between the HU val- tion between the variables.7. between the two variables. always takes the value between −1 and +1. (Fig. in the figure 2. r2. stability quotient. 0. For example.110 15 (B) tapered: y = 0.4). and y.4 are reported strong linear relationship between the variable x the scatter diagrams and the correlation lines.354 0 0 100 200 300 400 500 600 CT value (HU) Fig. units of the peri-implant bone and primary A value of r closer to 1 means that there is a implant stability. if one increases the other increases as well.394 straight: y = 0. 2  Basics of Biostatistics 27 The correlation describing the strength of the lin.714 in (C). shown for all the variables analyzed and in par- A value close to 0 means that there is no associa. a 45 b 90 40 85 Insertion torque value (Ncm) Implant torque stabitity quotient 35 80 75 30 70 25 65 20 60 15 55 10 50 5 45 0 40 0 100 200 300 400 500 600 0 100 200 300 400 500 600 CT value (HU) CT value (HU) 40 c 35 Tapered implant group Straight implant group Removal torque value (Ncm) 30 25 Equations: 20 (A) tapered: y = 0.069x . the other decreases. 0. and the removal torque value ity in the y variable explained by the x variable.7.813 in (A). 2. denoted tionship between the CT values in Hounsfield as r.

5).28 O.4 Time-to-Event Analysis 3. odds ratio.3. III.1643 means that an individual in type II group has a probability of losing an implant at the following Time-to-event curves are used to describe the evaluation period 3. which is the HR. to compare and combine the results of multiple all survival on the y axis and time from diagnosis selected studies on a given topic. the smaller will be the weight. it came out that the 2.3 Logistic Regression exponent for the regression coefficient. an HR of 2. raw mean differ- group. II. was 3. we understand that the higher is the vari- bi are the regression coefficients for the variables xi ance..1643 times higher than type I. if we calculate its reciprocal xi are the predictor variables value. [5] which evaluated the survival of Straumann regressions to a case in which we have more than dental implants with TPS surfaces over a period one independent variable (e. we have subjects that entry at the begin- ning or during the study and other that complete.1643 times higher compared to type III.1643 with a 95 % CI of 1. ence. or drop out from the study. we can take as an example the study by Becker and Multiple regression extends the two variable col. according to the ITI implantation types (types I. etc.1. represents the odds that an individual in the group will manifest the outcome at the next evaluation period. x2. and IV). In type IV 3. outcome of an intervention over time. The basic data on the x axis. Regarding the previous example. standardized mean difference. tributed with known variance. 2. . Common effect ratio (HR) is the estimate of the ratio of the sizes extracted from the studies can be propor- hazard rate in the treated versus the control tions.2 Multiple Regression Without going into calculation of the data. relative risk. variable y exists in binary form (0 or 1). 2. If we consider that baseline the variance represents the entity of dispersion ht/h0 is the hazard ratio from the mean.459– Logistic regression is used when a dependent 6. It can be What is important to understand when a study of adopted to know which x variable increases or this kind reports the HR and its CI is that the HR decreases a clinical outcome (y = 0 or 1). where One of the strengths of a meta-analysis is that we are able to assign a weight to each study h(t) is the probability of the outcome at time t included. and trials commonly employ this kind of analysis. In this study.g. correlation Cox proportional model is a regression method (r). Iocca 2. Clinical type III 3. of 12–23 years. fact. Fig. These data are commonly represented with the Kaplan-Meyer Meta-analysis is a statistical method that allows curve which is characterized by plots of the over. Conversely. x1. of meta-analysis are the effect sizes which are Hazard rate is the probability of an event to quantitative indices that measure the strength of occur in the next time interval. It fits a model of the form: A meta-analysis allows to statistically manip- ulate the extracted effect sizes in order to assess log e  h (t ) / h 0 (t ) = b1 x1 + b2 x2 + …+ bp x p the consistency of effects across the studies and compute a summary effect.5 Meta-analysis die. for survival data that provides an estimate of the Effect sizes are assumed to be normally dis- hazard ratio and its confidence interval. x3).1643 times higher compared to type II. and the hazard the effect in individual studies. This is done calculating the inverse of h0 is the probability of the outcome at the the variance for each study.863 (Table 2.3. in clinical trials during the length of the study.

For example. the larger the weight of accordingly if we consider age. but the effect size is comprised ∑ wi i =1 in a range due to various factors.277 3. etc.0 Proportion of implants surviving Proportion of implants surviving 0.0 1. analysis is considered statistically significant. with the fixed effect model. fixed effect and random effect. systemic disease. VY i If the analysis is performed under the fixed effect model.00354 a Implant Survival b Implant Survival According to type 1. value falls under 0. k Random effects instead implies more realisti- cally that there is no reason to assume that the ∑ wiYi M = ki =1 true effect size is the same for the whole popula- tion under study.5  Kaplan-Meier analysis of all the studied implants (a).1643 1.2 type 1 type 2 type 3 type 4 0.2 0.4 0. the result of the meta-­ We calculate the weight of each study first.4 0.0 0. the true effect size in a population can vary The variance of the summary effect is calculated as . the study. 2  Basics of Biostatistics 29 Table 2.6 0. a p-value is also calculated only one true effect size for the whole with the usual statistical tests.863 . we 1 w= consider all the observed effects in the included variance studies. socioeconomic status. further distinguished by ITI implantation type (b) (Reproduced with permission by Becker and coll) the smaller the variance.8 0. we suppose that all the studies Then.6 0. Meta-analyses are based on two statistical 1 wi = models. and we try to give an estimation of the In a meta-analysis.1  Values of the regression study by Becker and coll Regression Exp (regression Lower 95 % Upper 95 % coefficient coefficient) confidence limit confidence limit p-value ITI implantation type 1.05. normally if the population. the weighted mean of the effect size is included have one and just one true effect.8 0.0 0 5 10 15 20 0 5 10 15 20 Time [years] Time [years] Fig. 2.459 6. In summary. This computed as occurs rarely in medical and dental field.

023 barewal 2012 14 0. M + 1.990 0.570 30 0.750 0.115) -1 0. larger when the sample sizes in the primary stud- ies is smaller.240 (–0. 0. p-Value Iˆ2 0.047 –0.351 < 0.200 (–0.380 -0. I2 will get interval in the usual way. –0. and 75 % as low.  2. –0.768) Overall –0.092 0. This is calculated with the I2 with standard error SEM = √VM.083 0.422.129 schincaglia 2008 15 1.860 0.430 0.768 Continuous Random-Effects Model Metric: Mean Difference Model Results Estimate Lower bound Upper bound Std.200 0.) shibly 2012 –0.380 0.306.5 0 0. 0.100 0.569 Heterogeneity tauˆ2 Q (df=5) Het.345 -0.220 -0.135) jokstad 2014 –0.300 0.135 jokstad 2014 144 1.212 den hartog 2011 31 0. 0.029 24.700 -0.001 79.I.200 -0. ∑w i Another important aspect regarding a meta-­ i =1 analysis is the evaluation of heterogeneity between studies.286 meloni 2012 20 0. Iocca 1 And then we calculate the 95 % CI in the same VM = k way as for the fixed effect model.5 1 Mean Difference favors delayed favors immediate Fig.030 (–0.467 Studies Estimate (95% C. we take analysis evaluating marginal bone level change into account the between-study variance τ2 (in mm) of delayed versus immediately loaded (whose calculation goes beyond the scopes of dental implants after at least 1 year of follow-up this introduction). but in this case. since the amount of sampling error Now it is easy to calculate the 95 % confidence depends on the size of the sample.280 7 0. index. respectively. and high heterogeneity.770 0.345.377 -0.023) barewal 2012 –0.209 0. 2.209.129) schincaglia 2008 0.6  Example of a meta-analysis evaluating marginal bone level changes of delayed versus immediately loaded dental implants after at least 1 year of follow-up (see text for details) .96 * SEM ) of 25 %.306 0.377.30 O. (Fig. 0.069 0.160 0.900 0.610 -0.212) den hartog 2011 –0.069.330 0.430 (0. 0.910 0.550 15 0.047 (–0.225 0. 50 %. we can consider an I2 2 ( M − 1.700 104 1. moderate.6).010 (–0.105 -0.160 20 0.422 0.105 (–0.030 -0.286) meloni 2012 0. In case of the random effects model. In the seven studies included for the study name year delayed N delayed mean delayed SD immediate N immediate mean immediate SD MD lower upper shibly 2012 29 0. In general.240 -0.96 * SEM .170 26 0.830 0. the basic In the following example reported is a meta-­ assumption are the same.010 -0.115 0. error p-Value –0.092.

5 %. Is it possible to understand that a random hence the name of the analysis. results of this meta-analysis vention and combining the prior probabilities show that there does not seem to exist a differ. we can have a set of studies comparing has been conducted showing the results in a bar treatment A versus treatment B and another set of graph (Fig. Debridement Debridement+chlorohexidine Er:YAG laser monotherapy Photodynamic Debridement+periochip Vector system Debridement+Antibiotics Air abrasive Fig.8). 2.2  Basics of Biostatistics 31 analysis. high hetero. we create a graphical network. studies comparing treatment A versus treatment From the graph.1 Network Meta-analysis analysis was conducted [12] with the aim of assessing the efficacy of various peri-implantitis A network meta-analysis is a method of conduct. 2. effect model gives not statistically significant The majority of network meta-analyses are results (p-value (0. mean difference has been chosen for For the purposes of indirectly comparing effect size comparison. ranked first. A network of the studies has been ing multiple treatment comparisons.5. drawn (Fig. way.7  Network of studies as included in the study of Faggion and coll [12] (Reproduced with permission) . high heterogeneity to obtain an estimation of the probability that between studies is evident. a Bayesian network meta-­ 2. treatments. Bayesian network meta-analyses allow 1 year of follow-up. second. they estimate treatment effects of each inter- In conclusion.7). conducted using a Bayesian approach. etc.569)) Moreover. C. thereafter a Bayesian analysis ple. For exam. each treatment can produce better outcomes than competing interventions. In this geneity is evident from the I2 result of 79. Also. For example. give the corresponding posterior probability dis- ence in marginal bone level change after at least tribution. it is possible to check which C but no studies directly comparing treatment B treatment has the highest probabilities of being versus treatment C. treatment B vs. 2.

 Borenstein. because the underlying ogy: a Delphi opinion poll. D. J.-J. Network meta-analysis: users’ guide 3. surgical treatments for peri-implantitis. 1st edn. Iocca Fig. Clin. 1080–1083 (2005) Res. 1015–1025 (2014) . Tu. S.. 169–189 (2013) tion. Relationship between the CT value 11.J. Introduction to Meta-analysis. 330. natural bayesians. Long-term survival of straumann 12. A. 41.M. Magrez. Relat. Clin. Welton. H. Chichester. Westbury. 1.V. Methods 2. Clin. C. M.T. C. Cargo cult science and meta-analysis. Relat.32 O. Implant meta-analysis of randomized clinical trials on non-­ Dent.H. Listl. Oral Implants Res. Clin. Howashi et al. Faggion.. Gavini. Pacific Grove. Senn. Issues in 2nd edn. E.1111/cid. Pommer et al. Clin. 2009) References 8. Epidemiol. Vedhara. L. Sabin. interventions in coronary heart disease. Br. Stat. M.R. S. Med. 2000) performing a network meta-analysis. online first article (2015).M. 18(1). doi:10. Foote et al. 2166–2171 (2015) 4. A systematic review and bayesian network study with a follow-up of 12 to 23 years.-K. Pagano. Higgins. 473. Res. C. dental implants with TPS surfaces: a retrospective Y. N. Relat.12334 Periodontol. J.. 2. Front. Orthop. M. 282–287 (2016) 7. Principles of biostatistics. Why clinicians are for surgeons: part I – credibility. K. (Duxbury Press. J. Mixed treatment comparison meta-­ and primary implant stability with comparison of dif. 27(3). Am. B.. Caldwell.T. L. 1158–1165 (2009) 5. Med. How meta-analytic evidence Of course. 24. 107–116 (2016) J.P. Rothstein. Perel. Chang. primary studies are not always of high quality. C. 1 (2015) 1. H. Implant Dent. 192 (2010) 10. C. 169. 9. N. Bayes’ rule for clinicians: an introduc. Res. Becker. M.8  Ranking of Debridement + chlorohexidine gel Photodynamic therapy treatments after Bayesian Debridement + antibiotics Air-abrasive analysis as conducted by Vector system Debridement + periochip Faggion and coll [12] (Reproduced with Er:YAG laser monotherapy Debridement permission) 100% 90% 80% Probability to rank at each place 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 Rank for PPD 6. (Wiley. Frühauf. and cortical bone thickness at implant recipient sites K. S. results of analysis of this kind should impacts clinical decision making in oral implantol- be interpreted with caution. Psychol. Res. D. Adamopoulos. F. Gauvreau. 22.J.L. Implant Dent.J. Schmid. et al. analysis of complex interventions: psychological ferent implant types. Hedges. Scheen.F. Gill.

com Private Practice Limited to Oral Surgery.1007/978-3-319-26872-9_3 . 308. Rome. DDS. Teeth or Implants? 3 Oreste Iocca. O. Giuseppe Bianco. A Coruña. especially because trauma often involves young patients. Comparison with fixed prosthesis on natural abutments is best made analyzing separately the success and failure of single crowns and multiple- unit restorations. and failure. DDS (*) S. re-interventions. DDS. mainly for the prognostic implications associated with a history of periodontal disease. Bianco.). and Simón Pardiñas López Abstract One of the main challenges for the modern implantologist is to resolve the clinical dilemma about whether to extract or retain a tooth. DOI 10. Evidence-Based Implant Dentistry. Italy e-mail: gbianco@mac. Viale Regina Elena 324. which may complicate information retrieval from the literature. PhD Centro Polispecialistico Fisioeuropa.com © Springer International Publishing Switzerland 2016 33 O. Italy Clínica Pardiñas. Finally. At this regard. Rome 00144. Iocca. Development of treatment-decision algorithms in all these situations may aid the clinician in developing a treatment plan. Galicia 15003. Periodontology and Implant Dentistry. Rome 00161. Pardiñas López.edu G. Periodontology and Implantology. and endodontic surgical options. Viale dell’Umanesimo. evidence-based decisions are based on the concepts of survival. Comparison of implant solutions with endodontic treatment needs a sepa- rate analysis between primary endodontic procedures. the periodontal compromised patient must have a specific eval- uation before implant placement. success. These concepts are often not clearly reported in the literature. MS International Medical School. Spain e-mail: simonplz@hotmail. of Rome. Iocca (ed. Italy e-mail: oi243@nyu. The traumatized tooth may also pose some diagnostic and therapeutic doubts. Sapienza University Oral Surgery.

and suc. The majority of the studies measure whether to retain a compromised tooth or nonsurgical endodontic success as: replace it with an implant restoration.34 O. Even if proved reproducible and reliable between operators. and implant treatment modalities. causes in many factors such as behavioral pat. it becomes difficult to actually of hard tissues. Iocca et al. An updated PAI in order to make comparisons between endodon. (Table 3.1 Teeth or Implants • Implants do not preclude placement of crown or prosthesis. the One problem arises when the implant litera- clinician must take into account the individual ture is analyzed: survival is usually the only needs and preferences of the patient but also the parameter considered. tooth extraction followed by implant placement. radiographic.1 PAI index When implant treatment is considered.5 mm in the 8 mm first year after loading and 0. and environmental influences. odontic success criteria which are often based on tion. it is Quantitative bone alterations in mineral important to distinguish between survival. and patient-referred symp- It is not easy for the clinician to decide tomatology. Tooth loss is the result of compromised health For this reason. prosthetic.5–1 mm cess. or periodontium. Patients with missing teeth or damaged dentition • A minimum success rate of 85 % after 5 years can undergo different restorative procedures or and 80 % after 10 years should be maintained. In order to provide the highest level of care. and the evaluation of the pros and cons of a given approach. abovementioned criteria is usually not performed.1 and Fig.1 Survival and Success periapical lesion). clinical. which must be taken into • The healing of the previous periapical pathol- account in order to formulate an appropriate ogy evaluated radiographically treatment planning. In fact. socioeconomic status. [4] . • The prevention of the occurrence of the new dis- Helping patients to keep their natural dentition ease and the absence of subjective symptoms should be the aim of any dental professional. 3. evaluation in which a predefined set of x-rays and illustrations have been categorized in a scale from 1 (normal periapical structures) to 5 (large 3. genetic predisposi. it is not often Definitions of survival and success are important used in clinical studies.1) based on Cone-Beam tic. the different treatment options weigh peculiar • Retention of the treated tooth risks and benefits.1.2 mm thereafter Score (n) + Expansion of periapical cortical bone • No evidence of peri-implant radiolucency E* Score (n) + Destruction of periapical cortical bone Additional criteria were added by Smith and D* Zarb [2]: Reproduced with permission from Estrela and coll. 1 Diameter of periapical radiolucency > 0. which n structures is the simple evaluation of the implant loss or 0 Intact periapical bone structures persistence of the implant in the mouth. Table 3. 3. whose criteria have been defined originally 2 Diameter of periapical radiolucency > by Albrektsson in this way [1]: 1–2 mm 3 Diameter of periapical radiolucency > • Absence of mobility 2–4 mm • Absence of signs and symptoms referred by 4 Diameter of periapical radiolucency > the patient 4–8 mm 5 Diameter of periapical radiolucency > • Loss of bone around the implant <1. The challenge is to decide when a particular dental The periapical index (PAI) [3] is a visual sys- disease can be treated conservatively or should tem of categorization based on periapical x-ray lead to extraction and implant placement. Same issues exist for the definition of end- terns. It finds its evaluate the success rates of oral implants. pulp.

3 Teeth or Implants? 35 Fig.1 PAI index on CBCT (Reproduced from Estrela and coll) evaluation may be useful for the standardized The fixed dental prosthesis success criteria reporting of endodontic lesions [4]. . not exist. but a consensus classification system does of the above criteria. clinical retention of In practice. are not uniformly defined. 3. endodontic studies mostly evaluate the restoration and loss of the natural abutments the absence of clinical symptoms and radio. have been considered in the majority of the stud- graphic measure of periapical healing regardless ies.

36 O. the survival rates were found to be (Fig.2). follow-up. a high success rate even considering studies made When endodontic literature is analyzed. and the use of opera.1 Primary Endodontic Endodontics as a whole includes primary Treatment treatment. Endodontic treatment is necessary when the den- tal pulp is compromised for any reason. 3. Iocca et al. in the last two decades. In other words. 3.2 Innovations that changed the endodontic surgical practice: the microscope. A com- very important to take in mind that some innova.2. tory microscope and ultrasonic instrumentation Instead. 3. unfavorable clinical conditions. weighted success rate with studies of 6+ years of ration of the canal system. and microscopic armamentarium (Reproduced from Kim and coll) . 94 % (92–96 95%CI) for studies with a minimum All of these are innovations that likely of 6 years of follow-up and 97 %(97–97 95 % CI) improved the survival/success rate of previously with 6+ years of follow-up. secondary treatment (re-intervention). all of them have specific Nonsurgical primary endodontic treatment yields indications and different survival outcomes. Comparison of endodontically treated teeth the better comparison between endodontic and and dental implants may be confounded by a Fig. 3. angulated ultrasonic tips. favorably changed outcome of root-canal treatment in studies of the the prognosis of the endodontically treated tooth: last four decades reported an 89 % (88–91 95 % the introduction of rotary instruments.2 The Endodontically Treated implant literature is made with studies of the Tooth same era [5]. shaping and three-dimensional obtu. and endodontic surgery. the better CI) weighted success rate with a minimum of 6 understanding of the concepts of proper years of follow-up and an 84 % (81–87 95 % CI) irrigation. plete systematic review [6] which analyzed the tions. it is before the advent of modern techniques.

6) means that when a doubt exists whether a tooth Implants 94. filling. (fractured instruments.8–99. Common causes of failure are which treatment outcomes can vary substan. etc. Treatment Also. primarily the abovemen. 3. it is possible to state cedure shifted toward a microsurgical approach that nonsurgical root-canal therapy performed (Fig. In conclusion. results and success rates as showed in the follow- ing studies: A Cochrane review of randomized clinical tri- Table 3. This gives a clear Traditional endodontic surgery involves the indication that extracting a tooth which can be use of surgical burs and amalgam as a root-end saved by endodontic therapy is questionable. a traditional (95–99) surgical approach should be avoided due to the . and the results showed that there is no follow-up rate (CI 95 %) apparent advantage in one treatment choice over Iqbal and 72 months Endodontics the other in terms of long-term outcomes. difference in survival rate when compared with This had important repercussion on clinical implant treatment (Table 3.2. requires evaluation by the clinician in order to Finally.) is considered a major determinant of The presence of persistent periapical pathology survival. due to insufficient/improper instrumentation and tially due to improvements of techniques and irrigation of the canal system. 3. In the last few years. no (84–97) difference is expected in survival outcomes. but the majority of studies do not Orthograde retreatment is preferred if the focus or do not specify the kind of restoration tooth has persistent apical pathosis and a canalar used.2 should be re-treated via orthograde access or (92–96. the type of restoration (filling. apex.4) involving the use of a microscope. irre- Systematic reviews analyzing survival rates of movable post.2 % (94. or complex canal anat- Direct comparison of endodontic versus omy.3 Teeth or Implants? 37 number of variables. This Kim [9] 97.3) [8]. this being considered.2) (Fig.) or when a fixed dental pros- implant versus nonsurgical root-canal treatment thesis is in place and its removal is not advised put on evidence that there is no difference in out. mainly because they would be consid. Secondary endodontics includes two implant treatment is best made on single-tooth options: orthograde retreatment and endodontic restorations because of similarities between the surgery.4) Torabinejad [6] 120 months Endodontics 92 % with a non-microscopic surgical technique.2 Secondary Endodontic tioned unclear definitions of success and failure. intracanalar microbiota. etc. ered unethical in most instances. for economical or technical reasons [10]. 3. even the most recent systematic assess the need and the feasibility of endodontic reviews include studies of different eras in re-intervention. Endodontic surgery instead is indicated when It is anyway possible to identify studies that orthograde access is difficult or impossible due to try to compare indirectly endodontic versus complex canalar anatomy and iatrogenic causes implant treatment. accurate root-end preparation. but it is not always specified. endodontic surgical pro- mentioned limitations. Implants 97 % Indeed. post and core. Also. comes between the two groups. insoluble cements.2 Systematic reviews comparing nonsurgical root-canal treatment versus implants als comparing nonsurgical retreatment with tra- ditional endodontic surgery has been performed Proportion Minimal estimate: survival [11]. two options [7]. persistence of materials. and new better per- dictable treatment modality which shows no forming materials such as the MTA or superEBA. on a tooth with a healthy periodontium and no angled ultrasonic instruments which facilitate presence of other complicating factors is a pre. randomized clinical trials are not anatomy that allows instrumentation up to the available. having defined all the above.

3 In this case.88–0. etc. seems to give an advantage compared to orthograde Consequently.74–0.96 CI 95 %) risk of complications (post-op pain. the difference On the other hand.86 amalgam discoloration. exploratory surgery fact that surgery inherently predisposes to greater a pooled success rate of 92 % (0. Iocca et al. 3. a b d c e Fig. This was shown in a meta-analysis odontic microsurgery is a reliable treatment option performed comparing nonsurgical retreatment and the only effective alternative when orthograde with endodontic microsurgery [12] which showed retreatment is deemed difficult or impossible. a microscopic approach was statistically significant.38 O. for the microsurgery group and 80 % (0. scarring.) CI 95 %) for the nonsurgical group. it is safe to assume that end- retreatment. . after extraction and implant placement (d–e) 3 months suppuration ensued (b). an endodontic approach was revealed a vertical fracture (c) which rendered necessary attempted in order to treat the necrotic tooth #15 (a).

identification and management. Finally. the overall oral health status. Endodontic multiple factors needs to be evaluated: the prefer- microsurgery group showed survival rates of ences of the patient after thorough discussion of the 94 % (0. and MTA apical obturation (e–h) (Reproduced with page 33. the single implants had higher sur- implant treatment with endodontic microsurgery. .99 cedures with dental implants are lacking. odontics: prevention. vival rates than teeth treated with microsurgical Direct comparison studies are not available.97 CI 95 %) at 2–4 years and 88 % economical and biological costs of one treatment (0. but a endodontics [14]. systematic review by Torabinejad and coll. clinical decision making cannot be reports survival rates for single implant based on these data alone.1).91–0.93–0. Mosby 2010) In light of this.84–0.95–0. it is appropriate to compare In the end. and the follow-up. treatment planning as a whole (Flow Chart 3. 5e.98 CI directly comparing endodontic microsurgical pro- 95 %) at 2–4 years follow-up to 98 % (0.92 CI 95 %) with 4–6 years of over the other.4 Example of microscopic surgery performed permission from Kim and coll.3 Teeth or Implants? 39 a b c d e f g h Fig. 3. CI 95 %) at 6+ years of follow-up. [13] Of course. microscope. Problem solving in end- with angulated ultrasonic instruments (a–e). first of all because studies restorations that vary from 96 % (0.

there is no MICROSURGERY necessity of crown lengthening TREATMENT IS FEASIBLE procedures. good prognosis AND PATIENT WANTS TO at long term UNDERGO THORUGH COMPLEX PROCEDURES Poor periodontal prognosis/tooth YES NO NO YES important for the overall treatment planning/previous surgery failed/reduced crown to root ratio PERIODONTAL AND ENDO/RESTORATIVE ENDODONTIC TREATMENT TREATMENT CONSIDER IMPLANT TREATMENT Flow Chart 3.40 O. tooth usable as natural abutment compatibly with overall Indication /feasibility for treatment planning Orthograde Retreatment ORTHOGRADE NO YES ROOT-CANAL YES NO THERAPY Consider these conditions Microsurgical techinques are available TOOTH DOES NOT PERIODONTIUM IS CONSTITUTE A RELIABLE NO YES NECESSITY OF EXTENSIVE COMPROMISED OPTION FOR THE CROWN RESTORATION OVERALL TREATMENT PLANNING Consider Discuss with the patient the feasibililty and the cost of a combined periodontal and endodontic treatment The remaing portion of the tooth does gurrantee ENDODONTIC a ferrule effect. Iocca et al. ENDODONTIC TREATMENT NON SURGICAL REINTERVENTION PRIMARY ENDODONTICS AFTER FAILED RCT Healthy periodontium. portion enough to avoid crown-lengthening procedures. residual crown.1 Endodontic treatment .

it is logi- endodontic 2.3.3. the lon.1 Complications and Survival Periodontal disease 0. restorations on natural abutments (5-year estimate accord- ing to Tan and coll.8 % cal that the longer is the follow-up time.) attempted to describe the complications and the Single crown FPD.8 % Table 3. All-ceramic Resin-bonded metal-ceramic metal-ceramic crown prosthesis Post and core Goodacre Need for Caries 18 % Fracture 7 % Debonding 21 % Post loosening 5 % and endodontic Need for Loss of retention Tooth discoloration Root fracture 3 % coll.1 % Need for endodontic ger will be the risk of developing complications Caries 1. and 5. Anyway. single crown survival/success rates of different types of metal-ceramic all ceramic FDP. primarily for the superior that is luted.1 % and failures. FDP. various complications are associated with this kind of restorations so that the question Conventional FDP metal-ceramic is raised if natural teeth abutments are still an Tan and Need for endodontic treatment 10 % coll.2 % Fracture of the abutment teeth 2.4 Complication rates on FDP metal-ceramic reduction of tooth structure is necessary. and 3.7 % estimate Need for Loss of retention analyzed and the materials used.3 Fixed Dental Prosthesis Metal-ceramic crowns and prosthesis have on Natural Abutments been the gold standard in fixed prosthodontics for many decades.3 Teeth or Implants? 41 3.8 % 3% retention 2 % Esthetics 6 % Periodontal Periodontal disease Periodontal Periodontal disease 0.0 % disease 0.6 % disease 4 % Caries 0. [18] treatment 3 % endodontic 2% 18 % Caries 2 % Porcelain treatment 11 % Pulpal Caries 7 % Periodontal disease fracture 3 % Loss of health 1 % Porcelain fracture 2% Loss of retention 7 % Caries 0. This treatment option has been historically theses are analyzed.5. 3. or otherwise securely retained to natural teeth When complication rates of fixed dental pros- [57].5 % option in case of single or multiple edentulism.8 % treatment 2.4 % Tooth fracture 3 % Prosthesis fracture 2% Porcelain veneer fracture 2 % .3 % It is possible to understand that complication coll. 3.7. [20] Loss of Ceramic chipping rates differ according to the type of restoration 5-year retention 2. but in the last decade.0 % 0. a significant Table 3. 5-year estimate Loss of retention 6.4 % Porcelain fracture 3.5 % of FDP on Natural Abutments Table 3. all-ceramic Fixed dental prosthesis is defined in the glossary restorations have assumed an important role in of prosthodontic terms as “any dental prosthesis clinical practice. in order to obtain opti- mal functional and esthetic results.7 % discoloration 5. Also. Caries 1. treatment 2.4.) Moreover. 3.5 Complication rates of single crowns on natural Different systematic reviews and meta-analyses abutments (5-year estimate according to Pjetursson and coll.3 Complication rates on various types of restorations on natural abutments Single crown.6. complications of metal-ceramic restorations ple missing teeth. it is observed that common the standard of care for replacing single or multi.8 % 3. or mechanically attached esthetic outcomes. The results for each review are reported in Pjetursson Ceramic chipping Marginal Tables 3. [19] Caries 9.1 % 3. screwed.

3 % discoloration 8. 42 Table 3.5 % chipping 3.6 % endodontic treatment 0.8 % discoloration 4.7 % estimate Marginal Marginal Marginal Framework fracture Ceramic Ceramic discoloration 1.6 % Caries 0.6 Complication rates of various types of restorations on natural abutments (10-year estimate according to Sailer and coll.7 % Marginal Framework fracture Loss of treatment 0.8 % Loss of discoloration 0.3 % failure 3.5 % O.) Single crown Single crown all-ceramic Single crown Single crown Single crown Single crown all-ceramic leucit or lithium all-ceramic glass all-ceramic all-ceramic metal-ceramic feldspathic/silica disilicate infiltrated alumina zirconia Sailer and coll.4 % Marginal treatment 1.3 % retention 0.6 % Caries 0.7 % treatment 3.2 % Need for endodontic Caries 1.5 % discoloration 0 % 0.4 % failure 0 % retention 0.1 % chipping 3. Ceramic Framework Framework Marginal Esthetic Loss of [21] 5-year chipping 2.7 % Esthetic failure 0.4 % Caries 1 % Ceramic retention 1 % Need for retention 2.5 % Esthetic Esthetic failure 0 % treatment 0 % failure 0.3 % discoloration 2.3 % 2.6 % retention 4.5 % Ceramic fracture 2.2 % Esthetic Loss of chipping 1.6 % fracture 6.1 % Need for Need for Ceramic Caries 2.7 % fracture 2.5 % endodontic endodontic chipping 1.7 % Loss of chipping 1.5 % Need for endodontic Esthetic failure 0.1 % Framework Caries 0. . Iocca et al.

time influenced the outcomes of treatment.9 % Caries 2 % Need for endodontic treatment n.6 % fracture 6. tion.5 % Framework fracture 3. survival rates are also documented in different gingival inflammation. [22] discoloration 21.4 % fracture 8 % chipping 31.12). metal framework fracture (Fig.5 and tively. chipping.10 and 3.5 % Need for endodontic treatment 2. vary accordingly if we consider single crowns or FDP supported by an implant. and recession systematic reviews (Table 3. treatment n. Complication rates they were cemented or screw retained. higher rates are reported. A sys- tematic review by Pjetursson and coll. 3. common reported complications include prosthetic fracture.2 Survival and Complications 2000 and those published after the year 2000 [33]. Be careful that Prostheses Survival are 3.2 % Need for endodontic retention 2.5 % 5-year Ceramic Ceramic Marginal Marginal discoloration estimate chipping 8.9.4 % 19.a. An interesting aspect that must be analyzed is marginal discoloration. complications reported in this case. abutment fracture [27].) FDP all-ceramic FDP all-ceramic FDP all-ceramic FDP metal-ceramic reinforced glass alumina zirconia Pjetursson Marginal Framework Ceramic Ceramic chipping and coll. 3. Regarding single- implant restorations. ranges of 89–95 % and 80–95 % of survival are found for include loss of vitality. Implant fracture is a rare but possible complication (Fig.5 Three-unit restoration on natural abutments presenting with chipping. When just implant survival vary according to the materials adopted. but in gen. 3.6 % Caries 3. more or less common com- plications include loosening of abutment screw. is specifically analyzed. .7 Complication rates on FDP restorations on natural abutments (5-year estimate according to Pjetursson and coll.9 % Loss of retention 2. In fact.6 % Loss of retention 2.3. abutment or screw fracture. loss of vitality. fracture. 3.5 % Ceramic Ceramic Framework Framework fracture fracture 5 % chipping 5.a.6).2 % 0.9 % 1.a. when studies are subdivided by year of publica- There is a difference in survival between metal. investi- gated the studies published before and in the year 3.1 % Marginal Ceramic fracture Ceramic fracture Caries 1.2 % 28.6 % 14. root exposure and caries. single crowns and fixed dental prostheses respec- chipping.5 % discoloration 17.8. decementation.2 % discoloration 6. of Implant-Supported FDP The findings confirmed an improvement in over- and Single Crowns all prostheses survival in the most recent implant publications. root caries.11).2 % fracture 12. loss of retention. Regarding the implant-supported FDP [28].8) (Tables 3.5 % Loss of Loss of retention 6. These was true for both implant- Common complications reported in the literature supported FDP and single crowns regardless if are indicated in Table 3. eral. Caries 0. common adverse events are crown fracture.2 % Need for endodontic treatment n.3 Teeth or Implants? 43 Table 3. it seems reasonable that newer tech- ceramic and all-ceramic kind of restorations nologies and materials that have changed during which is not statistically significant. abutment or screw loosening. and caries. and esthetic problems [19] (Figs. Regarding all-ceramic crowns. the difference in complications and survival rates Survival rates results are showed in Table 3. Implant-supported FDP and single crowns Fig.7).

50–0.97 CI 95 %) after 5 years Single crown all ceramic 93.91–0.97 CI 95 %) after 5 years Pjetursson and coll. In particular. 3.6 % (0.79 CI 95 %) after 15 years Tan and coll. [27] Neurosensory Prosthesis screw loosening 7 % Fistulas 1 % disturbances 7 % Abutment screw loosening 6 % Mandibular Prosthesis screw fracture 4 % fracture 0. [20] Single crown metal-ceramic 95.9 Complication rates of implant restorations according to Goodacre and coll.83–0. 31]. the patient and the clinician . survival rates are high.95 CI 95 %) after 5 years Sailer and coll.44 O.97 CI 95 %) after 5 years Single crown all ceramic (zirconia) 96.8 Survival analysis of natural abutments restorations according to various meta-analyses Creugers and coll.97 CI 95 %) after 5 years Single crown all ceramic 92. Fig.1 % (0.94–0. Iocca et al.94 CI 95 %) after 5 years Sailer and coll. [24] Conventional metal-ceramic FDP 75 % (0. 28. esthetic between older and newer studies.6 FDP presenting with esthetic complications such as gingival recession. 32].91–0.3 % (0.3 % (0.85–0. [21] Single crown metal-ceramic 94.84 CI 95 %) after 15 years Pjetursson and coll. [23] Conventional metal-ceramic FDP 74 % (0. This is an rations are found to be significantly lower than aspect that merits consideration because even if the older studies [29.7 % (0.94–0.95–0.70–0.6 % (0.95 CI 95 %) after 5 years Table 3.3 % Metal framework fracture 3 % Abutment screw fracture 2 % Implant fractures 1 % If just implant-supported single crowns are If just implant-supported FDPs are analyzed. [26] Single crown metal-ceramic 94.7 % (0.1 % (0. ranging from 16 to 53 % [27.97 CI 95 %) after 5 years Conventional FDP all-ceramic (zirconia) 90. reduced prosthetic complication rate the rate of prosthetic complications remains similar are found in newer studies. Implant surgical complications Prosthetic complications Peri-implant soft tissue complications Goodacre Hemorrhage-related Prosthetic fracture 14 % Fenestration/dehiscence 7 % and complications 24 % Opposing prosthesis fracture 12 % Gingival inflammation 6 % coll.94 CI 95 %) after 10 years Salinas and Eckert [25] Conventional FDP 67. 30.80 CI 95 %) after 15 years Scurria and coll. and chipping Table 3. metal-border exposure. with a 5-year rate outcomes and biological complications for resto.4 % (0. analyzed.81–0. [22] Conventional metal-ceramic FDP 94.4 % (0. [19] Conventional metal-ceramic FDP 89.69–0.92–0.

to some extent. Also. implant placement requires of oral implants studies. in esthetic areas. Also. even if implants and natural abutment serve the same scope (i. comparison of the complications b is difficult for the inherent differences between the two treatment options. but performs better at long term compared to natural teeth prostheses [25].3 Comparison of Natural a Abutments Versus Implant- Supported Restorations Direct comparison of FDP on natural abutments with implant restoration is not straightforward due to the lack of direct comparative studies.3. 3. mostly due to lack of osseointegration instead of prosthetic problems. b) Implant fracture is a rare. . It is anyway possible that both factors in recreating natural hard and soft tissue contours have a role. tooth preparation of teeth certain amount of time will be spent fixing the adjacent to edentulous spaces requires sacrifice abovementioned complications.. That being said. it Fig. yet possible. b) Prostheses fracture is a relatively common complication of implant-supported restorations 3. this remains an open surgical expertise and can create some difficulties question.8 (a.3 Teeth or Implants? 45 a b Fig. of healthy tooth substance and is associated Finally. whether the lower complications and with a high risk of biological complications higher survival rates are due to true technological such as caries and fractures of the prepared improvements or simply to a positive learning abutments. substain a prosthetic device). a descriptive comparison of survival is feasible on the basis of the published studies. Consistent with the previous discussion. 3.7 (a. curve obtained by the clinicians after many years On the other hand. is possible to assume that implant-supported complication restorations have a better prognosis on the long term when compared to prostheses on natural must take into account that during the follow-up a abutments. Survival of implant restorations shows higher rates of short-term failures.e.

7 % Abutment or screw fracture 1.96 CI 95 %) after 6+ years Pjetursson and coll. The majority of traumatic den- FDP for multiple teeth replacement reduce tal injuries occur in children and adolescents. . Also. (2012) [29] Single crown implant supported 89.95 CI 95 %) after 8 years Pjetursson and coll.1 % Loss of retention 3. [32] FDP implant supported 93.9 % Abutment fracture 0.94–0. [6] FDP implant supported 95 % (0. site of injury is the anterior maxilla.4 % Table 3. [30] Chipping 7.8–89. Iocca et al.83–0. [30] FDP implant supported 80.7 % (0.8 % Implant fracture 0.) Biological complications Prosthetic complications Pjetursson and coll.4 % Abutment or screw loosening 5.18 % Pjetursson and Marginal bone loss 8.4 CI 95 %) after 10 years Jung and coll. when a single tooth needs to be replaced. implants used as a support to young population. single crowns Prosthetic complications. [29] Soft tissue complications (inflammation.8 % coll.6 % Abutment or screw loosening 5. [28] FDP implant supported 86.3 % 5-year estimates Chipping 2.5 % Implant fracture 0.11 Complication rate of single crown implant restorations (5-year estimate) Biological complications.12 Survival rate of FDP and single crowns according to various systematic reviews Lindh and coll.1 % Framework fracture 1.3 % Loss of retention 4.2).5 % Metal framework fracture 0. Most common FDP on natural abutments (see Flow Chart 3.5 % Esthetic complications 7.6 % (0.46 O. after careful evaluation of the 3.97 CI 95 %) after 5 years In conclusion. (2014) [31] Single crown implant supported 95.94 CI 95 %) after 10 years Zembic and coll.89 CI 95 %) after 10 years Torabinejad and coll.8 % Abutment or screw fracture 1.3 % Bone loss >2 mm 5.8 %% 5-year estimate bleeding. Loosening of abutment or screw 8. single crowns Jung and coll.4 % (0.2 % Abutment or screw fractures 0.93–0.4 The Traumatized Tooth needs and the will of the patient. [28] Overall without specifying the details Prosthetic fracture 13. It is mechanical and biological complications and estimated that 71–92 % of all dental traumas enhance prostheses longevity when compared with occur before the age of 19 [34]. [31] Crown loosening 4.6 % coll.2 % 5-year estimate 8.5 % Zembic and Overall without specifying 6.3 % Metal framework fracture 0. implant treatment is the Dental trauma is a common occurrence in the best option.91–0.7 % Esthetic complications 0.4 % Abutment or screw loosening 4.5 % Prosthetic fracture 7.8 % 5-year estimate Loss of screw access hole 5.2 % Table 3.6 % (0.4 % Implant fracture 0. Table 3.1 % (66.10 Complication rate of implant restorations (5-year estimates according to Pjetursson and coll. suppuration) 7.83–0.

lateral luxation. intrusive luxation. enamel-dentin-pulp fracture.2 Necessity of restorative treatment Different topologies of dental trauma are fracture. enamel. root fracture. and dentin fracture. concussion. crown Treatment decisions after evaluation of a fracture with pulp exposure. Bone available for there is no necessity of crown implant placement lengthening procedures in esthetic areas YES NO YES NO Bone regeneration is CONSIDER SINGLE feasible. extrusive luxa- identified: infraction.3 Teeth or Implants? 47 NECESSITY OF RESTORATIVE TREATMENT DAMAGED OR WORN DENTITION MULTIPLE TEETH MISSING SINGLE TOOTH MISSING Tooth can be restored without compromising the crown/root ratio. alveolar traumatized tooth are based on clinical and . avulsion. the patient CROWN ON wants to undergo NATURAL ABUTMENT through regenerative procedures and longer treatment time YES NO CONSIDER FDP ON NATURAL ABUTMENTS OR REMOVABLE CONSIDER IMPLANT TREATMENT PARTIAL DENTURE IF FIXED SOLUTION IS NOT FEASIBLE Flow Chart 3. subluxation. enamel fracture. crown fracture without pulp exposure. tion.

every effort tized dentition. ture and soft tissue contours in a way to prepare for ment is the first choice for fractures of enamel. dentin with or without pulp exposure (Table 3. 3. radiographic findings. adult population with no further bone growth Current guidelines. young patients. if radiographic signs of inflammation or impaired healing develops extraction. It is important to remember that should be made to preserve pulp vitality in order implant insertion can be performed only on the to ensure a positive long-term prognosis [35]. the fractured coronal portion is removed and restorative treatment is performed. ful evaluation of both the restorability and the plinary evaluation. the main International Association of Dental Traumatology goal of treatment is to preserve the bony architec- [36]. Iocca et al. When possible.48 O.13 Guidelines for management of dental injuries IADT guidelines for management of traumatic dental injuries Crown-root fracture In this case if the fracture line is above the gingiva level. and if implant placement is indicated . The choice to a traumatized tooth requires care- Other types of trauma require instead a multidisci. indicate that conservative/endodontic treat. implant placement when growth has ceased [37]. feasibility of a restorative approach depends upon the apical extension of the fracture line. and endodontic treatment is performed if pulp necrosis develops. In the case in which the fracture line is below the gingiva level. if this is too deep extraction with immediate or delayed implant placement is performed Root fracture Repositioning of the coronal segment may be a possibility if the displacement is minimal. Especially in the most reliable options for unrestorable trauma.13). Contrarily in younger patients.9). and implant treatment is one of prognosis of the tooth (Fig. a compromise treatment can be Table 3. proposed by the expected. this will be followed by splinting and monitoring for at least 4 weeks.

extrusive. rily results at long term (Flow Chart 3. saliva. delayment of removable denture or to allow a fixed restora- extraction even for teeth with bad prognosis is a tion on the periodontally compromised teeth. On the other hand. Discussion with the patient is This was accomplished with bone resective of utmost importance in order to obtain satisfacto. If this is not possible. Osseous resective surgery per- 3. Replantation is still considered the gold standard and it should be ideally performed immediately after the accident. lateral). With the advent of implantology.3). surgery or with root amputation procedures. milk. it is appropriate to evaluate with the patient if it is better to consider implant restorations chosen. It is one of the true dental emergencies and requires prompt evaluation and treatment decisions. the chance of developing ankylosis and/or root resorption is high. preserving In the past. there was a paradigm shift from tooth preservation to bone preservation.3 Teeth or Implants? 49 Table 3. if the replantation is performed after 60 min. therefore.5 Periodontal Compromised formed with the aim of eliminating the periodon- Patient tal pocket has been shown to be successful in the compliant patient. the tooth is maintained in appropriate storage media (balanced Hank’s solution. If the time delay is <60 min. the prognosis of the replanted tooth is good. . keeping in mind that these patients have possible the replacement of natural teeth with a high survival expectancy. possibility [38–40]. intrusive. tooth repositioning surgically or orthodontically allows to obtain optimal long-term results. Extraction and implant treatment is not usually indicated Avulsion It occurs in up to 3 % of all dental traumas of permanent teeth. saline) and transported to the dental facility. periodontics had the primary aim of bone for a future implant insertion may be more maintaining the teeth in the mouth as long as important than the short-term pocket reduction possible in order to postpone as much as around a compromised tooth.13 (continued) IADT guidelines for management of traumatic dental injuries luxation With all the types of luxation (subluxation. In this situation.

inappropriate due to the necessity of crown-lengthening clinically a slight crown displacement is evident (b.9 (a–h) Ct evaluation shows a root fracture (a). Iocca et al. 3. a d e a b f b g c Fig. c). restoration is considered . an extraction is removal of the fractured crown reveals a fracture line well performed and immediate implant is placed (e–h) below the gingival plane (d).50 O. procedures and poor esthetic prognosis.

furcation Anyway. poor. Moreover. ment because they allow collection and update of crown lengthening.9 (continued) Periodontal regenerative procedures are 3. It is assumed that patients affected by peri- With these premises. 3. been published on the argument so far. regeneration is possible Implant treatment in periodontitis susceptible only with some types of periodontal defects. endodontic surgery. complete in the Patient with a History regeneration of the periodontium has been shown of Periodontal Disease difficult to achieve and not predictable in some cases [41]. sidered strategic abutments.15.14. Meta-analyses are best suited for making a • Endodontic/restorative status: If the tooth comparison between healthy and periodontally necessitates complex endo/restorative proce. Periodontal regeneration is a possibility if the periodontal defect has a favorable prog- nosis (three to four wall pockets). the costs for the patient can The results of all meta-analyses published so be much higher if the failing tooth would need far are concordant with the fact that patients with to be replaced with an implant after a short a history of periodontitis have an increased risk period of time. This strengthens the . across all the studies [44–49]. Moreover. Fig. however. of implant loss compared with patients with a • Status of the adjacent dentition: If the peri. one should Potential shortcomings arise from confound- consider which would be the consequences ing factors. it must be pointed out that potential involvement. Also. negative history of periodontal disease odontally compromised tooth/teeth are con. etc. mellitus.5. Otherwise. this is a logi- In general. Bone resective procedures are excluded in this case. and 3. with the aim to assess the risk of implant loss and the only possibility is to try to slow the progres- success rates in this specific population. • Esthetics: Anterior teeth involved by peri- odontal disease merits careful evaluation. (Tables 3. patients has been evaluated in numerous studies while in patients with generalized periodontitis. increase the rate of implant failures.16).3 Teeth or Implants? 51 Poor patient compliance and poor tooth prog- h nosis should lead toward less complex treat- ment options.1 Implant Treatment another treatment option. four factors are taken into account cal assumption given the similar pathobiology in the evaluation of the dentition affected by peri- and microbiological aspects between periodonti- odontal disease: tis and peri-implantitis [43]. compromised patients undergoing implant treat- dures (post and core. it is important to resolve odontal disease are at increased risk of develop- when to proceed with the extraction or when a ing inflammatory complications which may conservative approach can be adopted [42].). no RCT have extraction should be considered. the prognosis is results from contradictory studies. sion of the disease. which are not always clearly accounted mising an extensive prosthetic work is high. and oral weakness in the analyses is overcome by the fact hygiene are all factors to consider before pro. If the risk of compro. such as smoking and diabetes once the treatment fails. for or not considered at all. • Periodontal status: Pocket depth. that the results are exceptionally homogeneous ceeding with complex periodontal treatment. extraction and implant placement may aid in achieving good esthetic results. 3. crown-root ratio.


10–2. [46] healthy patients Safii and OR 3. . be searched for in order to prevent or slow-down aggressive periodontitis ulteriorly increases this the progression of the disease [50–55] (Flow risk compared to chronic periodontitis [48]. [45] healthy patients Sgolastra and RR 1.15 Published meta-analyses evaluating aggressive versus chronic nonaggressive forms of periodontal disease Chronic periodontitis vs. Moreover. [44] healthy patients Chrcanovic and RR 1. [48] Table 3. most importantly.85) + In favor of periodontal coll. gives a clear clinical In conclusion.16 Published meta-analyses evaluating the risk of development of peri-implantitis Periodontal healthy vs.21 (1. when implant treatment is pro- indication: patients with a history of periodontal posed to this particular population of patients. [46] Monje and RR 3. [47] healthy patients Table 3.97 (1.42–3.68–9.01–1. [46] healthy patients Monje and RR 3. [44] healthy patients Sgolastra and RR 2. aggressive periodontitis Statistically Effect size patients results (95 % CI) significant Clinical meaning Wen and RR 1.66) + In favor of periodontal coll. 3.78 (1.01–1.05) + In favor of periodontal coll. [48] healthy patients results and.10) but should be informed of the fact that and maintenance procedures should be adopted there is an increased risk of implant loss compared and early detection of peri-implant disease must to periodontal healthy individuals.32) + In favor of nonaggressive coll.05) + In favor of nonaggressive coll.89 (1.03 (1.43) + In favor of periodontal coll. Chart 3.11) + In favor of periodontal coll.4).03 (1. periodontal compromised Statistically Effect size Results (95 % CI) significant Clinical meaning Wen and RR 1.37) + In favor of periodontal coll.04) + In favor of periodontal coll.97 (1. it disease are candidate to implant treatment must be taken into account that strict follow-up (Fig.59 (1.3 Teeth or Implants? 53 Table 3.68–9.02–1.50–2.14 Published meta-analyses on periodontal healthy versus periodontitis patient undergoing implant treatment Periodontal healthy vs.04 (1.37) + In favor of nonaggressive coll.12–1. periodontal compromised Effect size Results (95 % CI) Statistically significant Clinical meaning Wen and RR 1. [44] Sgolastra and RR 1.35–2.02 (1.

a b c d e f g h Fig. and healing is completed (d–e). considered of having poor prognosis. Iocca et al. initially just anterior teeth are extracted in order to treatment (f–h) . 3.10 (a–h) Patient affected by chronic periodontitis and give to the patient provisional restorations while he acquires poor hygiene control (a–b) after tartar ablation teeth are proper oral hygiene measures. the patient undergoes implant performed. (c) and extraction is After 3 months of follow-up.54 O.

4 Periodontally compromised dentition .3 Teeth or Implants? 55 PERIODONTALLY COMPROMISED DENTITION ENDODONTIC/RESTORATIVE STATUS OF THE ADJACENT PERIODONTAL STATUS ESTHETIC CONSIDERATIONS STATUS DENTION -No complex endododontic treatment is required Tooth is strategically -Good prognosis Periodontal regeneration is -Tooth can be restored without important and a treatment failure -Periodontal defect allows Possible compromising the crown/root ratio. could compromise an A regenerative approach No resective surgery is required -There is no necessity of crown extensive prosthetic work (single pocket. 3-4 wall defects) lengthening procedures YES NO YES NO YES NO YES NO Patient accepts the risk CONSIDER of treatment failure and PERIODONTAL possible higher costs TREATMENT Periodontal Regeneration/ YES NO Conservative Approach CONSIDER PERIODONTAL TREATMENT CONSIDER IMPLANT TREATMENT Flow Chart 3.

Outcome of endodontic surgery: a meta- implants: a review and proposed criteria of success int. In patients requiring single- 11. tooth replacement. 52. Salinas. Zwahlen. K. Torabinejad et al.S. 79. Torabinejad. 624–639 (2015) treatment. A systematic review of single crowns on endodontically treated teeth. Outcome of nonsurgical retreatment and end. Endod.E. All-ceramic or metal-ceramic replace a questionable tooth. U. Setzer.U.. Sun. Implants 22(Suppl). B. J. 35. J.P.A.C. J. S. B. A systematic review of the sur- 14. Oral Implant. Bernal. T.J. B. 603–623 (2015) 8. B. Dehom. Testori. Endod. Prosthet. Sailer. tooth-supported fixed dental prostheses (FDPs) and supported single crowns.J. N. P. 31–41 (2003) 1331 (2008) 19. Kim. Kan.E. Smith. rations and full arch reconstructions. 123–127 (2003) Maxillofac.M. Zwahlen. A systematic review of the survival and complication E. Lang. Outcome of endodontic surgery: a meta- cal index: a scoring system for radiographic assess. Kerekes. D.X. 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A relatively recent technology. Bone remodeling after extraction may have an influence on the implant treatment planning and clinical results.). For this reason. evaluation of chemical and physical characteristics is con- sidered important in order to choose the best implant and obtain optimal clinical results. DDS order to improve the interaction of bone to the International Medical School. Italy e-mail: oi243@nyu. Private Practice Limited to Oral Surgery. Periodontology and Implant Dentistry. Finally. Evidence-Based Implant Dentistry. Sapienza University implant and consequently enhance the success of of Rome. Although it is not clear which specific surface confers a true advantage. The implant surface plays a huge role in the bone response leading to osseointegration. Iocca (ed. It is clear that osseointegra- tion is dependent by the interactions of the Osseointegration is defined histologically by the implant surface with the bone tissue. Rome. 00161 Rome. optimal osseointegration mechanisms. Bone Response to Implants 4 Oreste Iocca Abstract A successful implant treatment presupposes an effective osseointegration. Iocca. there is a general consensus that a roughened surface gives better results compared to machined one. direct apposition of bone to the implant surface Materials and surface topography are crucial and clinically by the ankylosis of the implant in in determining the bone response to the insertion of the implant. and high bone-to-implant contact (BIC) should guarantee the best results at long term. it can aid in inserting the implants in difficult clinical situations like the contiguity to delicate structures such as the inferior alveolar nerve or the maxillary sinus. Viale Regina Elena 324.edu © Springer International Publishing Switzerland 2016 59 O.1007/978-3-319-26872-9_4 . which has the best cutting efficiency on mineralized tissue without overheating the bone. and many studies are performed in O. which is the direct apposition of bone to the implant surface. Italy implant treatment. the piezoelectric surgery. DOI 10. may contribute to reduce the bone trauma before implant placement.1 Bone Response to Implants the bone structure. good primary stability. Also. 4.

60 O. Iocca

4.1.1 Implant Surface • Coating with apposition of various materials
Characteristics on the surface of the implant has been adopted
by some manufacturers, whereas others are
Implant surface plays a fundamental role in the still being investigated as potentially improv-
processes of bone response and osseointegration; ing the performances of bone-implant interac-
for this reason, it is important to define the key tions. Hydroxyapatite coatings have been the
surface parameters so to understand how surface most widely used and studied extensively, but
modifications impact healing time for the long-term prognosis is controversial con-
osseointegration and ultimately success rates of sidered that microbial adhesion, osseous
oral implants [1, 2]. breakdown, and coating failure are regarded
The surface characteristics of dental implants as common occurrences.
can be categorized as chemical and physical.
Other materials such as bioactive glasses and TiN Chemical Characteristics coatings are currently investigated and gave good
Chemical characteristics refer to the core implant clinical results in vitro and in small in vivo studies.
material and the surface additions introduced in Due to the lacking of large accurate clinical studies,
different ways. Titanium (Ti) is the most widely a thorough comparison of the performances of dif-
used material for implant fabrication, but in the ferent implant coatings is not considered possible.
last few years, zirconia has emerged as an alter-
native to titanium implants. Physical Characteristics
Both pure Ti and alloys are used in manufac- Solid surfaces, independent of the method of for-
turing of dental implants. Commercially pure Ti mation, have irregularities and deformations that
is available in four grades, their composition gave them unique textures.
varying in the concentration of oxygen and iron. Micro- and nanoscale features are considered
Grade 4 is the most widely employed form of to have a huge impact on the bone-implant inter-
pure Ti for dental implants due to the high elastic action. Surface topography refers to the degree of
modulus and tensile strength. Alloying elements roughness and surface irregularities. In order to
are added in order to increase the mechanical describe the surface topography, 2D and 3D
strength. Grade 5 is Ti alloyed with vanadium parameters must be described separately [4].
and aluminum (Ti-6Al-4 V) The most common microscopic parameters
Zirconia implants are made of ittrya-partially used by investigators in performing a quantitative
stabilized zirconia (Y-PSZ) or ittrya-stabilized description of the bidimensional evaluation (pro-
tetragonal zirconia (Y-TZP); this last one is the file Fig. 4.1 are:
most widely used for superior corrosion and wear
resistance compared to other dental ceramics. Rz sum of the maximum values of profile peak
height and valley depth in a sampling length
• The surface of the implant can be defined as Fig. 4.2
the 100 nm superficial layer of the implant [3]. Ra arithmetical mean of the absolute values of
• Impregnation of the surface means that a peak heights and valley depths in a sampling
chemical adjuvant is integrated with the core length Fig. 4.3
material. Degree of impregnation refers to the Rsm average interpeak distance along the profile
percentage of the impregnated element on the in a sampling length
core material; the so-called high impregnation The most common reported three-dimensional
(i.e., >5 % of added element) can be observed parameters are:
when there is a true chemical modification of
the core material and the TiO2 layer such as it
happens with the anodized implants (see Sa is the 3D equivalent of Ra, expressing the average
later). Coating instead refers to a superficial of absolute values of peak heights and valley
apposition on the core material. depths on a three-dimensional display Fig. 4.4.

4 Bone Response to Implants 61

Sds density of summits or number of peaks in a According to Wennerberg and coll. [5], three-
given area Fig. 4.5. dimensional evaluation is the best way to describe
Sdr, developed surface area ratio, expresses a implant surface characteristics because it is more
measurement of the surface enlargement if a consistent and reliable compared to bidimen-
given surface is flattened out. A totally flat sional evaluation alone. In particular, Sdr value is
surface has Sdr value of 0 %; an Sdr of 100 % a hybrid parameter that must take into account
means that the roughness of the surface dou- both Sds and Sa values and in this way gives
bles its surface if flattened out. information about the number and height of
peaks over a given surface [6].

Fig. 4.1 Implant surface

Fig. 4.2 2D schematization of the implant surface and Rz representation

62 O. Iocca

Fig. 4.3 2D schematization of the implant surface and Ra representation

Sds= number of peaks

Fig. 4.4 3D schematization of the implant surface and Sa

At a nanoscale level, surface energy is a mea- Fig. 4.5 3D representation of the implant surface and Sds
sure of the extent of unsatisfied bonds at the sur- representation
face. In other words if the surface is hydrophobic
or hydrophilic, two properties that influence the not clearly visible or not homogeneous and
surface wettability. Theoretically, a high surface repetitive, the surface can be considered as nano-
energy (i.e., high hydrophilia) increases the wet- smooth [8]. Nanoscale topographies are consid-
tability to blood and in consequence cell attach- ered an important aspect and an exciting field of
ment, differentiation, and proliferation [7]. One research in the processes of osseointegrations,
aspect to consider in this regard is that all sur- mainly due to observations coming from in vitro
faces show some sort of nanotopography but not studies. In vivo applicability of the results com-
all show significant nanostructures (objects of the ing from basic research studies still needs to be
size between 1 and 100 nm). If nanostructures are cleared [9].

4 Bone Response to Implants 63

4.1.2 Implant Surface Topography
Modifications a

For decades, the gold standard implant surface
has been the Branemark implant which is often
described in the dental literature as synonymous
with “machined” implant, without actually
specifying the turning process applied in manu-
facturing. Indeed, no machining method, how-
ever precise, can produce a totally flat surface. It
follows that a machined surface, according to
the different machining methods adopted, can
have very different topographies. Therefore, in
many studies comparing machined surfaces
with various rough surfaces, it is unclear which
kind of surface is actually analyzed. With that
premised, it is possible to distinguish the vari-
ous surfaces in this way [5] (Fig. 4.6):

• Machined surfaces, Sa values <0.5 μm
• Minimally rough surfaces, Sa 0.5–1 μm
• Rough surfaces, Sa of >2 μm

It seems clear that the process of osseointe-
gration occurs independently of certain surface
characteristics, considering that osseointegra- c
tion occurs with a great number of different
surfaces. Surface modifications, in particular
roughening methods, have found to be impor-
tant in improving the bone-implant response
with the aim of reducing healing time for load-
ing and also to allow a stronger anchorage of
the implant to the bone in those situations
where bone quality is considered poor (type IV
bone type).

• Roughening of implants by acid-etching Fig. 4.6 (a–c) SEM picture of machined (a), minimally
rough (b), rough surface (c) (Reproduced with permission
Acid-etching with strong acids such as HCl, from Elias and col.)
HF, etc. is able to produce microscopic pits on the
implant surface with sizes in the range of
0.5–2 μm in diameter [36]. Acid-etching has • Roughening of implants by titanium plasma
been found to improve notably osseointegration spray
in experimental animal studies when compared
to machined surfaces, but no major clinical dif- TPS involves the injection of titanium powder
ferences in terms of survival rates are reported into a plasma torch at very high temperature, the
when comparing etched surfaces with machined Ti particles sprayed over the implant surface
implants in vivo. form a film about 30 μm thick.

64 O. Iocca

With this method, it is possible to achieve very optimal roughness with the blasting procedures
rough surfaces with an average Ra of 7 μm. and, at the same time, a smoothening of the irreg-
Analysis of the literature shows that this kind of ular peaks with the additional etching. A stronger
roughness is clinical disadvantageous in terms of osseointegration is found when compared to
survival rates when compared with smooth and machined implants, but no clinical studies are
minimally rough surfaces. available to clearly show a superiority of this sur-
face to others.
• Roughening of implants by grit blasting
• Ceramic surfaces
Grit blasting consists in roughening of the sur-
face via blasting with hard ceramic particles noz- Implants coated with hydroxyapatite (HA)
zled at high velocity by a means of compressed air. were introduced on the market around three
Different ceramic materials are adopted for this decades ago. The first generation of this kind of
scope. Alumina is frequently used but also tita- implants showed initial success, but later they
nium oxide and calcium phosphate can be showed high failure rates essentially because the
employed. initial osseointegration was then followed by
Optimal surface roughness can be achieved delamination of the whole surface from the under-
with this method, and a recent review [5] reported lying titanium. For this reason their use was
average Ra values ranging from 0.6 to 2.1 μm. abandoned.
Blasted implants show a better osseointegra- Modern coatings of HA instead are 1 μm or
tion when compared with machined surfaces, but less in thickness due to the fact that HA particles
this does not reflect as a clinical advantage in are plasma sprayed on the surface of the implant.
terms of success/failure rates. The risk of developing the complications of the
first-generation HA-coated implants should be
• Roughening of implants by anodization lower, but more clinical studies with long-term
follow-up are needed in order to definitely rec-
Porous surfaces are obtained in galvanostatic ommend them for clinical use.
chambers placing titanium implants in strong In summary, it has been shown that bone
acids at high potential (100 V). This electro- response to implant insertion is influenced by
chemical processing produces a thickening of the the surface topography. Many studies lack a
oxide layer on the implant surface to more than characterization of the topography, and even
1000 nm, this oxide layer is then dissolved by the machined surfaces can vary considerably in
strong acid in the solution along the current con- their topographical characteristics according to
vection lines, and this creates microscopic pores the turning techniques adopted by the manufac-
on the surface. turer. In light of this, it is difficult to compare
Anodized surfaces have been found to increase studies in an attempt to define which is the ideal
the bone response, most likely through increased surface. On the other hand, there is a general
mechanical interlocking and also creation of bio- evidence on the basis of animal and clinical
chemical bonding. From review of the literature, studies that roughening of the implant surface
anodized surfaces have been found to give a clin- leads to a stronger bone response [10].
ical advantage compared to machined ones when Moderately rough surfaces with Sa values
implants need to be placed and loaded between 1 μm and 2 μm and Sdr of 50 % are
immediately. considered to be optimal even if the biological
reasons of this are still unclear. The advantage
• Roughening of implants by blasting + etching of rough surfaces when compared to machined
ones is to be found especially in those situa-
This is a combination of blasting and etching tions in which stronger bone response is needed,
techniques. In this way it is possible to obtain an for example, in case of poor bone quality or to

mainly because surface characterization nium.1. to 5 years). rough surfaces displayed a higher rate and it is a reason of concern that.3 State of the Available Evidence About the Current Most Common Implant 4. For this rea- elderly patients with expected poor healing. Currently. this in order to test if aging might become an issue can contribute to the self-propagation of an estab. albeit poten- of re-osseointegration compared to machined tially successful both biologically and mechan- surfaces [12]. bacterial colonization.7). Restorations supported by modification gives better results in terms of more titanium implants might be compromised by rapid osseointegration and reliability in more the dark color that can become exposed. Ittrya-stabilized of processing dental implant surfaces have the tetragonal zirconia (Y-TZP) possesses some potential to improve some of the abovementioned properties that render it suitable for implant conditions. given the good results in animal and manufacturing. surface roughening seems to improve the in most of the available studies is improperly per. comparative clinical studies with dif- early loading protocols are adopted. abolic impairment. lished peri-implant disease. it is important to evaluate which surface the past few decades. There is a lack of studies investigating the Regarding long-term stability. and ered feasible after a systematic review of the lit. zirconia implants are available on the What needs to be addressed is that still addi. sons. to provide strong indications over the use of a In conclusion.4 Zirconia Dental Implants Surfaces Titanium dental implants with either smooth or Considering that implant success rates reported rough surfaces show high success and survival in the majority of the available studies exceed rates and have been used with confidence for 90 %. met. and it makes even more difficult to arrive at an objec- tive conclusion (Table 4. ically. On the other hand. due to the increased demand for esthetics. bone response in terms of enhanced of formed or not reported at all. This process refers to a progressive trans- no differences from a clinical and histological formation of the metastable tetragonal phase point of view between rough and machined sur. a phenomenon influence of implant surface characteristics on known as aging of the material has emerged as a the incidence of peri-implantitis. ferent implant surfaces are rarely performed. attempts strength and fracture toughness. into the monoclinic phase.1). cleaning. after to recommend the use of this type of implants. osteoporosis. but some experimen. soft tissue response.1. especially its high flexural some clinical studies.4 Bone Response to Implants 65 speed up the healing time when immediate or Moreover. which is detrimental faces at various follow-up periods (few weeks up for the mechanical resistance of the material. In vitro and made to provide a statistical synthesis of the animal studies show promising results in term available evidence on the topic were not consid. no scientific clinical data allows tal studies on dogs have shown that. for dental implant use as well [14] (Fig. market without long-term clinical investiga- tional clinical studies with proper specification of tions supporting their safety and predictability the implant surfaces adopted are needed in order on patients [15]. 4. Animal studies problem for zirconia implants used in orthope- and observational studies on humans [11] found dics. zirconia dental implants have emerged as an It is evident that currently available methods alternative to titanium [13]. not recommended based on the available infor- . osseointegration. 4. In the same way as tita- erature. espe- challenging cases such as low bone quality or cially in the thin gingival biotype. It is assumed that rough surfaces are Further long-term studies should be performed more difficult to clean than a machined one. the use of zirconia implants is surface over another in a given clinical situation. of osseointegration. etc.

00 % 40. Hydrophilic Sa 0.78 μm Sdr 24.00 % 37.3 μm 0. Iocca .00 % 97.1 μm 1.00 % 31. deposition implant dioxide by chemical nitrogen which is body particles modifications by protection and harder and hydrofluoric acid stored in NaCl smoother solution.00 % 27.00 % 143. Grade crystalline acid-etched titanium particles followed rinsed under Hydrophobic methods 5 titanium. CaP modifications Turned Turned Blasted Anodized Blasted with Acid-etched and Acid-etched and characteristics acid-etched created discrete collar.9 1.00 % O.75 μm 1. with titanium dioxide grit blasted then grit blasted.1 Most diffuse implant surfaces with reported values of Sa and Sdr as measured by Wennerberg and Albrektsson [5] Nobel Biomet 3i Biomet 3i Biomet 3i Astra Tech Biocare Astra Tech Straumann Straumann Prevail NanoTite Osseotite Branemark TiOblast TiUnite OsseoSpeed SLActive SLA Surface Turned collar.4 μm 1.68 μm 0.1 μm 1.00 % 34. 66 Table 4. and processing body.00 % 37.5 μm 0.

2 Bone Remodeling dimensional change occurs primarily in the first After Dental Extraction 3 months. 4.) mation. the bone loss in width is greater than when compared to post-extraction sites without the loss in height and that there is a more implant placement [20].5 mm on the occur after tooth extraction have important reper. crest and lingually positioned in relation to the dependent tissue distinguished from the alveolar center of the crest (Fig. There is a general concor- cussions on implant insertion. . both in vertical and horizontal issue of bone modeling after immediate implant dimensions [16.9).2). Tomasi and col. six dogs. ment methods adopted (surgical reentry or The alveolar process is defined as the bone radiographical evaluation). was confirmed but considered to be more modest on average. It is now clear that there is buccal crest resorption.0–4. and dance in this value regardless of the measure- esthetic results. This portion of the socket is a tooth. 18] the horizontal aspect opposed to the vertical one (Table 4. implant and its relation to buccal crest resorption. Two recent insertion in a clinical setting.4 Bone Response to Implants 67 Fig. The inner portion of the Caneva and col. values reported in the reviews based on clinical siderable consideration in the dental research studies fall in the range of 3. the reviews analyzed bone dimensional changes of usual pattern of more pronounced resorption on post-extraction sockets in humans [17. always some sort of alveolar ridge reduction fol. [19] experimentally placed alveolar socket is composed by bundle bone immediate implants in fresh extraction sockets of (alveolar bone proper) where there is the inser. success rates. in this study. b) Fractured zirconia implant at electron microscopic evaluation. Absolute Socket healing after tooth extraction gained con. surrounding the tooth. vertical dimension. The results showed that the buccolingual position tion and they have been studied both in animal of the implant has an influence on the amount of and human studies. 4. contrarily to what happens for the evaluated in a human study the position of the bundle bone. that the majority of the buccal plate is composed by bundle bone and in consequence rapidly resorbed following tooth extraction. In quantitative terms it can be expected and Tissue Healing that around 50 % reduction of the ridge will Around Dental Implants occur following extraction. Both are concordant on the fact that.0 mm on the community due to the fact that the changes that horizontal dimension and 1. This is consistent with the fact native to titanium implants.8). cracks are evident (b) (Reproduced with permission from Osman and col. persists even after tooth extraction. the conclusion was that implants should tion of the Sharpey’s fibers of the periodontal be positioned at least 1 mm below the alveolar ligament. 4.0–1. Most of the 4. 70] (Fig.7 (a. Dimensional changes occur after tooth extrac. bone which. One meta-analysis specifically addressed the lowing tooth loss. the molar regions suffering the greatest rate of resorption. and much more research efforts are substantial buccal bone resorption compared to needed before considering them as a viable alter. the lingual aspect.

68 O.56) (0. Different biomaterials have been used to will inevitably occur. Tan and col. C blood clot.2. and 8 weeks after extrac.9) placement may slightly reduce the amount of and col. B buccal. 4. 3. Materials available include: bone surface. PM provisional histologic examination (HE 16× magnification) in beagle matrix.4–1.) Table 4. patient Moreover. with permission from Araujo and col.67 extraction.1 Alveolar Ridge Preservation Prior to Implant Placement Knowledge of bone resorption patterns is impor.24 clinical (2. bone resorption in the esthetic Allograft – bone grafted from the same species areas may lead to loss of the physiologic bone (cadaver bone) . the insertion of a grafting material into the extrac- cussions on clinical decision-making. For example.06) (1. 3. Alveolar ridge preservation techniques involve tant for the implantologist because of their reper. tion socket in order to minimize as much as pos- placement of an implant immediately after extrac. Iocca a b c Fig. case resorption.8 (a–c) Alveolar ridge alterations after extraction. 2 weeks (b).2 Systematic reviews evaluating the bone contour which may render necessary a soft and dimensional changes of post-extraction sockets in humans hard tissue graft at the moment of implant place- Alveolar Alveolar ment or at the moment of implant uncovering. RCT. WB woven bone. trials. A space of at least 2 mm obtain this scope with different degrees of suc- should be left between the implant and the buccal cess [23].79 1. Weak evidence exists that immediate Weijden clinical (3. sible the alveolar process reduction in width and tion has to take into account the bone resorption that height.87 1.8–1. tion (c).46–4.7–4. otherwise the resorption that will occur in the following months would be the cause of Autografts – bone harvested from the same exposure of some of the implant surface [21]. width height Finally. but more studies are needed to con- series firm these results [22].5) trials. the current evidence does not seem to Studies change in change in included in mm (95 % mm (95 % show that immediate implant placement by itself the review CI) CI) is able to preserve the bone resorption after Van der RCT. cohort studies 4. L lingual. BM bone marrow (Reproduced dogs at 1 week (a).

b) Experimental study on dogs a b using implants of different diameter. it is evident that using a larger-diameter (a) implant does not prevent the buccal bone resorption but instead leads to implant exposure.086–2. one aspect on which all the system- clinical heterogeneity. 4. the buccolingual width and buccal available meta-analyses on RCTs and non ran. which are described in Tables 4. Toluidine blue (16× magnification) (Reproduced with permission from Caneva and col.99 1. As a consequence of this methodological and Anyway.5) (0.1) socket col. 4.3. Alloplast – synthetic material Both works found that alveolar ridge preser- vation techniques limit the physiologic ridge A problem in analyzing the effect of alveolar reduction when compared to unassisted healing ridge preservation techniques is that the majority and also point out that the effects of ARP are very of the studies on this topic are case reports. most likely for the influence of local and series. bovine bone [24–26]. and 4.99 0.4–1.9 (a.1–3.9 0. case variable. Bone Bone Bone height width Bone height changes Bone changes width changes in mm width in mm changes Bone height in mm after use changes after in mm changes in after use of a in mm use of a after use of mm after of a barrier after barrier a barrier use of a barrier and Effect grafting alone and grafting grafting alone grafting Clinical Size (95 % CI) (95 % CI) (95 % CI) (95 % CI) (95 % CI) (95 % CI) meaning Vittorini Weighted 1.9 In favor of Orgeas and mean (0. The smaller diameter implant instead is in contact with bone both lingually and buccally.66) grafting Evaluating width and height changes in socket grafting versus unassisted healing after 6 months .78 0.3 2.3 Meta-analysis by Vittorini Orgeas and col. wall height reduction when compared to unas- domized trials provided quantitative results sisted socket healing.01– (2.4) (−0. The completely. tion procedures limit.3) (−1. It is still unclear what bio- Fig.4 Bone Response to Implants 69 Xenografts – bone harvested from other species. systemic factors.) Table 4.5) (0.3–3. or inadequately performed clinical trials.5 for example.95–2. although cannot stop comes such as linear or volumetric changes.4. [24] difference 2. many systematic reviews atic reviews are concordant is that ridge preserva- performed are not able to provide relevant out.

5 Meta-analysis by Willenbacher and col.18–0.001 p-Value 0.62–1.79) 0.12 (0.001 p-Value <0. [25] mm p-Value <0.18 (0.19) 0.53) In favor of and col.102 socket grafting Evaluating width and height changes in socket grafting versus unassisted healing after 6 months Table 4.05–0.41–2. Buccolingual Apico-coronal Effect size measurement (95 % CI) measurement (95 % CI) Clinical meaning Willenbacher Mean difference 1. Buccolingual measurement (95 % Midbuccal Midlingual Effect Size CI) measurement measurement Medial measurement Distal measurement Clinical meaning Avila-Ortiz Mean difference in 1.002 p-Value 0. [26] in mm p-Value not reported p-Value not reported grafting Evaluating width and height changes in socket grafting versus unassisted healing after 6 months O.03–3.44–2.63) In favor of socket and col. Iocca .89 (1.24 (−0.07 (1.36) 2.4 Meta-analysis of Avila-Ortiz and col. 70 Table 4.12) 1.48 (0.64) 1.22 p-Value 0.54 (0.17–2.

described a dog model in reviews. the high heterogeneity between the studies resorbed and immature woven bone can be is another factor to consider [28]. were studied histologically alveolar resorption outcomes [27]. granulation tissue. • In 1 week most of the inflammatory cells are Also. more mature bone with the presence of between comparable clinical studies. surfaces. neutrophils. the rough implant surface: firms this assumption and adds that there is no evidence to conclude that the socket preservation • In the first few hours following implant instal- techniques have any impact to the look or lasting lation. ferent surfaces. matrix. and this was constant at different time . marrow will remain in contact with the device surface at the end of the 12th week. selection of representative population group. disorganized connective tissue matrix process. and As mentioned before. Osseointegration is defined as the direct bone-to. even if it is formed mineralized bone extends from the a simple technique with low risk of complications.3 Bone Integration of Dental In general. some studies strongly recommend to which two types of screw-type implants with dif- avoid flap surgery. and finally Regarding the results on flap vs. especially in esthetic areas. flapless extrac. sign of osteogenesis. The results of the study The use of barrier membranes seems to show no constitute an excellent model of osseointegration clear advantage compared to use of no barrier at all. Osteoclast formation is mize this process is desirable both from surgical evidenced and contributes to bone and prosthetic reasons. First. bone enters the remodeling mainly due to the high variability in results phase. at different time points. woven bone development. it is not well defined which one of the avail. but others suggest that the sur. conflicting results emerge from the Abrahamsson and col. sions on materials and techniques to adopt are still Both lamellar and parallel fiber bone deposi- unclear and further research is needed in order to tion are represented. Mature bone and bone draw stronger conclusions on the argument. blood clot is in contact with the implant qualities of implant restorations. trying to mini. In 3–4 days. formation of a provisional able techniques allow to obtain the best results. Primary bone marrow can be seen rich in vas- There is evidence that shrinking of the alveolar cular structures and mesenchymal cells. [33]. After 2 weeks woven bone formation is preservation techniques is that extraction of a tooth more pronounced and surrounds the whole will inevitably lead to a reduction in alveolar pro. the same sequence of events could Implants be described for the polished surface but some major differences need to be outlined. primary and secondary osteons is evident. and unclear and the first vessel sprouts are evident. These were the histological observations for A Cochrane review on the argument [23] con. Also. implant mixed with old bone which is a clear cess height and width. • In 6–12 weeks. tion of teeth. so that erythrocytes. lamellar bone organization (Fig. the main reason for these macrophages are trapped in a network of unclear results reside in the fact that the majority fibrin. 4. implant contact (BIC) compared with polished sue. prepared bone surface to the implant coating. one sand blasted/acid-etched and gical technique does not have an influence on the the other machined. Decision of grafting a post-extraction socket • Four weeks after implant insertion. roughened implants showed higher bone-to- implant contact without apposition of fibrous tis. Therefore. 4. remodeling. evidenced together with newly formed ves- In summary.4 Bone Response to Implants 71 material gives a clear advantage over another. newly should be evaluated carefully because. process can be minimized by some extent but. the rationale behind alveolar ridge sels. it adds a cost to the patient [29–31]. Temporal sequence of events that lead to ones. the clot is replaced by of the studies included in the systematic reviews granulation tissue composed by mesenchymal are at high risk of bias like unclear randomization cells. osseointegration include coagulum formation. net conclu. blinding of patient/examiner.10).

(b) The newly formed bone (arrows) forms a tra.10 Light micrographs illustrating the implant. in other words a direct contact surfaces only distant osteogenesis occurred. bone. The adjacent osteoid is with that of the implant. marrow (BM) close to the old bone. formed bone. On the other hand. Iocca a b d c Fig. (c) Initial bone apposition on the implant and ini- tissue interface and the peri-implant tissues of an SLA tial bone formation in the soft tissue is associated with implant after 14 days of healing.72 O. on the polished tact osteogenesis. with . which are more intensely stained than the mineralized becular network connecting the surface of the old bone matrix of the newly formed bone. 4. bone formation on roughened between the roughened surface and the newly surfaces was characterized by the so-called con. Second. Note the presence of bone rectangles in (a) are enlarged in (b) and (c). surface. whereas the interthread portion is filled provisional soft tissue matrix and on the implant surface. Note that the trabecular network weekly stained (Reproduced with permission from follows the paths where bone debris (BD) is present in the Bosshardt and col. respectively. (d) A higher magni- (a) The old bone (OB) is in point contact with the pitches fication illustrates initial bone formation (arrows) in the of the thread. The upper and lower bone debris and bone particles.) matrix of the provisional soft tissue and on the implant points. with a provisional soft tissue matrix and newly formed Note the presence of bone debris on the implant surface.

4 Bone Response to Implants 73 newly formed bone extending from the old bone remodeling at the implant surface have taken toward the implant surface. frequencies. face characteristics. It has been shown that ITV reflects placement and a secondary stability which bone quality and quantity. and Sox9. could mary stability. RFA applies the basic vibration theory in tially upregulated in the SLA group was the Wnt. and the bone-implant contact [41]. One of the main objectives at the moment of although giving very important clues on how implant placement is to obtain high values of pri- bone healing around dental implant occurs. poral contact of the tip of the device during tion genes typically expressed during craniofacial repetitive percussions on the implant. Fgfr-2. While after 1 week. in the SLA group compared to the machined one. compared to humans. so that a decrease in frequency is related to is differentially regulated according to the sur. PT values development like Fgfr-1. Anyway. mobility of the implant. PT gauges tem- same was true for mesenchymal cell differentia. [34] affects the resistance to micromotion and has evaluated the gene expression profile of bone on been shown to ensure proper bone healing and micro-rough surface (SLA) versus machined sur.1 Implant Stability mary stability is the measurement of insertion torque values (ITV) during implant placement Adequate stability of the implant is considered to and seating which can be evaluated with implant be crucial for appropriate healing and osseointe. Methods for objectively assessing the stability In particular. the major pathway that was differen. Donos and col. It is possible to define a primary sta. regeneration-associated genes like of the implant are the periotest (PT) and the reso- Notch-1 were upregulated in the SLA group. The nance frequency analysis (RFA). primary mechanical instead occurs after bone regeneration and stability. It is important to recall that a dog model. and finally the use of a manual wrench with bility which occurs at the time of implant torque control. which allows the implant to mechani- that occur in humans. which there is a transducer applied to the top of which is thought to be a major regulator of regen. Clinical studies report that the stability groups. especially after 2 weeks the Even if RFA techniques have been found to be genes associated with bone healing and regenera. after 14 days a large number of genes should be such to avoid implant mobility at clini- have been shown to be expressed at different rates cal evaluation immediately after the insertion. Micromotion consists of relative movement Interesting insights in the process of osseointe. A more diffuse and practical way to assess pri- 4. between the implant surface and the adjacent gration may come from studies using in vivo gene bone during functional loading. allow to state that the use of this instrumentation leads to higher success rates. as measured immediately after not reflect the exact temporal sequence of events insertion. place (see above). osseointegration [40].3. (range varies from 8 to 50) are the signals pro- Angiogenesis genes and skeletal development duced by the tapping that reflect the values of genes were overexpressed as well. the differences maximum recommended values of primary sta- in gene expression were minimal between the two bility. more accurate in depicting the primary stability tion are preferentially expressed on micro-rough values. . face implants inserted in rat’s calvaria defects at 7 There is no consensus regarding minimum or and 14 days. it is known that cally lock to the host bone until secondary stabil- healing processes in dogs occur at a faster rate ity is achieved. Actually. a decrease in stability. Primary stability expression profiles on rats. The resultant resonance frequency The results of this study corroborate the values are dependent on the stiffness of the struc- hypothesis that bone response to implant surfaces ture. the implant which is then excited over a range of erative response to different Ti surfaces. there are no clinical studies today that surfaces [35–38]. motors that allow to set the torque values in N/cm gration [39].

high insertion torques values. it the association was considered to be moderate to was found that the cumulative survival rate of high. bone quality is subdivided in case of low bone density. firms the assumption that implant treatment in gests that.2 %.2 Type IV Bone and Longevity implant bed preparation. [44]. analysis of the literature con- insertional and removal torque values. for type I. faces showed the best results in terms of primary This classification although very practical may implant stability when compared to acid-etched suffer of some amount of subjectivity. Lastly. success rates in case of immediate loading [42].74 O. and placement decreasing the diameter of the last drill it is pos- technique. Although bone or natural bone (swine rib). and this is more evident in the this classification. implants showed higher insertion torque when ered as minimal values in order to achieve high compared to conical shaped implants [45]. in other terms RCTs. given that mineral density in Hounsfield units (HU). which they were inserted. sible to increase the primary stability. of dental implants experimentally on synthetic respectively. Nowadays. In primary stability.7 %. such bone type confer reduced primary stability. ments and consequently improved rate of Regarding the implant design. implant design. results were Using the same surgical technique and implant not analyzed in subgroups regarding the type design. Higher HU values correlated strongly with implants inserted in type IV bone was 88. clearly defined the way on how to measure the bone density.8 %. correlation coeffi. from type I which is the denser to type Regarding the implant surface. with the wide. [4] evaluated primary stability of other bone types (97. suggestive. of Dental Implants spread use of cone beam computed tomography. In their review including cients ranged from 0. Iocca Torque values of >32 N/cm have been consid.88. 96. this means that as that full mouth rehabilitation with implants bone density increases. and it is not and machined implants [46]. II. these results suffer from the fact ferent design and surface characteristics were that just a small number of implant were evaluated for insertional and removal torques.3. which was lower compared to the survival rate Elias and col. inserted in type IV bone. larger and longer implants reduced implant survival rates compared to the warrant a high primary stability. and longer implants are associated with higher Nevertheless. [47] investigated if longev- positive correlation has been found between high ity of dental implants inserted in type IV bone HU measured in preoperative CBCT and primary is reduced compared to implants inserted in stability of dental implants. Surgical drilling technique seems to be more Factors influencing primary stability are bone important than implant design. Implants of dif. . anodized sur- IV which is the softest. a Goiato and col. in the sense that quality. retrospective and prospective studies. tapered other bone types. when it is feasible and especially in regions of poor bone quality may imply low bone qualities. be of particular importance because it is likely ues increased. it is now easier to perform a morphological and quan. better quality bone. when the implant was placed in a denser of prosthesis used. the primary stability splinted together could have less micro-move- increases proportionally. larger diameter osseointegration compared to single implants. ies did not clearly reported the jaw regions in tal implants is determined by the bone properties. this sug. in clinical terms. four types. Also. 96. and this information should substrate.4 %. An under- Bone quality is commonly evaluated using the sized preparation site of insertion increases the criteria established by Lekholm and Zarb [43].46 to 0. the insertional and removal torque val. and III). moreover most stud- The results showed that primary stability of den. In the review by Marquezan and col. It is common for the clinician to determine it with the tactile perception at the moment of 4. It is assumed that implants inserted in type IV (soft titative analysis of the bone estimating the bone bone) bone have reduced survival rates.

anterior maxilla. 4. 4.4 Bone Response to Implants 75 4.4 Implant Overload Bone is a dynamic tissue able to respond to the external forces with the adaptation process of remodeling itself.6 95 % CI).e. implant brand. The authors concluded that BIC of implants in the mandible (68. defined by the letter ε. A meta-analysis evaluating BIC of dental implants in humans has been performed recently. 4. at least 3 months after insertion) show higher BIC than immediately loaded implants. Toluidine blue 16× stress application. Mechanical loads provoke a stress and a consequent strain on the tissues. The low- est values of BIC were found in the posterior maxilla.and long-term treatment outcomes.8–73. Conventionally loaded implants (i. In essence. Fig.8–56.1 % deformation. The loading state of the implant has important effects on BIC values. This is consistent with the fact that BIC is dependent on bone density at the moment of implant placement. loading state.. and healing period were considered separately [48]. and in fact the anterior man- dible has the densest bone. 50× magnification (b) (Reproduced corresponds to a 0.3. moreover the anterior mandible shows 10 % higher BIC than the posterior mandible. Another interesting result was that BIC values looks to be more dependent upon anatomic site b than surface chemistry or topography.11). better performing surfaces (read previous chap- ters) are important especially in low-quality bone areas which will show inevitably lesser degree of osseointegration.3 Bone-Implant Contact a Bone-to-implant contact (BIC) is defined as the percentage of bone found in direct contact over the implant surface (Fig. followed by posterior mandible.11 Bone healing at 3 months after placement Strain is defined as the deformation that follows a showing high bone-implant contact. Anatomic site.) . with permission from Donati and col. but this does not seem to impair long- term success rates. 1000 με magnification (a). and finally posterior maxilla.8 95 % CI) is 25 % higher than those located in the maxilla (49. this parameter is considered to be important in defining the degree of osseointegration and may play a role in both short.

On the other hand. because it cannot be measured directly in vivo. but evidence that confirms this claim is still lacking. Instead. general recommendations human bone physical properties. Retrograde peri-implantitis may there- reports and cohort studies gave no strong evi. peri-implant bone [51]. Today the stress of avoiding precontacts and careful treatment produced at the bone-implant interface in the dif. oral hygiene was maintained. it can contribute to speed up the plaque- stress produced at the bone-implant surface. pathogenic bacteria may still persist in healed Clinical observations coming from case bone [54]. load (2500–3500 με). The mental supra-occlusal contacts did not seem to four microstrain zones are disuse (<200 με). At the current state. . regarding the BIC sites of chronic inflammation and infection. and pathological loading the same kind of overload seemed to increase the (>3500 με). It has evaluation. a static load on dental implants been shown that even after careful debridement seemed to increase the remodeling activity of of the infected tissue and irrigation of the socket. to be extracted exhibits a periapical or periodon- All the available experiments on animal. reported implant failure. but at the same load on a prosthesis do not take into account the time. Animal studies seem to definition of “overload” in dentistry is not clear.5 Immediate Placement col. apical lesions. [50] reviewed both animal and clinical stud. Novaes and col. [55] in a study on Marginal bone loss has been reported in retro. given that they would be considered unethical. dogs created large periapical lesions exposing the spective studies as a result of overload. healthy ones. Iocca Frost defined four levels of mechanical strain The review of Naert and col. particular on monkeys and dogs.76 O. Overloading of dental implants is considered to cause loss of osseointegration. Given the uncertainty of the biological and Finite element analysis can simulate it.[53] concluded on long bones but these categories can be that it seems that overload coming from experi- extended to the mandible and maxilla [49]. this is a very wide gen. played a role. Lack of RCTs is obvious. physiological over. It is important to remark that this peri-implant bone resorption caused by plaque- classification applies to static loads. Worries exist that implant survival could be nificant implant loss when static or dynamic impacted by the presence of residual bacteria in overload was applied. planning in parafunctional patients remain any- ferent loading situations remains unknown. of Implants in Infected Sites ies on this argument. way valid. BIC not clear if this showed that it was caused by an values measured around immediately placed actual excessive load or other causes. mainly because the defi. induced bone resorption. but It is a common occurrence that a tooth that needs other sources of evidence are sparse as well. have an impact on osseointegration when good steady state (200–2500 με). indicate that overload should not be a common and anyway models simulating the amount of cause of loss of osseointegration. like poor implants were not different compared to the oral hygiene. fore develop. but it was canal space to the oral cavity for 9 months. Moreover. in tal pathology. the on peri-implant bone. although its occurrence is just dence that excessive load was the cause of sparsely reported in the literature. but it is clinical effects of cyclic and static overload on based on too many assumptions regarding the the peri-implant bone. Chang and 4. therefore for induced inflammation. it is impossible to state eralization considered that the forces exerted on with certainty which is the role of excessive load these bones are usually cyclic. Animal studies conducted in dogs attempted to nition of overloading itself was considered to be evaluate the osseointegration and BIC values of totally subjective and changing in the different implants placed in experimentally created peri- studies [52]. the mandible and maxilla. showed no sig.

and high mode should guarantee good results similar to implants for cleaning and smoothening bone borders. in which some ceramics and complications [63]. Therefore. frequency is in the range of 25–30 kHz which A systematic review on this topic showed that lead to the formation of microvibrations of survival rates of implants placed in endodonti. pared to conventional burs. In fact. 60–210 μm of amplitude. the and GBR with or without grafting. systemic or topic antibiotic administration.6 Bone Response and Implant prepared bone compared to conventional prepa- Placement with Piezosurgery ration burs. clean and debride the infected socket or the ideal Different tips are available for the various uses use of systemic antibiotics. Also chlorhex. Minimal pressure of the tip on the area of Suggested protocols to treat the infected tissue interest guarantees the greatest cutting efficiency. from end- generally assumed that deep debridement with odontic surgery to implant site preparation and oth- curettes. period in order to reduce the frequency of infec. mond burs exhibited some amount of bone loss. interface leads to production of gas bubbles that are parisons are available in regard of the best way to considered to wash away blood from the field [62]. best clinical results are achieved with delicate idine rinse was suggested in the postoperative pressure and continuous movement of the tip. to an increased rate of complications or failures. placed in noninfected sites [59. Potential advantages of implant site prepara- tion resides in the fact that use of piezoelectric preparation tips should cause less trauma to the 4. Moreover. once primary stability is achieved. Ultrasound and then analyzed after 3 months of healing [56]. the use of the Piezosurgery instrumentation is based on the Piezosurgery should reduce the risk of surgical piezoelectric effect. Piezosurgery is particularly useful when deli- tive complications [58]. These oscillations are then transferred to 56 days showed an osseous repair of the surgical the vibration tip connected to a handpiece which sites. Nevertheless it can be in oral and maxillofacial applications. gation in order to avoid overheating of bone and analysis of prospective and retrospective studies the following necrosis. when implant site prepara- tion is close to delicate structures. oppositely a greater pressure limits the amount of ment. Histologic results after quency. Piezosurgery requires adequate irri- to implants placed in healthy sites [57]. boosted mode dine 0. Piezosurgery also provides a clear surgical infected sites given that appropriate clinical pro. 60]. When the tip comes in contract with the bone. while the site treated with carbide or dia- will be applied by the clinician to the tissues. this is because direct exposure to the piezo- survival rates and normal marginal bone changes electric tip does not cause dissection of the soft can be obtained with implant placement in tissues.4 Bone Response to Implants 77 The same was true in another study on experi. mentally created chronic periodontal lesions on the so-called cavitation effect causes a mechani- dogs in which immediate implants were placed cal cutting of the mineralized tissue. . The deformation causes the response to Piezosurgery in a dog model com- ceramic to oscillate and produce an ultrasonic fre. Also. different modes can be set for the various gation with antibiotic or H2O2. this can be obtained pref- showed that. erably with continuous irrigation with saline immediate implants in infected sites did not lead solution precooled at 4 C° [61]. uses: low mode for apical surgery.12 % rinses in the postoperative period for osteoplasties and osteotomies. generating a power cally or periodontally affected sites were similar level of 5 W. [62] evaluated the osseous through them. No com. cutting and generates more heat. and chlorhexi. systemic antibiotic administration. before implant placement included deep debride. irri. cate structures such as mandibular nerve or The limited short-term data available from Schneiderian sinus membrane are at risk of dam- both animal and human studies suggest that high age. ers. crystals deform when an electric current passes Vercellotti and col. field because the cavitation effect at the air-water cedures are adopted before placement.

c). but this is counter- There is a lack of RCTs comparing acted by the reduced risks of traumatizing the Piezosurgery preparation techniques with con.12). it these positive aspects are also reflected in greater should be remembered that just 40 patients were implant survival and success rates when com- included in the study and that a single operator pared to traditional surgical techniques. Anyway. Soft tissue protection is one of the increase of ISQ values in the piezoelectric group. reduced bone trauma and the consequent lowered Well-designed studies are needed to confirm if inflammation and bone resorption. third tip for coronal bone enlargement (f. Also. applications of the piezoelectric technology. One of the reported disadvantages of tent osteogenesis in terms of increase of BMP-4 Piezosurgery is the relative lack of cutting effi- and TGF-2 expression for piezo group [63]. ciency on the cortical bone. but also the reduced bone which were always higher than the conventional trauma. it is clear that site preparation techniques. On the other hand. primary stability are all factors that are every tive of faster bone healing probably thanks to the important for implant surgery applications [67]. and potential greater preparation group. Results showed an initial decrease and early (Fig. [64] evaluated in an RCT the analysis are not feasible yet due to the lack of implant stability (in ISQ values) using different properly designed studies. 4. g). or conventional drilling showed a more consis. the ventional ones. clean surgical field. This was considered sugges.12 (a–k) Sequence for implant site preparation tion (d. with Piezosurgery tips. Bone crest exposed (a). Larger trials are implant sites where prepared with Piezosurgery needed to confirm these positive results. a c b d Fig. e). Iocca Another animal study on minipigs in which performed all the procedures. first tip for final tip and implant insertion (h–k) initial bone penetration (b.78 O. main advantages. second tip for site negotia- . Although quantitative reviews or meta- Stacchi and col. 4. ISQ measurements Piezosurgery technology is a very promising tool were performed at specific time points up to 90 for applications in oral surgery and implantology days. observational greatest surgical safety is paid back in terms of studies showed the safety for the various clinical increased working time [66]. bone and the soft tissue structures [65].

12 (continued) .4 Bone Response to Implants 79 e f g h i j k Fig. 4.

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imme- diate placement in previously infected sockets may be possible after accu- rate debridement and antibiotic use. 00161 Rome. successful and was considered the standard of Clínica Pardiñas. in 1969 recommended a Periodontology and Implant Dentistry. DDS. Sapienza University of Rome. Regarding the loading time. Evidence-Based Implant Dentistry. in the majority of the situations. Pardiñas López. Rome.). healing period after extraction up to 12 months. and better © Springer International Publishing Switzerland 2016 83 O. Periodontology and Implantology.1007/978-3-319-26872-9_5 . Implant Placement and Loading Time 5 Oreste Iocca and Simón Pardiñas López Abstract The first protocol proposed by Brånemark extended the treatment time to more than 1 year after extraction. DOI 10. surface treatment. Spain care for many decades. which is advisable due to the prompt restoration of function and esthetics in the vulnerable elderly population. improvements e-mail: simonplz@hotmail. S. 3°. Anyway. Italy The first implant treatment protocol defined by Private Practice Limited to Oral Surgery. A Coruña. Moreover. Brånemark and coll. DDS (*) and Loading Time International Medical School. early or immediate protocols seem to give comparable results to the conventional ones. The knowledge of the physiologic mechanisms of socket resorption after extraction allows to reliably place an immediate implant. 5.1 Implant Placement O. Real 66. and delivery of the pros- theses after ulterior 3–6 months. Iocca (ed.edu insertion of the implant. Italy e-mail: oi243@nyu. Iocca.com in implant design. MS This treatment sequence has been historically Oral Surgery. Since then a tendency toward an accel- eration toward the final prostheses delivery has been made possible by the development of new implant designs and surfaces and by an increased understanding of the processes of osseointegration. One important aspect to consider is the possibility of accelerating the loading time of implant overdentures (OVD). Galicia 15003. Also. Viale Regina Elena 324. immediate placement and loading can give esthetic outcomes comparable to conventional protocols.

Many studies have showed that formed.84 O. poor esthetic outcomes that may follow the expo- supported prosthesis loaded at least 2 months sure of the implant following the unpredictable after implant placement amount of alveolar wall resorption. immediate ing the exact definitions of terms. Immediate placement in fresh extraction sockets tocols for immediate insertion and immediate or gives the advantage of reducing the number of early loading. and (c) possibil. therefore. Iocca and S. kind of graft [5]. it would be preferable for both the the defect heals optimally without the need of patient and the clinician to reduce the treatment intervention. it is advisable to leave at least a gap of 1 mm in order to prevent implant 5. reduce it by a variable amount.1. a gap between the implant and the buccal alveolar tial problems may arise if shortened placement/ wall. at sites ing implant placement where teeth with intact periodontal tissues are present. and the resorption is limited to the are (a) reduction of treatment time which has an buccal bone [2].1).1 Placement Protocols exposure (Fig. It has been a Immediate loading any implant-supported pros. Recently a series of experimental extraction sockets within 1 week and 2 months studies on dogs clarified that immediate implant after extraction placement is not able to prevent the physiologic Early loading any implant-supported prosthesis resorption of the alveolar bone. Also. the observations on animal model [3. For this reason it was suggested impact on the satisfaction levels of the patient. . it is delivery of a provisional restoration so that better to give some definitions commonly esthetics is maintained and the patient does not accepted in the dental literature [1]: suffer psychologically for the loss of his/her dentition. However. It has been a matter of debate if healing of the gap can be improved with some When extraction of one or more teeth is per. 4]. Immediate implant placement any implant placed As discussed in the previous chapter. matter of debate if immediate insertion of an thesis loaded earlier than 1 week subsequent implant into the fresh extraction socket can pre- to implant placement vent the loss of soft and hard tissue at the extrac- Early placement any implant placed in healing tion site. Conventional (delayed) placement any implant On the other hand. ity to maintain a good esthetic appearance soon Subsequently. 5. there is a need to critically review More lingual placement of the implant creates the existing literature on this topic because poten. though can loaded between 1 week and 2 months follow. osseointegration have led to development of pro. and. several clinical prospective after the extraction in case of immediate studies have provided clinical data confirming loading. only in the presence of a dehiscence. the implant surface. Considered ing evidence emerges from the literature. some conflict. surgical procedures. that the buccolingual width reduction can approx- imate 50 % of the ridge. This gap can be of different dimensions loading protocols are adopted. the height of interproximal bone can be The main advantages of shortened protocols maintained. avoidance center of the crest just to prevent the exposure of of a second surgical procedure. Some confusion still exists regard. a sig- in fresh extraction sockets after tooth nificant reduction in alveolar width and height extraction occurs following tooth extraction. to place the implant lingually compared to the (b) in the case of immediate insertion. the diameter of the chosen implants. if possible. Pardiñas López understanding of bone healing processes and time and the invasivity of the procedures. potential complications inserted at least 2 months after tooth include an increased risk of infection from resid- extraction ual bacterial niches in the extraction socket or Conventional (delayed) loading any implant. and although according to the morphology of the socket and much research has been produced.

1 (a–d) Immediate implant placement tooth #15. b). Root fragment is extracted (a. 5. d) .5 Implant Placement and Loading Time 85 a b c d Fig. immediate implant placement leaving a buccal gap of at least 1 mm (c.

However. Moreover. (2014) conventional loading ≥6 months of follow-up after loading Atieh and coll.54) In favor of Yes coll. Outcomes ate and delayed placement. short-term evaluation.1 Soft Tissue and Esthetic show any statistical difference between immedi.70–5. RCT RR 0.0–12. Iocca and S.84) In favor of Yes Single crown non.1. there are no appreciable differences Table.31–1. 5.3). the failure studies have shown that this may be true at a rate was higher than in the mandible.22) In favor of No coll.92 (0. Of course.77 (0. and 5. this is accentuated One aspect to consider for immediate place. (2008) conventional loading ≥1-year follow-up after loading Sanz-Sanchez and RCT RR 1.1.2. RCT OR 0. There is some reason to believe that immedi- ing this last one was suggested. theory. studies (Tables 5. reducing the micromovements and the are well above 90 % in the majority of available stress at the bone-implant interface. Pardiñas López a graft with alloplastic material seemed to confer placed implants showed higher failure rates than some benefits [6].35–1. even if a trend favor. The meta- analysis on RCT by Esposito and coll.92 (1. it is expected that the grater loading forces The authors compared also immediate single exerted on the molar and premolar regions may implants versus immediate full-arch restorations. implants in the posterior location leads to inferior This can be explained by the fact that full-arch survival rates or increased risk of complications. another meta-analysis [8] arrived vation of optimal soft tissue contours. but after 1 year of func- regardless of the site of placement. RCT. immediately tion.82 (0. ately placed implants may have a role in preser- Conversely.1 Meta-analyses evaluating different loading time protocols – implant failure Immediate loading versus conventional Included Effect loading Statistically studies size Results (95 % CI) Clinical meaning significant Esposito and RCT RR 1. in the maxilla where primary stability is fre- ment protocols is the specific anatomical region quently more difficult to achieve due to the poor of the arch in which the implant is placed.00 (2. RR 5. at the conclusion that in the maxilla.04–3.93) In favor of No (2014) conventional loading Single crown implants only 1-year follow-up after loading Engelhardt and coll. but no failure rates were found to be higher for implants evidence exists that immediate placement of supporting a single crown. conventional loading implants only randomized ≥1-year follow-up trials after loading Benic and coll. conventional ones. have a detrimental effect on the implant.1.94) In favor of No 2015 conventional loading ≥1-year follow-up after loading . [7] did not 5. prostheses allow splinting of the implants to one Survival rates of immediately placed implants another. 5. In bone quality.86 O.

24 to In favor of No coll. a healthy bone.05 to 0.30–2. [17] conventional loading ≥1-year follow-up after loading MD mean difference (measured in millimeters). RCT RR 0.32 (0.61) In favor of No ≥1-year follow-up conventional after loading loading RR relative risk Table. non.70) In favor of No and coll. MD −0. main objectives of immediate or early place. Considered that one of the largely on a healthy soft tissue. and patient perception of beauty.10 (−0.26–1.08) In favor of No coll.3 Meta-analyses evaluating marginal bone level change Immediate loading versus conventional Included loading Statistically studies Effect size Results (95 % CI) Clinical meaning significant Esposito and RCT MD –0.064–1.046 (0. RR 0. (2014) RCT OR 0. 5. 5. [16] 0. it is ticular. interproximal papillae and marginal gin- important to establish if this is actually giva play a fundamental role in terms of esthetics possible. retrospective studies Benic and coll.5 Implant Placement and Loading Time 87 Table. It is well known that esthetic outcomes depend ment protocols. immediate ≥1-year follow-up randomized loading after loading trials Xu and coll.31) conventional loading only 1-year follow-up after loading Engelhardt and RCT WMD 0.04) conventional loading ≥1-year follow-up after loading Sanz-Sanchez and RCT WMD 0.63) In favor of No (2008) immediate ≥1-year follow-up loading after loading Schrott RCT.041 to In favor of No Single crown implants 0.2 Meta-analyses evaluating different loading time protocols – implant failure Immediate loading Included versus early loading Clinical Statistically studies Effect size Results (95 % CI) meaning significant Esposito and coll.65 (0.01 (−0. .27 to In favor of immediate No ≥1-year follow-up non. and a properly manufactured prosthesis.05 (−0. [21] RCT MD −0. [22] RCT. in other words. WMD weighted mean difference (in millimeters) between immediate and conventional place.09 (−0.9 (0. [18] loading ≥6 months of follow-up after loading Suarez and coll.043–0. 0. In par- ment is to achieve optimal esthetic results.049) In favor of immediate Yes coll.09) loading after loading randomized trials.

and the results periodontal of endodontic disease can be a pre- showed that delayed provisionalization. For this reason in the last few . clinical soft tissue height variation and the radio- graphic marginal bone level (MBL) change. term studies comparing immediate with conven- For these reasons. these problems were evidenced only authors also reported that around 11 % of the in case series or case reports. Mid. and tissue outcomes. considered to be at high risk of developing the nificantly associated with bone loss >0. of the mid-buccal mucosa was reported when tant to take in mind that subjective measurements compared to delayed placement. it is impor.27 ± 0. contrasting with the studies showed important mid-buccal recessions fact that animal studies in which proper debride- (>1 mm). 5. tion even if higher frequency of recession >1 mm ies reporting the esthetic outcomes. 5. Also previous periodontal pathology papillary rebound was evidenced after 1 year of has been considered the cause of similar prob- crown placement. Pardiñas López the papillae adjacent to the implant and the acceptable esthetic outcomes may be achieved mid-buccal gingiva should mimic those of a for single implants placed following tooth extrac- healthy tooth. When analyzing the clinical stud. color and texture.88 O. Regarding persist around the implant and cause peri- papilla modification. place an implant in a fresh extraction socket Because of underreporting. in the included stud. these are the definitive conclusions. such as Bacteroides species. but long- tain degree of subjectivity.2 Immediate Placement A recent review [10] on immediately placed of Implants in Infected Sites implants in the anterior maxilla evaluated the It has been a matter of controversy if it is safe to main risk factors for poor esthetic outcomes. review. so-called retrograde peri-implantitis is that one Khzam and coll. no esthetic indexes were considered for ing from endodontic or periodontal pathology.2). response around the implant which can impair buccal gingival recession instead gave a mean of osseointegration. 0. this means that interdental lems due to the persistence of periodontal papillae around definitive restorations tend to pathogens and subsequent inflammatory regrow and compensate for the initial loss. results in terms of esthetics (Fig. surrogate end points of the tional placement are needed in order to arrive at esthetic outcomes are adopted. are infrequently adopted. facial mucosa. placed implants in anterior maxilla. root convexity. and implant restora.38 after at least 1 year of follow-up.50 mm. which is site of inflammation or infection deriv- ies. tooth. This is a visual evaluation in which the esthetic result and that the esthetic indexes a score going from 0 (poor esthetics) to 10 (excel. A situation flap. Instead.5–1 mm of papilla loss is to be expected regard- a common pitfall of many implant studies [9]. in which residual bacterial niches typical of ating the soft tissue outcomes of immediately periapical pathosis. [11] analyzed studies evalu. less of flap or flapless surgery. use of a dictive marker of implant failure. In this case.23 ± 0. a mean loss of implant infection and ultimately treatment fail- 0. Pink esthetic score (PES) was proposed for Considered that the majority of the studies evaluation of gingiva. ment and prophylactic use of antibiotics allowed The systematic review and meta-analysis of to obtain proper osseointegration after immediate Chen and coll.1. the authors concluded that techniques in esthetic evaluation and reporting is 0. Regarding are frequently adopted and a lack of standardized papilla recession. but a ure [12]. The Anyway. [9] arrived at the conclusion that implant placement.1. and use of connective tissue grafts were sig.27 mm occurred after 3 months. show a lack of uniformity in the assessment of tion esthetics. it is difficult to arrive at lent esthetics) is assigned to mesial and distal an objective quantification of the esthetic papilla. Iocca and S. the problem is that In general terms it is possible to conclude that few studies adopt this score for reporting the immediate implant placement gives acceptable esthetic outcomes and anyway it is liable to a cer. mean bone level changes after 1 Some clinical reports suggested that a history of year of loading were considered.

2 Tooth #14 needs to be extracted due to the presence of a vertical fracture (a. d). b). Immediate implant placement is performed and provisional crown is applied (c. Optimal esthetic outcomes at 3 months follow-up (e) years. ies.5 Implant Placement and Loading Time 89 a b c d e Fig. . ing specifically the use of different antibiotics A recent review based on retrospective stud. 5. lesions and infections can be treated with imme- Even if definitive recommendations on which diate implant placement after debridement and type of antibiotic and dosage could not be drawn use of systemic antibiotics. and dosages in case of immediate placement. prospective studies. Also the use of antibiotic irrigation prior to and randomized clinical trials [13] arrived at the implant placement remains unclear. controlled clinical trials. conclusion that immediate implant placement in Another review [14] based on human case infected extraction sockets can be successful series and one randomized trial gives weak evi- after thorough debridement and postoperative dence that patients with residual inflammatory care with antibiotics and chlorhexidine rinses. a number of reviews have been published considered that no study has been found compar- in order to clarify this issue.

it is possible to state that placement of restoration. Pardiñas López The same conclusions are drawn by Alvarez. edentulous patient who.) . the treatment solutions. if treated with the con- cations in recommending immediate implant ventional protocols. On the other hand. on the basis of the available lit. provision- In conclusion. at 3 years (d). 5.3). there was a trend suggestive of higher failures for the early Immediate or early provisionalization and load. perioperative management of the patient in this The Cochrane review of RCT by Esposito and situations. The ment of the socket before implant placement may results of the meta-analysis. early. The analysis attempted to function and esthetics (Fig. it is important to understand if is possible without fear of much higher failure accelerated loading protocols are comparable in rates when compared to implants placed in terms of survival and success rate to conventional healthy sockets (Fig. this becomes particularly important for the fully Camino and coll. it would be desirable to lack of well-designed RCT on this topic does not know if implants loaded in the maxilla or the allow to draw definitive conclusion regarding the mandible give different results. the aim of bone around the implant just in the period when accelerated prostheses delivery is to reduce the primary stability drops. were suggestive of lower survival failures. 5. In other words. although no statisti- confer some protection from complications and cally significant.90 O. alization. loaded implants may impair the healing process of out tooth replacement.3 (a–f) Implant positioning on a previously infected site (tooth #14). and MBL were observed. needs to wear a removable placement in infected sockets. Also. This was explained by the fact that early period of time in which the patient remains with. tional loading strategies between each other. rate for immediately loaded implants when com- pared with the conventional loaded ones. At baseline (a). [15]. and secondary stability is discomfort of the patient attaining immediate not fully established yet. Iocca and S. 5. and conven- course of systemic antibiotics and deep debride. denture for months before uncovering. Also. and at 5 years after placement (e. immediate implants into infected extraction sites Therefore. It is anyway reasonable that a full coll. No sig- nificant difference for prosthesis success. at 1 year (c). It is clear that investigate if occlusal versus non-occlusal loading a b c d e f Fig. implant 5.2 Loading Protocols success.4). and loading of the definitive erature. They found no contraindi. loading when compared with the immediate load- ing of dental implants are aimed at reducing the ing. after 3 months (b). [16] analyzed immediate. f) (Reproduced with permission from Jung and coll.

5. control at 1 year (i–j) .4 (a–j) OPT showing the necessity of extraction (a). extraction and immediate implant placement (e).5 Implant Placement and Loading Time 91 a b c d e f g h Fig. appearance of implants and delivery of prosthesis the day after surgery (f). intraoral examination (b–d).

A likely clusions were considered feasible. order to avoid excessive stress on it. ridges. [20] showed that immediate placement/immedi- The systematic review by Sanz-Sanchez and ate loading was subject to higher risk of failure coll. the success rates were considered was found for immediate loading. parafunctions. but just one RCT was immediate and conventional loaded implants. tocols. The meta. the patients need to be informed about Also. it was included studies comparing immediate versus concluded that it is possible to plan an immediate conventional loading. and the sample the contrary compared to other reviews. a thorough review of in drawing definitive conclusions on this matter. At the protocols. 5. On found studying this hypothesis. and smok. . under-occlusion for a single crown implant in tors other than loading protocols. cally significant higher risk of implant failure At the end. ventional loading in favor of this last one [19]. non-occlusal loading ures of immediately loaded implants occurred gave different outcomes.92 O. it seems clear that better mandibular implants even if the significant het. at the conclusion that a statistically significant dif- umentation and very limited scientific evidence ference was found between immediate and con- supports the adoption of immediate loading pro. therefore. ing habits. but no definitive con- within the first 3 months after loading. Therefore. These results ventionally loaded ones. results in terms of survival are achieved with con- erogeneity of the included studies suggest caution ventional loading. in any difference exists between immediately loaded particular evaluation of good bone quality and implants in fresh extraction sockets or healed good primary stability. randomized and non-randomized studies arrived It was concluded that there is insufficient doc. These results to be high for all the treatment options in the can be explained by the fact that the analysis majority of the published trials. [18] evidenced high success rates for both compared to immediate loading in healed ridges. can be explained again by the splinting effect that Another meta-analysis examining RCT and occurs with extended restorations. same time. Iocca and S. analysis also showed no statistically significant When the focus is shifted exclusively on difference in survival between maxillary and single-implant crowns. Pardiñas López i j Fig. if immediate occlusal vs. a statisti- size was too small to reach any conclusion. immediate loading of single teeth the slightly higher risk of failure for implants implants seemed to have higher risk of failure loaded early or immediately if compared to con.4 (continued) yields different outcomes. expanding the inclusion to non-randomized trials The authors also tried to answer the question [17] showed that the vast majority of implant fail. careful patient selection was One point that merits a discussion is whether recommended in case of immediate loading. The meta-analysis by Del Fabbro and coll. In fact. excluding the early loading or early loading protocol with confidence. compared to multiple restorations. Regardless of explanation for this is that failures occurring after this it seems reasonable to create a condition of 12 months of loading are probably caused by fac.

to conventional loading. For this reason. Immediate when discussing the opportunity of tooth extrac. On the other hand. This can be a cause of additional costs protocols. removable pros- It is possible to state that with careful patient theses are associated with psychological and selection. prosthesis given that soft tissues are allowed to The majority of the available reviews point out heal after surgery and before prostheses delivery. geous. Treatment modalities for fully edentulous jaws given that the majority of implant losses usually traditionally have included conventional remov- occur in the first year after loading. most studies have for Implant-Supported short follow-up.1 Esthetic Outcomes are traumatized the day of surgery and tend to of Accelerated Loading change morphology during the following weeks. Also. At long term. ate stabilization and a quick restoration of func- tion. even if slightly lower. relining and adjustments are fre- quently necessary before achievement of optimal In the same fashion as for immediate placement results. it is better to Early loading can therefore be considered a rely on quantification of marginal bone level good compromise because it eliminates the neces- change and soft tissue status instead of the poorly sity of large readjustments after delivery of the reported esthetic indexes. of waiting long healing time before the final Also. protocol that gives high rates of success compara. proper communica. complications are probably inde. and implants between immediate and conventional conventional loading of two-implant OVD. the elderly. Protocols Therefore. the patient receives a restoration without the need but the results were not statistically significant. In summary. after this able dentures. it is possible to con. One of the aspects to consider when planning an OVD placement regards the soft tissues. the majority of the studies focused on man- . The loading [21]. these 5. advantage of conferring to the patient an immedi- and the type of restoration.2. Mandibular retained OVD showed high suc- tion with the patient is of paramount importance cess rates and cost-effectiveness. the different loading pro- placed in a fresh extraction socket are exposed to tocols seem to give the same esthetic results higher risk of complications and failure. in order to evaluate the esthetic results and multiple visits [24]. of the different loading protocols.5 Implant Placement and Loading Time 93 This was consistent with the fact that implants delivery. analysis was suggestive of a superior implant sur- sider a theoretical advantage for immediately vival at 1 year of follow-up for early and conven- placed implants.2 Loading Protocols ous systematic reviews. they are reliable methods for resto- period of time. [25] conducted a meta- in terms of MBL and mucosal level changes of analysis of RCT comparing immediate. loading of implant-supported OVD gives the tion. that there is no statistically significant difference Schimmel and coll. Overdentures Anyway this last point is not a big issue when immediate or early placement is considered. loading time. The use of osseointegrated implants can ble. 5. benefits. immediate implant placement. improve the outcomes of removable dentures and Again. especially in pendent from the loading time. Implant-supported overdentures (OVD) bility of the clinician to decide when accelerated possess a great increase in stability and high loading protocols are appropriate and advanta. early. the majority less than 1 year. it is the responsi. between each other. immediate/early loading is a treatment functional limitations. ration of function for many patients. but this refers just to the fact that tional loading in respect to immediate protocols. a low number of well-designed RCTs and small prospective studies are one of the major drawbacks that emerge from the vari. degree of patient satisfaction [23]. given the clear advantage in terms of at the same time maintains their cost-effective patient’s comfort and function. Without any doubt.2.

and was similar to the splinted group (96–100 %). The conclusion that can be drawn is that In particular. man. Good periodontal health. and therefore a rapid regain of a for the splinted group and 98–99 % for the proper masticatory function is of paramount unsplinted group. cannot be over- loaded OVD was noted. At the current micromovements may impair the process of state. come due to excessive resorption of the alveolar A particular issue discussed in the review was crest. Also. in this way avoiding the risk of acquir- Alsabeeha and coll. improper higher implant failures for the immediately occlusion. it must be taken into The same observation was done for the maxillary account that the geriatric patient is predisposed to OVD.4). absence of pain.03 (−0. This might be important especially in treatment modality when careful patient selection old age when the majority of OVD are placed is performed.071–6. tocols applied to mandibular OVD seems to give The problems associated with conventional good clinical results. terms of rapid return to a normal social life. achieve.94 O. tors that allow to obtain optimal results [27]. the use of splinted or unsplinted implants for Implant-retained OVD have resolved such immediate loading. [26] analyzed both RCTs ing a poor nutritional status.4 Meta-analysis evaluating the survival of implants used as support to OVD Immediate loading versus conventional Effect loading Statistically Included studies size Results (95 % CI) Clinical meaning significant Schimmel and coll. if a tendency exists toward 2 years of follow-up.1 % undernutrition.0. In tudinal studies.08) conventional loading loading Schrott and coll. reduced compliance. this is balanced by substantial benefits in loading OVD. vast majority of the cases is performed in the dibular unsplinted implants gave a mean survival elderly population where there is an increased rate at 1 year in the range of 96.67 (0. [27] RCT. the studies included in the review allow to We need to consider that OVD treatment in the draw interesting conclusions.6–100 %. prosthesis. Pardiñas López dibular OVD and clear statements on maxillary ment of a primary stability of at least 30 N/cm. non. and protocols for mandibular OVD are a predictable discomfort. Iocca and S. importance. OVD in comparison to conventional loading pro- ilar success rates when compared to conventional tocols. and creation of a balanced occlusion are all fac- The conclusion was that the three loading pro. with a mean survival range of 97–98. solutions were not considered possible. fragility. [25] RCT RR 0. and non-randomized studies with a minimum of In conclusion. reality. which incidence of systemic diseases. considered that issues in the majority of the cases. a splinting bar should increase loaded OVD is questionable due to lack of longi- the success rates of immediately loaded OVD. Table 5. In particular. (Table 5. It is thus possible to state that immediate/early proper chewing capacity. Other reviews show similar results. but a slight tendency toward removable dentures. maxillary rehabilitation with immediately osseointegration. Both early and immediate slightly higher failure rates of immediate/early treatment protocols were considered to have sim. the adoption of shortened treat- splinting does not give an advantage compared to ment protocols may help the patient to acquire unsplinted implants when immediate loading immediately a better retention and stability of the protocols are adopted. RR 0.25) In favor of No ≥1-year follow-up after randomized trials immediate loading loading RR relative risk .03 In favor of No ≥1-year follow-up after to 0. such as instability. In theory. and pressure ulcers.

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Trinidad and Tobago its success. Objective analysis if data from the used of short and varying implant diameter need to be carried out to allow a fair comparison of this trend and how it compared to the long term predictability that has been achieved with traditional implant lengths. Its evolution has led to the development of 1000s of implant types manu- factured by an ever increasing number of companies in both industrialized and developing countries. as there have been no well-documented studies that show the superi- ority of one implant system over another [2] and most studies focusing on one implant system and N. Implant body shapes can generally be classified into threaded. Iocca (ed. influenced their selection being challenged. MFD. Quong Sing. This fact has been further over 1300 dental implant types [1] and more than emphasized by how changes in implant macro. Implant Design and Implant Length 6 Nicholas Quong Sing Abstract Implant Design is a fundamental aspect of successful implant treatment. as well as the surgical protocols required Implant design has always been a fundamental for their placement. shows no e-mail: nick_quong@hotmail.). This vast and micro-design has improved implant survival selection of implants can be intimidating when rates when placed across varying bone types. Implant design has continually evolved over the years. choosing an implant (Fig.com evidence to suggest that one implant system led © Springer International Publishing Switzerland 2016 97 O. 6. FFD OSOM. 6. term osseointegration of these endosseous restor.tapered or stepped designs and further subdivided into sur- face chemistry and material composition. Evidence-Based Implant Dentistry.1 Implant Design: General prosthetic loading times.1). with many of the axioms that feature that has facilitated the successful long.1007/978-3-319-26872-9_6 . Improvements in implant design and its composition has prompted a rethink of selection criteria for different clinical scenarios. an example being the use of short implants to avoid the need of advanced bone grafting techniques. DOI 10. cert OSOM Carenage. The evolution of implant design has lead to ative platforms. 250 implant manufacturers worldwide. BDS. A review by Esposito et al. and patient comorbidi- Review ties.

98 N.) . 6.1 Common implant designs and surface characteristics according to the manufacturer (Reproduced with permis- sion from Barfeie and coll. Quong Sing Fig.

multiple missing teeth [4. are the most favorable [14]. v internal Morse tapered connections [8] shaped. and thread design (pitch. and diameter [7]. and improved shear. Threaded implants (Fig. The stepped exposed to the oral cavity and therefore subject to implant however was designed to mimic the natu- two environments. such as Thread designs come in a variety of configura- less screw loosening. Branemark et al. angle. 6. thread depth. This reduction in micro- but can be an external spline or internal Morse strains is achieved in tapered implants by direct- taper. Shear loads have features.and microstructural features. In square and but- position. anti-rotational functional surface area [13]. axial forces are transmitted to the implant design is centered on the modifications of bone mainly via compressive forces. as mechanical friction with the surrounding bone its design has to take into account that it is addi. Design used among the first Branemark implants. buttress. and it also served the purpose of increasing tionally connected to a prosthesis which is bone-to-implant contact area [11]. affects bone strength. material com. can either be external or internal in nature. nections due to their advantages offered. as first documented by connections are hexagonal or octagonal in shape. The most common external and internal cause of crestal bone loss. showed no significant differ- implant center) are applied to implants. dense cortical bone and toward the resilient tra- centration levels. and reduced bacterial leakage in thread shape. and spiral. intermediate point that there is no one implant design that is stresses in internal tapered connections. and compressive forces [9] stress distribution during functional loading. This again enforces the trations in internal hex connections. tions due to differences in pitch. tensile. Off-center ences for implant failures after 1 year between the loads however showed the lowest stress concen. are a reliable Endosseous implant body shapes can generally be treatment option for the replacement of single or classified as threaded. becular bone. stepped. faster and better quality osseointegration. where the implant abutment con. An extensive review by Esposito between internal and external connections when et al. or tapered. have shown ing the stresses during function away from the that there is no statistical difference in stress con. tested implant designs.1 Implant Body Shape another [3]. while tapered implants nects. thread helix). 5]. What is definitive is that implants in general. Studies by Bernardes SR et al. while micro-design fea. as a restorative therapy. reverse buttress. The difference between implant designs highest stresses in external hex and one piece con. Implant design can be classified broadly into Most implants have threads incorporated into macro.3). in 1977. type I and type II dense bone. This prosthetic interface on the ral root form. there has been a gradual shift to internal con. does not however seem to play a significant role in ever. been shown to be the most detrimental force that thickness. transmitted to the bone by a combination of reduced peri-implant bone loss. having a solid connection to the abutment (one These micro-strains are thought to be the main piece).6 Implant Design and Implant Length 99 to fewer implant failures or less bone loss than 6. in the peri-implant region. [12].1. External connection platforms were density and reduced primary stability. improved aesthetics. how. are more pronounced in type IV bone due to low nections [6]. and bioactive coatings. evaluating 13 different implant shapes centralized axial loads (directed through the over seven trials. and the superior. number of thread improved reliability with narrower abutment helixes. while compressive forces tures comprise surface topography.2) were introduced into Dental implants are unique when compared to implant design to improve the initial stability via other implantable devices in the human body. were created specifically in an attempt to reduce There are however exceptions. with some implants repetitive micro-strains at the crestal margins [8]. Thread shape can be square. [10]. 6. creating what was hoped to be a implant body. (Fig. while in these features to achieve: high levels of primary v-shaped and reverse buttress. depth. There are currently no well-controlled . Most evolution in tress threads. threads. Macro-design their design as it reduces shear loads and increases features include body shape. load forces are stability. favorable load distribution. thread angulation.

and the functional avail. cylindrical v-shaped implants [18].100 N. leading to more square threads have resulted in higher reverse favorable stress distribution.2 Schematization of the thread designs (Reproduced with permission from Abuhussein and coll. Orsini E. ferent thread shapes.8 mm as the optimal thread pitch in of square thread profiles shows that it has an opti. bone- Steigenga et al. able for load transmission. facilitates better mechanical interlocking between . this mized surface area for intrusive forces and still remains inconclusive and requires further compressive load transmission. [9]) prospective clinical studies that compare the dif. It plays an especially important role in cially in cancellous bone.2 Surface Topography a thread to the center of the next thread. showed in their animal study that increased means that has been used to increase both pri- primary stability and bone-to-implant contact mary stability and functional surface area of was gained from decreasing thread pitch.1. Modifying the implant surface is one of the et al. critical to osseointegration [17]. Quong Sing Standard Square Buttress Reverse Spiral V-thread thread thread buttress thread thread Fig. however. the area strength and decreases implant loosening. Thread pitch is the distance from the center of 6. implants. which within the thread region. What can lower strain profile [15]. where it can prove short implants as discussed later in this chapter. torque when compared to v-shaped and reverse buttress implants [16]. Studies by Kong et al. espe. but finite element analysis considered 0. Animal studies by be certain is that as thread pitch decreases. have shown that these features of to-implant contact increases. 6. resulting in a vigorous and expansive clinical trials. Changing the Surface irregularities increase the metal sheer thread pitch alters the thread depth. measured along the major axis of the implant.

Modification of surface data showed no difference. [9]) bone and implant surfaces. of three . that moderately rough surfaces (S (a) 1–2 The successful use of zirconia in the orthopedic microm) showed stronger bone responses than field has seen it become a potential alternative the smooth (S (a) <0. however. Roughened implants con. zirconia. Titanium laser peening. et al. These coating layers are Currently the vast majority of implants are made only functional if they adhere firmly to the with commercial pure titanium or its alloys. high degree of roughness would be ideal for the osseo. noted its biocompatibility and mechanical properties. This has resulted in by peri-implantitis when compared to rough sur- better primary stability and faster osseointegra.. topography can be carried out by an addition or subtractory process. good biocompatibility. A systematic material of choice for implant fabrication. however. 6. These roughened tial aesthetic and immunological complications surfaces stimulate the bone healing process as of titanium use. for implant fabrication given its toothlike color.1. Addition processes.5 microm) or rough (S (a) material for dental implants. This was reflected clinically in implant types showed a 20 % reduction in risk of similar removal torque values [23].3 Relationship between thread design. Zirconia is an attractive material noted by Soskolne et al. mechanical resistance. with similarly shaped and roughened titanium Esposito et al. acid etching.’s meta-analysis of different implants [21. shot peening. forces. 6. Animal studies have shown that versely facilitate bacterial adhesion to its surfaces roughened zirconia implants have comparable [20]. involve plasma deposi.3 Implant Materials tion using hydroxyapatite or titanium particles. decrease in the long-term implant survival rate. et al. to give a uniform pattern. 5.6 Implant Design and Implant Length 101 Direction of forces Compression Tension Shear Fig. which create convex surfaces. machined. and its ability to be integration process. Subtractory processes however a small percentage being hydroxyapatite-coated involve the use of sand blasting. titanium. or zirconia alloy. given review carried out by Wennerberg A.. or a combination of and its alloys have a proven track record as the these to create concave surfaces. faces at 3 year follow-up.and 10-year tion clinically [19]. A 5-year turned (smooth) surface implants being affected review in humans by Oliva J. with implant surface. which can facilitate peri-implantitis and a bone-to-implant contact and osseointegration. overcoming poten- >2 microm) in some studies. rently no consensus among the literature on what low plaque affinity. there is cur. and shear stress on bone (Reproduced with permission from Abuhussein and coll. 22].

still remains more important in achieving titanium surface which promote the stimulation primary stability [28] and reducing crestal strain of osteogenesis and an inhibition of osteoclasto. however. Longer implants have been indicated for promise for the future use of zirconia implants. as advances in implant design have shown them to have comparable survival rates to implants of standard length.2. 6. than implant length [29]. immediate extraction sites. and mor- that were acid etched. cost. This therefore raises 6. which modulates the biological cascade Techniques of events at the bone-to-implant interface. and mandibular regions. distraction osteogenesis. coatings that aim to induce specific cell and tis.1 Clinical Outcomes length implants in these situations would com- promise the maxillary antrum or inferior alveolar Implants are currently manufactured in a wide canal (Fig. Therefore. guided bone implants to 53 mm zygomatic implants. concluded that implant length was the most implant contact and increase the rate of important factor in maintaining implants over the osseointegration. et al. There are many experimental long term [27]. with the advanced augmentation treatments and its associ- highest success rate shown in zirconia implants ated prolonged treatment times. efit is mainly seen in type IV bone types where One factor is the lack of sufficient vertical alveo- bone quality is poor and additional mechanisms lar dimension.4 Implant Surface Chemistry the question of whether is it is really necessary to place the longest implant that can be accommo- Implant surfaces can be modified with chemical dated. This can be attributed to the sinus pneumatization phenomenon after extraction [30] and resorption of the alveolar 6. Titanium and its alloys still are the to engage the zygomatic bone in severely material of choice for implant fabrication. These results hold great bidity.4). elevation. Modification Implant-supported prostheses have been shown of surface chemistry as a part of implant design is to be a reliable and predictable restorative option one of the many factors that can increase the for single and multiple missing teeth. placement of angulated implants. especially in the posterior maxilla are required to enhance integration. such as block grafting. sinus floor length selection is dependent on a patient’s exist. Short a greater body of evidence proving their long.1. which has been the conventional wisdom.2 Implants of Different ridge due to prolonged periods of edentulism or Lengths periodontal disease. Surface chemistry can also be 6. speed and quality of osseointegration. having resorbed maxillary alveolar ridges.2. advanced surgical range of lengths. this chapter. several challenges are faced in their placement.102 N. phic bone.2 Comparison of Short Implants used to increase the hydrophilicity of implant Versus Bone Reconstruction surfaces. Quong Sing different roughened zirconia implant surfaces. Implants of nerve repositioning. from short 4 mm alveolar techniques. Implant regeneration. Placement of what is considered standard 6. Results of a review conducted by Chung DM sue responses which help improve bone-to. where patients are reluctant for showed an overall success rate of 95 %. but its ben. These procedures . or term review. implants and their selection are discussed later in term efficacy. where primary stabil- but should be taken with caution as it is a medium. these anatomical limitations. pro- moting faster osseointegration [26]. were developed to overcome short length may be chosen for regions of atro. how- coatings such as strontium ions incorporated into ever. ity is required for successful osseointegration. or ing vertical alveolar dimensions. The diameter of an implant. genesis [24] or the use of hydroxyapatite and bio- active glass coatings for their osteoconductive properties [25].

had shown that which has shown to have any statistically differ. and minimal bone loss [46]. All of the review literature agree complication rates of 7. which promoted choos. short implant. 4 mm. with most indicating that implants less sites [32]. Short implants are now regarded as a safe and predictable treatment options with reduced failure rates. autogenous bone is still con. short implants which were mostly option to avoid the need for bone augmentation. smaller subset granting that classification to sensory disturbances.4 Short implants may be useful in case of man. none of follow-ups of more than 3 years. some of which had long-term materials. One review even further classi- which serve to decrease patient acceptability for fied implants ≤6 mm as ultrashort [37]. 6. Postsurgical complications can range than 10 mm can be classified as short. sized crowns needed to reach occlusion in When discussing the topic of short implants. bone substitute Earlier studies.6 Implant Design and Implant Length 103 do however come with their disadvantages. 6. encountered termed short. cost. This can prove to be a bit problem- namely. maxilla [41]. especially dibular atrophy within the last decade. neuro.6 % in short implant and that implants ≥10 mm in length are considered 15. length [38–40]. This decreased rate of survival sidered the “gold standard” for augmentation was presumed to be because of several factors procedures [36] such as less bone-to-implant contact with short Short implants have been heralded as an implants. Lee SA et al. complications. it was suggested in some reviews that short implants be splinted to longer ones to rein- force their support [43] or to place wider diame- ter implants to increase the bone-to-implant surface area [44. the bone was relatively poor.3 % in standard implants placed in augmented standard. all of implants ≤8 mm. increased treatment time. or a combination of both. If short implants were placed. swelling. extensively resorbed ridges [42] we firstly have to define what can be considered a This evidence of higher failures in short machined implants would naturally bias most cli- nicians to augment bone in order to achieve enough vertical dimension for the placement of standard length implants and hence allow longer survivability of prostheses. short machined (smooth) surfaced implants suf- ence when it comes to implant survival [35]. This is due to the increased use of modified implant sur- Fig. Multiple systematic reviews. 33] (Fig. as there is no consensus in the literature for surgical morbidity. ried out using autogenous bone. especially in the ditional implant protocol. with the bone augmentation procedures [22. fered from increased rates of failures when com- however. and being what length an implant has to be before it is technique sensitive [31].5). and graft resorption. with a from severe postoperative pain. pared to machined surfaced implants ≥10 mm in ated after grafting. post. shortest commercially available implants being Bone augmentation for implants can be car. More recent systematic reviews of short implants however have challenged the idea of increased implant failure when compared to lon- ger implants. biological/prosthetic com- plications. placed in the posterior zone where the quality of yet their placement contradicts what has been tra. on the basis of total bone volume gener. 45]. have concluded that there . and an unfavorable higher crown- ing the widest and longest implant feasible to to-implant ratio which was created due to the out- insure long-term implant survivability. faces. atic.

97.3. the survival rate of treated sity. A meta-analysis conducted by Monje A. In a systematic review carried out by Telleman G. 6. to the increased bone density of the mandible tioned above increase the mechanical interlock.7 %. which imparts improved mechanical properties ing at the bone-to-implant interface as well as of the bone-to-implant interface.2. bone type as follows: type I.. All of which has resulted in clinically length.9 and 92. and type IV. reduced stress provide increased functional surface area for concentration. [42].1 %) than that of machined sur- table. type of implant system. after similar findings of a significant association between 6. over two decades ago. cantilever length.5 Example of full mouth restoration with short implants (Reproduced with permission from Calvo-Guirado and coll. size of occlusal was higher (97. concluded that short implants should be Implants considered cautiously in smokers.3. when compared to those studies where heavy smokers 6. with the esti- the subgroups listed above. consistent with implants of standard length [40.2.1 Bone Density heavy smoking (>10 cigarettes/day) and the Multiple reviews have shown that short implants frequency of implant loss. and opposing dentition [37]. et al. A systematic review carried out by significant higher removal torque values [48] and Goiato. showed how the survival rates increased implant survival rates in different bone of all implants in general varied according to types. all transmission of compressive and shearing loads of which compensates for reduction in implant to the bone. type II. 6. MC et al.6 %) [19]. The association of placed in the mandible had lower failure rates smoking and increase implant failure was than those placed in the maxilla. which was also reviewed by Bain C. splinting. 88.2 Smoking Habits sources of heterogeneity were explored to see Smoking habits as it relates to short implants whether there was any variation between some of were analyzed by Telleman et al. Quong Sing Fig. et al. has shown a mean survival rate for short short rough surfaced implants in native bone and implants in the mandible and maxilla as being standard rough surface implants in augmented 94. Successful osseointegration and its continued 96.5 %.104 N. in which their study of Branemark implants over 42].8 %. type III. a period of 6 years revealed increasing tobacco . smoking habits. Strietzel FP and Their Effect on Short et al. 96.2. Roughened implant surfaces as men. [34]) is no statistical difference between the survival of et al. This is attributed bone [47]. mated failure rates in studies where smokers were strictly excluded being twice as low. to surface roughness. implant surface. face implants (91. respectively. surface implants inserted in low-density bone crown-to-implant ratio. preservation for short implants depend on bio.3 Heterogeneous Factors (≥15 cigarettes/day) were included.2 %. and increased primary stability.6 %. especially type IV [19]. When implants were further classified according logical and prosthetic factors such as bone den.

3 Crown-to-Implant Ratio. et al. although chemical modifications to implant failure rate (23. et al. who noted increased mono. results of Ortega-Oller I. have shown that physical rate [49].2. et al. This increased crown-to. of short implants increased with wider diameters. [55]. as failure rates favorable and parafunction was controlled [51]. Yet for short factors influenced the survival and complication implants.33 %) and multivariate survival analysis wettability and hence cell attachment [54]. short implants recommended more evidence cyte proliferation and adherence to rough tita.65-fold reduction in crestal strain when implant 6. It was stated by Monje A. strated that increasing implant diameter resulted in tory [50].3 mm). cortical plates which promotes increased primary implant ratio would be problematic in natural stability and hence osseointegration. was required.3 mm) had significantly lower questionable in their review of how prosthetic rates than wider implants (≥3. as a result distribution. This lack of robust long-term main feature which allows short implants to over. Laboratory trials by Conserva ing short implant survivability and the factors et al. that is that short osteoblast-like cells were used [53]. Increasing implant Splinting. et al. showed this precaution to be that implants (<3. A review by Deluca S. and Occlusal Table diameter therefore decreases the risk of peri- Short implants in resorbed areas usually have implant overloading and allows for better stress unfavorable crown-to-implant ratios.2. provided that results of that meta-analysis were contradictory to force orientation and load distribution were studies of standard length implants.08 %) than nonsmokers implant surfaces can increase implant surface (13. There was an increase in complication rates for short implants in bruxers of 15 %. who concluded Tawil G.6 Implant Design and Implant Length 105 use correlating to an increased implant failure Pivodova V. trials was mentioned by Lee SA et al.. but the value Conclusion was found not to be statistically significant by Many reviews on the topic of short implants Tawil G.5-fold reduction in crestal strain compared to a 1. et al.3. search [32]. in their data come handicaps of length and poor crown-to. The major biomechanical risk factor. Three-dimensional finite element analysis demon- cantly associated with a positive smoking his. All of these teeth.5 Implant Diameter surgery and late implant failure to be signifi. length was increased [29]. et al..3. leaving them with only four random- implant ratios in atrophic poor quality bone. as observed in studies Although many conclusions of articles on by Soskolne et al. showed early implant failure to be significantly associated with smoking at the time of stage 1 6.3. displayed similar results when SaOS-2 that affect them are similar. showed surface treatments (such as surface roughness) that patients who were smokers at the time of play a more important role than chemical modifi- implant surgery had a significantly higher cations. and it was therefore suggested that short positive benefits holds true for standard length implants be splinted to better distribute occlusal implants and confirmed by the meta-analysis forces [43]. The ized control trials which satisfied the criteria for roughened surfaces have been shown to increase their meta-analysis.4 Implant Surface Treatments ies or prospective studies not based on random- Implant surface roughness is thought to be the ized clinical trials. this does not appear to be the case as rates of short machined surfaced implants. lacked large sample populations monitored over long periods of time and were retrospective stud- 6. who found that neither concluded that increased crown-to-implant ratios implant length nor width seemed to significantly and occlusal table values did not seem to be a affect the survival rates of short implants.2. Increasing implant diameter also of the tall crowns needed to attain occlusion with allows better engagement of the buccal and lingual the opposing dentition. rough surface implants is an effective treatment . the osteogenic response. the most important findings regard- nium surfaces [52]. a 3.

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Platform Design 7 Giovanni Molina Rojas and David Montalvo Arias Abstract Implant platform is defined as the portion of the implant on which the abutment rests.ae humans. Possible factors that seem to contrib- ute to the preservation of marginal bone in platform-switched implants are the shifting of the microbial leakage far from the bone or of the abutment- platform micromotion.1007/978-3-319-26872-9_7 . DDS (*) bone and protects it from the contaminants of the Prosthodontics.” The crestal bone changes after implant placement (one-stage protocol) or abut- It is well documented in the literature that the ment connection (two-stage protocol).). about 1. 7. more clinical studies are needed to confirm its validity. Apa Aesthetic and Cosmetic Dental Centre. Molina Rojas. The peri-implant mucosa establishes a soft tissue attachment which seals the underlying G. Umm Suqueim 2. about 2 mm long. Evidence-Based Implant Dentistry. Montalvo Arias.5 mm high. The apico-coronal dimension of this LLC. DDS lium coronally. face is initially located at bone level or subcrest- ally. DOI 10. and a supra- Periodontics. Dubai 213487. Al Thanya Street. United Arab Emirates has been studied histologically in animals and e-mail: gmolina@apaaesthetic. Umm Suqueim 2. a barrier epithe- D. The mucosa around dental United Arab Emirates implants presents several features in common e-mail: dmontalvo@apaaesthetic. Scalloped implant design is a new platform solution indicated in the esthetic zones. Al Thanya Street. It consists of two zones. soft tissue interface is called biologic width and Dubai 213487.ae with the gingiva around teeth. This particular design has been found to be associated with reduced marginal bone loss. Both have a © Springer International Publishing Switzerland 2016 109 O. Platform-switching design uses an abutment that is smaller in diameter than the outer edge of the implant neck. Iocca (ed. LLC. Apa Aesthetic and Cosmetic Center. alveolar implant-connective tissue interface.1 Introduction logic width. It remains to be established if this favorable outcome occurs in all the clini- cal situations and with which extent. but although promising. Implant Dentistry. Other cofactors may also contribute. and it crestal bone and the peri-implant mucosa heal resorbs apically if the implant–abutment inter- around two-piece implants establishing a “bio. Implant and Cosmetic Dentistry. oral cavity.

At the to convey the loading forces inside the implant second-stage procedure. This research led to the idea that a meet the prosthetic requirements for stable. The external hexagon was not ture. the purpose of the body. in esthetic duced and used without matching wide-diameter areas and in conjunction with grafting proce. connection width and length. and surface characteristics. in implants such fibers are orien. since it was not controversial topic. The purpose of such changes stood. Radiographic evaluation after abut- . and reduce the implant connection was merely to connect bacterial microleakage. verification mechanism.7 mm-tall external-hexagon connection could attachment to the metal body. The main difference between the two surgical placement. materials. therefore. Since then. a fortuitous finding led to Branemark. The purpose of the external hexagon was improve components precision. protocol for edentulous arches developed by In the early 1990s. prosthetic components. it soon became an important resides in the quality of the supra-alveolar con. not satisfy the esthetic requirements and with- Which factors contribute to the stability of the stand the increased occlusal forces of single and peri-implant tissues and in what extent is still a multiple fixed restorations. seating required for the prosthesis.110 G. The parallel with the implant surface without any 0. there was the need to sim- causes of early peri-implant bone loss. abutment designs. The whole implant dentistry ment collagen fibers that are connected to the evolved to a “restoration-driven” philosophy. Arias biologic width composed of an epithelial and connection changed: originally intended only for connective tissue compartments. Molina Rojas and D. together with different screw and of biologic width was not yet completely under. the concept of implant platform. with similar rotational torque transfer mechanism during the heights. based on the two-stage submerged surgical proto. Secondly. every com- the transmucosal attachments used to stabilize pany developed various designs of indexing fea- the prosthesis. and microgap are some of implants became accessible to the large dental the elements that have been studied as possible community. and the connection mechanical limitations of dental implants and to microleakage. prosthetic component with indexing and antirota- nective tissue: while in teeth are present attach.M. the peri- been developed to overcome the biological and implant bone loss patterns. and there were no esthetic needs since was to improve the connection strength. increase implants were used only to restore edentulous the horizontal and rotational stability. Thirdly. and arches. loading forces. Infection. designed for such purposes. a number of devices and designs have cept of biologic width around implants. The initial changes were made to overcome col introduced by Branemark. to allow the engagement of the fixture mount dur. implant dentistry developed rapidly. resulting in an implant– dures. The initial 0. better seal and different connection configura- esthetic restorations. strengthen the connection. the introduction of the concept of platform Implants begun to be utilized for fixed partial switching. The broader use of implants and their abutment interface horizontally shifted inwardly application to single restorations entailed several and away from the outer edge of the implant consequences. internal engaged since no antirotational features were tapering. Wide-diameter implants were intro- dentures and single tooth restorations. new mechanical and esthetic failures tated in a completely different manner and run emerged and needed to be addressed. tional purposes.7 mm-tall tions could prevent peri-implant bone loss and external-hexagon connection was developed improve peri-implant tissue stability. Since the discovery of osseointegration in the And finally. root cementum. abutment emergence Following the introduction of the two-stage profile. plify the clinical steps required to restore them. the internally hexed connection was introduced ing the surgical placement of the implant. The platform the mechanical problems and involved the intro- design was developed giving priority to surgical duction of different external-hexagon heights and rather than prosthetic requirements: the concept configurations. dental neck configurations. In the late 1980s. locking and sealing mechanism. First of all. several studies investigated the con- 1980s.

Since then. 7.60 mm in the subgroup The implant platform is defined as the portion with ≥3 years follow-up time.7 Platform Design 111 ment connection of these implants showed a Crown reduced crestal bone loss compared to the platform-matching implants.1 Does Platform Switching advantage. soft tissue sup.2.1 The platform-switching concept involves an understand that there is no such thing as the per. tions with a total of 1216 platform-switched port. every reported a significantly reduced marginal bone design seems to work efficiently. The implant–abutment interface is currently one of the most researched areas in implant den- tistry. In Another systematic review [3] included nine this type of connection. studies. Further clinical Abutment and histological studies confirmed the reduced pattern of bone loss with platform-switched Platform switching implants. either randomized or not. ginal bone compared to platform-matching. the outer edge of the implant neck Fig. . choosing the implant–abutment Reduce Marginal Bone Loss? combination that better fits the single case. in which platform switching is effective in preserving mar- extent and for which reasons. The article showed also an increase able implant design [1]. the junction between randomized controlled trials and prospective the implant and the abutment is moved toward comparative clinical trials with a minimum fol- the center of the implant axis and away from the low-up of 1 year. However. The same increase of the implant on which the abutment rests. posterior restorations instead. Seven out of the nine selected bone crest.2 Definition of Platform time: from a mean difference of −0. the priority often is given A recent meta-analysis [2] selected 28 publica- to marginal bone preservation.1. and the choice of esthetic materials. The study During the initial period of loading. erties of this design. abutment of lesser dimension compared to the implant platform fect connection.29 mm). loss in platform-switched implants compared to long-term success can be achieved only with the platform-matched implants (mean difference: careful choice of the most convenient and reli. while studies have analyzed the biomechanical prop. The discovery of the effect that the studies reported a beneficial effect of platform platform-switching design has on marginal bone switching in reducing peri-implant marginal preservation was fortuitous. two studies reported no significant differences. The clinician needs to evaluate the different qualities and defects of each design and use the connection properties in his or her 7. The biological and mechanical behavior of the implant connection and the peri-implant tissues determines the functional and esthetic success of the restoration. It is important to Fig. 7. of the mean difference of marginal bone loss between platform-switched and platform- matched implants with the increase of follow-up 7. several bone loss compared to platform-matching. strength and sta. primarily to understand if The overall conclusion of the article was that the marginal bone is actually preserved. −0.13 mm in the Switching subgroup with ≤3 months’ follow-up time to a mean difference of −0. The eligibility criteria included clinical human bility during function are usually prioritized. The of mean difference of marginal bone loss was platform-switching design is based on the use also noticed with the increase of mismatch of an abutment that is smaller in diameter than between the implant platform and the abutment. In implants and 1157 platform-matched implants. For anterior restorations.

Most of the articles used a small role of bacterial leakage from the microgap in sample size and short follow-up period. The extent of overall lower degree of marginal bone loss marginal bone preservation related to the with the platform-switched implants compared amount of implant–abutment mismatch is still to the platform-matched implants. Animal opposing dentition. presence or absence of grafting procedures. The study reported an able data to proof causality. The meta-analysis showed phenomenon. connection types and prosthetic once the implant is uncovered and exposed to the designs. and marginal bone loss between platform-switched 7. [5] included ten randomized controlled trials and controlled clinical trials with a minimum follow- up of 1 year.M. three studies of implant–abutment mismatch seem to mag- reported just a slight difference. seems to play an important role in the crestal may have affected the results. types of inflammation of the peri-implant tissue. Implant platforms are avail- preventing crestal bone loss when compared to able in numerous designs.6). together with the size and location of the micro- Confounding factors of the analyzed articles gap. sur. timings of implant placement and load. Molina Rojas and D.3. common the presence of an interface between Systematic reviews and meta-analysis about the implant and the abutment called microgap this topic present several limitations. A total amount of 643 platform. but they all have in platform-matching. a mean difference in marginal bone loss between The most accredited explanation relates the the two groups of −0. the increase of time and extent and platform-matched implants.2).5). platform-matched implant groups (Tables 7. In vitro studies have shown ing. Six of the ten studies switching design is effective in preventing peri- identified a statistical significant difference in implant marginal bone loss (Figs.37 mm.1 Another systematic review and meta-analysis and 7. 7. ginal bone preservation phenomenon of the ference in marginal bone loss between the platform-switched design has still to be consid- platform-switched and platform-matched ered a hypothesis since there is not enough reli- groups of −0. 7. It is also important to underline that evident marginal bone preservation effect with all the studies reported no difference in survival increasing the extent of implant–abutment rates between the platform-switched and mismatching.2.2 Why Platform Switching switched implants and 546 platform-matched Seems to Preserve Marginal implants was analyzed. Several the crestal bone resorption (Fig. there a minimum follow-up of 1 year and a total of is evidence to suggest that overall the platform- 933 analyzed implants. Peri-implant bone resorption only begins face textures.4). Every selected bone remodeling and in the soft tissue architec- article presented different implant systems. Seven out of ten articles Bone? reported a statistically significant reduction in peri-implant bone loss around platform-switched It is still unknown why platform switching seems implants compared to platform-matched to preserve marginal bone. with a more not clear. Several hypotheses implants. 7. 7. that bacteria colonize the microgap causing implant locations and angulations. The . while three studies failed to show any have been formulated to explain this statistical difference. Considering all the limitations. in preserving crestal bone. However. and patient-related local and human histological studies confirmed the risk factors. The design of the implant platform. Arias A systematic review and meta-analysis [4] articles also presented methodological issues selected ten randomized controlled trials with and biases. and one study nify the beneficial effect of platform switching did not test the results for statistical differ. and the (Fig. bone loss pattern to the presence of bacterial sion was that platform switching is effective in microleakage [6]. 7.112 G. The article conclu. oral environment. Moreover.2. ture. The meta-analysis showed a mean dif. the mar- ences.55 mm. obtained data need to be evaluated carefully.

7. crestal bone. attachment leads to the establishment of the mum biomechanical stress and has been linked to biological width horizontally instead of verti- peri-implant bone resorption [7]. This results in less resorption of the switching design would again keep these micro. cally. Such the medial repositioning of the soft tissue interface is considered to be the area of maxi. implant central axis and reducing bone The inward shifting of the implant– resorption.7 Platform Design 113 a b c Fig. the spatial distribution of the biological width: motion of the abutment-platform interface. abutment connection appears to also change Another possible factor seems to be the micro.) platform-switching design carries the microgap movements away from the implant shoulder away from the implant shoulder. The platform. therefore reducing the stress on the peri-implant ing the inflammatory cell infiltrate toward the crestal bone. .2 Radiographic appearance of a platform-switched implant (Reproduced with permission from Del Fabbro and coll. therefore shift.

and (c) 28 days (lingual site).4 (a–c) Representative histological views (Masson. BC cal downgrowth of the barrier epithelium over an observa.55 to –0. Landmarks for Goldner stain) of crestal bone changes at platform-switched histomorphometrical analysis: IS implant shoulder. MD −0. aJE the implants (original magnification 40×). most coronal level of bone in contact with the implant. The circumferential apical extension of the long junctional epithelium.3 (a–c) Representative histological views (Masson. and (c) 28 days (buccal site).20) + In favor of platform switching Annibali et al. (lingual site). IS implant shoulder.) a b c Fig. (b) 14 days mission from Becker et al. platform-matched implants Platform-switched vs.19) + In favor of perio healthy patients Atieh et al. CLB the most coronal level of bone in in dogs (original magnification 40×). 7. 7. Arias a b c Fig.38 to −0. MD −0. (a) 7 days (buccal site).) Table 7.1 Meta-analyses comparing marginal bone loss (MBL) of platform-switched vs. crest (Reproduced with permission from Becker et al. Effect platform-matched Statistically size implants (95 % CI) significant Clinical meaning Chrcanovic et al. aJE the apical extension of the long Goldner stain) of crestal bone changes at matched implants junctional epithelium.24) − In favor of platform switching RR relative risk . (a) 7 days (buccal contact with the implant. (b) 14 days (lingual site). Molina Rojas and D.M. CLB the horizontal mismatch of 0.37 (−0.5 mm was able to prevent the api. the level of the alveolar bone crest (Reproduced with per- tion period of 28 days. BC the level of the alveolar bone site).86 to −0.29 (−0. RR −0.55 (−0.114 G.

93 − In favor of platform switching RR relative risk a b Fig. RR 0. .3 What Are Other Possible 7. 7. prospective randomized controlled clinical trial. Koutozis et al. tion on soft and hard peri-implant tissues in a form switching.7 Platform Design 115 Table (a–b) The microgap of two different implant types is evident at SEM analysis.6 The presence of bacterial micro leakage from the connection is considered to be the main cause of the different crestal bone resorption patterns between platform switching and platform matching implants 7. platform-matched implants Platform-switched vs.3. (Reproduced under CCC permission from Lorenzoni and coll) crown crown bacterial bacterial microleakage microleakage abutment abutment platform switching matched abutment-platform Fig. platform-matched Effect size implants (95 % CI) Statistically significant Clinical meaning Atieh et al. 7.2 Meta-analysis comparing survival of platform-switched vs. [9] evaluated the effect of Several factors have been studied as contributors healing abutment disconnection and reconnec- to the marginal bone loss in relation with the plat.1 Abutment Disconnection Times Cofactors That May Influence It has been proposed that the abutment connec- the Marginal Bone tion/disconnection may increase the amount of Resorption? marginal bone loss [8].

Molina Rojas and D. yses. within the limits Tissue culture studies have demonstrated cellular of this animal study. abutments. 36 months no significant differences were observed reporting a 10 % decrease in all the prosthetic between the two groups of patients with regard to loading forces transmitted to the bone–implant vertical bone level changes. Alves et al. the collar surface is alter bone levels significantly. laser microtextured with 8. Arias They indicated that implants receiving a final implant interface. He suggested that the great. interface. 22]. at one time concept. may keep away the micromotion between the ited minimal marginal bone loss and were similar implant and abutment from the bone. adjacent to the laser-microtextured collar lated to micromovements at the abutment– implants were statistically significantly lower . The platform-switch approach abutment at the time of implant placement exhib. Vigolo et al.116 G. suggested that this design reduced the stress In the study of Degidi et al. which the changes were minimal.3. 24].3 Laser Microtextured Collar associated with an increased apical extension of the A different strategy proposed is to promote the junctional epithelium and subsequently crestal attachment of bone and connective tissue to the bone level changes after 8 weeks of healing. another study [12] transfer stress from the implant to the crestal with short-term data (4-month post-loading) bone [21. [19] noticed that this procedure up period (5 years).2. In addition. adjacent to implants with microtextured collars it may present a negative influence in the buccal may achieve more coronal attachment than connective tissue attachment that becomes implants with machined collars. supported by finite element anal- and reconnection up to two times. attachment by osteoblasts and fibroblasts to laser- nection of platform-switching abutments during microgrooved surfaces [23. Maeda et al. [10]. Furthermore. of 15 overdenture patients with immediately As a practical implication.2 Micromovements 2. based on a case control study resorption. shifts the stress concentration away from the est amount of bone changes occurred between bone–implant interface. help to As an opposite finding. that the connection/discon. In both Ti and ZrO2 groups. All these findings are also supported by Becker et al.” reported that over a period of Hsu et al. The probing depth and the crestal bone loss Additional bone resorption seems to be corre. implant collar surface and. it prosthetic phase of implant treatment does not has been hypothesized that crestal bone levels induce bone marginal absorption. to implants subjected to abutment disconnection This theory. especially in thin biotypes. the abutments at the bone–implant interface and in the crestal were removed a total of four times. High-strength abutments should be tissues formed at both mismatched Ti and ZrO2 chosen to prevent fracture. the clinician should loaded implant designed with laser-microtextured carefully consider the detrimental impact of a and machined collars.M. collar did not increase the plaque or sulcus bleeding indices. but these forces are then surgery and crown/abutment placement. [13] concluded. [11] reported the longest follow. and within the another study [20]. shorter anyway preventing marginal hard tissue Botos et al. determined that: repeated abutment dis-/re-connection on soft and hard tissues during the initial phase of peri.and 12-μm grooves. it is claimed. 7. [25]. 1.3. [8] also concluded. The presence of a laser microtextured implant implant wound healing (4–6 weeks).2. after increased in the abutment or in the abutment screw. a repeated abutment dis-/re-connection at 4 and 6 weeks was 7. that repeated manip. implant fracture with platform-switched implants ulation of the abutments may be associated with than with conventional diameter-matched dimensional changes of peri-implant soft and hard implants. showed that repeated abutment changes do not Based on this strategy. [18] confirmed the hypothesis. and compared region of cortical bone by shifting the stress to to other group of patients using the “one abutment cancellous bone during loading [14–17]. in which a greater risk of limitations of an animal study.

platform-switching model [42]. the possible etiologic mechanism for crestal bone resorption is required to compensate for the bone resorption.2. These findings ings of reduced bone remodeling accompanying were related to a decreased microgap in the con- a larger implant–abutment difference may be due nection interface whenever using platform to an increased implant diameter rather than to switch. 0. Cocchetto et al. connection. It dependent.5 Size of the Microgap of the implant–abutment interface allows the bio. this design might It is likely that there is a bacterial leakage increase the distance between the inflammatory within the implant system. age at implant–abutment interface of implants Canullo et al. findings.3. marginal bone loss. since an microgap at the implant–abutment interface. if at the time of 0. texture of the neck and showed no significant They observed that the degree of marginal bone influence on marginal bone level changes [26]. between implant and abutment. Radiographically. similar implant types differing only in the surface Atieh et al.25 mm was applied between the implant shoul- der and the abutment (platform switching). 38–41]. after its prosthetic cell infiltrate at the microgap and the crestal bone. [33] evaluated the biologic 7. because a bigger mismatch is Berberi et al. and adjacent bone may increase the anti-bone. [43] investigated in vitro the leak- often caused by the use of a wider diameter [31]. distance between the implant–abutment interface resulting in bone support loss [6. biologic seal.7 Platform Design 117 than those observed adjacent to the machined. that the resorp- resorptive effect of the platform-switching tion resulting from biological processes after concept. [27] concluded that both implant–abutment mismatch. laser microtexturing of implant collar or platform. The cone Morse taper internal connection. it was observed that increasing the an inflammatory process close to the crestal bone. however.5 mm was demonstrated with several prospec- implant placement vertical soft tissue thickness tive studies [34–36].6 Connection Type effect of using a wide platform-switching restor. Furthermore. It was pointed out. This meant that less vertical cus. for whom the effect of platform switch The original components were showing signifi- on marginal bone level seemed to be “dose cantly better results than the compatible ones.2.3. 29].” He demonstrated that the greatest can be assumed that the source of the abutment platform–abutment mismatch resulted in the least used can also result in bone loss. additional horizontal surface area is created for resulting in bacterial colonization of implant sul- soft tissue attachment. with subsequent penetration of bac- thereby minimizing the effect of inflammation on teria and their products within the microgap marginal bone remodeling [28.4 Amount of Mismatch It has been suggested that the inward positioning 7. the influence on marginal switched implant–abutment connection did not bone remodeling of a mismatch of 0. The results indicated designed to be completely stable with absence of .25 up to eliminate crestal bone loss. ative protocol in human. it has been speculated that the find. that patients receiving wide platform-switched collar implants.3. [5] also reached similar results. Many authors have identified the presence of a logic width to be established horizontally. This would cause Moreover. was ≤2 mm. 7. prosthetic restoration changes with the use of a However. resorption is inversely related to the extent of the Linkevicius et al. implants may experience less crestal bone loss than that resulting from the use of regular plat- A recent human clinical trial evaluated two form switching.2. another study [37] implants may present less proximal bone loss failed to show significant differences in both hard than platform-switching implants in the period and soft tissue dimensions when a mismatch of before implant loading. However. the platform [30]. [32] are also supporting these connected to original and compatible abutments. laser-microtextured As an opposite finding.

the bacterial contamination occurred They evaluated the hard and soft tissue responses quite lately during the course of the experiment around a new implant concept with an inward (on the 22nd day). and surface topog- tion. for etration of screw-retained implant–abutment example. The 7. Rodriguez-Ciurana et al. [49] indicated that the closer the studies. the platform-switching concept implant–abutment connections. implant restored according to the traditional pros- hexagon and Morse taper implant systems. Every study includes implants with different sur. and it is not characteristics. it must be inclined mismatching. The texture of the to bacteria of the conical implant–abutment con. Several implant neck configurations have been face treatments. that extends closer to the abutment-platform The aim was to evaluate with an in vitro study junction tend to have less alveolar bone loss [40]. Furthermore.2. connection. chemical. implant was missing in the study. It has been shown. junction. However. whereas the contamination inclined platform. less marginal bone loss would occur. In addition.3.2. the tissue response around an external-hexagon Jaworski et al. one surface modifica- A study confirmed the very low permeability tion is better than another [53]. Switch rial contamination occurs in different types of In the literature. has been performed with horizontal flat or outward- ferent percentages.10 External vs.2. As a conse. the presence of microthreads might mask the platform-switching restoration is slightly the true effect of PS on marginal bone more favorable in an internal than in an external preservation.2.3. implant’s surface may play a major role in mar- nection and the high prevalence of bacterial pen. seems to be able to resist more to the bacte. [45] compared external. They thetic concept. clear whether. a study [55] tested pointed out that in the conical implant–abutment the benefits of an inward oblique mismatching. [56] in a two- In addition. ginal bone resorption [54]. Titanium implants with different implemented to preserve marginal bone level. 7. Internal Some studies have shown that microthreads help Connection to preserve peri-implant marginal bone [46–48]. A a better bacterial seal than the external-hexagon comparison with a regular platform-switching design of the implant system used in the study. In their study. the study reported that the loca. since it improves distribution of the loads applied to the occlusal surface of the pros- 7. that implants with a roughened surface assemblies [44]. No surface modifications shows a wide range of evidences have been found about the effectiveness . raphies or morphologies.3. depending on how they ria penetration due to of their self-locking are prepared and handled [50–52]. Arias micromovements between the parts during func. Molina Rojas and D.M. and compared them to implants. the with a traditional restoration model. tion values as high as those reported in the earlier Song et al. the authors concluded that force dissipation in quence. in general. it is described a better concluded that both implant designs showed outcome of this type of design compared to the tra- leakage. but the Morse taper connection provided ditional external-hexagon matching connection.9 Inward Inclined Platform results of their in vitro study showed that bacte. the leakage observed in internal hexagon and Morse taper implant–abutment connections. dimensional biomechanical study involving plat- tion of the microthreads on the implant platform form switching integrated into the implant design may have influenced the degree of marginal bone failed to obtain peri-implant bone force attenua- loss encountered. which is believed to amplify the was always earlier in the butt-joint connection platform-switching concept.3.8 Polished Neck or Rough Neck thesis along the axis of the implant.118 G. even if with dif. physical properties. when comparing platform expansion microthreads were to the top of the implant.7 Microthreads 7.

with short implants. one present a low evidence level due to con- ate implant and abutment sizes have to be chosen founding factors. there is a need to further understand the mechanisms by 7. platform switching can be combined was introduced in the market [57]. The most important variations introduced so far have been the internal connection and the platform-switching design. implants can presents more tissue coronal to the bone inter- be placed closer to natural teeth and to each proximally than facially (Fig. Only two studies reported a positive causes a different emergence profile of the resto. therefore causing interproxi- cases. the scalloped design than the flat design and turer. A scalloped horizontal crestal bone loss compared to the tra. All the available articles but ration. where papillae scalloped bone and soft tissue architecture and preservation and facial recession are often very preserve the papilla level especially in the esthetic challenging problematics. In the posterior region.4 Scalloped Implant Design which the peri-implant bone remodels at the mar- ginal level and how to preserve it before evaluat. These properties represent a major the interproximal papilla. 64]. will not be able to fully maintain the alveolar tions. Similarly. The original implant 7. In conclusion. surface area. randomized clinical trial with 5-year follow-up . without causing bone loss and apical bone crest. in the maxillary with a scalloped contour of bone and soft tissue lateral incisor or the mandibular incisor posi. configuration. In such situations. small sample size. The dental implant design at the platform level ing the effectiveness of a specific implant neck has been modified throughout the past 25 years. allowing greater bone– Very few studies have been conducted so far implant surface contact. narrow form is placed at the level of the lower facial ridges can receive implants avoiding. grafting procedures and buccal soft tissue mal bone loss and eventually the possible loss of recession. The bone contour of the edentulous ties of the platform-switching design would be patients is described as flat. Based on the tour of partially edentulous patients presents var- assumption that the design reduces vertical and ious degrees of interproximal scallop. The appropri. Often a slightly more apical posi. The implant–abutment mismatch [58–62]. An implant other. which pres- Switching? ent a significantly different bone and soft tissue morphology compared to the partially edentulous The reported crestal bone preservation proper. essential for the about the clinical efficacy of the scalloped mechanical stability of implants with reduced implant design. morphology is described as a bone crest which ditional platform-matched design. and with contradictory results. while the bone con- useful in several clinical situations.7 Platform Design 119 of these configurations in the preservation of tion of the implant is required to allow for an marginal bone level. Marginal bone loss in the appropriate and cleansable emergence profile. and poor study design. with a thinner apical base. in 2003 a new scalloped implant design region. The clinician has also to understand the therefore the failure of the scalloped implants in different properties of the platform-switched maintaining the bone and soft tissue architecture implants. for example. short follow- depending on the loading forces and final pros.3 What Are the Risks design with a flat implant–abutment interface and Benefits of Platform was intended for edentulous patients. the implant plat- migration of the papillae.7). In order to preserve the advantage in the esthetic region. A recent thetic design. implant neck area seems to occur regardless of all the efforts to eliminate it. up periods. 7. Single implants can be placed in narrower with a classic flat collar design placed in a crest mesiodistal spaces. the implant design must Most studies reported more crestal bone loss in be carefully planned and tested by the manufac. in some alveolar bone crest. However. patients. outcome [63.

D.P. Implants and components: entering the new millennium. M. Albrektsson. Atieh. Koutouzis. Al-Nsour. bility of peri-implant tissues? Four-month post- loading preliminary results from a multicentre tions based on clinical evidence about the effi. M. inflammation and time: non. Peri‐implant marginal bone level: a systematic review and meta‐analysis of studies comparing platform switching versus conven- tionally restored implants. 629–646 (2015) 3. M. G. M. Mihatovic. 103– 109 (2009) designs. J. 774–780 (2012) area and soft tissue architecture and in this way the papilla 9.S. J. J. J. F. Platform switching for marginal bone preservation around den- tal implants: a systematic review and meta-analysis.L. A prospective multicenter 5-year radiographic evaluation of crestal bone levels over time in 596 dental implants placed in 192 patients.H. K.D. Hermann.L.M. Platform-switched restorations flat implants.V. T. This design soft and hard tissue changes at implants with platform- should preserve the scalloped bone in the interproximal switching. F. Implants 27(1). V. A. Ramos. J. prospective. Clin. analyzed the clinical outcome of the scalloped 807–814 (2013) design in the esthetic region [65]. Impact of abutment material and dis-re-connection on Fig. Previous changes of abutments have any influence on the sta- reviews [66. Oates. Oral Maxillofac. 1097–1113 (2012) 5. Becker. A. P.removal of an immediate abutment and its effect on bone healing around subcrestal tapered bleeding of peri-implant soft tissue. 22.A. and probing implants. The study 10. Wennerberg. Nummikoski. F. B. 72. Vigolo. Degidi. Binon. Cristalli. C. Grusovin. 1303–1307 (2011) depths around scalloped implants than around 11. Molina Rojas and D. J. 1350–1366 (2010) 6. D. Ibrahim. Esposito. D. Schenk. The study concluded that the scalloped 12. Annibali.R. P. 725–733 (2009) 8. Cochran. A. J. Bignozzi. Oral Maxillofac. Effect of the platform-switching technique on preservation of peri- implant marginal bone: a systematic review. H. Periodontol. Atieh. Arias Bibliography 1. Marginal bone and soft tissue behavior following . J. A histometric evaluation of unloaded non- submerged implants in the canine mandible. J. 76 (2000) 2.L. Int. H. Jones. Periodontol. design had no beneficial effects compared to the K. 129–140 (2015) long-term. 81(10). Implants 28. Neumann. P. J. L.P. 67] couldn’t establish recommenda. Clin. 39. cacy of the scalloped design since further 8(2).120 G. Oral Maxillofac. Polimeni. D. Sbricoli. required to have reliable data. Oral Maxillofac. Givani. randomised controlled trial. T.L. d’Avenia. Oral Implantol. Implants 24. I. Buser. J. One abutment at one reported greater bone loss. Oral Implants Res. Nardi. Neves. 43. Periodontol. Golubovic.A. S. The effect of healing abutment recon- morphology nection and disconnection on soft and hard peri- implant tissues: a short-term randomized controlled clinical trial. J. A.W. La Monaca. Chrcanovic.G. M. I. Clin. Eur. controlled studies were 13. Int. R. Graziani. J. Dent. Do repeated classic flat design in the esthetic region. Int. Int. Platform switch and dental implants: a meta-analysis. J. 39(11). Cochran. Schoolfield. Muñoz. A. Chan. 7. A. T. Piattelli. 138–145 (2011) 4. Blanco.K. Luongo. H. Implants 15(1).M. F. Alves. Schwarz. Wang.M. Bressan. 1372–1383 (2001) 7. M. Periodontol. Periodontol. 80. Schoolfield.C.7 Example of scalloped implant. The interimplant papilla showed on wide-diameter implants: a 5-year clinical prospec- similar results in both the scalloped and flat tive study. E. J. G. I. D. Influence of the size of the microgap on crestal bone changes around titanium implants. M.

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Italy role in the success of implant treatment. Iocca (ed. Rome. it seems that internal connection gives best results in terms of lower rate of complications. Biocompatibility is fundamental in order to ensure an appropriate formation of the mucosal seal. Sapienza University Dental implant abutments play a fundamental of Rome. depending by the torque. Finally.1007/978-3-319-26872-9_8 . DDS International Medical School. the use of angled implant abutments is necessary in some situ- ations. In order to discuss this topic. Both materials seem to give similar performances in terms of bio- compatibility and incidence of complications. 8. An optimal preload is a prerequisite for preventing screw-related complications such as screw loosening and stripping. is the initial load and elongation of the screw that is important for optimal hold- ing of the components together. Implant Abutments 8 Oreste Iocca Abstract Abutments are important for the success of the implant treatment. which increases the stress around the peri-implant bone at the same time does not seem to impair the clinical results. Regarding the types of connections. The abutment screw is an important component that serves to secure the abutment to the implant. Given the increasing esthetic requests. 00161 Rome. Histologic studies show that the peri-implant mucosal barrier forms around the abutment and acts as a protective seal between the oral cavity and the underlying bone. Italy esthetic outcomes. Abutment Private Practice Limited to Oral Surgery. e-mail: oi243@nyu.1 Implant Abutments O. DOI 10. zirconia has emerged as an alternative to titanium abut- ments. Evidence-Based Implant Dentistry. Iocca.).edu it is important to define the different segments © Springer International Publishing Switzerland 2016 125 O. The preload. Viale Regina Elena 324. may have a huge impact on the functional and Periodontology and Implant Dentistry. when internal versus external typologies are compared.

8. Various materials are used for abutment man- ufacturing [1]. two categories: Anyway it is not suitable as a definitive solution. Titanium nitride (TiN) can be used in challenging esthetic cases because the plasma-coating process with Ti and N ions confers to the abutment’s surface a gold color that helps in achieving an esthetic mimicry with the overlying gingiva. the ered a protective seal that forms between the oral majority of manufacturers offer the possibility to environments and bone (Fig. In abutment: the same fashion as for implant manufacturing (see Chap. It is a mate- rial easily modifiable at the chair side.1). In the natural choose between straight and variably angled dentition. therefore.1. the use of ZrO2 needs a thor- • The superior portion of the abutment is the ough review of the scientific evidence in order one that connects to the prosthesis.1 Representative histologic image of the peri- implant mucosal margin (PM). and the most coronal bone in contact with the Zirconia (ZrO2) has also been adopted as an implant (CBI) (Reproduced with permission from Iglhaut abutment material due to its high esthetic and coll. A flaw of this modification is that it does not allow any adjustment due to the fact that the coating is usually less than 0. and with good mechanical properties. 8.126 O. They were used mainly as customized abut- ments but the introduction of reliable prefabri- cated solutions and CAD/CAM technology Fig. junctional epithelium led to progressive reduction in their use. 4). this seal is ensured by the presence of abutments. • Prefabricated usually manufactured by the same company that produces the adopted implant 8. Grade 5 titanium (Ti-6Al-4 V) is also used in manufacturing of dental abutments considered that it is stronger than pure Ti. Gold abutments have been generally abandoned. Pure titanium (Ti) is widely adopted and has shown good mechanical properties and bio- compatibility. abutments can be subdivided in color. • The transgingival portion is the part in contact Poly-ether-ketone (PEK) is normally used in fab- with the mucosa above the implant platform. to be sure of its mechanical properties in clini- • The inferior portion connects with the implant. (JE). even a minimal modification of the abutment would damage it.) .5 μm thick.1 Mucosal Attachment • Customized fabricated as cast custom or with at Different Abutments CAD/CAM technologies The peri-implant mucosal barrier can be consid- According to the clinical indications. Iocca that characterize the structure of a generic properties and excellent biocompatibility. white in Moreover. rication of temporary abutments. cal practice.

It has been stated that the mucosal connective Another issue that may have some importance tissue around an implant resembles a scar (Iglahut in the soft-tissue adaptation is the disconnection 2014) [3] rich in fibrous tissue with scarce cellu. The first difference is that peri-implant soft-tissue For this reason. Considered experimentally that abutment disconnection and that with an implant there is the absence of the reconnection can have some influence in periodontal vascular plexus. 8. dogs. Also the quality of connective tissue [5] outlined the fact that controversial results is different.32 mm for Ti.36 for ceramic. In this study was also per- formed a qualitative assessment of the tissue From the clinician standpoint.55 for gold. it is important to around the abutment.2 Titanium Versus Ceramic ment by Welander and coll. Anyway. the vascular supply increased epithelial downgrowth. and 2.5–4. whereas gold does not con- there are no collagen fibers running perpendicu. In summary. mea. months the percentage had decreased to 3. this happened because soft tissue receded compared to gold cast alloys [7]. and reconnected abutments five times every Abrahamsson and coll. approximately 60 % of collagen exist in terms of soft-tissue healing around differ- fibers and 10–15 % of fibroblasts are evident ent materials. 8. nium and zirconia seem to favor a proper healing hemidesmosomes are also present.5 mm around natural dentition). implant uncovering helps in the maintenance of metric analysis took in consideration the distance the soft-tissue levels. reduced performances of gold dimensions are enlarged (mean dimensions of abutments were supposedly caused by other fac- 3–3. but usually around the abutment. It’s been shown larity and reduced vascular supply. and reconnection of the implants. Polymorphonucleate leuko. . whereas around implants it accumulated such that gold abutments seem to is possible to find around 85 % of collagen fibers favor a detrimental mucosal downgrowth when and just 2–3 % of fibroblasts. are present. complication due to the presence of microorganisms in the sul. and ultimately bone resorption occurred in a great quantity than the other two materials. [2] which evaluated Abutments: Clinical titanium. compared to Ti and ceramic materials. and gold abutments with the and Esthetic Results same methodology. understand which kind of implant abutment gives cytes and other inflammatory cells were present the best results in terms of survival. stitute an ideal material for soft-tissue integration. the percentage tooth structures via hemidesmosomes. instead parallel fibers The comprehensive review of Iglhaut and coll. zirconia. titanium and ceramic materials cluded that with gold abutments the length of like zirconia can be considered equivalent in junctional epithelium and connective tissue terms of biocompatibility and soft-tissue adapta- attachment was smaller compared to the other tion and seem to warrant better results when two.1. Also some clinical studies showed that place- ceramic (Al2O3).5 %. In particular. These results were confirmed in another experi. tita- mean 2. need to be validated by large randomized clinical surements gave mean results of 3.5 mm of biologic width compared of the tors than induced inflammation. The experiment examined titanium. rates. But sufficient evidence has been around natural teeth. Abrahamsson is provided mainly by the supraperiosteal vessels and coll. It was con. The histo. After 5 formation of the same histologic structure [2]. there is no abutments with a range of 5. and gold alloy abutments ment of the definitive abutment at the time of installed in the mandibles of beagles. Second. of leukocytes was similar in all three observed At the implant-abutment interface.8 Implant Abutments 127 the junctional epithelium which attaches to the cus. and after 2 months of healing. [4] evaluated the month showed greater bone resorption than abut- mucosal attachments of different abutments in ments left untouched. trials.2–6.8 %. and esthetics.1). lar to the abutment surface. [6] showed that repeated disconnected (Fig. 3. these observations between PM-CBI at 3 months of healing.

while a 5-year estimate conia. component. was found to be worst for metal abutments. No clear advantage in the abutments which was in contrast to most studies use of one material over the other can be showed showing a similar biocompatibility of titanium analyzing the current evidence. CI 95 %. there was a trend sug. cal results in terms of survival and risk of com- cations for ceramic abutments compared to metal plications (Fig. In particular.71–9.48. complications related to this prosthetic Linkevicius and coll. 8. no significant difference between the ues emerged for zirconia abutments (∆E. 3). [8] obtained with a colorimeter or spectrophotometer analyzed the abutment survival rates. long-term studies are available in the case of tita- denced no esthetic failures for the studies adopt.128 O. 8.11–11. although considered dif. an objective evalu. adjacent tissues. The meta-analysis showed that lower val- compared. 7. Considered that screw loosen- in the majority of the studies.9 % for metal abutments restorations. evi. The higher the difference between of different materials.94) compared to titanium (∆E. and zirconia abutments seem to give good clini- gestive of higher incidence of biological compli. an attempt to describe the low number of abutments analyzed and the short mechanics of the abutment screw may help to follow-up time and it cannot be excluded that this understand how to decrease the incidence of has a role in the results of the analyses. On the other hand. are expressed in numerical as ΔE values (change dence of biological and technical complications. but the same thing does not occur with zir- ing ceramic abutments. it needs to be pointed out that many reporting and heterogeneity of the studies.88. two materials was found in terms of abutment CI 95 %. adoption of a particular material instead of On the basis of the available data. more information from long- authors concluded that no difference in technical term follow-up studies will help to draw defini- or biological performances can be found.1 Preload ation of the buccal gingiva color with a colorimeter was used as a term of comparison The screw is retained to the implant by a tight- between zirconia and titanium abutments at 1 ening force that is dependent by the torque week after placement and healing. 10. outcome difference.2 Abutment Screws Another systematic review on the perfor- mance of ceramic and metal abutments support. 8. 3). but the zirconia gives better esthetic results compared to incidence of complications was not linked to the titanium [11–13]. it was statistically significant.2. Esthetic tive conclusions.64).2). zirconia as implant-abutment material. The results applied to the screw (in N/cm). the results were Regarding the technical complications. titanium another. An implant abutment is secured to the implant by ing fixed implant reconstruction concluded that an implant screw. 10. analysis on the only three RCTs available about specific esthetic results of zirconia versus tita- nium abutments. esthetic outcomes emerge with the adoption of Esthetic evaluation. in color between the peri-implant gingiva and and esthetic outcomes of single abutments made tooth gingiva). Considered that mechanical strength of esthetic complications was found to be around concerns arise when a ceramic material is used 0. confirmed that the most common occurrence was This further strengthens the consideration that abutment screw loosening (see Chap. The transformed . the information ing is a common unwanted occurrence in implant regarding ceramic abutments is limited by the dentistry (see Chap. [10] conducted a meta. nium. The for restoration. although better and ceramics. the lower is the esthetic out- When titanium and zirconia studies were come. On the ficult for the lack of standardized methods of other hand. survival estimates at 5 years. the inci. 8. in particular the tissue color change. Iocca The meta-analysis by Zembic and coll.

ing are important in increasing the preload.3). load value to be 75 % of the yield strength. 8.2 (a–c) Zirconia implant placed in region #11 (a). [15] established the optimal pre- newtons (N) (Fig. Finite element analysis (FEA) studies have mately results in holding the components examined the dynamics of the preload develop- together. from 15 rpm to 30 rpm. reducing the coefficient of friction. while Preload is crucial in ensuring the clamping that for a common Ti screw is around 825 N. This contact force cific screw. either with surface modifications or with the use There is an almost linear correlation between of a lubricant. least 825 N. and the surface achieve the recommended preload values of at conditions [14]. has a role in . This initial load and elongation of the ment when specific torque values were applied. this corresponds to the optimal abut.) force is transmitted to the abutment screw to apply a given torque value which should threads and to the implant threaded surfaces allow to obtain the optimal preload for the spe- accommodating the screw.8 Implant Abutments 129 a b c Fig. we don’t reach an optimal particular. In while below this point. zirconia abutment in place (b). In of the screw to the implant. There is a point in which optimal preload is Another FEA study by Bulaqi and coll. [16] achieved. tightening. more than 35 N/cm was necessary in order to the material adopted. screw is called preload which is measured in Lang and coll. may help in achieving optimal pre- the torque applied and the preload achieved. and above this friction of the surfaces and the speed of tighten- point we have a plastic deformation of the screw. 8. produces a linear stretch of the screw that ulti. load values. the design of the screw. Also increasing the tightening speed. usually the different manufacturers recommend for example. it was stated that a torque of the torque applied. it is dependent by their FEA study. esthetic results after 13 weeks (c) (Reproduced with permission from Kohal and coll. arrived at the conclusion that the coefficient of ment/implant stress interface.

Beam-type wrenches were not affected by speed of use. Moreover.130 O. not conform to the nominal values of 35 N/cm.2 The Settling Effect Fig. spots. This is due to the fact that no surface ing of the screw with the abutment is completely smooth and the inevitable small imperfections do not allow two surfaces to stay in slightly increasing the preload because of its full contact.4). this occurring variable time after abutment screw causes elongation of the screw and ultimately the clamp. but some used devices produced very high values. placement. well posed to impair the stability of the screw to below the required torque necessary to obtain implant already after few minutes (Fig. [18] evaluated the accu- racy of the torque wrenches in producing a pre- cise torque value. On the other hand. [19] suggested that in order devices can aid in achieving optimal torque to reduce this mechanical phenomenon. Numerous experiments have the screw. it was . but in practice the most diffuse devices are the torque wrenches. bilizing the screw occur at the level of the rough An important aspect to consider is that appro. 8.2. ideal preload. this can be dangerous because excessive force transmitted to implant collar and marginal bone can lead to marginal bone loss. priate torque values cannot be obtained by hand. This phenomenon is sup- wrenching is in the range of 10–12 N/cm. McCracken and coll. torque-limiting Winkler and coll. It follows that the main contacts sta- influence on the frictional resistance. and the head of the wrench flips to the side thus impeding further torquing. the deflection allows to visualize on an special marking the torque values achieved. when the desired torque is achieved. Iocca values [17]. the ball rolls out of the mech- anism. Beam-type wrench instead uses a beam that deflects increasing the torque. The study sug- gests that clinical use and autoclaving procedure may impair the mechanical properties of the instruments and reduce their accuracy. the rough spots are compressed due to shown that the mean torque produced by manual the pressure developed. 8. Electronic drivers have shown to be reliable in producing the nominal torque values.3 Representation of the preload developed with Settling effect refers to a decrease in preload the application of a torque on the abutment screw. 8. Toggle-type wrenches use a small ball that engages in the locking piece of the mechanism and compressed with a coil. Already after few minutes after placement of held screwdrivers. Brand new instruments actually produced accurate torque values. the toggle-type wrenches tended to lose accuracy when speed of rotation was increased.

it is safe to assume that reduc. metals dence of screw-loosening complications. it deforms irreversibly and becomes non- The driver head engages the screw through a fit. on the risk of occurrence of screw loosening. [20] evalu. friction with a lubricant or selection of screws Screw diameter may play a role on the preload manufactured with the smooth surfaces is indi. some authors recom. stronger contact surfaces. The most by titanium screws. retrievable. in order to do so. the 30° that in order to increase the preload. Gold is subject to plastic deformation. Also. Regarding the material composition. applied torque and friction coefficient in obtain- mend a periodical retightening at the follow-up ing an optimal preload.2. designs of abutment screws and their incidence ing the preload.8 Implant Abutments 131 Rough spots that serve as contact points for engagement of screw to the internal implant surface Rough spots flattened due to the setting effect Fig.3 Antirotational Features sequence of this. After few minutes. it has been replaced ting site. a reduction angle allows to put a shear load on the material of the coefficient of friction is more important and allows the stretching of the screw responsible than retightening. in con- 8. a reduction of of complications. respond to prerequisites of high elasticity and adequate yield strength. Given the importance of the over the course of the years.4 Schematization of the settling effect showing the relation of the screw with the internal surface of the implant. metals employed should visits as well [21].5). 8. because a greater diameter corresponds to a cated. Different thread designs may have an impact The FEA study of Bulaqi and coll. this can have different shapes. ating the dynamic nature of screw retightening A 30-degree V-shaped thread is the most com- and the settling effect arrived at the conclusion mon design adopted by manufacturers. after placement can help in reducing the inci. common are the slot and the hex type. the simple act of retightening 10 min greater surface of engagement. studies are available comparing different thread tion of the settling effect is important in increas. for an optimal development of the preload. thus allowing the formation of new. for this reason. once the torque is applied. No On this basis. the rough spots that serve as contact points are flattened out and can be a cause of screw loosening sufficient to retighten the screw 10 min after obtain an optimal preload with the hex type com- placement. pared to the slot [22] (Fig. 8. are universally adopted in fabrication of implant- Considered that torque loss is likely to develop abutment screw. Grades 1–5 Ti have lower modulus of elastic- Experimental studies showed that it is easier to ity and lower yield strength when compared to .

5 The most common driver heads are the slot (left) in place and with the adoption of a smaller and the hex (right) screw. [23] confirmed that reliable in producing consistent torque values. Toggle.4 Screw-Related Complications Torque values of ≥35 N/cm seem to be necessary to develop an ideal preload and prevent Screw loosening is one of the most common screw loosening. using a high-speed handpiece but being careful of tion coefficient. carbon-coated screws have been not damaging the implant. reduced adopting modified screw surfaces or 3). screw is one of the main factors for producing an optimal preload and therefore optimal clamping of the screw to the implant. abutment screw loosening can be prevented but the clinician should be aware that deterioration . although less frequent [24] (Fig. Common reasons of abutment screw fracture are found on the excessive torque applied at the moment of insertion.and beam-type wrenches are Theoharidou and coll. screwdriver does not allow to achieve acceptable tling effect. in order to decrease the fric. employed and gave promising results in experi. This can be achieved strength. An effective method might be to remove the most coronal portion with a driver and then try to move the apical fragment in a counterclockwise direction. Otherwise implant removal becomes necessary.. screw loosening over time and the consequent development of unfavorable forces on the screw. the clinician must decide if res- torations are still possible leaving the fragment Fig. Iocca applying proper torque control and antirota- tional features. A systematic review by preload. This can be achieved with an ultrasonic tip actioned around the fragment or with instruments adapted for this scope [25]. These complications Titanium alloy is the most used material for must be resolved removing the stripped screw this scope. insufficient Moreover. Whatever the reason.e.2. To summarize. exerted during placement. once the screw is fractured. in consequence of a number of cases. This task can become difficult to accomplish if the most apical portion of the screw remains engaged. pure Ti is not used anymore as screw use of the inadequate driver or excessive force material. 8. torque applied to the abutment mental studies.132 O. screw are discussed above. The causes of loosening of the abutment with lubricating materials. If retrieval is consid- ered impossible. through creation of a contact point that allows load and low risk of fracture due to its high rotation and removal [26]. 8. Coefficient of friction should be complications in implant dentistry (see Chap.6). Screw fracture is another possible complica- tion. or material failure due to the overcoming of its yield strength. hand tightening with a manual preload and development over time of the set. i. Stripping of the head or threads may occur in titanium alloy (Ti-6Al-4 V). given its ability to provide higher pre. it needs to be removed. 8. this usually results after the this. Moreover.

6 (a–c) The arrow indicates a fractured screw (a). it was possible to retrieve the apical portion with the use of an ultrasonic tip (c) due to clinical use and sterilization processes features. 8. The first implant introduced by Brånemark had Another one is the Morse taper which can also be a small external connection with the implant defined biconical and does not require an implant abutment that was designed primarily to facili. 8. implants. and periodic retightening at the follow-up visits External connection has an external compo- should reduce the incidence of screw-loosening nent extending coronally. in order to reduce the settling effect. Internal connection events. screw for retention given that the stability is tate the surgical placement of the implant ensured by mechanical engagement between the instead of conferring stability and antirotational implant and the abutment.3 Internal Versus External because it contributes to the antirotational fea- Connection tures. The shape of the connection is important 8. Only with the increasing use of dental may impair their reliability and lead to the neces. The most common for both the external and internal connections is the hexagonal.7). instead is located inside the implant body (Fig. abutment connection for the long-term retightening of the screw 10 min after placement success. the clinicians and manufacturers sity of recalibration or substitution.8 Implant Abutments 133 a b c Fig. coronal fractured portion of the screw removed with a driver (b). . started to understand the importance of implant- Finally.

The review focused on factors that may Many manufacturers provide pre-angled abut- generate impression distortions and the technical ments available ranging from 10 to 35° of angu- complications of the various connecting systems. in the anterior maxillary evaluating the advantages and disadvantages of region. and the prostheses. at this regard. for example.134 O. the responding copings which can generate difficul. an abut- different connections. On the other hand.4 Angled Implant Abutments a lower antirotational capacity due to a possible misfit between the abutment and the implant Implants should be positioned parallel to each when compared to internal connections. stress created by the angled abutments may lead Screw fracture complications were instead simi. this acts as a lever. It can frequently occur that brought by Gracis and coll. types. In the end. biological factors such as stress on Mechanical stability seems to be better bone are difficult to be implemented in a FEA achieved with Morse taper connection compared study [30]. When a force is applied to an angled The authors concluded that internal connection abutment. to worst clinical outcomes when compared to lar for both internal and external connection straight ones. force to the implant-abutment connection. peri-implant bone. 8. distributing the configurations have an intimate fit with the cor. Reported disadvantages of external connec- tion include a higher risk of screw loosening and 8. [27] who analyzed implants are placed in a more or less angled posi- retrospective and prospective studies and RCTs tion. and esthetical performances of the on purely mechanical components (e.g. The stress ties in impression removal and may increase the produced with an angled abutment is greater than risk of generating distortions. FEA studies can give some clues regarding the Goiato and coll. reduced rate of screw loosening with internal It is important to understand if the increased connection systems is reported in the literature. ment screw). the natural conformation of the bone dic- external. [28] addressed the question if amount of stress generated by an angled abut- any difference exists regarding the mechanical. 8. ment (Fig. systems. The biological evaluation was made measuring the level of bacterial leak- age and bone loss around single implants. the does not take into account the quality and quantity .9). the Morse taper seemed to be more effi- cient in providing a better bacterial seal respon- sible for the maintenance of the peri-implant bone. Iocca increased stability of Morse and internal hexagon connections may contribute to decrease the micromovements at the level of the marginal bone around the implant which may positively contribute to a reduction in the marginal bone level resorption rate. opposite for what happens biological. 8. but. other and be vertically aligned in order to pro- A synthesis of the available literature was duce axial forces. lation. it emerges that internal and Morse taper connec- tions give better clinical results in terms of inci- Fig. The computer-generated simulation to internal and external hexagon. the stress created by a straight one..7 External (a) and internal (b) connection dence of mechanical and biological complications when compared to external connection. internal. Also. and Morse taper connection tates an angled implant placement [29] (Fig. from analysis of the literature.8).

8. When clinical studies are considered. in this restoration may be a better solution (a). and the bone This can suggest caution in applying immediate properties in general. in angulation. approximation of the magnitude of stress applied These results were confirmed in other studies to bone with different angulations of abutments. The results pointed out that the major. and the screw allowed an axial placement. [31] performed a three. Cruz and coll. only dimensional FEA of dental prostheses supported sparse data can be retrieved from the literature. micromotion and peri-implant bone stress was The survival rate of implant with connected analyzed in another FEA study [32] in which angled abutments up to 30° was above 97 % in all abutments of 0°. the bone cells’ response to load. is with those of straight abutments and suggest that concentrated at the level of the cortical bone on the use of angled abutments is a reliable option the crest of the alveolar ridge. Compared with the when necessary (Fig.8 Implant Abutments 135 Fig. it is safe to assume that it remains even if angles of 25° led to an increase in within biologically tolerable limits. peri-implant bone is greater around angled abut- Regarding the micromotion. In (b) the anatomy case. the stress increased of 12 % with In conclusion. it was considered ments and is directly proportional to an increase to be into the safety limits for osseointegration. These figures are comparable ity of the stress. 8. 15°. also the screw access hole is more palatal of bone around the implant. even if the stress placed on the angles of 15° and 18 % with angles of 25°.10). this was dictated by the bone anatomy. 0° abutment. was above 95 %. conducted with the same methodology. and a straight abutment was access hole was almost at the level of incisal margin which sufficient.8 Angled abutment may be necessary because of can create some esthetic issue. micromotion of 30 % compared to 0° abutments. by straight and angled abutments. a cemented the placement of the implant at a certain inclination. the implant material. . independent of the angulation. any FEA loading protocols when such angled abutments simulation must be taken as a very general should be used. in this case. and 25° angulations were the studies analyzed. clue regarding the survival of implants and pros- The influence of abutment angulation on theses on angled and straight abutments [33]. No difference Few prospective observational studies are avail- in stress distribution patterns was evidenced for able which can be analyzed in order to have some the two groups. the survival of prostheses compared. For these reasons.

especially higher than 15°. blue to red color Mises stress (MPa) in model (right).136 O. represents stress values from lower to higher (Reproduced and the cross sectional view of the model (left). Iocca a b c d Fig. are modality of treatment when necessary. Various with permission from Tian and coll [30]) The adoption of angled abutments does not Experimental results suggest precaution in seem to reduce the survival rate of implants and adopting an immediate loading protocol when prostheses and can be considered a predictable angled abutments. . 8.9 FEA study showing the distribution of von implant models are represented in a–d. necessary. in implant (center).

1 CAD/CAM Technologies is no waxing and casting. A cemented restoration was used and results were optimal (b) a b c d e f g h i Fig. ing of titanium. or zirconia abutments Kapos and coll. Anyway. alumina.4. b) In this case the angled abutment on implant #12. Continuous improvement increased homogeneity deriving by manufactur- have rendered possible to think about a routine ing from a single block. and (d) the mechanical properties of the been available in prosthetic and implant dentistry adopted material are improved because of the for at least two decades. were included for the evaluation of single implants niques include (a) increased precision since there and single-unit restorations manufactured with . (b) abutments are cre- for Implant-Abutment ated by a software so the final work is less depen- Construction dent by technician skills and expertise. the clini- on the market and allow to provide manufactur. the studies on CAD/CAM abutments. the precision methods of recording and manufac- ufacturing (CAD/CAM) is a technology that has turing.#22 of dictated the access hole to be buccal instead than palatal (a). 8.10 (a.) 8. use of this technology in the everyday practice. 8. 8. cal outcomes are still being investigated [34]. while in vitro experiments have con- Different CAD/CAM systems are available firmed the validity of such techniques.11 Example of computer-aided design for an implant abutment (Reproduced with permission from Wu and coll.11). (c) crown-abutment fit is potentially improved due to Computer-aided design and computer-aided man. Two studies Potential advantages in employing such tech. [35] systematically reviewed (Fig.8 Implant Abutments 137 a b Fig.

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com Private Practice Limited to Oral Surgery. risk of complications. implant prosth- odontics poses many decision-making challenges. The All-on-FourTM is a prosthetic concept which employs four implants in the anterior jaw. and Simón Pardiñas López Abstract The goal of a prosthetic restoration is to provide good esthetic and func- tional outcomes on a long-term basis. A Coruña. Another doubt may arise regarding the adoption of cantilever prosthe- sis in place of more complex surgical or prosthetic options. Pardiñas López. DOI 10. and chair time are all factors that need to be evaluated in the choice of a retention system. which are useful when more traditional approaches are unfeasible. Oral Surgery. Ease of manufacturing. Rome 00144. MS Periodontology and Implant Dentistry. PhD O. Italy e-mail: gbianco@mac. Iocca (ed. Galicia 15003. Evidence-Based Implant Dentistry. Choice of screw. The sparse evidence coming from the literature suggests that this can be a reli- able option in selected cases.com © Springer International Publishing Switzerland 2016 141 O. Implant Prosthodontics 9 Oreste Iocca. cost. 00161 Rome. Viale Regina Elena 324. S. 308.or cement-retained implant prosthesis is still a matter of personal preference. DDS. Finite element analysis studies and clinical trials may help in providing survival and com- plication rates of cantilevers.edu e-mail: simonplz@hotmail. In selected cases. DDS. although some specific indications and contraindi- cations are retrievable from the literature. Considering the delicate structures involved and the surgical skills required. Italy Rome. Periodontology and Implantology.1007/978-3-319-26872-9_9 . Sapienza University of Viale dell’Umanesimo.). DDS ( ) Centro Polispecialistico Fisioeuropa. placement and restoration of zygoma implants should be performed in adequate structures by properly trained clinicians. International Medical School. G. For the clinician. Bianco. It is the case of zygomatic implants. Giuseppe Bianco. Rome. advanced treatment options are necessary. Iocca. Italy Clínica Pardiñas. of which the distal two are maximally angulated. Spain e-mail: oi243@nyu.

Iocca et al. the incidence of implant loss appeared to be higher for cemented recon- Retention systems for implant prostheses can be structions.2). Accurate impression taking is a fundamental step for achievement of optimal prosthetic results. Clear indications are available for full- mouth fixed rehabilitations. FDPs. but doubts still exist if the choice of a retention sys- tem over another can give some improvement in Table 9. day practice (Fig. and full-arch Prosthodontics restorations.1 Cement-Retained found for single crowns between cement-retained Versus Screw-Retained and screw-retained groups.1 Screw-retained restorations terms of success and survival rates (Tables 9. prospective and retrospective in Implant-Fixed studies on single crowns. Another question that seeks for an answer regards the ideal number of implants to achieve optimal results. although for FDPs Implant Reconstructions and full-arch prostheses. providing restoration even with summary estimates at 5 years. Materials adopted should possess some funda- mental basic properties. with a variable amount of cement excess around tages and disadvantages in clinical practice. in which minimum four implants in the man- dible and six implants in the maxilla are considered the most reliable solutions.1. Finally. Ease of retrievability Impossibility of placing a The choice one of the alternatives is still a screw when the position of the screw-access hole lies on matter of personal preference for many clini- the incisal margin in case of cians. These two options gave distinct advan. especially in the elderly. This is in line with precedent observa- obtained via screw retaining or through cemen.1 Advantages Disadvantages and 9. two options are available: transfer and pick up. [1] systematically reviewed cement accommodate the screw- the survival and complication rates of cemented Possibility of access hole and screw-retained reconstructions. Analysis of the various attachment sys- tems and the number of implants can help in selection of the best treatment options. tions: cemented reconstructions are associated tation. of the absence of this is due to the necessity of Sailer and coll. no difference was 9. It is not easy to arrive at strong evidence-based conclusions on this topic.1). optimal esthetic results depend by numerous factors. Regarding the impression techniques in implant dentistry. Regarding implant survival. 9. therefore. it is the mimicry with the natural tissues that ensures the best outcomes. mainly due to the lack of RCTs and a poorly standardized way of reporting the esthetic outcomes. an evidence-based approach excessively angulated should elucidate which are the main indications implants and problems of the two fixation methods in Decreased risk of Slightly larger bulk of the order to facilitate decision-making in the every. biological prosthesis framework complications because compared to cement retained. The analysis limited crown space .142 O.1 Prosthetic Options included RCTs. 9. Implant overdentures are still an important option for edentulous patients.

more reconstructions statistically significant. The use of a screw. reconstructions on natural abutments As expected. for single crowns. one may ask why cemented prostheses suffer a lesser degree of ceramic dam- Table 9. fore.2 and 9. 9. in particular screw loosening group. It must be addressed that complications of this kind. although time- consuming and unpleasant for the patient. and consequently their full load acts their similarity with biological complications on the ceramic. if the abutment screw loosens under cemented restorations. they are not manipulation. It is also expected that retention. 9. FDPs showed a trend and implant loss in some cases. The analysis outlined that technical complica- arch prostheses group showed a similar trend tions were generally higher for the screw-retained with higher reconstruction failures in the screw reconstructions. the authors concluded that cemented reconstructions exhibit less technical complications but more serious biological problems reflected in higher implant failure rates. but again results were not in single-crown study. Regarding cally significant. retightening of the abutment screw may become difficult/impossible and destruction of crown necessary in order to uncover the screw hole. the most frequent being loosening of the screw. it is likely that the occlusal forces exerted on Advantages Disadvantages the cemented restoration simply lead to dece- A general ease of Difficulty in removal of mentation. Technical complications were higher for the screw-retained group. Fig. unless screw loosening occurs. suggestive of greater prosthetic failure rates for When survival of the prostheses was analyzed.9 Implant Prosthodontics 143 the implant which is the cause of inflammation On the opposite side. Oppositely. For this reason. this last complication. Also the full. In the end. Anyway.2 Cement-retained restorations age. Specifically. incidence of ment is necessary due to the bone anatomy. a cemented restoration is and full-arch restorations are employed. On the opposite side. there- usually occurs in the anterior regions. when forces are exerted manufacturing and excess cement. which is contraindicated in the esthetic zone. this is in screw loosens line with the numerous studies about the inci- Considering that cemented dence of peri-implantitis due to excess of cement prostheses necessitate at least 5 mm to provide around the implants. failed in the screw-retained group. which is one on screw-retained prostheses. adoption of reconstructions. the cemented group. but when FDPs buccal aspect (red line). in case of reduced access to cement remnants is impaired with large occlusal space. this may explain the higher fail- a screw-retained restoration ure rates of implants under cement-retained is the only choice restorations. these results were not statisti. are usually resolvable within a single visit. both types of fixation methods can be rec- retained restoration will result in an access hole on the ommended (Figs. and chipping/fracture of the ceramic. screw- preferable retained reconstructions seem preferable for the .1 This is a typical case in which an angulated abut. serious biological complications Reduced cost and less Difficult removal of the (bone loss exceeding 2 mm) were more frequent chair time restoration if the abutment for cement-retained reconstructions.3). this situation complications was similar for both groups. due to of the main causes of dissipated.

arch restorations.3 Example of screw-retained restoration in the molar region (a. a b Fig. and full- of reconstruction. 9. 9.4). this is a case in which the choice of the retention without contraindications system is a matter of clinician’s personal preferences. FDPs.144 O. a b Fig. ease of retrievability and for the lower rates of Failure rates by reconstruction type put in evi- biological problems (Fig.2 Example of cemented restoration in the molar A screw-retained restoration would have been feasible region. b) . giving estimates at 5 years. Iocca et al. dence a not statistically significant higher sur- Another systematic review [2] analyzed the vival for cement retained when compared to survival rates according to material type and type screw-retained single crowns. 9.

4 (a–c) Example of screw-retained restoration for the highest retention. further strengthen- ing the assumption that cement residues are one of the main causes of peri-implantitis and implant loss. recommended. But the author concluded that for the different materials employed.3 % for the short- c term and up to 10 % for long-term studies. It showed the ZOE cements perform better than resin and glass ionomer. b The authors draw the conclusion that the higher risk of implant loss and the limited possi- bility of reintervention after definitive cementa- tion should lead to propension toward screw-retained restorations. more technical complications were reported in long-term studies. Biological complications were significantly higher for the cement group.9 Implant Prosthodontics 145 Regarding the technical complications. At the end. reliability of cement-retained ther cemented nor screw-retained reconstructions single-crown restorations was deemed similar to showed a statistically significant difference with screw retained. 9. An interesting observation was that more recent studies showed lesser incidence of abutment screw loosening. In particular. The review of Chaar and coll. a sta- a tistically significant difference was confirmed between the two groups. nei. Zinc phosphate ensures Fig. loss of retention and ceramic chipping/fracture were higher for the screw-retained group. but on the other hand provi- a three-unit implant prosthesis sional cements such as ZOE may work properly and at the same time provide retrievability if needed. Incidence of abutment screw loosening amounted to up to 4. Loss of retention was the most common tech- nical complication. As expected. an inter- esting comparison between the type of cement adopted and the loss of retention was performed. . Specifically for the cemented group. [3] focused on cement-retained restorations only. but controversies still exist on this matter. the was obtained analyzing different prosthetic and adoption of cement-retained restorations is not cement materials. subdividing the analysis in long-term (1–5 years of f-up) and short-term studies (>5 years of f-up). the type of cement used can improve the clinical results. likely because of the improve- ment in manufacture and mechanical characteris- tics of implant components. Same result long-span FDP and full-arch restorations. When abutment material was analyzed.

1) (93.2 Cantilevers for Implant- cement. [1] (64.e.9) 5-year estimate 95 % CI Wittneben 91.3) (95.7 % / and coll. (76.89 mm (0. retained by natural or implant abutments ies performed for other kind of evaluation. When all these alternatives ence was not deemed statistically significant. it should be recalled that MBL may Due to the particular design of this solution. poor oral the use of cantilevers could be the cause of exces- hygiene.8) (93. a cantilever can be adopted [5]. tions such as framework fractures.53 mm (0. Only two studies. Iocca et al. lated implants.4 Summary of the systematic review providing a quantitative analysis of implant survival rates for screw- retained and cement-retained groups Screw. were In some situations such as bone atrophy or the found to directly compare the two groups.5– (85.3) 10-year estimate 97. maxillary sinus. 9.8 % 100 % (88.or screw-retained restorations was per. tures (e.5 % 98.8–98.6 % 97. (Figs..3 % 96.1 % 96.6 % 98. and it is not known to what extent sive load over the supporting implants and if such each one may have a preponderant role design could lead to increased rates of complica- (Tables 9.1) (94.4) (97.6 % 96. Screw. full-arch full-arch crown single crown FPD retained FDP restoration restoration Sailer and 89.8) (%76. and 9.4 % 94.7 % 97.8–98.7) (96.6). An analysis on MBL changes around implant 9. this differ.6).4) (86. a first-class lever. use of short implants.9–97.7 % 98.0 % 96.76).8–99.g. out of a total of the nine included.6–98. Moreover.8–99.33). [4].5 and 9.146 O. be influenced by many other factors than reten.0) (90. 9.2 % coll.9–100) coll. i.3 % 91.9 % 95. 9. and for Cement dures.0) (91–97. A cantilever the fact that the majority of comparisons were prosthesis is defined as a free-end extension not direct but instead an extrapolation from stud. the need of avoiding damage to anatomical struc- others described cement-retained and screw. Cement. or placing angu- group. Cement.5 94.3) (96. it was a matter of debate if tion systems..1. Follow-up was in the insertion of implants becomes possible only with range of 12–48 months.4. Supported Prostheses formed by de Brandao and coll.2–99. [1] (96. more complicated implant treatment options. retained MBL separately.8–98.31–0.6–99.7–96. Screw-retained Cement-retained single retained retained Cement. mental foramen).1) 95 % CI Table 9. etc.. full-arch full-arch single crown crown retained FPD retained FDP restoration restoration Sailer and 98. it was 0.44–1. such as smoking habits. It cannot be employed or are excluded for any rea- must be noted that the results might be biased by son.3.6–99.9–97. The pooled mean peri.5–97.5.8–97.4) (96. Screw-retained Cement-retained retained retained single Screw.6) 5-year estimate 95 % CI . implant marginal bone loss for the screw group these may consist of bone augmentation proce- was 0.3 Summary of the systematic reviews providing a quantitative analysis of reconstruction survival rates for screw-retained and cement-retained groups Screw- retained Cement. Table 9.

4) Screw Abutment screw fracture Screw fracture 3.0–17.8 % (1.4 % (1.0 % Screw fracture 6.8) Chipping 2.3) 5-year (14–39.8–5.7–18.4 % Screw loosening 3.0 % (0–49.3–6) (Na) 147 .4) loosening (8.9 % (2.6 Summary of the systematic review providing a quantitative analysis of biological complication rates for screw-retained and cement-retained groups Screw-retained single Cement-retained single Screw-retained full-arch Cement-retained full-arch crown crown Screw-retained FPD Cement-retained FDP restoration restoration Sailer and Soft tissue Soft tissue recession Soft tissue Bone loss >2 mm 6.5–6.0 % (0–36.0 % Bone loss >2 mm Soft tissue recession (Na) (Na) (0–6.5–33.5) (7.7) Soft tissue complication Soft tissue complication Soft tissue recession (Na) Bone loss >2 mm 0.6 % Screw fracture 0.4 % Soft tissue complication estimate Soft tissue recession complication 4.1 % 95 % CI (2.0 % Screw fracture 0.9–83.7) (16.0) 2.6) complication 6.4 % (0.1–33.5 % Soft tissue recession Bone loss >2 mm 34.0 % Screw loosening 9.4 % coll.3 % Chipping 24.0 % fracture 0. [1] 21.8 % (1.9) (18.0–6.8 % Screw loosening 0.7–24.7 % coll.5) (6.0) (49.1) 16.5 Summary of the systematic review providing a quantitative analysis of technical complication rates for screw-retained and cement-retained groups Screw-retained single Cement-retained single Screw-retained full-arch Cement-retained Implant Prosthodontics crown crown Screw-retained FPD Cement-retained FDP restoration full-arch restoration Sailer and Screw loosening Abutment screw Chipping 13.2–16.6) (3.6–9.8–23.4) Screw loosening 11.4) (0–5.9) (Na) 95 % CI 0.3 % Chipping 67.3 % Bone loss >2 mm 0.6) (1.4–5.7) 5-year estimate Chipping 9.8) (1.6 % 3.7–8.5 % (4.1–1. 9 Table 9.7 % (11.7) (6.1) Soft tissue (2–20) Soft tissue recession Bone loss >2 mm 11.7) (none) Table 9.5–70.5–54.4–20.4–30.1) (1.9 % 4.2 % (14.9 % Chipping 23.1–26.1) 2.7) (0–5.9) (3.5) (0–37. [1] complication 23.3–4.5 % (2.

give any problem considered that is the most favorable situation from a biomechanical point of view Instead. the length of the cantilever was induced by FPD with cantilever extensions was simulated at 10. the implant. In order of magnitude. [7] for evaluation of stress distribution on a mandibular-cantilevered implant crown sub- jected to vertical and oblique loads. a 3D FEA models of the maxilla were . On application of vertical forces at the most dis- tal point. While going attempted to study the stress distribution on bone. The distribution of [8]. toward the center the stress increased on the buc- implants. moving toward the lingual side. and 20 mm from the distal also performed. the least amount of stress on the bone and implant occurred when the force was exerted at Finite element analysis (FEA) tests have 5 mm from the center of the crown. a Fig. stress was greatest on the implant first and on the Padhye and coll. It was suggested that implants connected between each other in a rigid manner may help balance the ten- b sion developed where the force is exerted. [6] simulated a mandible lingual bone going at a distance of 7 mm. In the study of Wang and coll. 9. A similar FEA was conducted by Park and coll. and the cortical bone and least on the medullary bone. Also. b) Example of mesial cantilever retained by increased linearly in proportion to the distance of three implant abutments. This can be considered a predictable solution although no strong evidence in this regard is available yet loads around the peri-implant bone was studied. regardless of the cantilever length. the stress was greatest on the framework. part of the terminal implant. 9. and prostheses in the presence of a cal bone. the cantilever. This configuration unlikely will the applied load from the center of the crown. Iocca et al. 15.148 O. the results suggested a direct increase of stress on all the components of the simulation every 5 mm increment in cantilever length. when oblique load was applied lingually at 30°.6 Example of distal cantilevers in a full-mouth restoration. the greatest amount of stress was placed around the most dis- tal implant. Vertical forces applied on the cantilever resulted in an increased stress upon the cortical bone which Fig.5 (a. model and six implants supporting a cantilevered An attempt to simulate the bone remodeling fixed prosthesis.

complications. veneer fracture.47). In lain fracture was the most common. between the various studies and in general In light of this. assumption that bone is an isotro. It was possible to draw the conclusion that figuration. technical. bone cell response to dif.1–99. The most common complication detected was enced by many factors other than the peri-implant chipping followed by screw loosening. and meta-analysis evaluating the marginal bone loss bone loss when compared to non-cantilever (MBL) and the prosthetic complications of group. ficult to simulate the patterns of mastication The authors also analyzed the component- loading. applied establishing a reference stimulus. Summary estimates at 5–10 years were calcu- Bacterial influence.9 Implant Prosthodontics 149 created. screw loosening for the bone responds to different prosthetic designs. exerted by the loads of the cantilever model. implant-supported cantilevers. retrospective. extension. 3). but the mean of implant loss was higher for cantilever results were not statistically significant (p = 0. in which weighted be less for the non-cantilever group. porce- cortical and trabecular bone. and their . overload threshold. 90. the simulated forces are simplified in implant prostheses without cantilever extensions respect to what happens in vivo because it is dif. bone density induced by the non-cantilever con. 3–8. therefore. the cantilever model resulted in a MBL does not seem to be related to the cantilever lower density around the implant neck indicative and that only minor prosthetic complications can of increased bone remodeling due to the stress occur when a distal extension is present. pic material when in fact it is anisotropic. and bone remodeling equations were stress caused by a cantilever extension. very similar to previous results on Also.2 years. lated by the inclusion of prospective and retro- ferent stresses. [9] performed a terms of implant survival. an the results should be taken cautiously. These con. It was pointed out that MBL is anyway influ. implant prostheses than non-cantilever group. was not evaluated for poor reporting in the troversies arise because of the high heterogeneity included studies. related complications and the prosthesis compli- Nevertheless. The same was true for evaluate in real-life situations. on the other hand. Cumulative incidence for implant fracture giving orientations to the clinical research allows was again similar to other studies on non- to understand some phenomenons difficult to cantilever restorations. system. (see Chap. and a lazy zone. MBL cantilever have been conducted by many groups did not seem to be influenced by the cantilever of research with some conflicting results emerg. rehabilitation with a cantilever because of a paucity of well-performed RCTs. and esthetic com- attempting to evaluate what happens in a given plications of cantilevered implant prostheses clinical scenario are always a simplification of with a mean of 5 years of follow-up was the real mechanisms occurring in a biological performed. but its this way. A systematic review [10] of the survival rate It must be pointed out that FEA studies and the biological. a remodeling coefficient for Regarding the technical complications. extension was not considered detrimental in Torrecillas-Martinez and coll. this kind of studies can help in cation. these Implant survival in implant-supported cantile- are all factors that are difficult or impossible to ver prostheses was estimated to be 91. Only cohort stud. Clinical studies on dental implant prosthesis Regarding the biological complications.2).1 % (CI include in a FEA study. within the relation with the presence of cantilever was not limits of computer-generated values. spective studies. how the clear. Similar results were obtained in a systematic ies were included with a follow-up range of review [11] including prospective. while the incidence of peri-implantitis ing from the analysis of the literature. cantilever group had a relatively higher incidence The model gave the results of a more distributed than the non-cantilever restorations. it was possible to simulate. The amount of MBL was found to and case-control studies.

loading and Table 9.5) 5-year estimate 95 % CI . incidence was slightly higher in the cantilever ported by two or more implants is a valid option group.1 % 91. the question if.7). the use of tilted ver extension can be considered a predictable and implants inserted adjacent to the maxillary sinus reliable treatment option. but overall.5 %) 5–10-year 99.2–8. numerous biases such as smok. assumption that incorporation of cantilever pros- theses may be associated with a slight increase in technical complications. more compli- no effect on significant peri-implant bone loss.2–7.8–97. alternative to a bone grafting procedure.8) Weighted mean 98. moreover.5– (88–95.7). In cated solutions are excluded from the treatment the end. uating single implant cantilevers are scarce. [12] on a 3D edentulous jaw compared Within these limitations. and oral hygiene can implant structures.9–26.7 % 96. [11] (95.3– (0. confound the results of the biological The FEA analysis performed by Bevilacqua complications. alternative in treatment of partial or complete It seems clear that implant-supported cantile.1 % 84.5) versus distal cantilever posterior regions may render the placement of on the survival and complications rates of tilted implants in the intraforaminal area the only implants and prostheses.5) estimate 95 % CI Zurdo and 97. it is safe to 9.3 % 10.7) (3.7) (0. edentulism. [10] (96.7 Systematic reviews evaluating the effect of cantilever on implant-supported prostheses – implant survival Screw or Implant abutment Implant Prostheses fracture fracture Veneer fracture Biological survival survival complication complication complication complications Romeo and 98.1 % (0. As expected. On the other hand.1 % (−98) 1. pared to axially placed implants.1) 10.9–5. Also. the excessive bone atrophy of the effect of mesial (Fig.6 % (0. 9.7–16.6) 5-year survival 95 % CI Aglietta and 97.3 Tilted Implants say that implant-supported short cantilever exten- sions may be considered an acceptable treatment The use of tilted implants represents another option.8–3. FEA studies may help in addressing be low. neity between the various studies is considered to Again. stress loads are increased on the bone and on the ing. and coll.9–26.6) Cumulative 98. 9.1–4.5 % 0.1. degree of angulation.7 % 1. this review further corroborates the planning (Table 9.3) (3.1 % 5. parafunctional habits. although a positive factor is that heteroge.3 % 2.150 O.5) 10.2– (94.6) coll.4) coll. this is related to worst clinical outcomes com- able. The question is if the angulation of an implant all the systematic reviews and meta-analysis may lead to unfavorable loading conditions and if point out that few studies and no RCTs are avail. in the presence of tilted implants.5 % (3. [50] (94. In should be noted that no study clearly defined the the mandible. Furthermore.7 % (4. For example.9 % / / / / coll. studies eval. Iocca et al. it wall can spare a sinus lift procedure (Fig. the adoption of axially placed versus tilted implants at various implant-supported cantilever restorations sup. The presence of cantilever seemed to have that may be adopted when other.

Furthermore. The authors performed a sub- cannot be eliminated. the cantilever length. Therefore. studies with longer follow-ups were included (>1 year after loading). no difference was evidenced for the Lan and coll. This . a These results encouraged the adoption of tilted significant difference was found favoring the axi- implants in clinical studies in order to improve ally placed compared to tilted implants. two was found. Conversely. Limitations of these reviews and meta-analyses need to be considered. the parallelism or divergence of implant About MBL changes. prone to suffer from the higher stress derived by ing type (vertical or oblique) is the main factor in tilted implants. it was sug. no significant difference between the practice. retrieved by clinical studies specifically evaluat- lever decreased the stress on both the bone and ing tilted implants. in the maxilla. the prosthetic structure when compared to verti. with no decreasing the stress on the peri-implant bone presence of RCTs. tions [15] on this topic. No significant differences were found between axial and tilted groups regarding implant survival and MBL change. especially in the pos- inclination) of two adjacent implants supporting terior regions. showing that although failure rates of tilted implants when compared to increased loading from the presence of cantilever vertically placed. Also. is of poor quality and consequently a splinted prosthesis. This problem instead seems to determining the stress on the peri-implant bone. and this probably led to equilibrate the success and failures between the maxillary and mandibular groups. 9. mandibular implants. it is anyway reduced group analysis in order to evaluate maxillary and greatly with the inclination of the distal implants. the prosthetic and biological outcomes. [14] simulated different combi. mandibular implants separately. or distal the fact that maxillary bone. stress. First.9 Implant Prosthodontics 151 tilting single implants increased the stress on the Systematic reviews and meta-analysis peri-implant bone. mesial. no RCTs evaluating the use of angulated implants in the mandible or Fig. sinus lift procedure additional long-term studies are necessary.7 Tilted implant placed in a patient that refused the maxilla were available for inclusion. Obviously. no significant difference apices seemed of not having an influence of bone was outlined between the two groups. It was found that the load. A positive factor was the low and prosthesis because they allow a reduction of heterogeneity between the included studies. immediate loading with tilted implants in the maxilla was considered a reliable procedure. A recent meta-analysis included 44 publica- cal implants supporting cantilever prostheses. An interesting finding was attempted to draw some conclusions from data that tilted implants supporting a shortened canti. A systematic review and meta-analysis addressed the question of immediate loading rehabilitation with tilted implants only of the maxilla [18]. This can be explained by nations of angulations (vertical. but only retrospective and This suggests that tilted implants may aid in prospective clinical studies were found. the distal inclination of one Two other previous meta-analyses [16. 17] implant and vertical position of the other resulted draw similar conclusions. but when subgroup in peak of maximum stress: therefore. probably because in these analy- ses. Results showed that there was a not statisti- A two-dimensional FEA [13] arrived at the cally significant difference regarding implant same conclusions. not affect the denser mandible. analysis of mandibular and maxillary implants gested to avoid this configuration in clinical was done.

02 Axially placed No coll.8 and 9. and oral hygiene measures.39–1. and impossibility to set the participants of the Anchorage of long implants to the zygoma bone is study.575) Maxilla only Monje and Retrospective and Mean difference −0. Many clinical studies have small sample yet another alternative in case of extreme maxillary size and short follow-up period. dental implants (Tables 9.152 O.70 (1.137) Del Fabbro Retrospective and Mean difference −0. prospective studies placed (p-value 0. there is no consensus in the definition of the minimal angulation that allows to define an • Avoidance of bone grafting or complicated implant tilted or axially placed.1. especially smoking. which does not allow to have much control on the study 9.4 Zygoma Implants in terms of record of information.9).13 Axially placed No coll.05–2. [16] prospective studies in mm (95 % CI) (−0. Moreover. • Eliminate the morbidity associated with these tated by the highly variable individual anatomy. prospective studies in mm (95 % CI) (p-value 0.05) Chrcanovic Retrospective and Mean difference 0.450) Risk ratio (95 % CI) Table 9. procedures.66) Axially No and coll.041–0.09) (p-value 0. Advantages of zygomatic implants include: Finally. Iocca et al. it is surgical procedures such as Le Fort I osteoto- difficult to standardize the angulation in the vari. [68] prospective studies in mm (95 % CI) (−0. after maxillary plane does not seem to jeopardize the implant tumor ablation surgery.01) (p-value 0.66–2.9 Meta-analysis tilted versus axial – MBL change Tilted versus axially placed Statistically Studies included Effect size implants Favoring significant Menini and Retrospective and Mean difference 0.35–2. [18] and prospective placed (p-value 0. [18] prospective studies in mm (95 % CI) (−0.298) (p-value 0.575) Maxilla only studies Risk ratio (95 % CI) Chracanovic Retrospective and RR (95 % CI) 1.8 Meta-analysis comparison of tilted versus axially placed implants – survival Tilted versus Studies axially placed Statistically included Effect size implants Favoring significant Menini and Retrospective RR (95 % CI) 1. para.450) Subgroup mandible Subgroup 1. atrophy.74) Axially placed Yes maxilla p-value (0. for example.06 Axially placed No and coll. has direct repercussions on the inability to control survival and the crestal bone level changes around confounding factors.03) . ous clinical circumstances because this is dic. moreover.23 (0. the consistent results in various • Allow implant rehabilitation in situations that published reviews and meta-analyses suggest that normally would not allow to obtain good pros- angulation of dental implants in the mesiodistal thetic outcomes.12–0.52) Axially placed No and coll.30) Axially No coll. functional habits. mies or distraction osteogenesis. missing data.77 (0.05–0. most studies are retrospective. Table 9. Nevertheless.89 (1.

Osteotomy is per- two zygoma implants associated with two to four formed in the zygoma bone and widened traditional implants in the anterior maxilla. and the entrance from the maxillary lead to prefer a given surgical approach. therefore. but instead of raising the • Invasive surgery whole sinus mucosa. Zygoma implants are available in lengths up The exteriorized approach (Fig.75 mm. After technique over another is a matter of personal identification of the infraorbital nerve. not include antrostomy. crest with a round bur is made through the sinus. This should allow positioning surgical techniques available for zygoma implant of the implant without antrostomy. Computer-aided surgery involves the use of The classical approach (Fig. On the other hand. the exposure of the maxillary bone up to the in theory. such that the whole implant threads are exposed pared to other implant surgery techniques for visualization. placement of two zygoma implants per side a 3D model manufactured on the basis of a CBCT will serve as the retention for the prosthesis.9 Implant Prosthodontics 153 Disadvantages are: The sinus slot technique (Fig.8) begins with intraoperatory navigation system that can allow. 9. 9. there are situations that reflected. In detail.) .8 Classical approach for zygoma implant placement Fig. 9. The smaller antrostomy that results renders this technique less invasive. 9. Fig. This progressively. insertion [19]. The authors concluded that the choice of a matic bone for a complete visualization. 9. the implant is inserted manually to the proper depth. to execute a flapless procedure. finally reaching the zygo. the implants Traditional protocols include the placement of are placed outside the sinus. a space or “slot” is created • Risk of damaging delicate structures like the along the insertion path of the implant into the orbital cavity maxillary bone up to the base of the zygoma. the most common diameter is 3.10) does to 50 mm. Custom-made drill guide (Fig. infrazygomatic crest. mally invasive technique that involves the use of wise. The sinus mucosa is ies. scan.9 Sinus slot technique for zygoma implant placement (Reproduced with permission from Chrcanovic and coll.11) is a mini- rior maxilla is not excessively atrophied. • Need of sedation or general anesthesia com. and finally the drill guide is produced with Chrcanovic and coll. a window preferences due to the lack of comparative stud- at the sinus wall is made.) (Reproduced with permission from Chrcanovic and coll. reported five different stereolithography. is a protocol that can be followed when the ante.9) is similar to the traditional approach. a severe resorption with a prominent concavity When the zygoma bone is reached and the between the zygoma and the maxilla suggests the implant site prepared. 9. other.

First.) employs four implants in the anterior jaw (max- illa or mandible). 100 %. Portugal by experienced clinicians that had a Reported survival rates of zygoma implants huge experience with this procedure. mally angulated in order to minimize the cantile- pens when no concavity is present. the majority of the ture. 98. 9. ness and long-term success of the All-on-Four The most common complications as reported protocol. while the most distal are maxi- use of an exteriorized approach. Studies reported patients. [22] included three studies in their systematic review with a total of 196 implants placed in 49 patients.12). Iocca et al. of which the central two are vertically placed. sical or slot techniques should be employed. Anyway. no RCTs are available. The follow-up in the included studies in the literature are sinusitis in up to 21 % of ranged from 12 to 36 months.10 Exteriorized approach for zygoma implant strength to these results. Despite this. specialized centers are involved in the placement of this kind of implants [21–23].5 The All-on-Four Concept The All-on-FourTM is a prosthetic design concept (Nobel Biocare.6–99. and further studies are needed to give Fig.9 to Maxillary or zygomatic nerve deficits and intra.) those cases in which other options are unfeasible. the lack of RCTs and . their use still needs to be thetic solution compared to other ones. Regarding the custom-made drill guides and No RCTs are available for evaluation of this pros- computer-aided surgery. the reported weighted mean survival rate was 96. Moreover. the study suggests the reliability of zygoma implants in full-mouth maxillary rehabilitation (Fig. provisional. they’re more expensive and tematic review [24] analyzed six prospective and limited to centers where the necessary equipment retrospective studies for evaluation of effective- is available. in adequate structures ready to face the possible complications which may occur. but a sys- validated. The delicate structures involved in the placement procedures should be taken into account. 9. Wang and coll. and the clas.1. Second. immediately placed fixed prosthesis (Fig.13).7 % (92. the contrary hap.5 CI 95 %). so it is dif- are in the range of 95. 9. Goteborg. 9. placement (Reproduced with permission from Chrcanovic Zygomatic implants are very useful solutions in and coll. ver length and support a full-arch. be taken cautiously. placement of zygomatic implants should be limited to experi- enced surgeons.5– 98.1 % and for the prostheses from 99.154 O. Sweden) which Fig. implant failure in up to 11 % of patients. therefore.6–100 %. The high survival ficult to understand if these excellent results may rates are likely dependent by the fact that careful be replicated by the average practitioner in the patient selection and skilled clinicians in everyday practice. 9. success rates for the implants in the range of and perforation of the orbit in to 6 % of patients. especially post-oncologic ablation patients and very severe atrophy of the upper jaw.11 Custom-made drilling for zygoma placement (Reproduced with permission from Chrcanovic and coll. but these serious complications are limited studies included were conducted in Italy and to single case reports [20]. this high survival rates need to cranial penetration are also reported in the litera.

there is still a lack of clarity 9. some clinicians advocated the term studies with follow-ups of at least 5 years option of one implant for every missing tooth.12 (a–e) Zygomatic implant placement (a). [25] tried to find One of the questions that accompanied the dental answers to the question reviewing the evidence of implant practice since its beginning is about the the past 30 years.2 Optimal Number of Implants when the issue of the ideal number of implant is for Fixed Reconstructions analyzed. c). in the past. are necessary. but clinical results have shown that this is not the case. regarding the implant number and prosthetic . it is not an easy draw any certain conclusion.9 Implant Prosthodontics 155 a d b e c Fig. long. Mericske-Stern and coll. Maxillary prosthesis (b. e) the short follow-up periods does not allow to Addressing this question. task. Delivery of the prosthesis and X-ray showing the correct placement of the implants up to the zygomatic bone (d. Nevertheless. The authors concluded that optimal number of implants that guarantees the despite the lack of long-term studies and RCTs best clinical results. 9. Undoubtedly.

recalled that four implants of standard dimen- a sions (≥10 mm long and ≥3. prostheses consisted of four implants in the man. Fig. high survival have proposed the distinction between implant- rates and relatively low risks of complications are supported and implant-retained OVD. the authors concluded that four to six implants in the edentulous jaws are a good number for full-arch restorations. The results of the analysis were considered just extrapolation from studies performed for other kind of evaluation. esthetics. Iocca et al. tal implants but finding its support on the mucosa therefore. .13 (a–c) Example of a mandibular All-on-Four Implant overdentures (OVD) aim at overcom- implant placement and restoration ing these problems conferring better retention. Moreover. it was and maxillary OVD exist. and phonetics. In particular. The majority of articles to rehabilitate implants and the second instead retained by den- edentulous jaws report four to six implants. phonation. consistent results are reported in the tially supported by dental implants. it was established that a sufficient number vival and complication rates of the implants and of implants for full-mouth restorations with fixed the OVD prosthetic components. This may have a huge detrimental impact on chewing abilities. given that no trial exists that specifically attempts to answer the original question. and quality of life as a whole.156 O. OVD are defined as complete dentures par- design. 9. Some authors implant literature. function. the first achieved regardless of the number of implants referring to a prosthesis entirely supported by used. Different attachment systems for mandibular dible and six in the maxilla. Therefore. c 9. Also Heidecke and colleague [27] assessed the 5-year survival ad complication rates of implant-supported fixed reconstructions in par- tially and totally edentulous patients in the attempt to establish the optimal number of b implants according to a specific type of recon- struction (FDP or full arch). while for FDP the evidence remains unclear. full-mouth rehabilitation with implants ≥10 mm Analysis of the literature allows to evaluate long.3 Implant Overdentures It is common for edentulous patients wearing a maxillary or mandibular complete removable denture to suffer from insufficient stability or poor retention of the prostheses. this seems a reasonable number for as well [28]. the various attachment systems and optimal num- At the FOR Consensus Conference in 2014 ber of implants which should ensure optimal sur- [26].5 mm in diameter) can be considered a valid alternative in the maxilla.

9 Implant Prosthodontics 157

Bar, ball, magnets, and telescopic attach- the clinician, but it should be important to
ments are the most commonly employed mecha- understand if treatment outcome is in some way
nisms of retention [29]. dependent by the type of attachment chosen.
Kim and coll. [30] systematically reviewed the
• A bar (Fig. 9.14) mechanism has the purpose publications on this topic; in their research, they
of splinting the abutment teeth and at the same included RCTs and prospective studies with fol-
time support the prostheses. low-up in the range of 1–10 years. Survival rate of
• Ball (Fig. 9.15) attachments are the simplest implants ranged from 97 % to 100 % with a mean
type, constituted by a small ball on the implant survival of 98 %. Magnet attachments were most
which houses a corresponding space con-
tained within the prostheses.
• Telescopic attachments (Fig. 9.16) are made
of a primary coping attached to the implant
which inserts in a secondary coping present
within the prostheses.
• Magnets (Fig. 9.17) are composed of the rare
Earth material neodymium-iron-boron (Nd-
Fe-B) which is the most powerful magnet
available or another rare material which is
samarium-cobalt (Sm-Co).

In general, the selection of an attachment
system has been dependent on the preferences of Fig. 9.15 Example of ball attachments



Fig. 9.14 (a, b) Example of bar attachment for a man-
dibular OVD Fig. 9.16 (a, b) Example of telescopic attachments

158 O. Iocca et al.

need of rebasing/relining, attachment fracture,
OVD fracture, opposing prosthesis fracture,
acrylic resin fracture, abutment screw loosening,
and implant fracture. Higher incidence of com-
plications was observed for the maxillary OVD in
respect to the mandible.
Although it was considered not feasible to
perform an objective assessment of the retention
systems, it was any way possible to observe that
the majority of the studies outlined a substantial
lack of difference in terms of implant survival
b between splinted and unsplinted OVD. Single
attachments are less costly and easier to manu-
facture; therefore, it should be preferable to adopt
them instead of a bar retaining system.
The ball retentions seem to show the highest
retentive capacity. On the opposite side, magnets
and bars tend to show a decrease of the retention
capacity over time.
Also, it was observed that there seems to be no
Fig. 9.17 (a, b) Example of magnetic attachments correlation between attachments and prosthetis,
(Reproduced with permission from Chu and coll.) aside from bars with distal cantilever that show a
higher degree of fractures.
Regarding the optimal number of implants for
commonly affected by complications due to wear mandibular implant OVD, a systematic review of
and corrosion. These complications were more RCTs and prospective studies with a follow-up
frequent with old magnetic materials such as ranging from 1 to 10 years [31] draw the conclu-
AlNiCo, but with new materials such as Nd-Fe-B sion that the prognosis of OVD is excellent and
or Sm-Co, they can be potentially reduced. implant survival rates were similar between the
Clip loosening in bar attachments and matrix one, two, and four implant OVD designs; it was
loosening in ball attachments were the second concluded that high survival rates can be obtained
most common reported complications. regardless of the number of implants inserted.
Andreiotelli and coll. [28] evaluated RCTs Also, denture maintenance and patient satisfac-
and prospective studies with follow-up ≥5 years. tion scores seemed to be not affected by this
The authors found that information regarding factor.
mandibular OVD was found more commonly Raghoebar and coll. [32] specifically evalu-
than maxillary one. Results showed that implant ated the ideal number of implants for the maxil-
survival was in the range of 93–100 % at 10 years lary OVD. Considering that implant survival
and did not seem to depend by splinting or the rates are generally lower than the mandibular
number of implants employed. Implant survival ones, it is reasonable to assume that in order to
was higher for the mandibular OVD compared prevent loss of the prostheses, a greater number
the maxillary ones. of implants are required for maxillary OVD
Prosthetic success ranged greatly and was not (Fig. 9.18).
calculated cumulatively; therefore, a numerical In fact, the meta-analysis showed an event
synthesis between the various studies was not rate/year for implant loss of 0.019 in case of ≥6
performed. splinted implants compared to 0.030 event rate/
In order of frequency, the most common year for ≤4 splinted implants and 0.111 event
reported complications were loss of retention, rate/year for ≤4 unsplinted implants.

9 Implant Prosthodontics 159

concluded that four implants maxillary OVD
need to be considered as a second-line treatment
option, although good results can be obtained in
any case.
The McGill consensus statement, published
after the symposium held at McGill University in
Montreal, recommended that the minimal accept-
able treatment for the fully edentulous mandible
is the two implant OVDs. This was not intended
as the best treatment option but instead the mini-
mally acceptable solution for patients that cannot
b undergo more extensive prosthetic and implant
treatment [34].
This concept was widely validated by numer-
ous RCTs. In a recent meta-analysis [35], the
patient-assessed quality of life evaluated with a
Visual Analogue Scale was considered to be
higher in patients having an implant-supported
OVD compared to conventional denture
Also the functional aspects, such as chewing
ability and phonation, were notably improved
Fig. 9.18 (a, b) Example of maxillary overdenture. In with the adoption of an implant-supported OVD.
these cases, implants connected with a bar seem to be In light of this, it is possible to state that the
more reliable than other prosthetic solutions (Reproduced
with permission from Slot and coll.) McGill consensus statement in which two
implant OVDs are the minimally acceptable
treatment options for the fully edentulous patient
About prostheses loss, the event rate/year was should be fully incorporated in clinical practice
of 0.005 in case of ≥6 splinted implants, 0.031 at any level.
for ≤4 splinted implants, and 0.012 for ≤4 An aspect that merits consideration is the
unsplinted implants. This figures led to the con- degree of MBL around implants retaining or sup-
clusion that implant-supported maxillary OVD porting OVDs. When literature is systematically
should be ideally supported by six implants reviewed, attachment type and implant design do
splinted between each other, the minimum num- not seem to influence the MBL change [36]
ber being four splinted implants. The worst out- although the high heterogeneity of the studies
comes were observed with ≤4 unsplinted reporting this value does not allow to draw strong
implants (Tables 9.10 and 9.11). conclusions at this regard.
Another similar systematic review, on studies Finally, maintenance of OVD is an aspect
with a mean observation period of 1 year [33], investigated by researchers in light of the fact that
arrived at similar conclusions. it reflects the chair time spent for this kind of
The survival rate of both prostheses and treatment and has important economical reper-
implants was >95 % for all the design configura- cussions. There is a general consensus in the lit-
tions analyzed (six splinted implants, four erature that the highest frequency of
splinted implants, four implants with bar attach- reinterventions and readjustments is performed
ments). Anyway, the best results were obtained in the first year after loading. Loss of retention
with six splinted implants, followed by four due to damage or wearing of the attachment sys-
splinted implants, the least successful being the tem is the most common cause of reintervention.
four implant ball design. For this reason, it was Also relining of the denture is a quite common

160 O. Iocca et al.

Table 9.10 Maxillary OVD treatment – overdenture survival
Six implants and bar Four implants and bar Four implants not
superstructure superstructure splinted
Slot and coll. [33] 98.1 % (96.4–99.0) 97.0 % (91.4–99.0) 89.0 % (96–97.4)
Survival rate per year
(95 % CI)
Raghoebar and coll. [32] 99.5 % (97.8–99.8) 96.9 % (92.4–98.7) 98.8 % (91.4–99.8)
Survival rate per year
(95 % CI)

Table 9.11 Overdenture complication reported rates increase in complications such as loss of reten-
OVD complications tion, especially at long term.
Andreiotelli Loss of retention 30 %
and coll. [28] Needs of rebasing/relining 19 %
Clip or attachment fracture 17 % 9.4 Dental Implant Impressions
OVD fracture 12 %
Opposing prosthesis fracture An accurate impression is one of the fundamental
12 % steps in the success of the implant treatment.
Acrylic resin fracture 7 % Accuracy of the impression has a direct role in
Prosthesis screw loosening 7 %
the accuracy of the cast and the proper fit of the
Abutment screw loosening 4 %
definitive prosthesis. Various materials and tech-
Abutment screw fracture 2 %
niques have been employed in implant dentistry,
Implant fracture 1 %
and choosing between them can be a challenge
necessity, in the range of 6–18 % according to for the practitioner [37].
various authors (Table 9.7). First of all, the ideal impression material
In conclusion, implant-supported or retained should possess some basic properties:
OVD constitutes an excellent treatment option in
edentulous denture wearers that for economical, • Accuracy refers to the property of the mate-
surgical, or anatomical reasons cannot undergo rial to reproduce the fine details in a precise
extensive implant surgery for full-arch fixed den- way. An accurate material should be able to
tal prosthesis. reproduce details with a limit of at least
From a review of the literature, it emerges that 25 μm.
the various attachment systems available are all • Elastic recovery means that, after induration,
reliable although a possible increase in complica- the material is deformed by the undercut areas
tions can occur with magnets and ball attach- in the mouth during removal, but then it recov-
ments. The presence of a bar does not seem to ers its original shape.
confer appreciable improvements in clinical out- • Hydrophilia is another important property
comes for the mandibular OVD, whereas in the because it allows the material to flow even in
maxilla, six implants connected by a bar consti- the presence of saliva or blood. In fact, the
tute a safer option in terms of implant and pros- more a material is hydrophilic, the more it can
thesis survival. “spread” over a given surface.
Finally, it was observed that mandibular OVD • Viscosity refers to the ease of the material to
sustained by two implants gives excellent results flow readily. It is important for a given mate-
and should be considered the treatment of choice rial to possess an equilibrium in viscosity such
for denture wearers. The choice of the attachment that it can be contained in the tray without
system does not influence the success and sur- flowing away but at the same time maintain a
vival rates of implant and prostheses. Anyway, it certain degree of flowability into the small
seems that magnets are associated with an anatomic details.

9 Implant Prosthodontics 161

• Workability is the property of the material to
be handled with ease for insertion in the mouth
and at the same time possessing a setting time
that allows impression taking without much
discomfort for the patient.

Two materials, belonging to the elastomeric
class, have emerged as possessing all the quali-
ties to achieve excellent results in implant den-
tistry. These are the polyethers and the addition
silicones (polyvinylsiloxanes or PVS).

Polyethers are available in low-, medium-, and
heavy-body consistency. b
PVS are available as extra low, low, low medium,
heavy, and very heavy (putty).

Polyethers have shorter working times and are
more hydrophilic compared to PVS, even if sur-
factants have been added to silicones in order to
improve the wettability of these materials. On the
other hand, PVS have the best elastic recovery.
Both materials undergo shrinkage after polymer-
ization in the order of −0.15–0.20 % after 24 h;
this means that the models should be prepared as
soon as possible if the maximum accuracy is
Three methods are commonly employed in Fig. 9.19 (a, b) Putty-wash technique in which a putty
making implant impressions, material (the picture is purple in color) is inserted in the
tray, and a first impression is taken. Then in the indenta-
tions left by the first impression, a low-consistency mate-
• Dual-viscosity technique, a low-consistency rial (yellow in the picture) is injected, (a) and the final
material is injected, usually through a syringe, impression is taken (b)
on a higher viscosity material already present
in the tray.
• Monophase technique, impression is taken
with a single, medium-viscosity material.
• Putty-wash (Fig. 9.19) technique, a putty
material is inserted in the tray, and a prelimi-
nary impression is taken. Then, in the created
cavities, a low-consistency material is
injected, and the preliminary reimpression is

Regarding the techniques of impression cop-
ing, it is possible to differentiate between transfer
(closed tray) and pickup (open-tray) techniques.
In the transfer technique (Fig. 9.20), the Fig. 9.20 Transfer (closed tray) technique performed
impression copings remain in the mouth on with a monophase material (polyether)

9. only possible alternatives to the traditional techniques narrative reviews are available for assessment (Figs. an open tray is used to Linear distortion is the most common method take the impression. ponents. tor determining the impression accuracy. their insertion 9.z plane of the implant or abutment heads together. and technique accuracy. the majority of the available 9.22. there is the possibility to splint the cop. With the tray still in the mouth. An open tray is used to take materials (dual-viscosity method) of different consistency the impression (b). 9. along a reference plane. at the end. the impression copings and the analogues studies comprise in vitro evaluations. With the tray still in the used for the evaluation of impression accuracy. Finally. Two is screwed to the implant (a).25).4. selves). Displacement is the most important fac- To ensure the maximal stability of all the com.23).y. are screwed to the implant. Angular distortion instead aims at evaluating ings together in the mouth with a scaffold formed the rotation of the implant head around the of dental floss or orthodontic wire covered by a implant long axis and the translation of the head resin. between each other after having established two nected to the copings outside of the mouth and reference points (such as the abutments them- sent to the laboratory. mouth. and the coping-impression .21. 9. the coping assembly is finally removed from the mouth (d). digital impressions have emerged as Due to the nature of the evaluations. the analogues will be con. the were used (PVS) analogues are removed (c).162 O. the analogues are removed.1 Implant Impression Accuracy occurs outside of the mouth on the indentations left on the impression. Regarding the assessment of implant impression In the pickup technique (Figs.21 (a–d) Pickup (open-tray) technique. Iocca et al. and finally which is the assessment of the displacement on the coping-impression assembly is removed the x. removal of the set impression. and comparison of various implant impression a c b d Fig. 9.24 and 9.

including only in vitro conclusions. It was concluded that high-accuracy scanners and the usage of powder particles as a marker give the best results. fundamental role on the esthetic outcomes. adjacent teeth proximity. and implant b height may also have an influence on accuracy. 9. Anyway. Regardless of this. but the first has been reported to be the most accurate. a Acrylic resin with dental floss splinting was the most often used. regarding digital impression.22 (a–c) A custom tray can be used for the pickup technique. There is small difference between pickup/ open-tray and transfer technique. In conclusion. perfect mimicry with the natural tissues depends . this ensures greater comfort for the clinician implants. and greater ease in impression taking. In this case. it is possible to state that splint- ing seems to ensure a greater accuracy than non- splinting technique. Finally. Implant Dentistry rate impressions with the open techniques. The followed by PVS. it was found 9. insufficient data exists on digital sions can be drawn by analysis of the literature. Also. and digital impression improvements may potentially lead to elimina- tion of multiple materials and clinical/laboratory steps. unclear evidence emerged mainly due to the lack of stud- ies. It is obvious that a current trend exists of shifting toward digitalization of implant procedures. a Polyether and PVS show similar perfor- monophase material was used (polyether) mances. Optimal esthetic results depend by numerous The material evaluation evidenced that the factors. Sectioning of the resin before full polymerization has been advocated to give the best results.9 Implant Prosthodontics 163 Splinting techniques were also analyzed. general conclu. Of course.5 Esthetics in Prosthetic that a large part of the studies showed more accu. Regarding the transfer versus pickup technique. but more studies are needed to confirm c their clinical validity in comparison to the tradi- tional procedures. As expected. Finally. sectioning of the resin before complete polymerization seemed to pre- vent the detrimental shrinkage effect to occur. splinting impression technique was the most accurate compared to non-splinting. accuracy comparison of implant impres- sion techniques was performed. techniques [38–44]. espe- cially in case of four or more implants. the prosthesis itself plays a most used and accurate material was the polyether. impression techniques to draw definitive In a recent review [38]. studies. angulation of the implants pre- sented the worst accuracy even if number of implants. even if it seems that pickup technique may guarantee a better accuracy in case of divergent and multiple Fig.

164 O. Iocca et al.

a d




Fig. 9.23 (a–f) Splinting of the implants with resin at the scaffold for the resin was made with tooth floss (a, b);
moment of taking, the impression ensures the greatest dual-viscosity materials (PVS) were used in an open-tray
precision due to the absence of micromovement at the technique (c). Excellent reproduction of details for an
moment of tray removal from the mouth. In this case, the immediate loading restoration (d–f)

upon the materials adopted and upon the perfect Implants malpositioning seems to play a
integrations of the implant and the prosthesis role in esthetic outcomes. In particular, an
with the surrounding structures. excessive buccal inclination of the implant
Other factors such as implant position, pro- increases the possibility to incur in mucosal
visional restorations, and timing of loading recessions.
may have a role in obtaining optimal esthetic Adoption of a provisional to allow proper
results. adaptation and evaluation of the tissues before
The review of Martin and coll. [45] addressed temporary restorations was strongly recom-
this topic, examining RCTs and prospective and mended because it allows the possibility of plan-
case series studies published in the last decade. ning the final restoration. Moreover, soft tissue

9 Implant Prosthodontics 165

papilla index and other standardized objective
evaluation systems.
A true evidence-based comparison of esthetic
outcomes in implant dentistry is impossible and
this problem must be addressed in future studies.

9.5.1 Zirconia Versus Metal Ceramic

As already pointed out in the previous chapters,
the use of zirconia has gained popularity due to
its better esthetic mimicry with the natural dental
tissues. The use of zirconia implant restorations
is therefore aimed at improving the esthetic out-
comes of the implant treatment in the cases in
which the patient expects the best esthetic results.
The worries expressed for other applications
of ceramics (see Chaps. 4 and 5) in implant den-
tistry persist even for the prostheses manufactur-
ing. In particular, the theoretical reduced
b mechanical performances in posterior regions of
the mouth.
When the literature is critically reviewed [46],
it is found that implant-supported single crowns
tend to show similar cumulative survival rates at
5 year (97.1 %) compared to the metal-ceramic
The studies used for comparison present the
usual problem of limited number of patients and
follow-up, but results are anyway encouraging.
Also, rates of complications associated with
all-ceramic crowns were not different from the
metal ceramic. Although it must be pointed out
that these results can be different for FDP and
Fig. 9.24 (a, b) Virtual impression techniques allow a full-arch restorations, because of their greater
digital view and study of the case complexity.
Veneer chipping was considered to be the
most common technical complication of all-
maturation was considered an essential prerequi- ceramic single crowns.
site for excellent results. In the same fashion, systematic reviews on
Regarding the retention system in relation to zirconia FDPs [47, 48] showed excellent results
the esthetic outcomes, few studies available do at short-term clinical evaluation both in terms of
not allow to propend to screw or cement retained. survival than technical complications.
The problem that emerged from this analysis The encouraging results must be balanced by
is a general lack of RCTs having esthetics as the the recognition of the fact that well-designed RCTs
first aim of evaluation. PES/WES scores are not are missing in the dental literature. Also, some of
uniformly reported; the same is true for the the available studies lack in reporting some

166 O. Iocca et al.

a b


Fig. 9.25 (a–c) Example of digital impression taken with intraoral scan bodies and custom abutment fabrication
(Reproduced with permission from Brandt and coll.)

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Periodontology and Implantology. soft and hard tissues do not present an adequate volume that is required to achieve an ideal situation to ensure the survival. clinicians have to face situations where implants cannot be placed in an ideal position. MD. Alkhraisat. MS (*) M. When the alveolar ridges lack appropriate volume. Clinica Eduardo Anitua. and the wide acceptance of minimally invasive surgery. bone grafting procedures may be indicated in order to prepare the site in advance or sometimes at the time of implant surgery.1007/978-3-319-26872-9_10 . and Mohammad H.H. There is an increase in the demand for reconstructive surgery and thus bone substi- tutes. changes in the lifestyles with expectation of a good life quality. To solve these problems. MSc. Biotechnology Institute. 3°. Several surgical techniques and bone grafting materials are available for that purpose. Eduardo Anitua. Real 66.). Alkhraisat Abstract The long-term predictability of dental implants is directly associated with the quality and quantity of the available bone for implant placement. For that. Spain 15003. Many times. The use of bone grafts in the repair of defects in dentistry has a long history of success. DDS. DDS.com E. S.com © Springer International Publishing Switzerland 2016 171 O. The ultimate aim of the surgeon is to maximize success and minimize morbidity. PhD Oral Surgery and Implantology. DDS. principally due to the increase in life expectancy. A Coruña. Pardiñas López. PhD. the surgeon needs a critical evaluation of all these techniques and biomaterials to be able to select the most appropriate procedure and graft type. Evidence-Based Implant Dentistry. Vitoria-Gasteiz 01007. Spain e-mail: dr. Spain e-mail: eduardoanitua@eduardoanitua. function. For different reasons. Anitua. Clínica Pardiñas. Iocca (ed.khraisat@gmail.com e-mail: simonplz@hotmail. DOI 10. Galicia Jacinto Quincoces 39. Clinical Dentistry. Eur PhD Oral Surgery. and aesthetics of our implants. Vitoria-Gasteiz 01007. Pre-Implant Reconstructive Surgery 10 Simón Pardiñas López. Jose María Cagigal 19. primarily with the use of autogenous bone. reconstructive surgery is needed.

and easy to manipulate.172 S. tion. advantages. fre- thirds of which occurs in the first 3 months [1]. sterilizable. clinicians have to face situations ables include patient expectations. and clinical trials were the main source of data obtained to compare different therapeutic alternatives and materials. disadvantages such as morbidity. congenital anomalies. absence of infec- function. tissue thickness. vascularization. high muscle attachments. the alveolar ridge resorbs factors. increased costs. and scarring. finances. meta-analyses. conventional removable dentures of different treatment options have been proposed and/or fixed bridges over natural teeth were to achieve an adequate bone volume and over- the only available prosthetic rehabilitations. graft materials used. not antigenic. evaluating the necessary bone to rehabilitate function. and technically demanding procedures that require an expert surgeon are associated with these techniques. systematic reviews. as 50 % loss in width in the first 12 months. In this chapter. Success rates of different bone grafting techniques are high and often have the same success rates as in native pristine bone. augmentation technique employed to reconstruct dures may be indicated in order to prepare the different ridge defects depends on the horizontal site in advance or sometimes at the time of and vertical extent of the defect. prolonged treat- ment times. Bone graft is placed to sustain coagulum stabilization and reduces the risk of soft tissue collapse into bone defects. immobilization of achieve an ideal situation to ensure the survival. and infection). bone grafting proce. this is not always possible due to era of treatments. The graft would thus support the maturation and remodeling of the coagulum into an osseous tissue. Ideally. num. This evidence-based approach assures clini- cians that their therapeutic decisions are supported by solid research that will help standardize implant protocols. osseointegrate the implants [2]. limitations. bone substitute materials should be biocompatible. However. and aesthetics of our implants. growth When a tooth is lost. it can reach as much planned recipient site for the keratinized gingiva. These include soft not present an adequate volume that is required to tissue closure. implantology has introduced a new However. . come these limitations. etc. focusing on its indications. Nowadays. The clinician should analyze the in width and height very fast. space maintenance. pliance. 10. For different reasons (trauma. aesthetics. tion. A great number In the past. the graft.1 Introduction implant surgery. and survival and success rates. Also. different patient-related variables. These vari- Many times. phonation. com- where implants cannot be placed in an ideal posi. and aesthetics. This chapter will summarize the most common reconstructive options and the different grafting materials available for bone augmentation. periodontal be known in advance in order to achieve a good disease. complications. among others. and medical history. Pardiñas López et al. A great number of different treatment options have been proposed to achieve an adequate bone volume. The ideal and most appropriate approach is first to plan the prosthetic reconstruc- Osseointegrated implant is a highly predictable tion and then place the implants in the optimal method to restore an incomplete dentition and 3D position. soft and hard tissues do prognosis of the procedure. type of defect. two. prolonged There are different important factors that must edentulism. the bone To solve these problems. sufficiently strong to maintain space.

Each complications. avoiding graft surgery. and risks. and their cations as well as postoperative and long-term outcomes. Moreover. Also many times implants are placed in also have their indications. rates as in native pristine bone. the first choice. natural dentition.1). Pardiñas López) . cient clinical practice and enough patient This chapter will summarize in an evidence- follow-up that will enable the clinician to based approach the most common reconstructive become familiar with intraoral surgical compli. although it may be true. and aesthetic restoration in harmony with the many practitioners currently receive their surgi. These trainings usually lack of the suffi. implant and will show their most successful Therefore. many clinicians and patients are will.1 3D image of an osteoblast over bone surface (Copyright © Dr. grafting. cian has the required experience to perform it. options available. tions. Many courses and lectures often show high niques are high and often have the same success implant and grafting success and survival rates. cases. and consequently a more number of den. cess rates as the more complex one.. or the lecturers may have a great treatment has its own indications and contraindi. the clinician should be aware tists started to place implants and perform recon. ing to perform the easiest and less invasive proce. materials. increased costs. tilted diate implant placement with immediate loading implants. more aggressive In this sense. Fig. 10. Another reason is that nowadays due to patient dure to solve their situation. compromised sites where there is inadequate There are different reasons for the number of bone and soft tissue that requires augmentation complications and failures experienced by the procedures before implant placement. many other options are also available protocols such as extraction. materials used. computerized implantology. However. The easiest procedure could be cal training from continuing education courses. etc. However.10 Pre-Implant Reconstructive Surgery 173 Success rates of different bone grafting tech. the inclusion and exclusion cri- demanding procedures that require an expert sur. expectations or clinician desires. teria may eliminate patients with high risk of geon are associated with these techniques. as well as advantages and disadvantages. focusing on its limitations. complica- complications. lyzed with care as they may not have enough ment times. short implants. and success rates (Fig. that the most important thing and the end goal of structing procedures. clinicians. 10. and technically long-term basis. experience with a specific type of material or cations. often without the necessary treatment is to provide the patient a functional academic background and training. One is that the total number of Considerable controversy still exist regarding implants placed has increased during the last 10 the choice of the most reliable technique and years. prolonged treat. which are used. provided it offers the same suc- many times given by implant and material com. and the clini- panies. limitations. and imme- such as zygomatic implants. this data should be ana- disadvantages such as morbidity.

2 mm annu- clinician’s office is sponsored by companies. materials used. follow-up time. graft plant bone resorption. vertical (class II). crown-implant aesthetically compromised or may have periim. when considering the levels of evidence. Most of the articles refer to Not all studies evaluate the same parameters.5 mm in the first tistry. and survival rates. clinicians’ heuristics and biases. As a result. Implant survival surgical technique. These parameters include the initial ion is considered the lowest level of evidence [3]. patient-related factors (age. but most of the research that flows into the year of function and less than 0. which means that their studies are based on new Although these criteria would need to be products and technologies. reviews. [6]. medical history). many clinicians are alternatives and materials. previously and not all parameters are defined the same way. approach assures clinicians that their therapeutic Decision making in evidence-based implant decisions are supported by solid research that dentistry involves diagnostic and therapeutic will help standardize implant protocols. treatment. ally has been classified as horizontal (class I). success if the following criteria. ferent surgical situations as well as indications. making their accumulated knowl. occlusal situation). or custom. • Vertical bone loss less than 1. Their decisions are mostly based on intuitive comparisons with In this chapter.2 General Review • Absence of mobility of the Literature • Absence of a continuous radiolucency around the implant Implantology has become a main field in den. survival and success [8. It has been suggested that priority may be such as pain. There is a hierarchy may be more generalizable. ratio. Pardiñas López et al. defined by Albrektsson et al. implant char- It is important to differentiate between implant acteristics (dimension. complications. • Absence of persistent subjective complaints. as well as cost meta-analysis or systematic review because data considerations [3]. systematic other patients. whereas expert opin. assumption that studies are similar enough to be sidered more reliable than information based on compared with confidence. 9] (Fig.2). and clinical trials were the main source edge and reliance on standard practices to be of of data obtained to compare different therapeutic great importance. prosthetic refers to implants still in function. and outcomes (success criteria. evaluated as good function. from multiple studies are pooled based on the Information derived from clinical trials is con. and limitations. 10. clinical alveolar ridge situation (which tradition- Several treatment choices are analyzed for dif. based approach in their practices. updated in the following years according to Many dentists still adopt a self-experience. smoking. Heterogeneity of studies is important in a patients’ preferences and values. micro-/macrostructure. Implant success should be harvesting sites. complications). are fulfilled: and no long-term investigation comparing all available treatment options could be identified. and thus. rates. • Absence of periimplant infection with This chapter will evaluate different preimplant suppuration surgery options and materials available to help . uncertainties. Systematic Studies evaluate different parameters which reviews of randomized controlled trials are consid. good aesthetics. 10. ally in subsequent years of function [7]. survival and implant success. and/or given to procedures that appear less invasive and dysphasia carry a lower risk of complications [10]. or combined (class III) defects) advantages. absence of pathology. may have an impact on the final outcome of the ered to be at the highest level. but may be characteristics (type and fixation. loading protocol). authority. [4] and adapted by There is a lack of comparative effective research Buser and coworkers [5] as well as Karoussis to guide decision making in oral grafting surgery et al. foreign body sensation. the results intuition. meta-analyses.174 S. This evidence-based slow and reticent to welcome a change. the new implant surfaces and designs. gender.

Autogenous bone is the “gold standard” in bone grafting as it is osteogenic (has bone-forming cells [11]).3. class II. 10.3 and 10.1 Classification of Grafting Materials According to Their Origin 10.3. freeze-dried bone allografts (FDBAs) and demineralized (decalcified) freeze- dried bone allografts (DFDBAs). 10. Extraoral and intraoral donor sites have been established as donor sites that will be compared afterward (Figs.3. 10. class III (Copyright © Dr. Pardiñas López) clinicians to make decisions based on the avail- able scientific evidence literature. 13]).3 Autogenous particulate bone mixed with tion [12.1 Autogenous Bone The bone is transferred from one position to another within the same individual. Fig.1. 10.10 Pre-Implant Reconstructive Surgery 175 Fig. 10. osteoconductive (facilitates the PRGF colonization and ingrowth of new bone cells and sprouting capillaries on its surface [14]).2 Classification of alveolar ridges: class I.2 Allografts The bone is obtained from an individual and placed in another individual of the same species [15]. osteoinductive (actively promotes bone forma. and osteotransductive (degradability to be replaced by new bone). Fig.1.4 Autogenous block graft . 10. Two main types of allogeneic bone grafts are clinically used.3 Materials Used in Pre-Implant Surgery 10.4).

which explains its pres- The use of this source of bone substitute mate. Co. cium phosphate (BCP) and beta-tricalcium phos- tite (FRIOS® Algipore®) (Friadent GmbH.3. the in vivo resorption of [16. Synthetic.5. NY). It is available in cancellous and the most frequently used as an alternative to cortical granules and blocks. apatite (HA). ing presents several advantages like unlimited phogenetic proteins (osteoinductive proteins)..5–0. Saint conducted to study the efficiency of biphasic cal- Connery. Germany). new bone formation reached a value of hydroxyapatite as shown in Fig. Bio-Oss Collagen (Osteohealth hydroxyapatite materials are also available. calcium and phosphate ions due to its chemical dure [19. A 10 % of highly autogenous bone in the USA [18]. The most common calcium phosphates that 10. However. viability. β-tricalcium phosphate (β-TCP) is one FL) are examples of commercially available of the most frequently used synthetic grafts in bovine-derived bone substitute materials. Geistlich Pharma AG.6). NY). The acid (0.3. Biocoral (Inoteb.3 Xenografts are commercially available are ceramic in nature The bone is harvested from an individual and (synthesized at high temperature) like hydroxy- placed in another individual of different species. Lakewood. 34]. New bone Mannheim. ated with the harvesting of autogenous bone. quantity.95 and 28. surgery for more than 100 years [27]. 10. β-TCP) [27]. The β-TCP promotes Deproteinized.. and There is evidence that Bio-Oss® undergoes injectable forms and are composed of cortical resorption by giant multinucleated cells (like bone. 10.176 S. 41 % after 8 months [32]. ence in biopsies obtained after 10 years of place- rials varies between countries. 17]. Both bone Switzerland) is one of the most studied bone sub. Bio-Oss (Osteohealth Co. LLC.4 Alloplastic Materials demineralization of bone samples to obtain the The use of synthetic biomaterials for bone graft- DFDBA would preserve and expose bone mor. and porcine. ductivity of DFDBA shows great variation and is Most alloplastic materials are composed of highly dependent on the manufacturing proce. phosphate) for sinus floor augmentation [28]. CO). 24]. 30–36 % of new bone formation after 6 months of Oss®. or a composite of both osteoclasts).6 molar hydrochloric acid) 10. the osteoin. OsteoGraf/N (VeraMed Calcium phosphates have the ability to pro- Dental. The mineral composition of all these grafts is study. implant dentistry [28]. sinus floor augmentation [33. substitutes are resorbable with a residual bone stitute materials [21]. nonceramic resorbable Shirley. Mannheim.1. Bio-Oss® is very slow.1. Wolhusen. Bio-Oss® is an anorganic graft between 10 and 28 % for BCP and between bovine bone that is chemically and thermally 13. block. avoidance of surgical morbidity associ- Urist has been the first to describe the osteoin. Shirley. after 5–6 months postoperatively [29–31]. it is ment [23. treated to extract all organic components. formation with BCP ranged between 21 and 30 % cially available products of coral and algae ori. Tatum in 1986 was the first OsteoBiol® Gen-Os (Tecnoss Dental. and Three main sources could be identified: bovine. Calcium sulfate has been used in craniofacial taining the 3D structure of the bone [22]. biphasic calcium phosphates (sintered HA and coral. The FDBA is purified porcine collagen is added to produce both an osteoconductive and osteotransductive Bio-Oss® collagen (Fig. and dimensional geometry to promote cellular Endobon ® (Biomet 3i. tricalcium phosphate (TCP). main. anorganic bovine bone (Bio. Palm Beach Gardens. stitute that contains both porous hydroxyapatite Various randomized clinical trials have been structure and collagen. phate (β-TCP) in bone regeneration. cancellous bone.4 % for TCP [29–32]. 20]. bone substitute material. to successfully apply a bone substitute (tricalcium Italy) is a hydrophilic porcine-derived bone sub. However. They are available in particulate. Pardiñas López et al. PepGen P-15 mote bone growth and an appropriate three- (Dentsply Friadent. France) and porous fluorohydroxyapa. and ductivity of DFDBA [13]. For example. In one gin. Germany) are examples of commer. However. Turin. similarity to the mineral component of the bone [26]. no risk of disease transmission [25]. .

. coral. The bioactivity as property for bioglass refers to its ability to pro- mote the precipitation of biological hydroxyapa- tite on its surface that would result in its bonding to the hosting bone. Calcium sulfate has been after implantation. It has been shown to experi- of bone formation. TN.6 Bio-Oss® with PRGF potassium ions from the bioglass would result in the formation of a silica gel layer that would pro- calcium sulfate has a relatively high rate of deg. its resorption rate stabilizes [38]. although Successful outcomes in bone augmentation pro- this application has not been thoroughly exploited cedures and as filler for intra-bony defects have in the clinical setting [36]. USA) is an tion capacity has not been superior to calcium example of the use of calcium sulfate as a vehicle phosphate biomaterials [39]. beyond this point. however. 10. Bioglass or bioactive glass is a calcium- substituted silicon dioxide.10 Pre-Implant Reconstructive Surgery 177 Fig. Recently. Arlington. however. it has enjoyed a resurgence of sorts in the areas of periodontol- ogy. porcine. 10.5 Several sources (bovine. sinus augmentation. cle for growth factors and antibiotics. proportional to the content of sodium oxide [37]. However. and Endobon synthetic) are available for hydroxyapatite (HA) as Calcined grafting materials in oral Cerabone bovine bone and maxillofacial surgery PepGen P-15 Polylactic-HA HA Synthetic HA Ostim Bio-Oss Not-calcined Bovine bone Tutoplast for the delivery of an antibiotic (tobramycin in the case of Osteoset) for the treatment of osteo- myelitis. Osteoset® (Wright been reported [27]. its bone regenera- Medical Technology. and orthopedic surgery [36]. The leakage of sodium and Fig. The in vivo solubility of the biomaterial is Calcium sulfate is also used as a delivery vehi. Calcium sulfate has never attracted the same degree of research interest as have other biomaterials. and a barrier in guided tissue regeneration [36]. It is completely resorbable in ence severe resorption during the first 2 weeks 5–7 weeks in vivo [35]. mote the precipitation of a hydroxyapatite layer radation that may not be compatible with the rate on its surface [37]. used as a bone substitute. a graft binder/extender.

The vival after ridge augmentation using bone substi. respectively [40.7).178 S.6 %.6 and 39. a mean implant sur. uated in horizontal ridge augmentation [40. and 9. All these studies showed a survival or in combination with a particulate bone graft of rate of 100 % for both grafting materials [14] bone substitute material [40]. the 4. analysis. When resorbable membranes 97. Pardiñas López et al.3 mm.9.4 months). and when no membrane was used. 41].7 3D image of a block graft placed in the anterior maxilla (Copyright © Dr.1 months has been reported.6 ± 27. compared the clinical outcome of ridge augmen. mented grafting protocol included intraorally har- When autogenous bone blocks (alone or in vested autogenous bone block alone or in combination with membrane. Pardiñas López) .2 %.8 % [40]. 41]. 18. a mean gain in ridge width was (healing time before implant placement 4. of implants placed in augmented area with autog- vival rate of 98.4 ± 2. sures of 64 and 71 %. The meta-analysis has shown no statis. The same RCT reported that aug- 5.6 mm and 75.9 % for autogenous bone enous block from intraoral site ranged from 96.1 ± 1. The best docu- (Fig. Fig. In a RCT.25 ± 1. or no membranes.3 to 100 % [14].6 ± 2.7 ± 1.1 Alveolar Ridge block graft was used.9 mm. branes. the corresponding Five studies (from 2000 to Jan 2014) that rates were 23. the corresponding figures Augmentation were 2. or without coverage of barrier membrane [40]. the mean gain in ridge width was reported to for Alveolar Bone be 4. 10.4 mm. Implant rate was calculated for studies with the use of success was indicated in five studies and ranged nonresorbable membranes.5 % for bone substitute material alone were used. 10.2 Which Is the Best Bone Graft tion.9 alone (healing period before implant placement to 100 % [40]. When the complication 30.2. and the complica- tion rate was 3.4 % [40]. The outcomes have indicated that both groups tically significant difference between both types experience high frequencies of membrane expo- of grafts. most predictable horizontal bone augmentation tute material + autogenous bone or autogenous seems to involve an autogenous block graft alone bone alone.5 mm [40].3.9 months).3. the percentage of cases that had no Augmentation? additional grafting was 97. grafting materials) combination with anorganic bovine bone and with have been utilized for horizontal bone augmenta. 10. The survival In one systematic review.6. 100 % for bone substitute mented sites that were covered with nonresorb- material + autogenous bone (healing time before able membranes showed a mean gain in ridge implant placement 5. When no autogenous 10. and width of 2. anorganic bovine bone with resorb- tation procedure using bone substitute material or able and nonresorbable membranes has been eval- autogenous bone have been included in the meta.1 months) for a follow-up period of results were 4. resorbable mem- from 90. Three studies compared implant sur.

are anorganic bovine bone covered with a mem. such as into natural or synthetic. which does not induce immunologic ing procedures than the use of granular grafts. 10. which can lead to available. particulate autograft with or without a is that a second procedure to remove the mem- resorbable membrane [40]. 67. har.8 % [40]. whereas synthetic barriers are degraded by The best documented augmentation protocols hydrolysis [8]. 43]. made of various types of collagen of animal ori- enous bone (particularly when harvested from gin. Natural products are ABBM. tation with the GBR technique. 45].9 % and a 29. The grafts were Nonresorbable barriers are available as harvested from the mandibular chin or body/ e-PTFE. structure. graft and autogenous particulate.2. Titanium-reinforced increase with their use in comparison with hori.6 mm.2 Treatment of Fenestrations plications after premature membrane exposure and Dehiscences: Guided has been reported [2]. This could interfere with block harvest.8 % of the cases showing a complete cal bone augmentation. resulted in a defect fill of time is considered a major disadvantage. regarding verti. [40] in their systematic review decreased.7 % of the or bone substitute material has been utilized. They can also mers).7 mm. The use of block grafts density PTFE. The difference is their mode of resorption. since they are associated polyesters (polylactic and polyglycolic acid poly- with less postoperative morbidity. Implant corresponding figures were 3. The main advantage of resorbable membranes brane. 83. 83. tion. They have the gery to remove the membrane [2] (Fig. titanium-reinforced e-PTFE.2 % vs. the barrier function for an appropriate length of vested intraorally. 44. while synthetic ones are made of aliphatic extraoral locations). stability and allow the membranes to be shaped [2]. advantage of a more rapid vascularization [42]. including the symphysis. Once exposed to the oral Bone Regeneration cavity.5 % of the cases. The use of anor- 3. . ganic bovine bone with or without membrane ond grafting and the complication rate was resulted in a mean defect fill of 88. thus. reactions and resists enzymatic degradation by However. the porous surface of e-PTFE membranes Autogenous and nonautogenous options are is soon colonized by bacteria. However an increased rate of soft tissue com- 10.3 % [40].10 Pre-Implant Reconstructive Surgery 179 In the same systematic review. high- ascending ramus [40]. or titanium mesh [8]. be used in combination with autogenous bone collagen products undergo enzymatic degrada- [42.5 mm vs.0 % [40].2 mm. the difficulty of maintaining found that the use of autogenous bone grafts. was shown were intraorally harvested autogenous block in human studies [8. and maxillary tuberosity. patient morbidity is Jensen et al. when particulate autograft complete defect fill was achieved in 67. For small amounts of bone. brane is not needed. and the complication Successful vertical and horizontal ridge augmen- rate was 23. seemed to yield more gain in ridge height and a e-PTFE is a synthetic polymer with a porous greater reduction in the need of additional graft. the use of autogenous defect fill.8). 68. The source of autogenous particulate is infections and to the subsequent need for early the same as the one that has been discussed for membrane removal. Comparing the data whether a mem- brane was used or not. However. Bioabsorbable membranes can be classified Nonautogenous bone substitutes. the gain in ridge height Use of Membranes was 3.1 % of the cases did not require sec. using both resorb- The most frequent grafting materials used able and nonresorbable membranes. 4. may be also a valid alternative to autog. However. 25. Another disadvantage of sites can be used. the rate of dehiscence seemed to host tissues and microbes. e-PTFE membranes is the need for a second sur- ramus. The rate of dehiscence was 12 %. local bone regeneration. Membrane or graft dehiscence was block graft has resulted in a height gain of reported in 15. 21.3.4 and survival rates of 93–100 % have been reported. e-PTFE membranes increase their mechanical zontal bone augmentation [40].8 %. the cases.

[48]. indicated that the bone harvested from an .180 S.5 %) with nonresorbable membranes and Oss®.4 %) with resorbable mem. cell occlusive.5 and 75. However. Addition of bone graft material to the GBR most of these bioabsorbable membranes must be technique increases the amount of achievable used in combination with a graft material for vertical regeneration [8. Bio-Oss® + autogenous bone. ences were detected. the resorption pro. the differences in the total bone vol- The choice of membrane will depend on the ume between grafts disappeared over time.8 3D image of a PTFE membrane placed over a defect and following the GBR principle (Copyright © Dr. 46]. space maintenance in bone augmentation appli- cations [8]. a meta-analysis has were 75. Bio- 96. bioabsorbable tacks made from polylactic acid [8]. The study has demonstrated 94–100 % (median 95. space-making ability. [47] have per- ally 6 months) [8]. Also. lack of rigidity. In the study percentages of cases with complete defect fill by Handschel et al. the different grafting materials [47. Some studies suggested that the volume of 10. integration by the host tissue.7 and 87 %. the available scientific evidence regarding the In one RCT. Augmentation resorbable membranes in comparison with resorbable membranes [8]. and β-TCP).3 and 14. 10. Fig. 48]. maxillary sinus with autogenous bone.3.4 %. bone during the early healing phase (the first 9 Products that are available to stabilize mem. In general. no statistically significant differ- achieving the desired tissue regeneration (gener. the criteria required formed a meta-analysis of the total bone volume to select appropriate barrier membranes for present in biopsies obtained from augmented guided bone regeneration include biocompatibil. and required duration of membrane function for after 9 months.3 Lateral Sinus Floor regenerated bone achieved was higher using non. although this did not Histomorphometric Total Bone Volume affect the outcome of the treatment and implant There are two systematic reviews that discussed survival rates. and adequate clinical cess and length can vary [2]. because of a manageability [2].2.5 %. the rates of membrane/ been performed for those studies that report sinus graft dehiscences were 26. the volume in maxillary sinuses augmented with percentages of defect fill were 75. the presence of significantly higher mineralized branes [40]. Pardiñas López et al. and the elevation with various grafting materials (autog- implant survival rates were 92. Pardiñas López) Depending on the material. ness. histomorphometric parameter of total bone able membranes and resorbable membranes. in all but the smallest defects. months after surgery) for autogenous bone com- branes include nonresorbable mini-screws and pared to various bone substitutes. Klijn et al.9–100 % (median enous bone. The study ity. regarding the use of nonresorb.

autograft was mixed with Autogenous bone alone or autogenous bone DBBM. the meta-analysis results indicated the vival rate has been reported from 61. maxillary sinus has also been used as a donor site for onlay bone graft to gain alveolar width [54].2 to 94. All these studies have reported a 100 % survival rate up to 42 months. When using . In one system- used [50]. implant survival when using bone substitute vival rate with a range of 82. For that.. the overall implant sur.9 %) after a period of function of up implant survival between the two groups [14]. it The lateral and anterior wall of the maxillary is suggested that maxillary sinuses grafted with sinus and maxillary tuberosity has also been autogenous bone may receive dental implants employed as a donor site of autogenous bone but earlier than sinuses grafted with bone substitute in particulate form [53]. inclusion criteria.1). particulate autografts have shown higher survival When DBBM alone was used for maxillary rates than those placed in sinuses that had been sinus floor elevation. reported when autogenous bone blocks from the the results ranged from 90 to 96 %. In another Implant Survival nine studies. showing an implant survival sinusitis is independent of the grafting materials rate ranging from 84.4–100 % up to 52 materials compared to autogenous bone. The relatively lower implant survival rates When the xenograft was mixed with PRP/PRGF. bone. nous bone in four studies that completed the itis and graft loss [14]. the use of bone substitutes atic review [40].2 to 100 %. ranged from 85 to 100 % (median 95 %) [40]. to 102 months [40] (Table 10. augmentation [40]. demonstrated in their review that sisting of particulate and a bone substitute has the partial or total graft loss related to the event of also been evaluated.3 %) with a follow-up common grafting materials used for sinus floor of 12–60 months after loading [40]. When comparing autogenous bone alone and When autogenous bone block grafts from the bone substitute material mixed with autogenous iliac crest are applied.4 % absence of statistically significant differences in (median 84. allograft was added to autoge- would not increase the risk of developing sinus. The meta-analysis showed trends toward a higher ticulate autologous bone grafts resulted in a sur. The use of par. implant survival rates augmented with block grafts [51. In the systematic review by Pjetursson et al. 52]. Pardiñas López) intraoral site would result in higher total bone iliac crest were used can be explained due to the volume than the bone harvested from the iliac fact that most of the placed implants had a crest [47].9). 10. The implant survival rate ranged between mixed with bone substitute materials are the most 89 and 100 % (median 94. machined surface [51. The lateral wall of the materials [49] (Fig.9 3D image rep- resenting a grafted sinus with particulate xenograft (Copyright © Dr. how- months of follow-up. 10.10 Pre-Implant Reconstructive Surgery 181 Fig. Complications The use of a mixture of a composite graft con- Nkenke et al. the difference was not statistically signifi- Implants placed into sinuses elevated with cant [14]. 52]. ever.

182 S.3 (89.7 ± 34.8 (82–100) 88.2–94.5–95. particulate 84.6 ± 2. autogenous 97.9) 96.3 12–102 CIR [40] SR Xenograft 95 (85–100) Up to 68 [194] SR [44] Xenograft/PRP 95.8) More than 18 [49] SR Lateral.6) 99.2) 36 [51] SR Lateral.5–95.8 (84.0) 36 combination .6–100 36–84 specified) [148] SR/MA Lateral (material not 91.1 39. iliac block 83. bone substitute 98.2 (61.3 (52. particulate 95.5 (86.4–96 12–72 block/delayed load [49] SR Lateral.4–100) 12–54 [57] SR Autogenous block/ 75.1 (82.7 ± 34.87 ± 43.3 (78.80 [14] SR/MA Lateral.88 More than 12 [173] SR Autogenous + combination 93. xenograft + PRGF 90 85.2 (93.7–98.6 (4–170) autogenous + substitute [52] SR Autogenous + combination 94. bone substitute 92.5–99.8 (98.6 ± 4.1 (86.7–100 specified) [44] CIR Autogenous 89 6–134 [52] SR Autogenous 87. xenograft.6–97.7–100) 36 autogenous [40] SR Particulate autogenous 97. 92/91.5 More than 12 machined implants) [194] SR Iliac 88 12–102 [40] SR Iliac 84.3–79 Up to 36 immediate load [57] SR Autogenous 82.3 (90 94.2 39.1 (69.7 ± 34.8) 36 [40] SR Bone substitute 96.0–98.6/96 12–102 CIR [171] RS Lateral.8 89.4–92.7–98.6 39.4 ± 2.7 (90.7 More than 12 [40] SR Autogenous 94. particulate 92.8–98.3 (89–100) 12–60 [14] SR/MA Lateral.9 (61.9) More than 18 [52] SR Bone substitute 95.98 More than 12 [49] SR Lateral.6 More than 12 machined) [40] SR Autogenous + allograft 100 42 [40] SR Autogenous + xenograft 94.6–100 12–107 [51] SR Lateral.8 (94.1 12–102 or alloplast [49] SR Lateral (material not 90. Pardiñas López et al.6 (4–170) [49] SR Lateral.4) 58 [194] SR Alloplastic/PRP 81/95.7 (93.4 6–134 [40] SR Alloplast 96–100 Up to 36 [194] SR [44] Allograft 93.1) 96.4 (86.2–96.8) More than 18 [14] SR/MA Lateral. Table 10.5) 96.2–100) Up to 60 [173] SR Autogenous 92.6 (4–170) [173] SR Bone substitute 97.1 12–102 [44] CIR Alloplast 98. autogenous block 80.1–87. 88.8) 36 specified) [174] SR Lateral (material not 75.1 Sinus augmentation Implant survival Implant Implant survival (only rough Time (months Study Technique/graft success (%) (%) implants) (%) postloading) [194] SR Autogenous.

4–97.8–97. SR systematic review.4 (94. dence neither supports nor refutes the superiority of any specific graft material for sinus augmenta. xenograft 99 (95–100) 12–45 [40] SR Transalveolar. Only bone 82–100 88. The lowest particulate annual failure rate of rough-surface implants was Autogenous 84. 51.9–100) 6–93 [40] SR Transalveolar 96 (83–100) Up to 64 [40] SR Transalveolar. and an alloplastic tion and aesthetics have indicated that the evi.0) 36 [174] SR Transalveolar 95. bone substitutes. a combination of Autogenous 69.7–100 ure rates [49.9 (88.7–100 observed using autogenous particulate bone graft combined with bone substitute (Table 10.6–100) 36 (6–42) [51] SR Transalveolar 93. no material 96 (91.4–100 98. concluded that graft resorption seems not to with xenografts or alloplastic materials or bone affect implant survival [50]. it was reported survivals (all (excluding that when only rough-surface implants were types of machined Study [49. the results were lower for machined For lateral sinus floor augmentation.5 89.2 Implant survivals according to implant to 134 months. autogenous 94. Implant Implant survivals In different systematic reviews.1).1–87. lowing grafting protocols may be considered Consequently.8) up to 107 [40] SR Only coagulum 97.2–100 94.2).10 Pre-Implant Reconstructive Surgery 183 Table 10. 51. block alone enous bone blocks all showed similar annual fail. Graft Stability tion [56].8 (87. Autogenous 82.5 95 (60–100) 6–144 CIR (74.6–100 When the overall machined implant survival substitute rates were compared with rough-surface implant survival rates. or in combination with either anorganic bovine tutes would not affect implant survival.5–97. A Cochrane review has concluded that To overcome the inherent problem with resorp- bone substitute materials may replace autografts tion of an autogenous bone graft. in the consensus report on tissue augmenta.5–99. MA meta analysis. RS retrospective study alloplastic materials after a period of function up Table 10.5 [44] CIR Transalveolar 93.4–100 36 CIR clinical investigation review.2–100) 96–100 60 substitute [96] SR [44] 98.4–96. 55] (Table 10. anorganic bovine bone alone or et al. the survival rate ranged from 81 surface to 100 % (median 93 %) (Table 10.7–100 12–27.7–100) [40] SR Allograft + xenograft 90. Nkenke that particulate autogenous bone in a mixture et al.8 Up to 54 [172] SR Transalveolar 96 90.5 More than 12 [195] SR Transalveolar 92.8 96.2 autogenous bone and bone substitutes.7 (82. the fol- than for rough-surface implants [40. substitutes alone may reduce the risk of bone . it was suggested in this indication [43]. Klinge bone or DFDBA. 51] implants) (%) implants) (%) included. and autog.2).1–96. 52]. Furthermore. HA alone [40].1 (continued) Implant survival Implant Implant survival (only rough Time (months Study Technique/graft success (%) (%) implants) (%) postloading) [40] SR Autogenous/or with 94. the use of autogenous bone well documented: autogenous particulate alone alone or in a combination with other bone substi. in combination with DFDBA.2 (61.3) Up to 25 [40] SR Transalveolar.

184 S. Pardiñas López et al.

resorption and sinus re-pneumatization [44, 57]. with ABBM, particles were found surrounded by
The slow resorption capacity of the bone substi- a new bone even 10 years after the grafting pro-
tute can minimize the amount of resorption [57]. cedure, still showing osteoclastic activity [24]
In one histological analysis of a sinus grafted (Figs. 10.10, 10.11, and 10.12).

Fig. 10.10 Cross section of a core sample with ABBM between the residual ABBM particles. (HE, 40×)
and PRGF showing newly formed bone (nb) around par- (Reprinted from Pardiñas López et al. [24]. Copyright ©
ticles of ABBM (b). Vital bone formation is apparent 2015, with permission from Wolters Kluwer Health, Inc.)

Fig. 10.11 High-power image showing immature, newly ABBM (b). (HE, 100×) (Reprinted from Pardiñas López
formed bone (nb) around particles of ABBM (b), along et al. [24]. Copyright © 2015, with permission from
with osteoid (os). Note the osteocytes (ocy) inside the Wolters Kluwer Health, Inc.)

10 Pre-Implant Reconstructive Surgery 185

Fig. 10.12 High-power view of vital bone formation (Reprinted from Pardiñas López et al. [24]. Copyright ©
(nb) directly on the residual ABBM particles (b). Note the 2015, with permission from Wolters Kluwer Health, Inc.)
presence of osteoclast (oc) around ABBM. (HE, 400×)

In a systematic review, volume changes of The average volume reduction for allogeneic
maxillary sinus augmentation using different bone and for allogeneic bone + bovine mineral
bone substitutes were evaluated [58]. The study was 41 and 37 %, respectively [58, 60]. In one
has included only those studies that report on vol- randomized clinical trial, the volume reduction
ume changes using 3D imaging (like CT or after 6 months of sinus grafting with biphasic cal-
CBCT). The analysis has been performed for cium phosphate (BCP) was 15.2 % [58, 61]. The
only 12 articles that fulfill the inclusion criteria. study also found no significant effect on volume
Regarding autogenous bone, no statistically sig- preservation by adding autogenous bone in 1:1
nificant difference in average volume reduction ratio to BCP graft [58, 61].
was reported when comparing autogenous bone
in either particulate or block form. The weighted Extraction Socket Preservation
average volume reduction was 48 ± 23 %. There In the review by Horowitz et al. [62], it has been
was no statistically significant difference when concluded that although extraction socket
autogenous block from the iliac crest was com- grafting has consistently demonstrated to reduce
pared to allografts. A weighted average volume the alveolar ridge resorption, there is no superior-
reduction of 30.3 % was calculated for allografts. ity of one grafting material over the another. The
The use of bovine bone mineral showed a vol- biopsies of multiple studies that used mineralized
ume change of 15–20 % suggesting better vol- grafting materials demonstrated the presence of
ume stability over time compared to autogenous 17–27 % of vital bone following 3–6 months of
bone. The addition of particulate autogenous healing [62]. Nonmineralized products tend to
bone to bovine bone mineral in 70:30 and 80:20 demonstrate the presence of 28–53 % of vital
resulted in volume reduction of 19 and 20 %, bone [62]. However, there is a negative effect on
respectively, with no significant differences when alveolar ridge preservation for the use of collagen
compared to bovine bone mineral alone [58, 59]. plug alone [63].

186 S. Pardiñas López et al.

Fig. 10.13 3D image rep-
resenting a socket preserva-
tion procedure using
allograft material
(Copyright © Dr. Pardiñas

In one review [64], the freeze-dried bone growth factors (platelet concentrate) when com-
allograft performed best with a gain in height and bined with a bone graft for sinus augmentation.
concurrent loss in width of 1.2 mm. In one meta- Even more, those few studies have significant
analysis, the use of xenogeneic and allogeneic heterogeneity [75].
grafts has resulted in lesser height loss at the Regarding implant survival, the authors con-
middle of the buccal wall when compared with cluded that no evident benefit of the use of plate-
the use of alloplastic grafts [65]. However, let concentrates can be drawn from the included
another review [66] has indicated that the scien- studies [75]. However, there is a suggestion that
tific evidence did not provide clear guidelines in critical clinical conditions, the addition of
with regard to the type of biomaterials to use for plasma rich in growth factors could be beneficial
alveolar ridge preservation (Fig. 10.13). [75]. Regarding histomorphometric analysis of
biopsies obtained from grafted maxillary sinuses,
the review indicated the possible advantage of
10.3.3 The Use of Autologous using platelet-derived growth factors during the
Growth Factors and Bone early phases of healing (3–6 months) [75]. In a
Morphogenetic Proteins RCT, the addition of plasma rich in growth fac-
to Enhance the Regenerative tors (Endoret (PRGF)) could enhance the bone
Capacity of Bone Substitute formation supported by anorganic bovine bone
Materials with a slow healing dynamics [75–77].
Titanium grids have been used alone or with a
The use of platelet-rich plasma would improve graft material for the correction of height/width
the handling and placement of particulate grafts of the alveolar ridge. In the review by Ricci et al.
providing stability and avoid the need for com- [78], it has been shown that titanium grid expo-
paction [27]. A positive effect on soft tissue heal- sure occurred in 22.78 % of patients. In a RCT,
ing has been observed in most of the studies that the effect of using plasma rich in growth factors
were included in a systematic review on the use (Endoret (PRGF)) on the outcomes of titanium
of platelet-rich plasma in extraction sockets [67]. mesh exposure has been evaluated [42]. While
A beneficial effect of plasma rich in growth 28.5 % of the cases in the control group suffered
factors on postoperative quality of life could be from mesh exposure, no exposures were regis-
evidence, as a consequence of the enhanced soft tered in the Endoret (PRGF) group. Radiographic
tissue healing [67–71]. The use of plasma rich analysis revealed that bone augmentation was
in growth factors has also been reported to higher in the Endoret (PRGF) group than in the
reduce bleeding, edema, scarring, and pain lev- control group.
els [67, 71–74]. In the systematic review by Del Overall, 97.3 % of implants placed in the con-
Fabbro et al. [75], few clinically controlled trol group and 100 % of those placed in the
studies are available on the effect of autologous Endoret (PRGF) group were successful during

10 Pre-Implant Reconstructive Surgery 187

2 years after placement [42]. The authors have A 1.50 mg/mL rhBMP-2/ACS has been com-
suggested that the positive effect of Endoret pared to autogenous graft for maxillary sinus
(PRGF) on the Ti-Mesh technique could be augmentation [82]. One hundred and sixty
related to its capacity to improve soft tissue heal- patients with less than 6 mm of residual bone
ing, thereby protecting the mesh and graft mate- height were treated. A significant amount of new
rial secured beneath the gingival tissues [42]. bone was formed after 6 months postoperatively
Plasma rich in growth factors employs fibrin in each group. At 6 months after dental restora-
scaffold and endogenous growth factors that tion, the induced bone in the rhBMP-2/ACS
orchestrate tissue healing to promote adequate group was significantly denser than that in the
tissue regeneration and to reduce tissue inflam- bone graft group [82]. No significant differences
mation [79, 80]. These growth factors promote were found histologically. The new bone was
cellular growth, proliferation, and migration [79, comparable to the native bone in terms of density
80] (Figs. 10.14 and 10.15). and structure in both groups. 201 over a total of
251 implants placed in the bone graft group and
199 over a total of 241 implants placed in the
10.3.4 Bone Morphogenetic Proteins rhBMP-2/ACS group were integrated and func-
(BMPs) tional 6 months after loading. No adverse events
were deemed related to the rhBMP-2/ACS treat-
In a systematic review on the effect of using ment. However, when rhBMP-2 has been added
rhBMP-2 in maxillary sinus floor augmentation, to Bio-Oss (anorganic bovine bone), less bone
only three human clinical articles were eligible formation has been observed [81, 83].
for analysis [81]. Two of these studies were ran- Moreover, no significant differences have
domized clinical trials and one was a prospective been found when comparing autogenous bone
study, evidencing the need for more randomized and rhBMP-2/ACS after 6 months postsurgery
clinical trials with a long-term follow-up to pro- (although initially higher bone gain was observed
vide evidence-based criteria for the use of only subcrestally in the rhBMP-2 group) [84]. In
rhBMP-2 for alveolar bone augmentation. The another clinical study, guided bone regeneration
review has indicated that a higher level of initial with xenogeneic bovine bone and collagen mem-
bone gain and density was observed for the group brane was performed with and without rhBMP-2
of autogenous bone than for the group of [85]. There were no significant differences
rhBMP-2 [81]. Furthermore, higher cell activity, between the groups after 3 and 5 years of evalua-
osteoid lines, and vascular richness have been tion [85]. In both groups, the implant survival and
observed in the rhBMP-2 groups [81]. periimplant tissue stability were not affected by
the use rhBMP-2 [85].

Fig. 10.14 PRGF mixed with ABBM Fig. 10.15 Membrane of activated PRGF

188 S. Pardiñas López et al.

Based on these data, a comprehensive assess- Intraoral
ment of the cost-effectiveness of using rhBMP-2 Symphysis
for alveolar bone augmentation should be One study carried out by Pikos that reviewed
performed. more than 500 block grafts concluded that block
grafts harvested from the symphysis show a pre-
dictable bone augmentation up to 6 mm in both
10.4 Options for Preimplant horizontal and vertical aspects [87]. An average
Reconstructive Surgery block size of 20.9 × 9.9 × 6.9 mm can be har-
vested [88], which means that up to a three-tooth
10.4.1 Ridge Augmentation edentulous site can be treated [87].
This type of graft is considered as corticocan- Block Grafts cellous with a density D-1 or D-2, with an average
of 65 % of cortical bone and 35 % of cancellous
Autogenous bone [87, 89]. The corticocancellous nature of
Autogenous block grafts have been used for bone provides faster angiogenesis, achieving a
many years for ridge augmentation procedures more rapid integration and less potential resorp-
for implant placement since it was first described tion during healing [90, 91] (Fig. 10.16).
by Branemark et al. [86].
Treatments with autogenous block grafts Ramus
include different extraoral and intraoral harvest The ramus block graft can be used for horizontal
sites such as the iliac crest, calvarium, tibia, man- or vertical augmentation of 3–4 mm. An average
dibular symphysis, and ramus, among others. block thickness of 2–4.5 mm can be harvested
The election depends on the volume of graft from the ramus, with a length enough to treat a
required, the location of the recipient site, and the defect involving a one- to four-tooth edentulous
type of graft needed. area [87, 92].

Fig. 10.16 3D image representing block graft harvested from the symphysis area (Copyright © Dr. Pardiñas López)

97]. as many studies only The use of membranes has shown a significant report implant survival rates and do not report difference in width and height graft resorption. with higher resorption rates than for hori- (Fig.3 and 1. 97]. related to partial or total loss of the graft. these drawbacks were mostly to occlusal stimuli to the implants [104. timing of Membranes are often used in combination with implant loading. there mize graft resorption [8. respectively [44] (Fig. etc. Resorption Furthermore. problematic with both block and particulate cantly better than cancellous bone [92. site of bone harvesting. Using the same graft source. and results reported in the litera- ture have a great variability. (extraoral) source.1 ± 2.73 mm to 4. studies have reported that resorption of the bone graft consolidates after implant placement. 10. The cortical nature of bone exhibits less Vertical augmentation appears to be more volume loss and maintains their volumes signifi. suf- changes in grafts [96].17 3D image showing a block graft harvested from the ramus region (Copyright © Dr. 95]. in one study was reported in 3. type maximize the regenerative outcome and mini- of implant. which grafted edentulous ridges. other studies (using a CBCT scan) have reported a decrease in width from 6.4 % of the The capacity of bone grafts to resist remodel. 94.3). ing is variable. 10. type of material. Different aspects can Use of Membranes affect these results: differences in observation periods.6 ± 2. implant placement shortly after In the past. 106. 107]. use of provisional dentures on block grafts and/or particulate graft materials to reconstructed sites. 10. but can be excessive if graft dehiscence occurs [87. Wound dehiscence and/or infection is also atively affected the grafted jaws and also the non. is a paucity of information. maintaining the graft volume struct atrophic ridges was criticized because of and preventing further loss [96. Some proteins and growth factors [90.10 Pre-Implant Reconstructive Surgery 189 Several studies have analyzed resorption rates of autogenous block grafts and most of them reported similar rates of resorption (Table 10. Moreover.0 to 5.1 mm of augmented alveolar This type of graft has almost all cortical nature ridges after 4 months of healing [99].0 ± 0. type and site of reconstruction. [89]. before the era of osseointegrated graft consolidation could have a stimulating implants. which neg. One study showed that the contraction in the horizontal bone augmentation with a bone block from the ramus of the mandible was from Fig. due first year after the grafting procedure and in the to a higher concentration of bone morphogenetic first year postloading of implants [104]. Intraoral block graft resorption ranges from 0 to 42 % for vertical augmentation and from 9 to 24 % for horizontal augmentation. zontal augmentations [100–103]. Pardiñas López) 4.6 ± 0. 93] grafts.17). This fact is related to a faster Bone resorption is reported to be higher in the angiogenesis and greater inductive capacity. Maintenance the important resorption that they suffered. Bone blocks harvested from sites derived from One reason could be that the forces exerted on intramembranous bone (intraoral) have been the graft when the soft tissue envelope expands shown to revascularize faster and have less vertically are higher than in horizontal augmenta- resorption than those from an endochondral tions [92]. cases.18). due to the use of removable dentures. of the periimplant bone volume may also be due Nevertheless. 105].77 mm [98]. effect on the bone. fering less bone resorption in cases when a mem- . the use of onlay bone grafts to recon.

5 PS prospective study.5 %. However.8 Autogenous intraoral block 4. Regarding the disad- vantages of the nonresorbable membranes.7 [99] CS 13. the . Complications Both nonresorbable and resorbable mem- branes reported good results. 13.3 % Horizontal 5. but the nonresorb.20. it makes more difficult the surgical technique (needs to be adapted and fixated to the underlying bone to prevent micromotion) and presents a higher risk of exposure which can lead to wound infection and complications [40.12 of Bio-Oss [103] PS 7.7 particles [199] PS 18.46 of Bio-Oss [100] CS 23. 34.190 S.6 [106] CS 23. To avoid this.5–42 % Vertical 5–6 No Block alone 2.21.1 % Horizontal 4 PRGF Ramus block and autogenous 3. and the membrane was exposed [104. 10.5 % vs. Disadvantages.5 No Block graft covered with particles 4. 106].2 [104] CCT 13.6 No Block and autogenous particles 3.5 % Vertical 4.04 % Vertical 4–5 No Block and autogenous particles 4. 108].2 % Horizontal 6 Collagen Block graft covered with ABBM 4. 10.7 % Horizontal 6–8 PTFE 2. One disadvantage is that resorbable mem.1 ± 0.22). SR systematic review. as they report that no membrane is necessary for predictable block graft- ing [87] (Figs. 103]. 0–20 % Horizontal 5 3–7 196–198] and vertical RS [105] CS 17 % Vertical 4–6 No Block graft covered with particles 5. RS retrospective study. Table 10.6 Ti-Mesh Block and autogenous particles 5 [104] CCT 34.38 % Horizontal 6 No Ramus block with autogenous – particles [199] CS 9. Different aspects have to be taken into account able appears to have better results in terms of regarding the success rates of the different bone formation [40. and 10.6 No Autogenous intraoral block 4. mend the use of a membrane if a large quantity of Pardiñas López) particulate graft is used.5 % Vertical 4.3 Resorption rates of autogenous block grafts Type of Time Mean gain Study Resorption augmentation (months) Membrane Comments (mm) [87. the branes resorb relatively fast. this benefit was reduced when Advantages.7 membrane particles [40] SR Horizontal 6.3 % Horizontal 6.38 [200] PS 18. CS clinical study. CCT controlled clinical trial becomes unprotected. The time of evaluation. 10.3 No Block graft alone 4. the type of graft.5 % Horizontal 5–6 No Block alone 5 [100] CCT 32.4 [133] PS 13. 10. other authors only recom- Fig. On the other hand.18 3D image representing a block graft secured with screws in the anterior maxilla (Copyright © Dr. techniques.3 [40] SR Vertical 4.19. brane was used than without membrane. so the block graft residual alveolar ridge present before surgery. Pardiñas López et al. covering the block graft with ABBM particles will prevent surface resorption [103].

all complications should be considered as the final treatment will be affected by the whole range of procedures performed. 111] (Table 10. Temporary nerve disturbances involving the mental nerve have been reported as 10–80 % and 0–37. that were associated with a high rate of compli- Autogenous block grafts have shown evidence cations and graft failure in different studies [97. 97.20 Intraoral picture showing blocks harvested disturbances and graft exposure are the most from the chin area important complications that must be taken into account. 10. inflammation. the tension-free closure. The most common surgical complications include neural disturbances. On 102. of bone augmentation and high success rates. 103]. these techniques are associated with morbidity [92]. 102. Many studies refer to complications only on the recipi- ent site or only in the harvesting area. and hema- membrane or graft. The most common postsurgical area complications reported include mucosal dehis- cences with or without exposure of the grafts or use of barrier membranes.5 % when grafts were harvested from the mandibular ramus [97.10 Pre-Implant Reconstructive Surgery 191 Fig. 10. 102. can influ. Complications must be differentiated in between donor sites and recipient sites. and toma [92. 103. swelling. . Complications have been reported up to 80 % in different studies. also other studies mix these complications.4). among others.21 Block graft harvested from the symphysis review [96]. 108–110]. 10. the lag screw fixation.22 Intraoral picture showing symphysis block area grafts secured with screws in the posterior maxilla area the other hand. It is important to remark that there is heteroge- neity in the literature in terms of what is consid- ered a complication.19 Intraoral picture of the symphysis harvesting Fig. 108. Permanent neural disturbances were reported to 0 % for ramus and 13 % for symphysis in one systematic Fig. 10. Diabetes and smoking are common factors ence in the treatment results. the exposure of the membranes. Although neural Fig.

fast osseointegration of the autoge- is that the donor and recipient sites are in the nous block grafts allows an early reentry for same operating field.26). the quality of bone is simi- lar (mainly cortical). vertical bone grafting is also associated with more complica- tions rates than horizontal augmentations [102].5 % recipient site) [128] RS Ramus 27. in times are reduced as well as morbidity [92]. 22. comparison to the 6–8 months required for the Also these grafts require a short healing period.6 % major. in comparison to other techniques like GBR Cortical nature of the grafts results in optimal or particulate allografts or xenografts [97].5 % 12.7 % [108] SR Intraoral origin 10. 101]. 10.6 % 0. Pardiñas López et al. CS clinical study.5 % (in the Vertical 12.2 % minor) [40] SR Intraoral origin 3.2 % Vertical 10. PS prospective study.9 % Horizontal [40] SR Intraoral origin 24. 10. One important advantage of intraoral grafts Moreover.5 % Horizontal 2.25. and the risk of neural distur- Fig. Block .1 % 12. 10.3 %) 14. the amount of harvested bone may be higher. Table 10. 112]. 97.23 Intraoral picture showing the harvesting area bances is lower [44.23.5 %.192 S. horizontal 29.4 Complications intraoral grafts Total or Complications Neural Dehiscence or Type of partial Study Graft (total) disturbances graft exposure augmentation graft loss [103] CS Intraoral origin 9.5 % [44] CIR Ramus 0–5 % 0–5 % [44] CIR Symphysis 10–50 % 10–50 % [133] PS Ramus 50 % 37.2 % Vertical [96] SR Symphysis 10–80 % 10–80 % [87] SR Ramus 8 % (less than 1 permanent) [87] SR Symphysis 53 (transient) less than 1 (permanent) CIR clinical investigation review.4 % (of the total) [97] CS Symphysis 9.8 % (5. bone density for primary implant stability.6 % 10. 10. particulate GBR techniques. so surgical and anesthesia implant placement. and 10. RS retrospective study Regarding the type of defect. The mandibular ramus donor site results in fewer complications and morbidity and appears to have fewer difficulties in managing postopera- tive edema and pain in comparison with other donor sites [90.5 % Vertical 38. surgical from the ramus access in some patients is more difficult [97] (Figs. mixed 32. SR systematic review.1 % 3.62 % 7. However. often in 3–4 months.1 %. Ramus graft has some advantages as com- pared to the chin area.3 % (5–33.5 % [102] RS Intraoral origin 28.7 %(in the donor area) [97] CS Ramus 0% 0% 0% [108] SR Intraoral origin 43 % 14.24.

Ilium The hip offers an area where large amounts of bone can be harvested. which is the than with other donor sites.28. and tibia have been reported as reliable sources of grafts and are the most common extraoral harvest sites [113]. fracture. preventing collapse and allowing the include temporary gait disturbance. 10.10 Pre-Implant Reconstructive Surgery 193 Fig. hematoma/seroma. Fig. Extraoral Distant site bone harvesting has been suggested as an indication when a large graft is needed. The iliac crest. 10. reported as 87. with per- mission from Elsevier) final goal of the treatment and will be discussed Fig.27 Iliac harvesting site (Reprinted from Kademani and Keller [211]. 10. but these grafts usually have a thin cortical layer and a thick cancellous part [114]. grafts are also good space maintainers during The most frequently reported complications healing. 10.26 Intraoral picture showing a ramus block graft secured in place with a screw However the main disadvantage is the morbid- ity associated with bone graft harvest (Figs. Success of the grafting procedure has been and persistent pain [115–117].27. scaring. . paresthesia.5 % [102]. calvarium. and 10. from 1 to 63. 10.6 %. but the most relevant The reported complication incidence is higher data is regarding implant success. bone to form [90].25 Intraoral picture showing a ramus block graft placed in a maxillary defect further on.29). Copyright (2006). 10. infections.24 Ramus block graft Fig.

However.8 mm. a second surgical site (donor site) is related with higher morbidity [118]. although these results were attributed Fig. related with the personal resistance to pain. which has an average thickness of site are the simple accessibility and the potential 7. hematoma. part of the implant. This variability is also (Figs. which may produce more mission from Elsevier) initial resorption [55]. 44.31). When the resorption of iliac crest bone grafts used for vertical or horizontal onlay augmenta- tion was compared between the maxilla and mandible.28 Iliac harvesting site Reprinted from to the design of the 3.32). Copyright (2006). infection. vested (1 × 2-cm block).75 mm [121] and 0. (VAS) demonstrated that 70 % of the patients scarring. descriptive analysis of the visual analog scale gait disturbance.29 Iliac block graft Reprinted from Kademani one of the indicated harvest sites because it and Keller [211]. the tibia is Fig. paresthesia. Pardiñas López et al.5 % [116]. abundant amount and quality of bone [118]. so it Although this procedure is relatively simple is important to note that complications should and safe. in a range of 1. also be evaluated regarding patient feelings. with permission from Elsevier) provides an abundant amount of bone with a low morbidity [123. Resorption rates of the initial graft height 1–5 years postloading of implants have been reported in a range from 12 to 60 % [40. the resorption in the maxilla was significantly more pronounced after 2 years.85 mm (range of 0–4. the mean bone resorption was 4. Copyright (2006). 10. and 5 % reported that Calvarial oral and hip pain were similar [116. while the grafts were completely resorbed in the maxilla [111]. A Reported complications include prolonged pain. than oral pain.6-mm conical unthreaded Kademani and Keller [211]. and reported more severe pain from the harvest site fracture. 120]. 119]. The mean hospital stay reported in the literature after an iliac crest bone harvest is 3–5 days [118. a and can be higher if postoperative pain/gait is large quantity of cancellous bone can be har- considered.5 mm) [122] before implant placement. 10. 87 % of resorption was found in the mandible. Advantages include a low complication rate. After 6 years. wound dehiscence. it also presents some complications.194 S. . and it is a technically Pain/gait disturbances were reported from 2 to simple and quick surgical procedure [116] 97 % of the cases [44]. Calvarial grafts are usually harvested from the The advantages of the iliac crest as a donor parietal bone. 118]. Tibia The tibia serves mainly as a source of cancellous bone and a small quantity of cortical bone [113]. with per. Other authors reported a mean resorption of 2.30 and 10. infection. 124]. Another study showed that at the 5-year examination. 10. 20 % reported more intense oral pain compared to hip pain.4–5. 10.45 mm [125] (Fig. When cancellous bone is needed.

Copyright (2005). Different studies reported a range of 0–57. Another point of interest is that the scar on the scalp can be visible and can also lead to localized alopecia [116]. with permission from Elsevier) field is in proximity to the recipient site. and 0–12 % to neurosurgical complications [128. 2 % to dura mater exposures. 10. and pain [127.32 Calvarial harvesting site (Reprinted from tions. supe- rior sagittal sinus laceration. subgaleal seroma. this procedure usually requires general anesthesia in a hospital and requires a close postoperative care. 2. hemorrhage. Among which 0. Also minor and severe complications may occur.1 % of cases in which skull depression could be observed [129]. air embolism. A reconstruction by means of biomaterials is necessary to avoid this sequel. [212]. Elsevier) A close neurologic monitoring is required during the first 24 h postoperatively [129]. 10. Fig. hematoma.4–4 % correspond to hematomas. 128]. when compared to other donor sites.1 days of hospital stay is reported in ies showed less resorption of calvarial grafts the literature [128]. meningitis.10 Pre-Implant Reconstructive Surgery 195 Fig. These contrasts in complication rates may reflect differences in study designs and popula. 10. On the other hand. with permission from cal skill [128]. Ruiz et al. and levels of surgi. with permission from Elsevier) Large amounts of bone can be harvested from Fig.7 % of both major and minor complications. such as trepanation of the inner table. most of the stud- mean of 5.30 Tibia harvesting site (Reprinted from Tiwana et al. and a Regarding graft resorption. [212]. 129]. Two studies . harvesting techniques. brain injury. Copyright (2006). infection.33).3 % to alopecia. altered sensation. The main advantage is the presence of a dense corti- cal structure that can better resist resorption [126] (Fig. Also another study reported an 82. depression of the skull.31 Tibia harvesting site (Reprinted from Tiwana the skull with the advantage that the operative et al. 10. Copyright (2006). [213].

6). reported survival rates 0.75 mm) [130]. 131].52 ± 0.25 mm) [122] rates vary from 72.196 S. the resorption was 0. the resorption was 0.6 % grafts. However other Many different characteristics and situations can authors reported that although at 10 months fol. mandibles are reported to be better than in graft- Some studies reported resorption rates of cal. 10. while at a mean follow-up of 19 months ranged from 89. and implant success [130] and 0. influence the osseointegration of implants. Regarding intraoral harvesting sites.8 to 100 % for autogenous onlay bone grafts [44]. while success rates 130]. Implant Placement Implants placed in regenerated autogenous block grafts are predictable operations that have shown high survival and success rates [92].45 mm with calvarial bone grafts range from 86 to 100 % (range 0–1.3 to 100 %. Also.8 to 95. Implant survival and success rates have been reported in the literature in a mean range from 76.3 to 97. Implant survival rates was 0.42 ± 0. followed by implants placed in calvarial grafts. Data were more insufficient in terms of suc- cess rates of implants according to well-defined criteria [96]. at the time of implant placement and at a mean Implant survival rates placed in grafted areas follow-up of 19 months was 0. Pardiñas López et al. The resorption for statistically significant differences between the calvarial grafts ranged from 0.33 to ramus and symphysis. resorption than iliac grafts. such low-up calvarial bone had significantly less as waiting times for implant placement and .5).39 mm range from 60 to 100 %. after 30 months the difference was no longer statistically significant [132]. Copyright (2005). ing maxillae (Table 10. the least implant survival rates occurred in patients reconstructed with iliac grafts.67 mm [130].33 Calvarial block grafts (Reprinted from Ruiz were analyzed for success rates in comparison to et al. compared the resorption of calvarial grafts.85 mm (range of (Table 10. and lastly for implants placed in areas grafted with intraoral grafts (Table 10.35 mm (range of 0–1.5). Implant survival and periimplant bone levels have shown no significant differences between implants placed in block-grafted areas and implants placed in nongrafted native bone [133]. varial grafts ranging from 0 to 15 % of the initial graft height at a mean follow-up of 19.18 mm ± 0.28 mm at the time of implant placement [122.5 mm) at the time of implant placement Survival rates of implants placed in grafted [122]. In the case of iliac and success rates range from 90. with no ramus grafts.5 to 100 %.6 % (Table 10. ranged from 92. with permission from Elsevier) the number of implants analyzed for survival rates.5). Regarding the harvesting site.3 months Time of Implant Placement (range 6–42 months) [44. although the majority of articles reported survival rates of more than 90 %. 0–4. [213]. Regarding ramus placed in grafted areas with iliac bone grafts block grafts. a less number of implants Fig.41 mm ± 0. and iliac grafts.

6 94.4 93.6 94 (86–100) 6–90 [111] SR 90.6). The majority of studies suggest to wait similar The level of evidence for implant survival and times as to implants placed in native bone (3–6 success rates is better for the delayed implant months) [44]. therefore. Due to the high heterogeneity of the studies ment suggest that resorption of the onlay graft is available which analyze many different vari- more pronounced after transplantation. which increases the risk of no Bone for Implant Site Preparation? osseointegration [44].5 100 33 [96]a SR 91.6 82.9 100 13–22 [202] RS 83. although much controversy still exists areas may have a stimulating effect on the bone [44. General conclu- waiting time before the prosthetic rehabilitation.8–83. . 134] (Table 10.9–93 94.5 (92.3 [96]a SR 90.7–97. with the two-stage protocol. Based on the available scientific evidence.10 Pre-Implant Reconstructive Surgery 197 Table 10.5 23. LTR long-term review a Success rates only one-fourth of the total number of implants placed in the grafted jaws. and thus prevent bone resorption [96]. ables. Data were more insufficient in terms of success rates of implants according to well-defined criteria loading.8 12–120 [111] SR 76. 105.5 (60–100) 6–90 [55] PS 72.5 Implant success and survivals when placed in grafted areas with autogenous bone Time (months after Autogenous Study Implant success (%) Implant survival (%) prosthetic load) Ramus [44] CIR 95a 97. care. it is very difficult to compare results of immediate implant placement would shorten the the different treatment options. although there is also evidence placement and may be preferable to simultaneous that an early or immediate loading in grafted placement.7–97. PCT prospective controlled trial.7–100 97.5 6–90 Symphysis [44] CIR 90. Authors that rely on immediate implant place. there In addition. SR systematic review.1 33 ISuccess/60 ISurvival [194] SR 88 12–72 a [96] SR 83–95. 108.5 100 38 [111] SR 93.3–100) [111] SR 95.1 (93–100) [133] PS 89.1 120 [121] PCT 86.3–100) Iliac [131.1 72.8–83. macro. 202] LTR 73. Research It has been suggested that immediate has shown that primary implant stability is cru- implant placement is exposed to some risks cial to the success of implant therapy and to like wound dehiscence (which can expose the determine the election of immediate or delayed graft and lead to infection with the inherent loading.3 99 33 CIR clinical investigation review.7–100 94. bone. How to Select the Donor Site of Autogenous vascular bone. PS prospective study.1 (92. sions can be drawn but must be analyzed with thus preventing resorption [44].and micro-implant geometry and Loading of Implants materials.9 (86–100) [96]a SR 90.1 91 120 Calvarial [44]a CIR 90. risk of losing the graft partially or totally) and that immediate implants are placed into a non. and quality of bone [44]. the are several factors that may help the surgeon to operator can achieve prosthetically better implant decide on the different donor sites of autogenous placement and superior aesthetics [105].

8–92.50 [202] RS Intraoral autogenous 88 60 0–3. 6–240 Maxilla [96] SR X 83–100 91.2–100) 6–240 Mandible (median 89). [96] SR x Onlay iliac 95.9–100 96. 198 Table 10.67 [108] SR x Intraoral autogenous block 89.3 (range 6–120 Maxilla 72.3 [40] SR Intraoral autogenous block 96.9–100 12–24 Horizontal augmentation 0.69 ± 0.2 48 Mandible [120] SR x Iliac 72. .8 (range 6–240 Maxilla 72. [96] SR x Autogenous block 89.6 Implant survivals and success when placed in grafted areas with autogenous bone Immediate Delayed Implant Implant Periimplant implant implant success survival Time bone loss Study placement placement Graft (%) (%) (months) Area (mm) [44] CIR X Autogenous block 79.6–100 12–38 Vertical augmentation [96] SR X Autogenous block 81.69 ± 0.08 ± 0.50 [108] SR X Intraoral autogenous block 89. [96] SR x 83–100 100 6–240 Mandible (median 89).20 ± 0.20 ± 0.9 12 0. Pardiñas López et al.7 (88.9 (range 80–100).9–100 12–60 Horizontal [40] SR Intraoral autogenous block 96.6 12 [96] SR x Onlay calvarial 100 12–36 [203] RS x Intraoral autogenous 89.9–98 22–24 Vertical [120] SR x Iliac 88.2–100) 6–120 Mandible [44] CIR x Autogenous block 100 6–120 Mandible [108] SR x Intraoral autogenous block 96.5 100 12 (0.5–91 95.9 to 0.67) [203] RS x Intraoral autogenous 96.3) [44] CIR x Autogenous block 93. RS retrospective study S.9 12 Horizontal augmentation 0.3). SR systematic review.9 96.1 (88.4 (range 80–100) 6–120 Maxilla [44] CIR X Autogenous block 92.8–92.8 120 [120] SR x Iliac 83 Maxilla CIR clinical investigation review.

selection of an intraoral donor site [54].4 % with recreation. and 7. 15.28 % dehiscence 7.3 % major. LTR long-term review.8 % 0–2 % (0–12 % in 86 % skull other studies) depression [44] CIR Calvarial 0% CIR clinical investigation review. SR systematic review.5 % with work activity. 31.3 % 0. 14. RS retrospective study a 15. 7.8 % 100 % (within 15 days) pain as a complication) [119] SR Iliac 19.4 % minor [204] CIR Iliac 17 % (excluding pain) 97. vertical bone grafting is associated physis could provide sufficient bone to achieve with more complication rates than horizontal a horizontal augmentation of 4–6 mm [90.44 % 7.6 % 23. whereas a block from the mandibular Intraoral grafts have the advantage that ramus provides sufficient bone to thicken the donor and recipient sites are in the same oper- alveolar ridge by 3–4 mm [90]. followed by intraoral and calvarial grafts.37 % (10–39 %) 0.5 % with household chores.55 % reported some difficulty walking.5 %a [118] PS Iliac 20 % (excluding pain) 5% 65 % irregularities on gait and 25 % walking aid necessity [44] CIR Iliac 2% [117] RS Iliac 1.8 % with sexual activity.2 % major. Bone blocks retrieved from the sym. augmentations. 11. 136].7 % 19.5 % minor [129] RS Calvarial 6.4 % irritation from clothing .75 % more than 6 or graft exposure months [111] SR Iliac – 17–34 % (need for the use of crutches 37–50 %) [128] RS Iliac 63. The most common surgical amounts of bone which makes feasible the complications include neural disturbances. However. 16.02 % [128] RS Calvarial 57. Also regarding the type [135]. so surgical and anesthesia times Table 10.7).4 % at 1 month. ating field.10 Pre-Implant Reconstructive Surgery 199 • Graft volume: • Surgical morbidity: Extraoral donor sites are usually selected Harvest of iliac crest bone is associated with when a large amount of bone is needed for the highest percentage of complications. reconstruction of alveolar bone Intraoral harvest site complications have been for the placement of dental implants is usually reported up to 80 % in different studies localized to a small area and requires smaller (Table 10.5 % 7. jawbone reconstruction [54].7 Complications of extraoral grafts Neural Study Graft Complications disturbances Comments Pain/gait [115] LTR Iliac 1–25 % [116] SR Iliac 1–30 % 26. of defect. A Temporary nerve disturbances and morbidity recent study in cadavers showed that grafts have been reported more in grafts harvested harvested from the symphysis had higher from the symphysis area than grafts harvested thickness than grafts harvested from the ramus from the ramus area. 35 % 56.42 % at 6 months.4–16.88 % (not including 0. PCT prospective controlled trial. PS prospective study.28 % at 1 year [121] PCT Iliac 30 % [116] SR Calvarial 0. 38.

cation) and the alveolar bone (intramembra.200 S. membrane was not used.7). compensate graft remodeling [99]. These data would indicate the importance Different studies reported that the mean of taking measures to compensate the loss in gain at the time of implant placement (4–6 graft volume. than the bone graft from the iliac crest [47]. Long.3 % to show higher resorption rates than horizontal of the cases of alveolar ridge augmentation. 96]. at long-term follow-up. intraoral and extraoral grafts could be expected Intraoral block graft resorption ranges from [96]. and mainly The hip offers an area where large amounts cortical bone can be harvested. temporary pain/gait disturbance [96]. although that can better resist resorption. It has been one study reported an 86 % of cases presenting reported that calvarial grafts show less initial skull depression (Table 10. 141]. but it usually has a Main disadvantages of bone harvesting from thin cortical layer and a thick cancellous part extraoral areas include morbidity and hospital. Large amounts of bone can be harvested standing pain/gait disturbances were reported from the skull with the advantage that the from 2 to 97 % in the literature. do not provide sufficient rigidity period of time [94. and vertical augmentation appears wound dehiscence/infection occurred in 3. 126. then it is highly rec- that could influence the success of bone aug. are reduced as well as morbidity. resorption when compared to other donor • Promotion of new bone formation: sites. however.2 to 7 mm of bone substitutes could be useful tools to for intraoral autogenous grafts (Table 10. The surgical operative field is in proximity to the recipient morbidity when calvarium was used was site and that presents a dense cortical structure reported to be lower. This is a factor If a bone block is needed. Also have reported that the most frequent complaints resorption is more pronounced in the maxilla of bone harvesting from the iliac crest were the than in the mandible. Overaugmentation and the use months after grafting) ranges from 2. Uneventful healing/consolidation of both ume significantly better than cancellous bone. exhibits less volume loss and maintains its vol. Initial ization for general anesthesia and requires a resorption rates appear to be more significant longer surgical procedure [109.3). 137]. Pardiñas López et al. 142]. of bone can be harvested. ticulate bone. the use of membranes has shown less The embryonic origin is different between the bone resorption in comparison to cases when a extraoral harvested bone (endochondral ossifi.7 %. 140.4 % of the .5 %. while the dehiscence and/or infection is related to par- ramus has almost all cortical nature which tial or total loss of the graft. which is prone to more resorption. which provides faster angiogenesis. • Healing: nous ossification) [138. Studies in comparison with intraoral grafts. prostheses connection were documented with cated that bone harvested from an intraoral the use of extraoral autogenous block grafts site would result in higher total bone volume [8. augmentations. if not associated with titanium whereas endochondral bone graft undergoes a mesh membranes or titanium-reinforced variable degree of resorption over a variable membranes. The study indi. Cancellous bone alone and par- graft seems to maintain better its volume. 139]. sional removable dentures and may undergo achieving a more rapid integration and less almost complete resorption [86. to withstand tensions from the overlying soft Symphysis grafts have a corticocancellous tissues or from the compression by provi- nature. Extraoral to the total bone volume present in biopsies resorption rates of 0–15 % in calvarial grafts obtained from augmented maxillary sinus and up to 60 % in iliac bone grafts after the with autogenous bone [47]. differ- One meta-analysis was performed in relation ences may not be significant [122]. One systematic review reported that 0 to 42. from 0 to 57. Wound potential resorption during healing. while total graft loss occurred in 1. ommended to use corticocancellous bone mentation surgery as intramembranous bone blocks [96]. • Stability of augmented bone: Also.

grafts presented a resorption of 2.2 Particulate Graft: Guided permitting the selection of blocks with a pre.5 mm. first populate a wound area determine the type of and many different aspects have to be taken into tissue that ultimately occupies the original space. cations [143–145]. graft wound dehiscence and membrane screws.5-mm vertical gain and an average horizontal implant survival and success rates occurred in gain of 3. account like defect selection. The use of allogeneic bone block grafts repre- vesting has changed directions to the use of allo.9– grafts (as block or particulate form) still remain 90. enabling the the analyzed cases focused on anterior graft sites ingrowth of osteogenic cells and preventing having little information in posterior alveolar migration of undesired cells coming from the soft ridge augmentation. Bone Regeneration defined configuration and corticocancellous The concept of guided bone regeneration (GBR) composition [143].92–4. osteogenesis can occur without In terms of block graft failure rates. [147]. tissue. none was and lastly for implants placed in intraoral observed in the others after 3–4 months after grafts.79 mm [143. morbidity discomfort was first described in 1959 when cell-occlusive and operation time are reduced [144]. the quality of the source. with allogeneic blocks can achieve similar zontal ridge augmentation procedures [8]. the majority being related to extensive exposure appear to be the most common compli- reconstruction with iliac grafts [96]. Success rates in a range of 86.34). implant survival rates as implants placed in areas The behavior of an allograft depends not only grafted with autogenous block grafts. membranes were employed for spinal fusions Clinical evidence for allogeneic block graft.4. autogenous bone rates [143. implants placed in areas grafted FDBA and DFDBA block graft material in hori. They remained stable after implant grafted mandibles are reported to be better placement during the 26 months of follow-up than in grafting maxillae (Table 10. such as particulate grafts. Different space maintainers have been Graft failures most often involved mandibular described. and as with autogenous resorbable and nonresorbable membranes. 10. site morbidity associated with block graft har. The level of evidence for implant survival In another study. successful alveolar ridge augmentation using allogeneic onlay grafts has a high (92.1. Sites yielded an average of Regarding the harvesting area. Different studies demonstrated success with Furthermore. 144].10 Pre-Implant Reconstructive Surgery 201 cases. treatment This technique is used for space maintenance approaches. posterior defects (71 %). 144]. However.5 % was reported in one case series and a sue cells [148–150] (Fig. months after grafting [144].0 % have also been reported in another study the gold standard for ridge augmentation. Also implant survival rates placed in grafting. [146]. Therefore. a range of the interference of other competing types of tis- 2–8. sents a reliable alternative to autogenous block genic materials. on the harvested bone but also on the method in these conclusions should be interpreted with cau- which the harvested bone is prepared and also on tion due to the limitation of studies [144]. Also many of over a vertical or horizontal defect. among others. . Also.97 % at 6 placement and may be preferable to simulta. only one of the 57 allogenic block lowed by implants placed in calvarial grafts. neous placement. block grafts.6). donor [111]. In one study. the least 2–3. grafts for augmenting the atrophic maxilla. fol. patients reconstructed with iliac grafts. 145]. and onlay. systematic review [144. and follow-up period. Allograft bone grafts have the advantage of 10.8–99 %) Allogeneic short-term (less than 5 years) implant success Although for many clinicians. although much controversy The studies examined reported evidence that still exists. allogeneic block graft resorp- and success is better for the delayed implant tion ranged from 10 ± 10 % to 52 ± 25. This principle is based on that cells which ing is mainly limited to case series and reports.

35.38 Intraoral picture showing the grafted area (Figs. 10. Studies reported a mean augmentation from 2 to 4. 152].36 Intraoral picture showing a bone defect filled migration of undesired cells coming from the soft tissue with particulate xenograft (Copyright © Dr. GBR and GTR are based on the same prin- ciples [2. Pardiñas López) Fig. including the cementum. 45] Fig. while success rates ranged bone in situations where there is inadequate bone from 61. 10. GTR is referred to the regeneration of the periodontium.37. 8]. enabling the ingrowth of osteogenic cells and preventing Fig. whereas GBR refers to the promotion of bone formation alone.36. peri- odontal ligament. and alveolar bone.202 S. Studies reported implant survival rates in a eration is a successful method for augmenting the range of 76. The membrane acts a barrier. 10. Fig.5 to 100 % in a period of 6–133 months. Pardiñas López et al. which is inappro- priate. 44.38). 10.35 Intraoral picture showing a bone defect in the covered with a nonresorbable membrane and secured with maxilla screws Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are often used to describe the same procedure. 10. sutured and completely covered by soft tissue Implant Survival/Success It has been documented that guided bone regen. and 10.8–100 %. which is comparable to .5 mm for horizontal augmentations and from 2 to 7 mm for vertical augmentations [8.34 3D image representing the principles of guided bone regeneration. 10. higher than 90 %. 10.37 Intraoral picture showing the bone defect Fig. volume for the placement of endosseous dental Most of them showed survival/success rates implants [151. 10.

sure was present at the time of suture removal. defined [44]. 155]. Rates of expo- versus simultaneous) does not seem to affect the sure have been reported up to 50 %. particularly survival/success of the treatment [7].8). grafting materials and different membranes [44]. soft tissue dehiscences and exposures. the chances of partial or total loss of the graft. the time of implant placement (staged premature membrane exposure. Alveolar split osteotomy can be used to widen a The greatest amount of bone loss is reported horizontally narrow mandibular ridge. augmenting analyzed with care.8). they have less ability to the type of grafting materials used in association maintain an adequate defect space than a nonre- with membranes. It was demonstrated that the initial bone gain 10. no conclusive recommenda. 113. indications regarding the choice of simultaneous and can lead to infection and eventually partial or vs. or piezosur- dentures and may suffer from partial or total gical devices. Advantages. not associated with membranes of titanium 158. bioab- The type of graft material (or without material) sorbable membranes can experience premature and the use of resorbable or nonresorbable mem. Following ferent materials used. but not affecting the treatment final sorbable membranes were used. delayed implant placement have yet been total loss of the regenerated bone [8. of crestal bone width and a certain amount of Cancellous bone alone and particulate bone. It is classi- to be within the first year after loading and there. and However bone resorption was more pronounced Disadvantages in sites with GBR treatment [154]. for vertical augmentation. With the use of sequentially resorption [96]. using chisels. 153]. while procedures in the maxilla ridge augmentation. the bone can be forced . expanding osteotomes. con. tions can be given to clinicians as it is difficult to Although collagen barriers offer improved correlate the survival/success rate of implants to soft tissue response. Failures are mainly reported to be related to Also. the wide range of initial this reason. those performed in the mandible (Table 10. so no when large vertical augmentations are performed. this conclusion must be the regenerated bone matrix [8. osteotomes. and 44 % of the nonresorbable had to be removed Resorption prematurely [8]. This technique can be applied to extraction socket ences were found regarding vertical or horizontal defects. localized defects.4. Different studies report a range of 0.3–2. Complications. when a particulate graft is selected defects.8). and the paucity of comparative.2 Alveolar Split Osteotomy undergoes contraction over time (40 % of the ini- tial bone gain) [44]. branes (including titanium meshes) do not seem to Communication with the oral cavity acceler- affect the clinical survival/success of the implants ates their resorption rate and contamination of (Table 10. 156. may not provide sufficient rigidity to The procedure consists in splitting the alveo- support tension from the overlying soft tissues or lar bone longitudinally provoking a greenstick from the compression by provisional removable fracture. 156].10 Pre-Implant Reconstructive Surgery 203 implants placed in native bone [44. because of the wide range of dif. although some authors reported that One study showed that in 16 % of the cases a staged approach may have a lower risk for where GBR was performed using resorbable crestal bone loss as compared with a simultane. 157]. horizontal and vertical augmentation. Like the nonresorbable membranes. and correction of dehiscence tend to have lower implant survival rates than and fenestration defects around implants [8.9-mm resorption in a mean of 65 months of follow-up (Table 10. a rigid membrane may trolled. membrane expo- outcome [44]. meshes. if cancellous bone present to perform it [8. split-mouth studies comparing different be used to protect the graft [156]. sorbable one. membranes and in 24 % of cases where nonre- ous approach. which is more rigid [8]. cally admitted that there must be at least 2–3 mm after seems to remain stable [7]. No differ. However. 159].

3 % 98 % (range 6–133 2–4.5 % (all 74 failures in maxilla) [194] SR All 95.5 mm specified) 76.1 % 60 just membrane [162] PSR Autogenous or PTFE 0.9 mm 92.2 % 12–72 (93.6 % 60 CIR clinical investigation review.5 mm 96. 204 Table 10.3 ± 0.4–99 %) [44] CIR Horizontal GBR (all materials. Pardiñas López et al.5 [154] PS ABBM and resorbable membrane 1.83 mm 95. allograft.5–97.5 %) (99–100 %) [44] CIR All with resorbable membrane 91 % 95–100 % 6–133 [44] CIR All with nonresorbable membrane 61.1–100 % 22. not 67–100 % 1–2.8–83.5–100 % 92–100 % 6–133 [205] PS Autograft.5 % 12–72 [194] SR Xenograft 96.3 % range 6–133 2–7 mm specified) (61. both or none with 2.8 Guided bone regeneration Study Grafting material Success Resorption Implant success Implant survival Time (months) Bone gain [7] RM Autogenous/allograft 0.4–60 [112] SR Not specified 95.64 ± −0.9 mm 86–98. SR systematic review.03 ± 0.8 % ± 5.3 % 56.5 ± 25. not 67–100 % 1–2. RM randomized multicenter.8 mm 76. PS prospective study.22 mm 97. PSR prospective systematic review S.8 % 60 (Polytetrafluoroethylene) membrane (maxilla-mandible) alone [162] PSR Autogenous or xenograft 87–95 % 84. .8–100 %) [44] CIR Vertical GBR (all materials.21 mm 92.6 % range 99.4 % 60 [154] PS ABBM and nonresorbable membrane 2.

9 Alveolar split osteotomy Success of Implant Implant Time Study procedure Resorption success survival (months) [96] SR [44] 98–100 % 86. PS prospective study.5 to 100 % in the studies analyzed. ranged from 86 to 100 % in a 6–144-month Fracture of the buccal plate during the ridge period. RS retrospective study a Achievement of primary stability of the implant was impossible at six sites.2–97. cancellous bone layer between the two cortical The gap created by sagittal osteotomy/expan. reducing morbidity and costs [8. Implant Placement Success rates of the surgical procedure ranged In the studies reviewed. 10. 1.3 % 6–93 CIR [162] PSR 87. which is consistent with placement in expansion is reported to be the most common native bone.8 % 86–100 % 12–60 [167] CIR 1. plates [159].5–97. Pardiñas López) Table 10.4 % 6–144 [166] PS 97 % 27 (0–93) CIR clinical investigation review.10 Pre-Implant Reconstructive Surgery 205 Fig. SR systematic review. these were recorded as failures buccally with the possibility of interposition complication.9).1 mm 100 %a 52. 161–164] (inlay) bone grafts or simultaneous implants to (Table 10. ence of highly compact bone and the lack of a 113.39).77 ± 1. survival rates of implants from 87.2 % 100 % 6–96 0. 10. keep the segments separated and to shorten the The limitations of this technique are the pres- treatment time.69 mm (first year and an annual 93. Implant success rates ranged from . PSR prospective systematic review.5 % 91–97. 158.39 3D image representing the alveolar split technique (Copyright © Dr. sion follows a spontaneous ossification with a mechanism similar to that occurring in fractures. 160] (Fig. from 4 to 22 % [96.06 mm) after loading.61 mm vertical between postoperation and loading [194] SR 97.5 % 0.4 [161] RS 93.

the mean ridge width aug. 165. duces continuous bone formation.40 and 10. In one retrospective study. Copyright (2010). 10. Copyright (2010). the few the segment can be achieved in a vertical and/or a available homogenous data shows that a slightly horizontal direction. The primary advantages of the ridge split The classic basic principles suggest an initial technique using particulate graft.61 mm of vertical bone loss between postoperation and loading was also reported [161].03 ± 0.77 + −1. with permission from Elsevier) in the gap defect created when two pieces of bone are separated slowly under tension. 10.3 Distraction Osteogenesis Fig. Pardiñas López et al. The gradual ten- obtain a graft from a separate donor site [8] sion placed on the distracting bony interface pro- (Figs.41).35 mm) in a mean time of 52.41 Intraoral picture showing alveolar ridge split- ting with implants placed and space filled with particulate Distraction osteogenesis relies on the long- bone graft (Reprinted from Gonzalez-Garcıa and Monje standing biologic principle that a new bone fills [214].40 Intraoral picture showing alveolar ridge split. 1. 10. the mean marginal bone loss during the first year was reported as 0.42).69–0.42 3D image representing the distraction osteo- genesis technique and the distractor device (Copyright © Fig. Fig.4 months [167]. and the adjacent tissue expands and adapts to this gradual Resorption tension (histogenesis). resulting from avoiding the necessity to approximately 1 mm per day. The process involves cutting more marginal bone loss can be expected com. 10. block graft. and implants are usually placed at the [167. The mean vertical bone loss was time of distractor removal [8] (Fig. Distraction of 86. or latency period of 5–7 days. regeneration. A consolidation phase is needed for 3–4 months in order to allow bone In different studies.1 mm (ranging from 0. Then an appli- pared with implants placed in intact bone [159]. Dr. The distraction appliance is then mentation was 3. 166]. .93 mm–4. an osteotomy in the alveolar ridge.065 mm in the following years. 10.4.67 mm removed.35 to 4.5 % [90. ance is screwed directly into the bone segments. However.43 mm followed by an annual loss of 0.206 S. 10.5 ± 0. the appliance is grad- GBR are that treatment time and morbidity are ually activated to separate the bony segments at reduced. Pardiñas López) ting with implants placed (Reprinted from Gonzalez- Garcıa and Monje [214]. 168].2 to 97. with permission from Elsevier) 1.

4 % 94. and Complications This technique presents a low postoperative mor- bidity because there is no need of bone harvest- ing. 96] (Table 10.43 Intraoral picture showing a distractor device pared to other grafting approaches [165.7 % 12–72 [111] PS 0.9 % (88–100 %) 6–72 [194] SR 94. bone gain may not be well controlled and an ade- quate thickness has to be present. PS prospective study.45. However.3 + −0.2 % 100 % 34 (15–55) 9. making a Fig. and after removing osteotomy performed (Courtesy of Dr.3 mm and 1.46.7–100 %) [169] SR 96.7 to 100 % [44.10). Cristina Garcías) Bone resorption before implant placement was reported as 0. 10. this procedure has some limitations. 133. Another advantage is that the soft tissues overlying the distracted area also grow.3 mm (after 4 years) 2–8 mm) [44] CIR 98.43.10).47). Data on implant success in distracted bone at 3–5 years postloading showed favorable results com- Fig.4 mm after 4 years postloading [133].4–100 %) 6–60 3–15 mm (96.9 mm (4–15 mm) [165] SR 90.10 Distraction osteogenesis Success of the Implant Time Study procedure Resorption success Implant survival (months) Gain [96] SR 94.3 5. 10.3 mm implant placement) (range 1. Moreover. 10.4 % 36 6.3 mm (before 94. Implant survival rates reported ranges from 88 to 100 % after a period between 6 and 72 months after prosthetic rehabilitation. which are similar to implants placed in native bone [96. (Figs.2 % 95. 10. MPS multicenter prospective study The mean bone gain reported ranges from 3 to 15 mm.2 % 97 % (90.5 mm (3–15 mm) CIR clinical investigation review.44 Intraoral picture showing an activated distrac- provisional prosthesis while the device is in use is tor device placed in the anterior maxillary ridge with the very difficult or impossible. Also.7 % 100 % 41. Cristina Garcías) . 10.44. and the overall success rate of the proce- dure is reported to be in a range from 96. 10.10 Pre-Implant Reconstructive Surgery 207 Table 10.5 % ± 4.5 % 20 ± 22 [206] SR +90 % More than 48 [207] MPS 94. Advantages. SR systematic review. and 10. Disadvantages. 165]. 169] placed in the anterior maxillary ridge (Courtesy of Dr. The cumulative success rate of implants was reported as more than 90 % (Table 10. there is a low risk of infection of the surgical site.

47 Panoramic x-ray showing the distrac- tor device placed in the anterior maxilla (Courtesy of Dr. Pardiñas López et al. damage to basal bone (2. Complications include fracture of the move- able segment.7 %). Histologic results seem to demonstrate that distraction osteogenesis allows formation of ade- quate quality and quantity of bone tissue. and appearance. native intact bone [96]. compromised speech. Other disadvantages include the need provisional prostheses for 2 months [133].3–35. which can provide primary stability of implants and favorably withstand the biomechanical demands of loaded implants.1 % of the cases [96. for this reason. Cristina Garcías) . Cristina Garcías) and transient paresthesia in the innervation area of the mandibular nerve (1. increase in patient discomfort dur- ing activation of the device.208 S. A sec. 112. lowing after the distractor device was removed. Fig. 165].6 %).4 %). 10. resorption of the moveable seg- Fig. Cristina Garcías) of initial bone gain before implant placement. for daily activation. it (Courtesy of Dr. 10.7 %). Particulate The majority of authors reported some relapse graft was placed over the defect to augment the ridge hori- zontally (Courtesy of Dr. patients cannot wear any removable tor [112]. inadequate bone formation (2.45 Intraoral picture showing the intraoral device ment (7. eating. the device. 10.46 Intraoral picture showing the distraction fol. placed in the anterior maxilla and the soft tissue covering 2 %).6 %). Total failure of the procedure was reported in only 1. 169]. it is rec- ommended for an edentulous ridge span of at least three missing teeth [8. ond surgery is also needed to remove the distrac. Survival and success rates of implants placed in distracted areas are consistent with those reported in the literature for implants placed in Fig. fracture of the distraction device (1. Smaller ridge defects of one or two teeth in width were associated with higher rates of com- plications in different studies when treated with the distraction technique. incorrect direction of the distraction leading to excessive bone on the lingual aspect (8.

Therefore. SR systematic review due to marginal bone loss of the most coronal Also more implants were lost when placed at the part of the distracted segment.2–14.1 %) 12–108 [96] SR LeFort 99.49). 96] (Figs.7 % (67–95 %) 6–140 inlay iliac) [44] CIR Inlay mandible 98 % 10–15 % at the 95 % 90–95 % 12–84 (from iliac) time of implant placement [57] SR LeFort 89 % (60–96. onlay grafting. and 10.8 to 99. 57.48 and 10. When compared with the onlay technique. low-up and success criteria of implants.1 LeFort I cases. 10. The most common complications relationship [44. adequate scenario for implant placement.8 % 82. None of the publications reviewed proposed 10. crestal placed in two stages (4.11).4.9–91 % 87. may cedure was reported to be 3.5 % [96]. quality with regard to the completeness of fol- wich grafts) are mainly performed for recon. Few publica- bone changes around implants after the start of tions reported implant success rates according to prosthetic loading seem to be similar to those well-defined criteria in a range of 82. partial graft loss (3 %).9–91 % 88. an same time of the osteotomy (6.1 % (range of not be enough to achieve a correct intermaxillary 0–10 %).4. PCT prospective controlled trial.4. although lower.62 %) [96].7–95 %) [121] PCT Inlay 90 % 100 % 18 (17–22) CIR clinical investigation review.5 % 82. although it could create an The overall complication rate of this surgical pro. However. LeFort I osteotomy in association with inter- Big differences exist between augmenting the positional bone grafts and immediate or delayed mandible or maxilla with interpositional grafts implant placement is a reliable and demanding (inlay) and performing a LeFort I osteotomy in procedure that should be limited to severe maxil- the maxilla.4. outcomes. the Reported success rates of the grafting proce. but requires an experienced surgeon. Despite structing vertical defects.2 % at 4 months post- Different studies reported implant survival surgery) [121] and produces more predictable rates in a range from 60 to 96.9–91 % occurring in cases of implants placed in native [96]. segment is secured in its final position.4.9 % Two (range 66.4 Interpositional Bone Grafts: immediate loading of implants placed in the LeFort I Osteotomy and Inlay reconstructed maxillae [96]. Implant survival rates. can nonreconstructed bones [96]. lary atrophy cases which are associated with an unfavorable intermaxillary relationship. include wound dehiscences (3–4 %).96 %) than when overcorrection was suggested. inlay technique is associated with lower bone dure range from 95. Bone Grafts The analysis of the available publications demonstrated an average poor methodological Interpositional bone grafts (also known as sand.10 Pre-Implant Reconstructive Surgery 209 Table 10. . resorption values (10.5 % 82. be compared with those of implants placed in native maxillary bone. In these 10.1 % (Table 10.11 Le Fort I osteotomy and inlay bone grafts Success of Implant Time Study Graft the procedure Resorption success Implant survival (months) Stage [44] CIR LeFort (with 95. some conclusions can be drawn.2 Inlay midpalatal fracture (2 %) [96]. postopera- tive sinusitis (3 %). The osteotomized bone these limits.9–91 % 90.5 % One (range 79–95 %) [96] SR LeFort 99.

85 mm (0.3–1. Copyright (2011).48 Intraoral picture showing a LeFort I osteot- omy (Reprinted from van der Mark et al. the overall the outcomes are similar for both graft proce.50) (Table 10. include dehiscences (10–20 %) and neural distur. Pardiñas López) Fig.7 mm (1. with permis. Up to 40 % graft incorporation than the onlay method by of the patients reported altered sensation in the assuring blood supply by the cranially displaced lip during the first weeks after surgery [121].9 % of implant placement 4 months post graft 17.3–4. 10. while the success rate of implants (95 %) was The most common reported complications reported only in one article [44]. 10. segment [121] (Fig. once implant placement is performed. For inlay grafting in the mandible.4.2–2.10–2.8 mm) at 100 % 86.7 mm) at 0. [215]. with permission from Elsevier) Fig. dures (Fig.8 mm) at 100 % 90 % time of implant placement 4 months post graft 18 months (range 17–22) Onlay 4 mm (2–4.1 mm (2. survival rate of implants ranged from 90 to 95 %.210 S. However. Pardiñas López) Table 10. Copyright (2011). 10.5 months (range 13–22) .7–6.50 3D image representing a vertical osteotomy in the mandible with an interpositional inlay graft (Copyright © Dr.5 mm (0.12). Pardiñas López et al.9 mm) at 0.51 3D image representing a vertical osteotomy omy with inlay particulate graft placed (Reprinted from with an inlay particulate graft secured in placed by mean van der Mark et al.51). The inlay technique provides superior bone bances in cases of posterior mandible. 10.49 Intraoral picture showing a LeFort I osteot. 10. Fig. 10. 10.5 Sinus Augmentation Procedures The edentulous posterior maxilla is often a chal- lenging site for implant placement because of Fig.9 mm (0.3 mm) at 0.9 mm) at time 2. of titanium plates and immediate implant placement sion from Elsevier) (Copyright © Dr. [215].12 Onlay versus inlay technique Implant Implant [121] Vertical bone gain Resorption of the graft Periimplant bone resorption survival success Inlay 4.

56). although few studies reported information grafts. such as type of implant (machined vs. Evidence-based reviews have reported positive outcomes using different graft materials for maxillary sinus augmentation. placing graft material between the sinus membrane and the residual alveolar ridge. 10.7 to 100 % (machined or rough). 173]. poor bone quality.53 Intraoral picture showing the lateral wall plasts. The lateral wall sinus augmentation approach is considered as one of the most versatile pre- prosthetic surgical techniques.55).4. was introduced to restore this anatomic deficiency. Since then. 10. and 10. on this (Fig. Recent systematic literature reviews have demonstrated that the sinus augmentation procedure is well docu- mented with an overall implant survival rate well beyond 90 %. 10. differences were found between different bone ters related to implant survival are the preoper. 10. the implant surface to well-defined criteria range from 74. delayed. grafts in implant survival rates except block .52. 10. residual crestal bone. such as autogenous bone. with the majority of articles report- ing values higher than 90 %. 10. 171] (Figs.10 Pre-Implant Reconstructive Surgery 211 atrophy of the alveolar ridge. Fig. Regarding the type of material. initially published by Boyne and James [170] and described by Tatum [28]. but adequate quantity for implant placement [172. allo. and type of grafting material.54 Intraoral picture showing the lateral wall and even higher to implants placed in native bone osteotomy in the posterior maxilla with poor quality of bone. The maxillary sinus augmentation procedure. xenograft. Various approaches osteotomy performed with a piezoelectric unit have been proposed in order to achieve the neces- sary bone dimensions for the insertion of implants in the atrophic posterior maxilla [24. as many variables influence the outcomes. immediate vs. and increased pneumatization of the maxillary sinus [24]. and the use of block [96].1 Lateral Approach It is important to mention that results of the ana- lyzed studies must be reviewed with caution. sinus aug- mentation procedure has been shown to be a pre- dictable technique to increase available bone height in deficient posterior maxillary ridges Fig. 171]. 10.53. rough). which is comparable Fig. use of mem- branes. 10.52 Intraoral picture showing the lateral wall prior to implant placement.54.5 to 100 % in the ana- lyzed studies. allografts. no statistical The most statistically significative parame.5. Success rates of implants according ative residual crestal bone. Overall. and combinations of these graft materials osteotomy [24. survival rates of implants were reported in a range from 52.

Block grafts seem to reduce the survival rate of implants compared to particulate auto. 10. 10. 10. 10.60 Intraoral picture showing the lateral wall osteotomy covered by a PRGF membrane grafts. individuals [58]. In one meta-analysis of the volume changes grafts. 10. and a wide varia- cult because of the many variables existing [52] tion in graft resorption was observed between (Figs. Pardiñas López) Fig. Fig.212 S.57 Intraoral picture showing the lateral wall osteotomy Fig. . 10. 10. 10. Branches of the osteotomy with ABBM particle graft posterior superior alveolar artery can be observed in con- tact to the Schneiderian membrane Fig. after maxillary sinus augmentation. culated for controlled studies.58.56 3D image representing the elevation of the Schneiderian membrane through a lateral approach (Copyright © Dr. Pardiñas López et al. 10. the weighted gous particles than in block particles (Table 10.57.55 Intraoral picture showing the lateral wall Fig.59 Intraoral picture showing the lateral wall osteotomy with ABBM particle graft filling the sinus Fig.1).58 Intraoral picture showing the lateral wall osteotomy without the lateral bone block. comparison of survival rates is diffi.59. mean average resorption was 48 ± 23 % when cal- But again. although resorption is higher in autolo. and 10.60).

37.to <3-mm residual crest and an Fig. a 55 % reduction in hazard risk of failure was observed comparing 3–4. different studies show no statisti- cally significant difference in the survival rate of implants placed in simultaneously or delayed.1) [49]. Rates were reported to be 61. Implants that were immediately loaded indicated that there was no evidence whether the . some authors demonstrated that the survival of implants placed at the time of sinus augmentation using the lateral window approach is increased with crestal ridge heights >3 mm [8. and graft material is reported to have a positive larly controversial. one meta-analysis implants. some authors have sug. 10. 51]. and quantity to allow primary stability of implants [96] (Figs. and risk for low primary stability rates ranging from 93. maxilla.02–5.3 % gested that immediate loading is applicable for when no membrane was used [40. Moreover.1–96.61 3D image representing a pneumatized maxil- another study reported that delayed implant lary sinus without enough height to place an implant placement had a 2–3-fold higher hazard risk of (Copyright © Dr. 10. However Fig. Pardiñas López) implant failure in comparison with simultane- ous implant placement (HR = 2.1 to 100 % when mem- [171. 10. 95 % CI 1. barrier membranes over the lateral sinus window lowing sinus augmentation procedure is particu. reduced Different studies reported implant survival bone volumes. 10.7–100 % (mean 93.10 Pre-Implant Reconstructive Surgery 213 As far as the timing of implant placement is concerned. 175]. 96.7 %) in the case of a staged approach (Table 10. were not considered (which reduce implant sur- 177]. branes were used and a survival of 78.50) [171]. the survival rates with and without could positively influence the rapidity of bone the use of a barrier membrane were almost iden- mineralization also during the early modeling tical [40]. 96] (Fig. was analyzed. Few studies have been effect in terms of implant survival and new bone published on immediate loading in the posterior formation [8. another study reported a reduced were higher when a membrane was placed over implant survival with the immediate loaded the window [51].62).64). They suggest that early functional loading vival rates). it was shown in a systematic review with high implant survival rates (100 % in 13–24 that when smooth implants and iliac blocks months of postloading follow-up) [171. When the percentage of vital bone phase of new bone formation [177]. 10.63). had a 4–6-fold higher hazard risk of implant fail- gesting immediate implant placement when the ure than those with delayed loading [171] residual alveolar bone presents adequate quality (Fig. one study showed that results However. 176. 49. In one study. 174]. 44. However.to <3-mm resid.61 and 10. Use of Membranes Immediate Loading The placement of resorbable or nonresorbable Immediate loading in the posterior maxilla fol. the majority of authors agree in sug. Pardiñas López) ual crest [171]. sinus and the augmented bone needed for a proper implant insertion (Copyright © Dr. due to the low bone density. Although it is impossible to determine a clear indication. However.62 3D image representing a graft maxillary 86 % reduction comparing ≥5. implants placed in previously augmented sites However.2 % to 100 % (mean 95 %) for the simultaneous implants and 72.

63 Intraoral picture of a grafted sinus through a Advantages. Controversy exists regarding the implant Pardiñas López) success rate and perforation of the Schneiderian membrane. Disadvantages.64 3D image representing a grafted maxillary sinus and a resorbable membrane that is going to be 58 % (Table 10. sinusitis. 10. it also carries some risks. 179].13 Schneiderian membrane perforation Study Perforation % [208] 11 [49] 19.66). Some studies suggest a lower suc- use of a resorbable membrane over the lateral cess rate (70 % perforated vs.8 [171] 5.8 Fig.5–41 [182] 37 [180] 44 [181] 25 [14] 19.65). bleeding. membrane perforations. 10. which is reported to be in a range of 4. 10. and wound dehiscence.13) (Fig.214 S.6 [210] 59. other studies (Fig.8–40) [188] 25. Complications include infection. and lateral wall approach with an immediate implant placed Complications Although the sinus augmentation surgery is a predictable treatment. show no statistically significant differences in . Fig.3 [209] 8.65 Intraoral picture of a resorbable membrane placed over a lateral wall osteotomy Table 10.7 [186] 19. ridge resorption. However.5 [96] 10 (range 4. The most frequent reported intraoperative complication is Schneiderian membrane perfora- tion. 10. cyst formation. 100 % nonperfo- window would have a positive or negative rated) when the membrane is perforated (and effect on the amount of total bone volume [47] repaired) [178.8–58) [44] 10 (range 4. Pardiñas López et al.8– Fig. placed over the lateral wall osteotomy (Copyright © Dr. 10.2 ± 10. among others [8].

1). 10. which can be occasionally encountered during the lateral window procedure in 2 % of the cases [186].70). .5.66 Intraoral picture of a perforation of the using a piezoelectric unit Schneiderian membrane the posterior superior alveolar artery.69 Intraoral picture of a lateral wall osteotomy Fig.5 % [183–185] (Figs.9 %) [44.9 %.2 Transalveolar Implant survival rates are reported in a range Fig. 180] and wound infection López) (2. preoperative CT scan evaluations to detect the path of the artery should be per- formed [187]. 188]. 96.67 3D image representing a lateral wall osteot- omy using a piezoelectric unit (Copyright © Dr. 10.4. 10. 10. Another important intraoperative complica. Pardiñas 0 to 27 %) [44. 96.1) (Fig.6–17. followed by exposures and total or partial loss of the graft (less than 1.10 Pre-Implant Reconstructive Surgery 215 Fig. 3. ing (range 6–93 months) (Table 10. 10. which is considered a postoperative complication [40.68 Intraoral picture of a lateral wall osteotomy using a piezoelectric unit from 83 to 100 % with the majority of articles reporting values higher than 92 % (Table 10.5–97. after a mean of 36 months after prosthetic load- forated sinus [180–182]. 173]. Also some studies suggest that a history of sinusitis may be related to higher complication rates [171. block) is sug- gested to be related as more prone to total or par- tial loss of the graft. while success rates are reported to be 93. The type of graft (particulate vs. 49. To prevent this.68. The survival rate of implants placed in conjunc- the incidence of perforation is reported to be tion with the augmentation procedure is reported lower. The most common reported postoperative complications are sinusitis (2.4 %) [40. ranging from Fig. implants placed in a staged approach [44].69).67. 188]. 96. 49. When a piezoelectric surgical device is used. ranging from 0 to 7. 51. 181]. to show no statistical differences in comparison to and 10.5 %. 10. 10. Also the available data did not demonstrate tion that can occur is an excessive bleeding due significant differences in survival rates of implants to the trauma to the intraosseous branches of according to different grafting materials [44]. 10.8 % implant survival in the nonperforated versus per.

Fig.72). One systematic review showed that implant survival rates were more than 96 and 85. Different sinus eleva- tion techniques do not seem to affect the implant success rates [172]. Copyright (2015). 10. socket preser.14). Pardiñas López et al. unassisted socket healing. 10. 10. Some authors recommend an endoscopic control when the sinus membrane is lifted >3 mm [172].3 to 100 % after 6–144 months. Sinus grafting is now considered a safe and well-documented procedure to prepare an envi- ronment in which dental implants may have an excellent prognosis [52]. The average measured bone gain was 2. 10. using different bone materials can help in the which is consistent with implant survival rates maintenance of alveolar height and width [190]. 191] (Fig.70 Intraoral picture showing an osteotome used Membrane perforations are reported to be low. 10. socket preservation techniques have been proposed with the objective of maintaining the hard and soft tissue dimensions after a tooth is extracted. 10. simultaneous preservation of the socket ranging from 90. Fig. respectively [172]. placement survival is increased following socket vation techniques minimized the amount of preservation procedures in comparison with postextraction bone loss [62. placed in native bone [192] (Table 10. with permission from Elsevier) was lifted more than 5 mm [172].71). Therefore.7 % with pretreatment bone heights of ≥5 mm and 3 to 4 mm.72 3D image representing a socket preservation terior implant placement.71 3D image representing a socket preservation technique using particulate bone graft (Copyright © Dr. membrane (Copyright © Dr. regardless of the surgical is no evidence to support the fact that implant procedures and biomaterials used. success. Pardiñas López) ing a successful final treatment [65.9– 3. A prerequisite for using this tech- nique is that primary implant stability can be achieved [40]. Fig. The survival. in order to have the technique using particulate bone graft and a resorbable best bone and soft tissue availability for achiev.216 S. Maxillary sinus floor elevation using the transalveolar approach may be a valid and less invasive supplement to the lateral window technique. . the socket and alveolar ridge suffer a physiological healing pro- cess that results in a reduction of its dimension [65]. 189] (Fig. 66.25 mm (range 2–7 mm) [172]. 66. for performing a transalveolar sinus lift (Reprinted from and most of them occurred when the membrane Patel et al.6 Socket Preservation Pardiñas López) Preclinical and clinical studies have demon- strated that after a tooth extraction. There It is evident that.4. [216]. If a tooth is nonrestorable and extraction is Some studies reported an implant survival rate needed. as previously described in Chap. 4. which is particularly important in cases of anterior aesthetic and pos.

50 (horizontal) [191] SR −0. positive influence of the socket preservation ther.3–99) Mean 25 [192] SR 97. one systematic review suggested that the insertion of dental implants in fresh extraction sockets affects the implant failure rates (4. Different studies showed that immediate implant placement had a failure rate of less than 5 %. 10.74. . 10.2–98. and marginal bone levels of implants placed in No high-level evidence was found in the liter- alveolar ridges following socket preservation ature regarding contraindications specific for procedures are comparable to that of implants ridge preservation and if socket preservation placed in untreated sockets [193]. 10. and apy may be attributed more to achieving enhanced 10. −0. the requires primary closure [ 10. Fig. Also.76.10 Pre-Implant Reconstructive Surgery 217 Table 10.78. as well as bet- ter maintenance of healthy periimplant soft tis- sues [66]. 10.5 (95. 10.8) 48 [193] SR 95.30) (vertical). 10.36 (−3.58 (−4. 3 +3. 63] (Figs. into fresh extraction sockets in conjunction with able membrane bone augmentation has shown comparable suc- cess to that observed in delayed implant place- ment [8].73 Intraoral picture showing a socket preserva.48 to +3. 10. However.75 % in fresh socket and 1.14 Socket preservation Implant success Implant Time Study Resorption (%) survival (%) (months) [194] SR 90.74 Intraoral picture showing a socket preserva- tion technique using particulate allograft and a nonresorb.3 mm (vertical). the immediate placement of implants Fig.75 Intraoral picture showing a socket preserva- tion technique using particulate allograft and a nonresorb.59 % in healed sockets) [189].3 6–144 [192] SR 98. Therefore. tion technique using particulate allograft and a nonresorb- able membrane able membrane restorative and aesthetic outcomes.2–100 95–100 12 [66] SR −2.80).4 (97.48 to + 1.25 to −2. 10.27) (horizontal) SR systematic review Fig.76 to +1. 10. which is comparable to delayed placement [8].77.

78 Intraoral picture showing the healing of a preserved socket 1 week after membrane removal Fig. 10. 10.79 Periapical radiograph taken immediately after socket preservation procedure Fig. 10.76 Intraoral picture showing the healing of a preserved socket after 2 weeks Fig.218 S. 10. 10. Pardiñas López et al.77 Intraoral picture showing the healing of a preserved socket 1 week after membrane removal Fig.80 Periapical radiograph taken immediately after implant loading after 5 months . Fig.

and meta-analysis) Bone gain (mm) Implant survival Implant (at 6 months in Type of treatment rate mean/range success ratea autogenous) Graft resorption Complications (%) Autogenous onlay 91. implant surface. and the results reported in bone grafting materials. prospective studies.1 (2.5–58 (perforation) (74.4 – – 4. Also these percentages represent a mean of the data extracted from the studies reviewed a Limited number compared with survivals b Mean 35 % including pain (up to >90 % if pain persisting more than 1 month is included) c Up to 86 % if skull depression is considered.1 (0–10) Inlay 95 (90–100) 90–95 4. Big ranging on follow-up from minimum of 6 months d Up to 40 % in cases of posterior mandible neural disturbances e No difference between graft type.5–100) (0. and vascularization of the when a treatment plan is being developed bone graft.4 osteogenesis (90–94.8–99 86.79 52 ± 25.2–97. [133].4 ---------------------. implant reconstruction.5 vertical 10 ± 10 % to 2–8.5 3.9–91 – – 3.3 3.10 Pre-Implant Reconstructive Surgery 219 Conclusion table (only including systematic reviews.27) horizontal These percentages should be evaluated with caution because some publications in which different donor sites were used did not separate implant failures according to donor site distribution.7 (76.3 (90.30 vertical) +0.5 Horizontal and 0–42 % 32 (10–80) Chin 85.6) ---------------------- 93. timing of implant load- dependent on the extent of the defect and ing.92–4.7 mm Up to 22 (86.82 mm Up to 50 exposure regeneration (61.4 12–60 % 21.2 (0–57.97 % horizontal (6 months) Guided bone 93.6)a Allograft block 92. when analyzing the effect of volume varies. ity of bone grafts to restore original bone In this chapter.8–100)a ---------------------. 0–42 % 10.5 5.12 (2–7) 1.1) 82.2–100 – −0. and.8 (92.7) LeFort I 89 (60–96.5–4. It is most appropri. lateral.9 (93–100) (72. specific commercially . The approach largely is of reconstruction.9 (86–100) 95.8–95.6 mm (−4.9 (2–15) 1.03 0. or osteotome technique Conclusions the literature are contradictory due to differ- Many techniques exist for effective bone ences in observation periods. and membrane/ no membrane.5–100)e 92. mandible or maxilla.7–100) ---------------------- 83 ---------------------- (72.48 to +3.5) Distraction 96.6 (52.3 mm (4 years) 1.6 (0–37.5) Ramus 95. A second concern is the adequate adapta- ate to use an evidenced-based approach tion. randomized studies.3–100) 92. stabilization.3) 10–15 % 10–40d Sinus lift 92. 0–60 % 24+ bone graft 97.3–97.5 7.5–95) vertical 4. site of bone har- specific procedures to be performed for the vesting [133].5 (60–100) 90.3–100) 95. 0–15 % 16.4 (88–100) 93.7–100) 0–27 (others) Socket preservation 96.8–100) 87. No differences between materials.7)c Calvarial (90.35 to 4.0 2–3. retrospective studies.6–35.9–90.7–6.76 – to +1.6)b Iliac 95.8 (1–63.39 mm (−3.3 ---------------------. which are critical for graft success for bone augmentation cases [8].2 (90.5 (60–100) (89.9 mm) Alveolar split 96 (86–100) 92. type and site augmentation. The capac.3–2. last but not least.

thus. the use of growth fac. Burgin.K. R. G. 161–172 (1997) times in comparison to intraoral harvesting 6. short 2. Oral Implants increased morbidity and prolonged treatment Res. prospective cohort study of the ITI Dental Implant vide a faster soft tissue healing [113]. Moreover. J. the morbidy is significantly reduced. W. If autogenous bone grafts are and expectations and be aware of his/her skill used.S. Karring.P. order to choose the most appropriate technique Oversized grafts should be harvested to and materials. mentation by means of guided bone regeneration. In this sense. Behneke. Bragger. Reiser. M. patient with the most proper solution. Reconstruction of deformed. L. N. Technique and wound healing. Bone augmentation techniques. Nevins. 113].H. J. A. and microvascular free flaps present even Karatzopoulos. 2000 50. N.F. by eliminating 5. 8(3). Haghighat. Worthington. More surgical challenges arise from vertical Bone healing and soft tissue contour changes follow- ing single-tooth extraction: a clinical and radiographic augmentations. J. T. grafts when properly protected with the appro. in grafted sockets. 23(4). Oral Maxillofac. Long-term evaluation of non-submerged ITI implants. Int.S. Pardiñas López et al. onlay grafts [44]. J.E. it is highly suggested to use corticocan. A. Buser. if not associated with mem. Implants in regenerated edentulous ridges reconstructed with block bone: long-term survival. does not provide sufficient rigidity to withstand tension from the overlying soft tissues or from the compression References by provisional removable dentures and may undergo partial or complete resorption [44]. P. Eriksson. G. 18(1). 154–172 (2009) horizontal augmentation can be successfully 4. T. Hammerle. 13–40 (2014) Although autogenous bone has been con. Periodontol. Decision making in implant sidered the gold standard in the past. 15(1). The long-term efficacy of currently used dental performed with allogeneic and xenogeneic implants: a review and proposed criteria of success. McAllister. Periodontol. D. edentulous ridges. Hirt et al.S. branes of titanium meshes. Zarb.R. partially guided bone regeneration [108]. The clinician should be critical and crepancy not susceptible to be treated with evaluate the available studies in the scientific lit. 12-month prospective study. L. Behneke. the need for a second surgical site to harvest A. C.P. 34–45 (1998) placed in native bone. 2000 66(1). Int. Cancellous bone alone or hensive treatment plan in order to provide the particulate bone. Bernard. Int. osteotomy with interpositional bone grafts Contin.T. Dent. G. B. D. Implants 1(1). Wenzel. The practitioner should also maintain enough graft volume after the initial have the capacity to analyze the patient needs resorption phase. in 8. H. Seibert. the clinician enough knowledge and evidence-based data in should ask for randomized clinical trials. or with 9.A. success rates of titanium oral implants: a 10-year tors can enhance the success of grafts and pro. J. Schropp. Albrektsson. G. 8-year life table analysis of a prospective multi- Extraoral harvesting sites are related with an center study with 2359 implants. Periodontol. J. U. placed in horizontally and vertically resorbed G.P. 8–17 (2004). Compend.220 S. Kostopoulos. Survival and success rates of implants PubMed PMID: 9586460 7. Salvi. M. Esposito. Buser. Periodontics bone grafts are similar to those of implants Restorative Dent.I. Lang. Doing that. 11–25 (1986) priate membrane.G. P. H. more dentistry: an evidence-based and decision-analysis recent studies have shown that vertical and approach. Other surgical options such as LeFort I Part I. Effect of implant design on survival and sites [201]. System. being able to develop a compre- cellous bone blocks. K. Mellonig. 437–453 (1983) 10. Educ. Mericske-Stern. Part 1: the graft. Periodontics cult to reconstruct due to soft tissue collapse over Restorative Dent. P.. J.V. Beikler. which can be particularly diffi. using full thickness onlay grafts. limitations. in grafted sinus. 313–323 (2003) the graft if the space is not maintained. Worthington. 78(3). Flemmig. Grusovin. Coulthard more morbidity and should be limited to Interventions for replacing missing teeth: horizontal . Oral Implants Res. Felice. Benic. the clinician should have the that he/she would use. available bone substitutes have not been extreme atrophy or severe intermaxillary dis- assessed. Horizontal bone aug- implants may be a feasible option [108. 4(5). 3. 1. D. T. erature regarding the effectiveness of the product In conclusion. Clem 3rd.M. Karoussis. Clin. I. Clin. 377–396 (2007) distracted sites. M. T.

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Rome 00144. Italy e-mail: gbianco@mac. Italy e-mail: oi243@nyu.1007/978-3-319-26872-9_11 . The term cement-related peri-implant disease has been coined by some authors. Viale Regina Elena 324. The treatment of peri-implantitis can involve nonsurgical or surgical options.com Private Practice Limited to Oral Surgery. smoking.). Rome. Italy Viale dell’Umanesimo 308. Iocca. and genetic factors are all considered risk factors for the development of mucositis and peri-implantitis.edu © Springer International Publishing Switzerland 2016 229 O. although some etiologic aspects are peculiar to the first one. Peri-implantitis 11 Oreste Iocca and Giuseppe Bianco Abstract Peri-implant inflammatory conditions are not unfrequent in the implant population. Microbiological factors. diabetes. Sapienza University of Centro Polispecialistico Fisioeuropa. Periodontology and Implant Dentistry. inflammation. Comparison of various treatment modalities is not easy mainly due to the lack of direct treatment comparisons. O. DDS. Diagnosis of mucositis and peri-implantitis relies on clinical and radio- logical signs. The etiology of peri-implant diseases has many aspects in common with periodontitis. Evidence-Based Implant Dentistry. It is possible that cement remnants have a role in the incidence of many cases of peri-implantitis. Bianco. Clinicians should be aware of the definition and diagnostic criteria of mucositis and peri-implantitis in order to adopt prompt inter- ventions in order to save the implant. Rome. PhD International Medical School. referring to the peri-implant pathology arising around cement- retained implant restorations. 00161 Rome. Iocca (ed. DDS ( ) G. The use of network meta-analysis as a statistical tool for indirect treatment comparison may help to understand which are the best treatments available. DOI 10. The management of mucositis is always nonsurgical.

Variable tooth..1. but tion leading to pathology (Fig. bone loss the variation in follow-up time. patients with a history of imbalance in the equilibrium between the oral periodontitis were found to have an incidence of microflora and the host immunity system. knowledge of possible therapy option and meta-analysis as weighted mean value was prognosis should lead to an appropriate treatment 42. characterized by bleeding on may reenter in the classification of peri- probing but without signs of peri-implant implantitis in one other. Extent and severity of the conditions were poorly or inconsistently reported. In the first month after implant placement. be 18. that what is considered mucositis in one study implant plaque.8). A focus on prevention with careful case their study. and selection of Peri-implantitis: Inflammation extending to the patients in the various studies are all factors that supporting peri-implant tissues and characterized may lead to incorrect estimation of the true prev- by clinical and radiographical signs of bone loss alence of peri-implant disease. therefore. the prevalence of peri. Once peri-implantitis becomes mani- The prevalence of mucositis reported in the fested.2 Etiology of Peri-implant figures should be interpreted with some caution. Disease but they can be considered a good approximation of the actual prevalence.e.1) and prevalence of peri-implantitis to tal pathology.8–67.4 % (95 % CI implant disease share similarities with periodon- 59. the small samples.1 Definition and Epidemiology 4 mm in some study to 6 mm in others. plan.7 %(95 % CI 14–30). 11. ing depth values and gingival index scores.8–20. ultimately results in a destructive inflammatory It is worth mentioning that not all the studies process.1. 11.8). Given this relative heterogeneity. ranging from at least 11. colonization of the subgingival environment by Peri-implantitis diagnostic criteria also suffer the different species is similar to that of a natural of some heterogeneity in the literature. an assessment of the literature was selection and patient education is of the utmost performed extracting data from cross-sectional importance in order to avoid their occurrence studies and one RCT.9 % (95 % CI 32–54). i. but in to the seventh European Workshop on some other studies. which peri-implantitis of 21.5–27. it is possible Mucositis: An inflammatory reaction to the peri.1. clinicians should be aware that these Patient-based prevalence of these two condi.2) [5]. Moreover. . this is not considered Periodontology [1]. (Fig.1 % (95 % CI 14. [3] in a similar analysis estimated It has been considered reasonable that the peri- the prevalence of mucositis to be 63. of Peri-implant Disease the majority of the studies consider radiographic evaluation indispensable in order to make a Peri-implant inflammatory conditions. Periodontitis.1 Microbiological Factors Atieh et al. Anyway. like peri-implantitis. adhere to the above-defined diagnostic criteria of The microenvironment in the periodontal/ mucositis and peri-implantitis [4].8 % (95 % CI 16. different studies considered for diagnosis prob. can be subdivided in this way: important.1). When a subgroup is a multifactorial disease characterized by an analysis was performed. implantitis was 21. are problems commonly occurring in the implant tions was analyzed by Derks and Tomasi [2]. the 11. in practice. according definitive diagnosis of peri-implantitis. Gram-positive cocci and bacilli. 11.230 O.1 Peri-implantitis probing depths have been proposed as a thresh- old to make diagnosis. Also. Bianco 11. peri-implant sulcus favors the selection of spe- Mucositis has been diagnosed with just the cific bacterial colonies that are considered key presence of blood on probing (which is the pathogens in triggering the inflammatory reac- European Workshop Criteria for diagnosis). Iocca and G.2.

and ria have been ascertained in many studies. specific Gram-negative anaerobic bacte. Prevotella nigrescens (Pn). implant removal is necessary in this case.) Switching to a more characteristic Aggregatibacter actinomycetemcomitans (AA). In detail. The species common to ent bacterial species than those traditionally asso- periodontitis and peri-implantitis include ciated with periodontitis [6]. periodontitis-associated microflora has been Porphyromonas gingivalis (Pg). . using Fusobacterium nucleatum (Fn). Calculus is evident around the implants and prosthesis a b c Fig. sequences of the 16S rRNA gene for identifica.11 Peri-implantitis 231 a b c Fig.2 Bacteria proliferating on a contaminated implant surface at various degree of magnification (a–c) (Reproduced with permission from Mouhyi et al. sythia (Tf). In par.1 (a–c) Peri-implantitis affecting the mandibular implants. 11. Tannerella for- found in case of peri-implantitis as well. intermedia (Pi). 11. Treponema denticola (Td). Prevotella ticular. Some authors suggest the presence of differ- tion of bacterial species.

these molecules will end to pathologically destroy the peri-implant tissues. but it is not the As the inflammation is not properly regulated only factor. each one has some specific and some overlap- implantitis remains controversial. it was found that in par. cells.2. Metalloproteinases are pling and analysis methods are available (PCR. Immunohistochemical de Waal et al. research [9]. practice. collagenases that have the physiological function culture. B-lymphocytes perform important antigen- In both fully and partially dentate patients.1. because ping function. natural killer (NK) the presence of the putative periodontal patho. whereas edentulous patients in order to find any difference in periodontitis. and neutrophils play an gens is considered to be an eliciting factor in important role in tissue destruction. peri-implant inflammation. and the role of each one is a matter of Cytokines are key molecules in the orchestra. In the majority of Different cell types are involved in the inflam- the analyzed studies. What is clear is that in susceptible tion and clinical manifestations of inflammation. between the two conditions. CD4+ or T-helper. and RNA analysis). Bone cells are 11. The potential of using specific bacterial mark. binds to osteoprotegerin (OPG) on the sur- been studied in many animal and human studies. Pg. Moreover. In species found their ideal habitat only around a addition to dendritic cells. macrophages. much more frequently around implants affected Different classes of T cells are involved in by peri-implantitis. by itself. cannot indicate the future destruction phase is mediated mainly by neutro- loss or failure of dental implants. TNF-α was more prevalent. plasma proteins. DNA. but it is not of “creating space” for cells directed to the site of clear which one may have a role in clinical insult. and fluid factors are in play during the course of peri- from the vascular tissue [8]. Various sam. mated peri-implantitis. a member in the pathogenesis of peri-implant disease. in particular osteo- Host response is considered another key element clasts and osteoblasts. and Tf were detected vation and further production of cytokines. But when inflammation does not resolve. In consequence. the tissue these bacteria.232 O. regulatory T cell. implantitis. thus contributing together with Pseudomonas aeruginosa and to the characteristic bone resorption of concla- Bacteroides spp. RANK-ligand. reasonable if we consider that some bacterial they present the antigens to B and T cells. interleukin-1 (IL-1). Iocca and G. Complex interconnection between all these lation of leukocytes. ulation of type 1 collagen in bone. reacts to microbial pathogens is with the accumu. Bianco Staphylococcus aureus has been suggested to IL-1α and IL-1β isoforms have been strongly have particular affinity for titanium and was associated with osteoclast activation and downreg- frequently found in deep peri-implant pockets. it presenting function which can sustain T-cell acti- was found that AA. dendritic cells play an important tially edentulous patients. individuals. matory reaction. phils and macrophages. macrophages and tooth. Firstly. a potentially more role in recognition of the resident flora and mod- pathogenic peri-implant microflora was harbored eration in the mounting of the immune response. tory response is characterized by a chronicization . face of the osteoclasts which are in this way The major way by which the immune system activated and start the bone resorption process. and hard tissues. γδ. [7] reviewed the reporting of the studies have evidenced an increased staining of microbiota around implants in fully and partially IL-1α in peri-implantitis tissue specimens. The of the TNF superfamily produced by the osteo- inflammatory reaction elicited by the biofilm has blasts. the detection of in periodontitis and peri-implantitis. This is When dendritic cell homeostasis is disrupted. Failure of resolving the inflamma- interleukin-6 (IL-6). excessive cytokines and metallopro- The major pro-inflammatory cytokines are tumor teinases lead to a damage extended to soft and necrosis factor (TNF). compared to the fully edentulous. and ers as a tool in evaluating the prognosis of peri. CD8+ or cytotoxic T cells.2 Inflammation then involved in this phase. peri-implantitis pathogenesis.

76 Mucositis NO peri-implantitis (−247.002) release Subgroup 2 Mucositis versus −27. of disease. a vicious circle mucositis/peri-implantitis.1) evaluated at multiple time points during the [11].33–281. Thirdly. firmed for TNF-α levels. valuable diagnostic/preventive tool for patients in which the risk of peri-implantitis is considered Role of Inflammatory Markers in Clinical high or when diagnosis is still unclear. the most studied cytokine were because these were cross-sectional studies report- IL-1β followed by TNF-α. mucositis. reports did not include the sensitivity of the A systematic review and meta-analysis ELISA’s tests employed or the correct kit name.001) IL-1β release Subgroup 4 Healthy versus 61.60 Peri-implantitis YES (p value peri-implantitis (8. or conclamated state [10]. IL10. IL-1β and TNF-α have been proposed as suit. Table 11. accompanied by chronic inflammation and for. and peri-implantitis Effect size MD Groups of in pg/ml (95 % Statistically Studies included comparison CI) Increased in significant Faot et al.02) TNF-α release . At the end. but this was not possible were included. was performed.66–114.23) Subgroup 3 Healthy versus 175. Finally. authors were that. as the destruction progresses compared to the healthy. Cross-sectional and interventional studies course of disease. Shortcomings of the analysis evidenced by the able biochemical markers because of their ele.79 Mucositis YES (P value mucositis IL-1β (99. it The authors evidenced a huge variability in was recalled that focusing on just two or three the techniques used for PICF collection and in cytokines may lead to not consider other unstud- general a great heterogeneity between the stud. and IL-8. early. The same was con- and peri-implant pockets deepen.52–458. attempted to answer if PICF may have a role in Secondly. ing a single-moment fluid collection. a more anaero.83 Peri-implantitis YES (P value peri-implantitis (70. the cytokine expression should be the diagnosis of peri-implantitis (Table 11.33) 0. therefore stressing the importance of a marker in order to identify peri-implantitis in an early and aggressive approach in the treatment latent. ied inflammatory molecules which may have a ies.1 Meta-analysis evaluating the inflammatory profile of healthy subjects.11 Peri-implantitis 233 of these processes.06) 0. mation of granulation tissue that creates an ideal A significant increase in IL-1β release in environment for the same bacteria that started the mucositis/peri-implantitis patients was evidenced process.80) IL-1β release 192. This was Practice considered of great importance given that no dif- It has been suggested that cytokine analysis in the ferences were outlined for early and later stages peri-implant crevicular fluid (PICF) may serve as of disease. evaluation of cytokine levels great impact in the development of in healthy subjects versus subjects affected by peri-implantitis. The results are shown in the table. expressed as mean ensues. bic environment develops favoring again the These results led to the conclusion that IL-1β harboring of the periodontal/peri-implant and TNF-α levels assessed in the PICF may be a pathogens. That being said. Cross-sectional and (2015) interventional studies Subgroup 1 Healthy versus 278. in which healing processes are difference of IL-1β and TNF-α. in the included studies. the vated concentration in PICF of affected sites.86 to (P value 0.55) 0.

1. and no clinical recom- pathological. needs further research for the development of periodontitis. the authors concluded that the available information on the risk of 11. smokers. And although normal immune response.4 Genetics for the advanced glycation end products (RAGE) Given the importance of cytokines in develop- whose interaction with its ligands elicits a strong ment of peri-implantitis. Iocca and G. a higher risk of peri-implantitis for smokers. the depletion of the so-called that smoking may be a risk factor for the develop- core microbiome (the population of bacteria ment of peri-implantitis in the implant popula- present in most of the study population) is evi. only two out of five prospective clinical trials vicular fluid samples.3 Smoking smoking associated with peri-implantitis devel- Smoking of cigarettes is an established risk factor opment. of inflammatory molecules and for the narrowing sidered an additional risk factor in respect to of the core microbiome. incorporating these techniques in everyday clini. peri-implantitis. totally reasonable that the same is valid for peri. Bianco In conclusion. microorganisms survive in this mendations could be extrapolated. leading to a shift toward a preponderant These results may be explained by the fact that a presence of microbes traditionally considered small number of studies were included and the pathogenic. albeit plausible. A meta-analysis [15] tried to clarify this point implantitis. the authors did not arrive at loss of several species is evident and just few. Patient-based true correlation exists between peri-implantitis analysis did not show a significant difference and smoking habits. and dence of peri-implantitis in some individuals. has been found to stim. especially for the stimulus in the production dent already in the healthy state. these limitations.1. when clinical studies are evaluated. Beyond the molecular and microbiological kines in the PICF of implant patients can be evidence. Before to show a correlation between smoking habits. at this time. Some studies seem follow-up of peri-implantitis patients. On the It has been shown [12] that smoking reduces other hand. resulting in elevated smoking should be discouraged for every implant white blood cells and granulocyte count which patient.2. clinical studies show con- Smoking has also been found to impair the troversial results in this regard. cules has been investigated as potential risk fac- ulate the production of IL-6 and IL-8. and others fail to do so.2. genetic tests may . employed as a diagnostic tool for early detection/ controversial results emerge. it is still not established if a analyzing prospective studies. negatively tors. it should be important to standardize In the review of Renvert and Quirynen [14]. genes that control the production of these mole- Nicotine. between the smokers and nonsmokers. On the other hand. and it is to be demonstrated. in particular. From a clinical perspective. nonsmokers. the methods of collection and analysis of the cre. In light of reduced when mucositis is triggered. and more long-term studies included in the analysis revealed a statistically should elucidate the real impact on the prognosis significant difference between smokers and non- of the implants undergoing these tests. For this reason. It is possible that the host genetic regulate the expression of the extracellular matrix susceptibility may be related to increased inci- and osteoblastic transcription factor genes. the implant-based analysis evidenced significantly the diversity of peri-implant micro. tion. this can be con. altered niche. cal practice. in vitro studies seem to show In smokers. polymorphism of the inflammatory reaction. raised levels of specific cyto. definitive conclusions. In conclusion.234 O. evidence-based information does not may contribute to triggering or aggravating the allow to draw strong conclusions on this topic. However. inhibit the epithelial cell growth [13]. biome. study did not allow to reach enough statistical This narrowed microbiome becomes further power for patient-based evaluation. Cigarette smoke has also been associated with an upregulation of the receptor 11.

biomarkers of peri-implantitis. and its inci. to arrive at strong conclusions regarding the implantitis as well. It is still premature to consider a clinical appli. and TNF-α [16]. but the nonenzymatic formation of the complications. even though practical applica.6 The Case of Cement-Related Glycated hemoglobin values (HbA1c) reflects Peri-implant Disease the glycemic control of the past 2–3 months and Cement-retained restorations are considered to for this reason can be used as a diagnostic/fol. if just one variant was present indi. While some research has been conducted phisms (IL-1A. advisable that a patient undergoing any implant dence and prevalence are expected to rise greatly treatment is strictly controlled from a medically in the next decades. Undoubtedly. such that has been proposed the adoption of the . Also. the most studied genes are those con. 11. Nevertheless.2. The 3 years’ time points.28 95%CI 1. with European descents less prone BOP values that seemed to significantly increase to show an association of risk. are needed therapy for diabetic patients can be a predictable to clarify the association between specific genetic treatment option provided that the patients have a polymorphism and dental implant failure. this resulted in no risk difference. it is mortality and morbidity worldwide. contribute to substantial cases of peri-implantitis low-up marker in diabetic patients. bleeding on 2. For It is difficult. IL1-B and IL-1RN) and implant evaluating the survival of implants in diabetics. and CXCR3 were distinctive genetic variants and implant failure/loss. and vidually.5 Diabetes Type 2 expressed together with IL-6 and IL-8 at a statis- Diabetes has been linked to an increased inci. 2. IL-1B. but in subjects affected by diabetes. association of type 2 diabetes and the risk of Diabetes type 2 is one of the leading causes of developing peri-implantitis. formed when an excess of glucose is present.1. Gomez-Moreno et al. the authors suggested that implant tions with diverse ethnic background.01–1. No significant difference authors pointed out that ethnicity was a source of was found for all the variables analyzed apart heterogeneity. these molecules were over- 11. especially stratifying popula.62). with the limited evidence avail- analogy. more with higher values of HbA1c.1. researchers investigated a link with peri. association between a variety of IL-1 polymor. abovementioned RAGE receptors and are a main A meta-analysis [17] attempted to evaluate the cause of damage between the other factors. and MBL) was evaluated at 1. that is considered the main cause of damage to tissues and organs characteristic of the disease. tically significant level. failure. The impaired insulin action point of view in order to decrease the incidence in type 2 diabetes leads to a hyperglycemic state of mucositis and peri-implantitis. probing. The other study [19] focused on the pro- cation of genetic testing for patients undergoing inflammatory gene expression at chronic peri- implant treatment. plays a huge role in tissue damage activating the trolling IL-1A. CCR5. mainly because the available odontitis and peri-implantitis sites in patients results do not allow to draw robust conclusions with diabetes type II. dence of periodontitis in affected individuals. In detail. so-called advanced glycation end products (AGE). failure/loss (OR 1. It was found that the levels regarding the association of risk between specific of TNF-α. good glycemic control over time. tions of genetic testing are still not fully clear. The evolution of with an increased risk (OR 1.2.21– hard and soft tissues (probing depth.57) while. able. Cautiously. large cohort studies. only two studies are available specifically Authors find a significant association between addressing the issue of peri-implantitis in the dia- the T allele of IL-1B and increased risk of implant betic population. [18] evaluated the peri- the genetic variants IL-1A (−889) and IL1B implant changes in a cohort of type 2 diabetes (+3954) composite genotypes were associated patients over a 3-year follow-up.11 Peri-implantitis 235 potentially lead to the possibility of predicting Pathogenesis of diabetic complications is not which patients are predisposed to biological fully clear.76 95 % CI 1. IL-6.

Only retrospective and prospective mens analyzed. Moreover. showed to be surrounded by cohort studies are available on this topic. The predominant composition of gained by analysis of the literature. it seems clear that the use of implants with excess cement in patients with a cemented restorations can act as a independent positive history for periodontal disease devel. The Also zirconium was found at SEM analysis. Within the limitations of a hand. [20] reported that 81 % of the cement. after placement. On the other oped peri-implantitis. Additionally history added to dental cements as a radiopaque material of past periodontal disease was recorded.236 O. found in 34 of 36 speci- (Fig. reaction responsible of bone loss around the site The foreign bodies. 11. [22] analyzed the foreign bod- It is possible that excess cement left in the peri. the authors concluded that act on controlling the amount of cement applied residual cement. the first signs of peri-implantitis did not ticles were produced as a result of corrosion of become apparent until 4 months up to 9. of implants with cement-retained resto- and also contribute itself to an inflammatory rations and affected by peri-implantitis. b) Cement excess in the peri-implant space was the cause of peri-implantitis (Reproduced with permis- sion from Wadhwani et al. Also. Bianco term “cement-related” peri-implant disease [20]. important information can be plasma cells. or from the abutment when zirconia restorations It was found that 85 % of implants with cement were employed. sidered a cause of peri-implant disease. in affected nance phases. risk factor for peri-implant disease. some patients were Regarding the cement remnants in the peri- reported to be completely resistant to cement implant space. they could have been introduced excess. a third possibility was that the par- patients. obtained during flap implant space may favor the bacterial overgrowth surgery. most is in the hand of the clinician who can study of this kind. can be associated the peri-implant space. especially in patients with a his. 11. dominated by Nevertheless. Iocca and G.5 years the dental implant.3). at the moment of cementation or during follow- A retrospective case analysis of 129 implants up visits during attempts of removing the excess [21] investigated if residual cement could be con. the foreign bodies was found to be Ti and dental Wilson et al.3 (a. and also checking the presence of any extrusion in tory of periodontal disease. intraoral with development of peri-implant disease. One hypothesis was that Ti was depos- implants restored with a cemented crown and ited due to friction at the moment of implant with signs of peri-implantitis had extracoronal placement or due to the wear during the mainte- residual cement evident. authors analyzed implants with and without this can derive from zirconium dioxide that is extracoronal cement excess. chronic inflammatory infiltrates. ies from soft tissue biopsies. x-rays are performed before the patient leaves the a b Fig. cement.) . all In conclusion. Wilson et coll. In order to do so. remnants were affected by peri-implantitis.

a b c d Fig. hand instrument.11 Peri-implantitis 237 office because the sole visual inspection is not clearly visible at an intraoral x-ray and accessi- sufficient to detect any excess cement. nonsurgical or surgical removal mandatory and removal of cement. and copious irrigation with chlorhexi- Finally. granulation can be attempted.4 Extensive lesion caused by cement excess left in place for 3 years (Reproduced with permission from Wadhwani et al. and surface decontamination with feasible when the amount of cement to remove is chlorhexidine are performed (Fig.4). Even the ble. ultrasonic smallest amount of cement is removed carefully. 11. devices. Nonsurgical approach is tissue. If access to the excess material is not inflammatory reaction in the form of mucositis or possible with a closed approach. in this way. a flap surgery is peri-implantitis. when cement excess is detected at dine should ensure the resolution of the inflam- follow-up visits already having caused some mation.) . 11.

a described in the seventh European Workshop more general advice remains to probe the peri- on Periodontology can be considered reliable implant sulcus very gently. The diagnostic criteria the existence of probes with force indicator.2. Peri-implantitis diag- nosed by signs of bone loss (c) (Reproduced with permission from Serino et al. How the clinician may caliber his interventions that can arrest or slow the pro. Mucositis characterized by slight bleeding (b). a b c Fig.25 N could not cause a permanent damage to is important in order to adopt promptly those the tissues. Bianco 11. probing force remains questionable.1 Diagnosis apply in order to avoid damage to the peri-implant tissues [23].5 (a–c) Healthy peri-implant tissues (a). Iocca and G. 11.238 O. and it was concluded that a force of The diagnosis of mucositis and peri-implantitis 0. A review assessed the ideal probing force to 11.5). aside from gression of the disease. 11.) .2 Diagnosis and Treatment and simple to apply in clinical practice of Peri-implant Disease (Fig.

can miss an early bone loss. moreover.7) or ultrasonic positioning of the implant. it is important to establish how the Fig. For this reason. it is devices (Fig. the implant surface. as well. inflammation with. 11.8) [26].) include [25]: • Nonsurgical therapy • Surgical interventions • Adjunctive treatments to nonsurgical or surgi- cal intervention • Implant removal 11. the main cause of inflammation. The roughness and irregularities ideal for biofilm presence of pus is a clear sign of peri-implantitis formation. In general. Teflon. a diagnosis of peri-implantitis ness higher than Ti.6 and 11. while out destruction of the tissues. i. 11. Cone-beam computed tomography has gained popularity in the last years for the low dose of x-rays compared to the past and a great quality of the 3D image which allows to detect even the ear- liest manifestations of bone loss. This kind of ered a sign of mucositis. 11. although the possibil. examination.2. it depends by the initial instruments (Fig. and being a 2D ones.11 Peri-implantitis 239 Bleeding on probing (BOP) by itself is consid.1 Debridement and Adjunctive Treatments Nonsurgical option refers to the debridement of the supra. be made of steel.) . 11.and subgingival space in order to Fig. debriding capacity compared with the titanium ity of underestimating the MBL. Intraoral radiography is a simple prone to rupturing and also possess a reduced and reliable diagnostic tool. are radiographically.6 Plastic curette (Reproduced with permission pathology should be treated.. Clinical attachment for conclamated peri-implantitis.2. in fact this material has a hard- In summary.2 Management of Mucositis and Peri-implantitis Once diagnosis is made clinically and radio- graphically. fact that an arbitrary reference point needs to be Debridement can be performed with manual established. Curettes manufactured in Ti are safe from this Regarding the radiological signs. they damage can be performed with the presence of bleeding the implant surface with the risk of creating more on probing and a sulcus depth of ≥5 mm. it is advis. examination in order to detect the bone resorption although safer because much softer than Ti. treatment is mainly reserved to mucositis. Different options from Figuero et al. cal peri-implant changes undergoes x-ray Carbon fiber.7 Carbon fiber curette (Reproduced with permis- remove the bacterial plaque and calculus which is sion from Figuero et al. surgical level (CAL) is difficult to determine due to the approach is usually needed. point of view and should not lead to damage of able that a patient suspected of having pathologi. assumed that a probing depth (PD) up to 4–5 mm Curettes used for titanium implants should not should not be considered pathological.2. 11.e. and plastic curettes.

Curettes made in aluminum-garnet (Er: YAG) and CO2. various techniques have been proposed [28]: • Simple access flaps for cleaning and decontamination Fig.. it cannot be applied in esthetic areas.e. so to more gently. Shortcomings of once daily for 3 months after debridement this approach include the fact that bone reduction • Chlorhexidine 0. sion is usually intrasulcular and aimed at visual- Laser has also been considered for surface izing the exposed implant threads up to the decontamination. specifically. i. • Locally applied antibiotics such as tetracy. Usually.20 % irrigations sitioned apically and sutured. At of lasers seem to not increase significantly the this point.2. 11. mechanical debridement.2 Surgical Treatment Regarding surgical therapy for peri-implantitis.2 % for 2 weeks • Full course of systemic antibiotics such as metronidazole or azithromycin after debridement 11. ate. for decontamination. 11. removal of the granula- less effort from the side of the dentist and with tion tissue.240 O. Iocca and G. from neck and sutured. a repositioned flap in increasing the antibacterial effect of debridement theory should allow to avoid the recurrence of the include [27]: disease. allow the patient to perform better self-hygiene Adjunctive treatments with the aim of procedures.2. the implant surface is treated with curettes by themselves. Bianco • Mixed topical application of 0.) • Access flap and regenerative procedures Access flap surgery has the same objectives Ultrasonic tips covered in PEEK are ideal for that were traditionally established for periodontal use on Ti surfaces. seem to damage hard and soft tissues. they allow a debridement with surgical treatment.1 % chlorhexi- dine gel after debridement followed by daily rinses of chlorhexidine 0. because profound pockets would serve as an ideal environment for pathogenic bacteria. and implant less discomfort for the patient.8 Ultrasonic tip covered by PEEK (Reproduced • Apically repositioned flap with permission from Figuero et al. after raising the flap. Additionally.9). Apically repositioned flap can be used instead A device based on glycine powder seems to act when deep peri-implant pockets are present.12 % or 0. . Additionally.12 % rinses once daily for 3 would lead to an exposure of the implant threads. and eventu- therefore avoiding the risk of necrosis of the sur. bacterial colonization. which are based on a possible the irregularities which can favor further powered air-abrasive system of sodium carbon. an osteoplasty is cline in impregnated fibers which are removed performed in order to reduce the depth of the after 10 days or chips that gradually resorbs pocket. Both types Ti may be used for surface decontamination. in vitro studies emerged a potential bactericidal Some authors [35] prefer to polish the Ti sur- effect against pathogenic bacteria. Their efficacy is surface decontamination and polishing. ally the flap is repositioned around the implant rounding healthy bone. adjunctive measures can be adopted. months therefore. erbium:yttrium. and finally the flap is repo- • Chlorhexidine 0. The inci- similar to the manual instruments. face completely in order to eliminate as much as Air-abrasive devices. healthy bone level (Fig. one of the previously described topical temperature of the implant during the procedure.

11 Peri-implantitis 241 a b c Fig. 11.9 (a–e) Mandibular implants in the anterior region and two newly placed implants are used for reha- region affected by peri-implantitis (a) cannot be treated bilitation after healing is completed (e) and are extracted (b. The two implants in the molar . d).

2. Bone lished in vitro experiments evaluating the effect grafting materials have been variously employed. but it the chosen material is grafted in the defect was most evident with plastic curettes.12 %. [29.10). Surgical access is made with a instrumentation may impair the proliferation of simple access flap. One important aspect chemotherapeutic agents on contaminated Ti sur- to clarify is the biocompatibility of Ti surfaces faces. 11. cells.242 O.3 Comparison of the Various bonate powder seemed to give the best results in Treatments terms of maintenance of biocompatibility of rough Ti surfaces. the same was not true for the Effects of chemotherapeutic and mechanical machined ones. and after careful debridement. peri-implantitis. agents on titanium surfaces have been investi. plastic instruments seemed to be unable to clean the structured Ti surfaces. alterations of the failure. This could happen with steel or gold. which anyway did not lished if. Moreover. It remains to be estab.9 (continued) Moreover. 11. bone removal could compromise the through bacterial plaque removal and decontami- insertion of future implants in case of treatment nation with various means. these are chosen just to avoid the Louropoulou et al. after treatment of peri-implantitis seem to reduce significantly the biofilm over Ti . of instrumentation on Ti implant surfaces. Iocca and G. They and the use of protective membranes has also found that the debris of the materials used for been advocated. The most used decontaminant was after those treatments. (Fig. The air-abrasive devices with sodium bicar- 11. Another review [31] analyzed the effect of gated in a series of reviews. Bianco d e Fig. chlorhexidine 0. implant surface may further impair what is called Regarding regenerative techniques in case of the process of re-osseointegration. 30] reviewed the pub- contraindications of a resective approach.

the tic curettes seem to be ineffective in removing authors suggested that some mechanical instru- bacteria and calcified deposits from the implant ments seemed to possess greater potential in the surface. GTR procedure is sion from Schwartz and coll. The implant surface (i) and postop (j) probing depth (Reproduced with permis- is polished with the handpiece (d). microscopically resemble the implant surface. the analysis of the literature allows abrasive devices and a sodium bicarbonate pow. but the effect of this compound ducted on Ti strips. and sheets that was not found to be investigated. Preop treat a deep periodontal pocket (a–c). clinical studies. for this reason. a review on in vitro reproduce exactly what would happen with a experiments [32] showed that the steel and plas. Also. scaler. . cylinders. the air- (VectorTM) instead showed a good capacity of abrasive devices with the use of sodium bicar- biofilm removal from both SLA and machined Ti bonate or glycine. they do not allow to mechanical instruments. threaded implant in the mouth. Good results were obtained with air. 11. which allowed to remove effectively bacteria not a feasible objective. although data reported in the literature Limitations of the in vitro studies on cleaning are scarce. Nevertheless. and the carbon tip VectorTM surfaces. and bacterial products from machined SLA and combination of treatments should be employed in TPS Ti surfaces. [47]) surfaces. to understand that a complete biofilm removal is der. In vitro studies also showed a good and decontamination of Ti surfaces reside in the potential for citric acid on bacterial killing on fact that the majority of the experiments are con- implant surfaces. In detail. The carbon tip piezoelectric scaler treatment of peri-implantitis. Regarding the decontamination capacity of but on the macroscopic level.10 (a–j) Access flap surgery in an attempt to adopted and the flap is repositioned apically (e–h).11 Peri-implantitis 243 a b c d e f g h i j Fig.

cant difference was found for PD. der. Both treat. for CAL and PD were observed. ultrasonic debridement metro. The results were inconcludent for the end osseointegration of a contaminated surface is pos.244 O. cine collagen barrier was applied. manual debridement substitutes. surgical approach. sible. Bianco A review of re-osseointegration in vitro and on and moved circumferentially around the animal and clinical studies was performed implant. In both groups.2 % irriga. air-abrasive device. the flow utilized a hydrophobic pow- recently [33]. plastic and parallel to the implant surface. vs. same treatment without sur- studies [35–43]: face smoothening. In Er:YAG laser vs. Variability in the results resides in the fact Adjunctive local antibiotics to local debridement that various surfaces. Er:YAG laser was used in the first group used followed by chlorhexidine 0.2 % irriga- chemicals should lead to obtain re-osseointegration tion was performed. The following comparisons of surgical treat- pared the different nonsurgical and surgical ments were included from the analysis of the options available. plastic curettes were used for debridement. The laser both groups. and com. Resective surgery followed by adjunctive implant Regarding nonsurgical interventions. decontaminating agents.2 % chlorhexidine. The meta-analysis of recurrence of surface under water irrigation with coronal to peri-implantitis did not show a significant apical movements. manual debridement with A statistically significance difference was out- chlorhexidine subgingival application. Scaling with curettes was performed followed by bone peaks removal. Carbon fiber tip curette defect after debridement with plastic curette. Er:YAG laser vs.5 % doxycycline irrigation in the peri- not seem to guarantee optimal results. The lined for CAL and PD 4 years after treatment laser beam was directed at the implant surface in favor of xenograft. implant sulcus and 0. Synthetic grafts made of nano- VectorTM system was used. aerosol spray was crystalline hydroxyapatite were placed in the made of HA particles. points analyzed. In the control group. After 6 months. animal-derived Air-abrasive device vs. with the beam directed to the exposed implant tion. For the curettes debridement before bone augmenta- manual debridement. bovine xenograft was eventually was applied in the same way as described placed in the defect. in one group the implant surface was nidazole gel 25 % injected into the pocket a depth polished with burs and the flap repositioned at 3 mm of depth. No statistically signifi. the fol. The authors stress the Full-mouth debridement with plastic curettes fact that surface decontamination by itself does plus 8. literature: No trials were found directly comparing non- surgical vs. performed. Both interven. was employed for debridement. and materials are available. A Cochrane Review [34] of interventions has been performed including the RCTs that com. Results showed no superiority of ments repeated at 1 week. under water irrigation from coronal to apical Surface debridement with laser vs. No significant dif. benefit for either intervention. finally. In the bined therapies with mechanical devices and control group. plastic curettes were tion. a resorbable por- ference for MBL change and PD after 6 months. with the conclusions that re. In the control group no polishing was fiber tip at the lowest power for 15 s. No significant differences in the treatment of peri-implantitis. no statis- before. plus two different antibiotics and surface lowing comparisons were made on the following smoothening vs. one treatment over the other. Iocca and G. . Animal-derived grafts were bovine-derived tions repeated after 3 months. The air-abrasive device consisted of a tically significant difference was recorded nozzle placed in the pocket for around 15 s between the two groups. chlorhexidine subgingival application. xenografts. just chlorhexidine 0. Augmentation with synthetic vs. US debridement with carbon apically. Local antibiotics vs.

Results pointed at debridement in conjunction short follow-ups do not allow to draw strong with antibiotics as the best treatment in regard to conclusions. a compare different peri-implantitis treatments. therefore. After implant placement. no reliable evidence could be only. premises of lack of large clinical trials in the sons are possible. prompt nonsurgical intervention should be Eleven studies (RCTs and controlled trials) employed in order to avoid a development to con- were included for the analysis. [44] attempted to When signs of peri-implant mucositis occur. reflect the characteristics of the true end point pared to synthetic bone substitutes. Results for Finally. a statistical tool that cigarette smoking being the most important risk allows to combine the results of various studies in factors. Regarding surgery. alternative treatments are available does not The results of network meta-analysis allow to allow to make head-to-head meta-analysis feasi. A Bayesian network meta-analysis was con- ber of patients included in the trials was small. Also low-quality trials may It results evident that. The fact that many PerioChip (Fig. clinical practice. multiple combinations of compari. and 12 months were included. Moreover there is a great treatment of peri-implantitis and the great hetero- heterogeneity in methods and reporting of results. there is no evidence .11 Peri-implantitis 245 Limitations of this review were that the num. only RCTs were included. a synthesis When this occurs. patient selection allows to avoid the implant treat- A methodological way of synthesis that may ment in those patients predisposed to the develop- help in this kind of scenario is the use of network ment of peri-implantitis. PD reduction when compared to debridement In summary. gain new insights into the effectiveness of the ble. and results at 4. but this Moreover. approaches available for the treatment of peri. the authors noted that many studies time only nonsurgical treatments were compared. (implant failure). it is possible to conclude that the CAL gain and PD reduction were better for sur. it results in the difficulty to operate various treatment options. given the multiple limit the strength of a network meta-analysis. 6.11 and Table 11. And in fact. ducted by the same group of authors [45]. again the surgical procedures plus seem to give the best results at short-term fol- bone grafts and non-resorbable membranes gave low-up periods. Also. clamated peri-implantitis. the selection of a At the current state. On the other hand. Nevertheless. in this way. although some limita- a synthesis of all the trials. peri-implantitis. The surrogate end points bovine-derived grafts with a resorbable barrier reported in most studies (CAL and PD) may not gave better results for CAL and PD when com. of adjunctive antibiotic therapy to manual A limited number of studies still limit the debridement is suggestive of better results in analysis of the different treatment modalities for terms of CAL and PD. are sponsored by the companies manufacturing and only PD was used as end-point estimate and the devices employed in the studies. Reviews seem to show that the best results in respect to CAL and PD at 12 laser therapy does not confer an advantage over months. Finally. Undoubtedly surgical approaches comparison. geneity between the various studies. the use tions should be kept in mind. 11. search of the best treatment option for patients gical compared to nonsurgical approaches. a “marketing” bias should be considered. It was followed by debridement plus extrapolated from the review. given the abovementioned implantitis. The NMA of Faggion et al. Careful still subjective. order to reduce the incidence of peri-implantitis. poor oral hygiene and meta-analysis (NMA). affected by peri-implantitis remains an open When adjunctive treatments were added for question. it seems that prevention is given treatment for peri-implantitis patients is the best way to face peri-implant diseases. a lifelong fol- a way to draw a realistic picture of the state of the low-up with regular checkups is mandatory in evidence.2). it may lead to difficulty in via an NMA is the only way available to draw translating the results of the available studies on some relevant conclusion. traditional systems.

S158–S171 (2015). systematic review of current epidemiology.18 to 5. N. Belibasakis.490 (−0. Clin.59) Faggion et al. J. Barrier membranes do not provide Animal models for peri-implant mucositis and peri- a clear improvement in surrogate end point implantitis. 50. Faggion. Periodontol. pathological aspects of peri-implant diseases. (Reproduced with permission) Er:YAG laser monotherapy Debridement 100 % 90 % 80 % Probability to rank at each place 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0% 1 2 3 4 5 6 7 8 Rank for PPD Table 11. Berglundh. 178–181 (2011) Oral Biol. Microbiological and immuno- workshop on periodontology. (2013) RCTs and controlled trials Surgical therapy + bone grafts + non.52 (−0. J. F. Bianco Fig. (2013) RCTs Debridement + antibiotics PPD 0. 59. C. G. L. Lang.80 (−0. Alsabeeha.Consensus of the seventh European 5. W.M. J. 84. 3. Duncan. PPD 3. Algraffee.81) resorbable membranes CAL 2. M. 68. Periimplant diseases: where (2012) are we now? . J. Periodontol.2 Network meta-analysis comparing various peri-implantitis treatment options Estimates in mm compared to nonsurgical treatments (HPD Studies included End-point 95 %) Faggion et al.S. 168–181 (2015) results.P. Clin. C Tomasi. Surg. mainly for the lack of direct compara.19 to 6. 689–694 1.252) of the superiority of one grafting material over 2. T. Peri-implant health and disease. N. 66–72 (2014) . 1–15 (2012) References 4. Atieh. J. A another. 42.11 Results of the Debridement + chlorohexidine gel Photodynamic therapy Bayesian network Debridement + antibiotics Air-abrasive meta-analysis by Faggion Vector system Debridement + periochip et al. 38.H.246 O. Borumandi. The frequency of peri-implant diseases: a systematic review and meta-analysis. Arch. Peri- implantitis. Derks. Ager.A. Br. 11. Periodontol. Oral Maxillofac.647 to 1. tive studies.N. Iocca and G. H.J.A. Cascarini. M.

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