Implants & prosthetics / /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


From 11 Cochrane reviews on
osseointegrated dental implants and 1
review on prosthetics
Updated to March 2006
http://www.cochrane.org
http://www.cochrane-oral.man.ac.uk

We shall discuss specifically the gaps of the topics covered
in the Cochrane reviews, since we know what has been
done in these fields.
It can difficult to discuss the gaps not knowing what has
been done (importance of the systematic reviews).
However, additional gaps can be addressed by the
participants.


1 BONE AUGMENTATION PROCEDURES
A) to test whether and when bone augmentation
procedures are necessary.
B) to test which is the most effective bone augmentation
technique for specific clinical indications.
Trials were divided into 3 broad categories according to
different clinical indications:
1) major vertical and/or horizontal bone augmentation
2) implants placed in extraction sockets
3) treatment of fenestration around implants.

1 BONE AUGMENTATION PROCEDURES
Last literature search: October 2005
13 RCTs with 330 participants (17 RCTs excluded)

Bone augmentation of athrophic edentulous mandibles (1
trial)
Stellingsma 2003

short implant vs “sandwich” bone graft

Sinus lifting (3 trials)

Wannfors 2000 1-stage block vs 2-stage particulated bone
Hallman 2002 1-stage particulated bone vs 80%Bio-Oss/20%bone vs 100% Biowww.indiandentalacademy.com
Oss

DESCRIPTION OF STUDIES
Vertical augmentation (2 trials)

Chiapasco 2004 bone + titanium barrier vs distraction osteogenesis
Merli submitted particulated bone: resorbable barrier + plates vs titanium barrier

Immediate implants in fresh extraction sockects (4 trials)
Cornelini 2004 resorbable barrier + Bio-Oss
Chen1 2005
non-resorbable vs resobable + particulated bone
Chen2 2005
particulated bone vs control
Chen manuscript
Bio-Oss vs Bio-Oss + resorbable barrier

Fenestrations and dehiscence around implants (3 trials)
Dahlin 1991
Carpio 2000
Jung 2003

non-resorbable barrier vs control
GBR + bone/Bio-Oss: resobable vs non-resorbable
resorbable barrier & Bio-Oss + rhBMP-2 (placebo)

Titanium reinforced barriers for vertical GBR
preoperative

postoperative

CONCLUSIONS
In atrophic edentulous mandibles there are more implant

failures, complications, pain, cost and longer treatment time
using “sandwich” bone grafts than short implants.

Sinus lifting with 100% bone substitutes (Bio-Oss and

Cerasorb) might work with sinus floor < 5 mm.

It is possible to augment bone vertically, however

complications are frequent and it is unclear which is the most
effective technique.


CONCLUSIONS
It unclear whether augmentation procedures are needed in
postextractive sockets and which is the most effective
augmentation procedure. In sites treated with Bio-Oss +
barriers, the gingival margins may be positioned 1.2 mm
higher than in sites treated with barriers alone.

GBR allows bone augmentation at fenestrated implant, but

it is unclear whether it is needed, and which is the most
effective technique.

Complications with GBR procedures are common. There

might be an association between bone retrieved with “bone
filters” also using a dedicated suction device and infective
complications.

• When bone augmentation procedures are actually needed?
• Which procedures are associated with the least discomfort

and complications for the patients, without jeopardizing
(ideally improving) success rates?
• Sinus lift: use of 100% bone substitutes.
• Vertical augmentation: bone blocks, particulated

bone/bone substitutes and GBR, osteodistraction, active
molecules, split-crest techniques (only for horizontal
augmentation).
• Postextractive implants: grafting or not, what to graft (bone

or slow resorbable bone substitutes), membranes?
• Duration of follow-up.

What trials are needed


Is a surface modification, an implant shape, a material or an
implant system more effective than the others?
Last literature search: February 2005.
12 RCTs with 512 participants and 12 different implant systems
(19 RCTs excluded). 4 RCTs with a 5-year follow-up.
Minor statistically significant differences in marginal bone loss
and in the occurrence of perimplantitis (20% risk reduction to
have perimplantitis at 3 years around implants with a
machined surface). No statistically significant difference in
failure rates.
We do not know whether any implant system is superior to the
others. It does not mean that they are all the same!

Where are the gapsthe surface characteristics
Is the material, the macrodesign,
or a combination of those characteristics relevant for the
success?
HA-coated implants?

No statistically significant difference but not a single study

was powered to detect any!
Duration of follow-up

Constant changes of surface characteristics (mostly for

marketing reasons!)
Is it better to have an early failure today or a perimplantitis
tomorrow? IN MEDIO STAT VIRTUS = Virtue stands in the
middle?!

Is there any difference if implants are immediately or early
loaded?

Last literature search: February 2004.
5 RCTs with 124 participants (2 RCTs excluded).
For “good quality mandibles” we do not know whether a
difference does exist. It does not mean that the techniques
provide the same results!


Where are the gaps
Other clinical indications (fully edentulous maxillas,

partial edentulism)?

More failures can be acceptable?
Factors affecting success of immediate loading.
Immediate loading is more interesting for the patients

than early loading.


Which is the most effective maintenance technique or
regimen?
Last literature search: June 2004.
5 RCTs with 127 participants (9 RCTs were excluded); electric
(1 RCT) and sonic (1 RCT) vs manual toothbrush; phosphoric
acid gel vs debridement (1 RCT); subgingival vs chlorhexidine
mouthrinses (1 RCT); adjunctive Listerine mouthrinse vs
placebo (1 RCT). Follow-up: 6 weeks-5 months.
Adjunctive Listerine mouthrinse reduces dental plaque and
marginal bleeding.

Where are the gaps
The longest follow-up was of 5 months!


Is there any surgical technique associated to higher success rates?
Last literature search: September 2002.
4 RCTs (5 RCTs excluded). 2 RCTs compared 2 versus 4 implants
with mandibular overdentures (170 participants); 2 RCTs compared
a crestal surgical incision with a vestibular incision (20
participants).
We do not know whether a surgical technique is superior, however,
2 mandibular implants are sufficient to hold an overdenture. It
does not mean that all techniques are the same!


Where are the gaps
1-stage versus 2-stage techniques.
How many implants for overdentures.
Incision techniques.
Techniques to reconstruct the papillas.
Techniques to increase the keratinized tissues.
Flapless implant placement.
Computer guided surgery.


How long time we need to wait to insert an implant in
postextractive sockets?
Last literature search: March 2006.
1 RCT with 46 participants: immediate delayed (ca 10 days) vs
delayed (ca 3 months) implants. Follow-up (loading) 1 year and
half.
Patients treated with immediate-delayed implants were more
satisfied, and the peri-implant tissues position was judged to be
more appropriate in relation to the neighbouring teeth by and
independent and masked assessor.

Where are the gaps
When placing the implants?
Immediate is better than immediately-delayed for the

patients.

How to place the implants (subcrestally, slightly

lingually)?
Are bone augmentation procedures needed?
What type of bone augmentation procedures are
needed?
How closing the flaps (1- or 2-stage procedure)?

Which is the most effective treatment for perimplantitis?
5 RCTs with 106 participants (2 RCTs excluded):
• local antibiotics vs debridement (2 RCT)
• mechanical (Vector) vs manual debridement (1 RCT)
• laser vs debridement and Chlorhexidine irrigation/gel (1 RCT)
• systemic antibiotics + 2 different local antibiotics + resective surgery +

modification of the surface topography.

Follow-up 3 months – 2 years


No difference between more complex procedures and
conventional debridement in light forms of perimplantitis.
The adjunctive use of local antibiotics (doxycycline) to
debridement showed an improvement of about 0.6 mm for
PAL and PPD, after 4 months in patients affected by severe
forms of perimplantitis (bone loss > 50%).


Where are the gaps
Length of the follow-up (1-5 years minimum).
To start with the simpler procedures.
To include enough patients to detect a difference.
Clearly define whether early or more advanced forms of

perimplantitis are treated.


Which intervention is more effective: preprosthetic surgery and
denture vs an implant supported prosthesis?
Last literature search: October 2005.
1 RCT with 60 participants.
Patients treated with preprosthetic surgery and dentures are less
satisfied than patients who received a mandibular overdenture on
implants.


Where are the gaps
………………………….?


Does the use of prophylactic antibiotics decrease
postoperative complications and early failures?

0 RCT.


Where are the gaps


Zygomatic implants with and without
bone grafting versus conventional
implants in augmented bone.
0 RCT.

Where are the gaps
Zygomatic implants can be associated with frequent short

and long-term complications (wrong positioning, chronic
sinusitis) and are very difficult to be placed.
It is extremely difficult to remove them.
Computer guided surgery?
Long follow-up (1-5 years minimum)


Does hyperbaric oxygen (HBO) therapy
decrease implant failures and
complications in irradiated patients?
0 RCT.

Which denture chewing surface design should be used?
Last literature search: April 2004.
1 cross-over RCT with 30 participants (1 RCT excluded):
lingualised (maxillary anatomic and mandibular non-anatomic)
vs zero-degree teeth.
Patients preferred dentures with lingualised teeth.


Where are the gaps
ANY OTHER SUGGESTED TOPIC


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