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Is flapless implant surgery a viable option in posterior maxilla? A review
Abstract
This article reviews the literature on the outcome of flapless surgery for dental implants in the posterior maxilla. The literature search was carried out in using the keywords: flapless, dental implants and maxilla. A hand search and Medline search were carried out on studies published between 1971 and 2011. The authors included research involving a minimum of 15 dental implants with a follow-up period of 1 year, an outcome measurement of implant survival, but excluded studies involving multiple simultaneous interventions, and studies with missing data. The Cochrane approach for cohort studies and Oxford Centre for Evidence-Based Medicine were applied. Of the 56 published papers selected, 14 papers on the flapless technique showed high overall implant survival rates. The prospective studies yielded 97.01% (95% CI: 90.72-99.0) while retrospective studies or case series illustrated 95.08% (95% CI: 91.0-97.93) survival. The average of intraoperative complications was 6.55% using the flapless procedure. The limited data obtained showed that flapless surgery in posterior maxilla areas could be a viable and predictable treatment method for implant placement. Flapless surgery tends to be more applicable in this area of the mouth. Further long-term clinical controlled studies are needed.
... Αυτή η μέθοδος επιτρέπει την ορατότητα της ανατομίας του οστού, ειδικά σε περιοχές όπου υπάρχει ανεπαρκές οστό και έτσι ελαχιστοποιεί τον κίνδυνο της λανθασμένης τοποθέτησης του εμφυτεύματος. Επιπλέον, η πρωτογενής σύγκλειση του τραύματος αποτρέπει τη μόλυνση 1,3,4 . Η αναπέταση κρημνού όμως έχει και μειονεκτήματα όπως είναι ο τραυματισμός αγγείων, η μετεγχειρητική απορρόφηση οστού, η υφίζηση μαλακών ιστών, η απώλεια φατνιακής ακρολοφίας και πιθανές επιπτώσεις στην αισθητική λόγω απώλειας σκληρών και μαλακών ιστών [4][5][6][7][8][9][10] . ...
... Στις μέρες μας υπάρχει μια συνεχής επιδίωξη για όλο και λιγότερο επεμβατικές χειρουργικές διαδικασίες [11][12][13][14][15] . Στην εμφυτευματολογία, ενώ κυριαρχεί η ανοιχτή τεχνική, υπάρχει ένα αυξανόμενο ενδιαφέρον για μια νέα τεχνική που δεν απαιτεί αναπέταση κρημνού 3,13,[16][17][18][19][20][21][22][23] . Ο σκοπός αυτής της προσέγγισης, είναι η διατήρηση της αρχιτεκτονικής και της αγγείωσης των μαλακών μορίων, όπως επίσης και η καλύτερη προστασία του εμφυτεύματος από το περιβάλλον της στοματικής κοιλότητας 24 . ...
... Ο σκοπός αυτής της προσέγγισης, είναι η διατήρηση της αρχιτεκτονικής και της αγγείωσης των μαλακών μορίων, όπως επίσης και η καλύτερη προστασία του εμφυτεύματος από το περιβάλλον της στοματικής κοιλότητας 24 . Η χειρουργική τοποθέτηση εμφυτευμάτων χωρίς κρημνό είναι μια ελάχιστα επεμβατική χειρουργική διαδικασία 3,5,14,17,19,[25][26][27] , η οποία μπορεί να διαχωριστεί σε δυο υποκατηγορίες: την άμεση και την έμμεση. Η άμεση προσέγγιση (Περιστατικό 1) χρησιμοποιεί απευθείας τα τρύπανα χειρουργικής τοποθέτησης των εμφυτευμάτων χωρίς αφαίρεση μαλακών ιστών 4,15,26 . ...
Nowadays, dental implants have become an extremely
useful tool, for the rehabilitation of edentulism. The standard
surgical protocol for the installation of dental implants requires
the elevation of a mucoperiosteal flap, named the “open protocol”.
Their use has led to a search for new and less invasive
procedures in surgery in order to improve their results for both
the dentist and the patient. In implant surgery, while the open
surgical procedure is still the predominant technique, there is
a rising interest in a more recently found technique that does
not require flap elevation. Its rationale is to preserve the soft
tissue architecture and circulation as well as to increase protection
of the implant and the implant socket from the infectious
environment of the oral cavity. The purpose of this study
was to provide a review of the current evidence concerning the
advantages, disadvantages, indications, contraindications and
complications of flapless implant surgery and to help the clinician
decide which approach (flap or flapless) is indicated in each
implant case. The flapless technique has a variety of advantages,
such as an increased biological and aesthetic outcome, while
the procedure is more tolerable for the patient. Nevertheless,
surgeon’s skills, learning curve and the careful selection of cases
are strong prerequisites.
... However, in edentulous jaws in which landmarks for proper implant positioning are missing, computerassisted flapless surgery may be recommended, due to the risks of dehiscences, fenestrations, and implant misplacement at an inappropriate depth or position. 6,10 Computer-guided surgery is a template-guided implant approach that requires several preoperative steps, starting with the fabrication of a radiographic template. Cone-beam computed tomography (CBCT) is acquired with the template in position, followed by computer-assisted implant planning and fabrication. ...
... Other concerns include the potential for poor control of the precise drilling, due to the difficulty in observing the drilling direction of the alveolar bone, and inaccurate implant positioning. 6,13 The purpose of this study was to evaluate the accuracy of computer-guided flapless surgery in edentulous arches through a prospective clinical study. ...
... Besides that, flapless computer-guided surgery appears to offer other benefits, such as maintenance of both soft and hard tissues, decreased postoperative pain and bleeding, faster recovery, and improved patient comfort. 6,7,10,11 This may be the reason that no patient in the study complained of pain or discomfort related to surgery. ...
Purpose:
Although flapless computer-guided implant placement provides important benefits, deviations from the planned implant placement in the edentulous arch may pose significant risks. This study evaluated the reliability and accuracy of a flapless computer-guided surgical approach.
Materials and methods:
Computer-generated preoperative implant planning was compared to actual placement by cone-beam computerized tomography (CBCT) scanning of patients before and after surgery. A well-fitting complete denture or optimized prosthetic tooth arrangement was used and converted to a radiographic template. Prior to scanning, esthetics and functional aspects were checked clinically. The implant positions were virtually determined by the implant planning software relative to the bone structure and prospective tooth position. After implant placement, new CBCT scans were obtained for each subject. Software was used to fuse the images of the planned and placed implants, and the locations and axes were compared. The normality of the data distribution was evaluated by the Kolmogorov-Smirnov test. Mean values were compared between groups based on the upper or lower jaws with the t test for independent samples. The level of significance was fixed at 5%.
Results:
Sixty-two implants were placed in edentulous arches with stereolithographic surgical guides in 14 patients. Damage due to implant placement was not observed in any critical anatomical structure. Compared to the planned implants, placed implants showed mean and standard deviation linear measurements at the cervical, middle, and apical implant portions of 2.17 (± 0.87), 2.32 (± 1.52), and 2.86 (± 2.17) mm, for the maxilla, and 1.42 (± 0.76), 1.42 (± 0.76), and 1.42 (± 0.76) mm, for the mandible, respectively. The angular deviations were 1.93 (± 0.17) and 1.85 (± 0.75) degrees for the maxilla and mandible, respectively. The linear deviation differed significantlybetween the upper and lower jaws, but the angular deviation did not.
Conclusion:
Flapless computer-guided surgery may be a viable treatment option for rehabilitating the edentulous arch.
... According to the Branemark dental implant protocol, a mucoperiosteal flap is always elevated, and the underlying bone is revealed to facilitate vision and accessibility of the operative site 4 . However, this increases the odds of post-operative complications such as pain, edema, bleeding, prolonged operational time, and discomfort due to the inability to use the prosthesis 3,5,6 . ...
Objective: The present study aims to evaluate the dental implant flapless technique as a successful treatment option for implant patients by assessing marginal bone loss after 3 months and post-operative pain.Methods: One hundred and twenty implants were placed in 40 patients. Two parameters were assessed post-operatively: marginal bone loss and pain; the difference in marginal bone loss (MBL) was measured based on an immediate post-operative OPG and another OPG taken three months after the surgery, and pain assessment was achieved using a 10-cm visual analog scale (VAS) post-operatively for five days. Descriptive and inferential statistics were used, and as most of the data were not normally distributed, Mann-Whitney test was used for comparing the groups.Results: The present study's findings demonstrate that the average marginal bone loss (MBL) around the implant at three months using the flapless technique was 0.2± 0.1 mm. No implants failed to osseointegrate. There was no statistical MBL significance between male and female patients or between upper and lower jaw. This study shows significantly reduced post-operative pain in the flapless implant placement technique. Conclusions: The flapless approach is predictable when patient selection, meticulous planning, and precise surgical protocols are followed.
... A very recent study suggested that the flapless approach coupled with an atraumatic tooth extraction technique provided better advantages than traumatic surgery (Menchini-Fabris et al., 2022). Probably an atraumatic surgery guaranteed a minimization of soft tissue trauma, a reduction of scar formation, preservation of the periosteal blood supply, and a reduction of patient discomfort (Doan et al., 2012). ...
... A reabilitação de pacientes edêntulos utilizando PTs fixas implantossuportadas (prótese tipo protocolo) é bem documentada na literatura 2 . Tradicionalmente, as cirurgias para colocação de implantes são realizadas com retalho mucoperiosteal 3 . Conceitos atuais de cirurgia para colocação de implantes têm introduzido a possibilidade de cirurgias sem retalho (flapless), apresentando várias vantagens em relação aos métodos tradicionais com retalho, devido a utilização de uma técnica menos invasiva, com menor desconforto pós-operatório para o paciente, reduzido tempo cirúrgico e com pequenas alterações na forma do rebordo 5 . ...
... GIS has several advantages, such as 3D evaluation of the relationship between prosthodontic reconstruction and bone, time reduction and lower invasivity during surgery (Wittwer et al. 2007;Pozzi et al. 2011;Doan et al. 2012). Furthermore, using templates might be helpful as a means of avoiding damage to vital structures (BouSerhal et al. 2002;Tyndall et al. 2012). ...
Objectives:
To compare the deviation of different systems for Guided Implant Surgery (GIS) related to the specific tolerance between drills and sleeves.
Material and methods:
Four different systems for GIS and their appropriate sleeves were used: Camlog Guide (CG), Straumann Guided Surgery (SG), SIC Guide (SIG), and NobelGuide (NG). System-appropriate metal sleeves were inserted into plexiglass boxes, and guided drilling procedure was performed (i) holding the drills in the most centric position of the sleeves and (ii) applying forces eccentrically. Digital microscope images of the plexiglass boxes were taken and axial deviations were calculated based on the Pythagorean Theorem, whereas coronal and apical deviations were measured with a corresponding software-device and calculated by subtracting the measured deviations from the original diameter of the drills. Statistically significant differences between centric and eccentric drilling were determined applying the t-test for independent data.
Results:
The axial deviation ranged from 0° (SG) to 5.64° (CG). The apical deviations varied between 0.01 mm (SIG) and 3.2 mm (NG) and the coronal deviations ranged from 0.01 mm (SIG) to 1.60 mm (NG). In terms of angular deviation, there were statistically significant differences between centric and eccentric drilling for all four systems. Coronal and apical deviations, showed no statistical significance between centric and eccentric drilling for SIG and NG, in contrast to CG and SG.
Conclusions:
The clinician may have considerable impact on the accuracy of GIS when applying eccentric forces.
... A recent review confirmed that flapless approaches provide some important advantages as minimized trauma to the soft tissue, reduced scar formation, preservation of osseous vascularization via the periosteum and reduced patient discomfort (Doan et al., 2012). ...
The buccal alveolar wall represents the most important structure to provide shape and volume of the alveolous following tooth extraction. The aim of the study was the evaluation of buccal alveolar bone structures following minimally invasive surgery. In 15 patients (3 male, 12 female), aged 20–67 years, 3 central incisors, 5 lateral incisors, and 7 bicuspids were removed using flapless enucleation. The enucleation comprised endoscopically assisted mesiodistal root sectioning with inward fragmentation of the oral and apical parts followed by internal reduction of the buccal root lamella. Buccal bone height before extraction was 10.61 mm, following extraction 10.50 mm. Crestal width of the buccal bone plate was 1.11 mm before and 1.40 mm after tooth removal. Apical buccal bone width before was 0.66 mm and after extraction 0.40 mm. Gingival height was 13.58 mm before and 13.56 mm following extraction. Following transalveolar enucleation, the buccal alveolar bone wall remains unchanged concerning height and crestal width.
... Due to the poor quality and size of the alveolar ridge, the success rate of sinus area implantation is relatively low. Numerous studies have been conducted into dental implantation in the posterior maxilla (26,27), and clinical studies, animal experiments and FEM studies (28)(29)(30) have been carried out regarding the influence of bone quality and size on implants; however, to the best of our knowledge, no study concerning the association between an implant and the sinus floor cortical bone has been conducted. Sinus floor cortical bone has a tendency to be thin, which has made it less important in the research of dental implantation in the sinus area. ...
The aim of the present study was to evaluate the effect of the association between the implant apex and the sinus floor in posterior maxilla dental implantation by means of three-dimensional (3D) finite element (FE) analysis. Ten 3D FE models of a posterior maxillary region with a sinus membrane and different heights of alveolar ridge with different thicknesses of sinus floor cortical bone were constructed according to anatomical data of the sinus area. Six models were constructed with the same thickness of crestal cortical bone and a 1-mm thick sinus floor cortical bone, but differing heights of alveolar ridge (between 10 and 14 mm). The four models of the second group were similar (11-mm-high alveolar ridge and 1-mm-thick crestal cortical bone) but with a changing thickness of sinus floor cortical bone (between 0.5 and 2.0 mm). The standard implant model based on the Nobel Biocare(®) implant system was created by computer-aided design (CAD) software and assembled into the models. The materials were assumed to be isotropic and linearly elastic. An inclined force of 129 N was applied. The maximum von Mises stress, stress distribution, implant displacement and resonance frequencies were calculated using CAD software. The von Mises stress was concentrated on the surface of the crestal cortical bone around the implant neck with the exception of that for the bicortical implantation. For immediate loading, when the implant apex broke into or through the sinus cortical bone, the maximum displacements of the implant, particularly at the implant apex, were smaller than those in the other groups. With increasing depth of the implant apex in the sinus floor cortical bone, the maximum displacements decreased and the implant axial resonance frequencies presented a linear upward tendency, but buccolingual resonance frequencies were hardly affected. This FE study on the association between implant apex and sinus floor showed that having the implant apex in contact with, piercing or breaking through the sinus floor cortical bone benefited the implant stability, particularly for immediate loading.
A BSTRACT
Background
Flapless surgery for implant placement has been gaining popularity among implant surgeons. it has numerous advantages, including preservation of circulation, decreased surgical time; improved patient comfort; and accelerated recuperation.
Materials and Methods
As a part of the study to evaluate crestal bone loss changes after placement of implant using the flapless technique, we placed twenty endosseous implants. Access was achieved to the crestal bone using a tissue punch. Clinical and radiographic analyses were performed second and fourth months after placement of the implant. Postoperative pain was measured by the visual analog scale at the 4 th , 8 th , and 24 th hour.
Results
The findings of the present study demonstrate that the average crestal bone loss around the implant at 4 months using the flapless technique was 0.19 mm. No implants failed to osseointegrate, and no implants exhibited bone loss greater than 0.5 mm in the first four months. This present study shows significantly less postoperative pain in the flapless technique of implant placement.
Conclusion
The flapless approach is a predictable procedure when patient selection and surgical technique are appropriate.
The aim of this study was to evaluate the linear and angular deviations of the implants installed by the Computed Tomographic (CT) guided surgery technique. Eighteen patients who underwent implant insertion by means of CT-guided surgery participated in this study. Ten of these patients had a fully edentulous maxilla, and 8 had a fully edentulous mandible. The patients received a total of 115 implants, of which 81 implants were installed in the maxilla and 34 installed in the mandible. Tomographic guides were made for tomographic examination in both the upper and lower jaws. After the image acquisition, the virtual planning of the positioning of the implants was performed in relation to the previously made prosthesis. The measurement of the linear and angular deviations between the virtual planning and the final position of the implants was performed with the overlap of the planning and postoperative tomography. There were no differences in the linear and angular deviations of the implants installed in the maxilla and mandible. Compared to the coronal region, there was a trend of greater linear deviations in the apical regions of the implants and a greater tendency toward deviations in the posterior regions than in the anterior regions of both arches. The CT-guided surgery promoted the installation of implants with high accuracy and allowed the installation of straight pillars in all cases evaluated. The linear deviations were not different in the different regions of the month and in the different portions of the implants.
The purpose of this study is to evaluate the therapeutic effects of MLS laser on clinical outcomes of flapless dental implants placed using split mouth study and to measure patients’ satisfaction using visual analogue scale in in post menopause women age 50 years or over. Materials and methods: This study is a retrospective split mouth study on the therapeutic effects of MLS laser on the outcomes of flapless involving the study of dental records of 26 post-menopause of patients undergoing bilateral implant surgery in the posterior maxilla. A total of 65 implants with no augmentative procedures were selected from 26 patients for the study. Flapless implant technique was used for both sides of the jaw. The patients were divided into two groups: the control group had 32 implants and had sham MLS laser treatment, and the test group consisted of 33 implants treated with MLS Mphi laser at day one, day 7 and day 28. Only those patients with complete dental record were involved in this study. The treatment results were calculated via key words: Satisfaction, Implant Survival, Visual Analogue Scale (VAS), Periotest, X-ray assessment. Results and discussion: The findings illustrated that therapeutic MLS Laser treatment had a slightly better outcomes as contrast to the control side: survival rate (100.0% and 96.9%), Utilizing VAS (0–10), MLS Laser treatment in test group had less: pain, swelling but no difference in bleeding and speech impairment and had better overall satisfaction at one day and one week than the control side (*P < 0.05). No significant discrepancy in bone resorption at 3 months. After 6 months, bone change in the control group vs the test group was statistically significant [−0.56 (±0.52) vs. +0.12 (±0.50), **P < 0.05]. No statistical dissimilarity in Periotest Value (PTV). Conclusion: Therapeutic MLS Laser in implant flapless surgery is a an adjunctive minimal invasive, efficacious, and innovative method that can deliver a significantly superior early phase satisfaction, minimal bone loss, less pain, less complications, and similar PTV as contrast to the control side.
Objective This study aims to evaluate the relationship between implant placement, poor quality bone, simvastatin, and osseo-integration of surface-treated implants in the posterior maxilla of osteoporotic rats. Materials and methods Sixty-four female Sprague-Dawley rats, aged 3 months old were used in this study, divided into three groups: Sham-operated (SHAM; n = 20), ovariectomized (OVX; n = 20) and ovariectomized treated with simvastatin (OVX + SIM; n = 20). Two rats from the SHAM and two from the OVX groups were used to verify osteoporosis. Eighty-four days following ovariectomy, screw-shaped titanium implants were immediately placed into mesial root sockets of the posterior maxilla. Simvastatin was administered orally at 5 mg/kg each day after the implant placement in the OVX + SIM group. The animals were sacrificed at either 28 or 56 days from the date of implant insert and the undecalcified tissue sections were processed for histological analysis. The osseo-integration indices used were: bone formation rate (BFR), bone to implant contact (BIC), and bone density (BD). Results The osseo-integration indices (BFR, BIC and BD) in the three groups demonstrated significant differences among the SHAM > OVX + SIM > OVX group, which implied that simvastatin could promote bone mineralization in OVX rats. Conclusion This study shows for the first time that simvastatin can positively affect the osseo-integration indices, and successfully promoted osseo-integration in the posterior maxilla in OP rats.
Background The surgical placement of implants into maxillary extraction sites in ovariectomized (OVX) rats could mimic implant placement in compromised bone in humans, such as is seen in osteoporosis. Purpose This study was designed to evaluate the effects of osteoporosis on osseo-integration around titanium implants following extraction in the posterior maxilla of OVX rats. Materials and Methods Forty-four 3 month old female Sprague-Dawley rats were used in this study. The rats were randomly divided into two groups: Sham-operated group (SHAM; n = 22) and ovariectomized group (OVX; n = 22). Surface-treated screw-shaped titanium implants were immediately inserted into the mesial extraction sites of the first molar in the posterior maxilla following tooth extraction. The animals were sacrificed at either 28 or 56 days post-surgery, and undecalcified tissue sections were processed for histological analysis. Bone-to-implant contact (BIC) and bone density (BD) were evaluated. Results With a carefully planned and executed surgical implant protocol, implant placement following extraction in the posterior maxilla can produce reproducible results. The BIC and BD in the OVX group were significantly inferior to those in the SHAM group at both 28 and 56 days, which indicated that osteoporosis could reduce the amount of osseo-integration of dental implants in the posterior maxilla. Conclusion This study demonstrated that osseo-integration (BIC and BD) was inferior in implants following extraction in the posterior maxilla of OVX rats, especially in the early healing period, indicating that lower local bone quality in OVX rats can reduce early bone formation on implant surfaces.
Background:
Sinus elevation is a reliable and often used technique. The success of implants placed in such situations, even with bone substitutes alone, led us to strive for bone loss close to zero and to seek out variables that cause higher or lower rates of resorption. The objective of this study was twofold: to evaluate the survival rates and marginal bone loss (MBL) around implants installed in maxillary sinus augmentation using anorganic bovine bone, and to identify surgical and prosthetic prognostic variables.
Methods:
A total of 55 implants were placed in 30 grafted maxillary sinuses in 24 patients. Periapical radiographs were evaluated immediately after implant placement (at baseline), at 6 months, and at the most recent follow-up. MBL was calculated, taking into account the distortion rate for each radiograph as compared to the original implant measurements, from the difference between the initial and final measurements.
Results:
The survival rate was 98.2%, with only one implant lost (100% survival rate after loading) over a mean follow-up time of 2 ± 0.9 years. The MBL ranged from 0 to 2.85 mm: 75.9% of mesial sites and 83.4% of distal sites showed <1mm of MBL, while 35.2% of mesial sites and 37% of distal sites exhibited no bone loss. The MBL was significantly (p<0.05) greater in open flap as compared to flapless surgery.
Conclusion:
Within the limitations of this study, we concluded that maxillary sinus elevation with 100% anorganic bovine bone presents predictable results, and that flapless surgery results in less MBL as compared to traditional open flap surgery.
Purpose:
The literature reports that flapless compared with traditional implant surgery can be associated with several advantages, including the maintenance of peri-implant hard tissues. This study investigated vertical bone resorption during long-term follow-up after implant placement with flapless versus traditional surgery.
Material and methods:
In this prospective, randomized controlled clinical trial, 40 patients underwent implant placement at the Maxillofacial Department Surgery of the Istituto Stomatologico Italiano Hospital in Milan, Italy. Patients were randomly assigned to the control or experimental group. The control group had implants placed with open flap surgery (traditional surgery), whereas the experimental group had implants placed with flapless surgery. The distance between the first implant thread and the marginal crestal bone level was measured at the basal, loading, and long-term control points. The basal recording was performed just after implant placement. The loading measurement was recorded at the time of implant loading, after 2 months of healing for the lower jaw and after 3 months of healing for the upper jaw, and the long-term control record was registered 36 months after implant placement. Statistical analysis was performed using mean values and standard deviations based on bone resorption in the 2 groups. To detect statistical differences, the Student t test was applied. Differences were considered significant if P values were less than .05.
Results:
The control group (open flap surgery) was comprised of 19 patients, and the experimental group (flapless surgery) was comprised of 21 patients. No statistical differences were found in peri-implant bone resorption between the 2 groups at the basal, implant loading, and 3-year control recordings.
Conclusion:
According to this study, the approach to implant surgery does not seem to influence peri-implant bone resorption in humans, at least for the period measured in this study.
Objective: To systematically review the papers to compare implant survival, postoperative complications and surgical procedure duration of dental implantation between flap and flapless elevation. Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE in June 2013 and selected studies according to the criteria for inclusion. Risk of bias of the included studies was assessed and meta-analysis was achieved depending on Revman 5.2. Results: Eight randomized controlled trials and two comparable prospective cohort trials involving 366 subjects and 1 152 implants were included in this meta-analysis. Eight of them had moderate risk of bias and two had low risk of bias. The implant survival rate revealed no statistically significant difference between the two groups [RR= 0.99, 95%CI (0.97, 1.02), P=0.64]. However, at a patient level, the postoperative complications (postoperative pain and postoperative edema) in the flapless group were significantly reduced [RR=0.52, 95%CI (0.37, 0.74), P<0.01; RR= 0.47, 95%CI(0.33, 0.66), P<0.01]. The analysis also identified that flapless technique significantly reduced the duration of operative procedure [MD=-16.23, 95%CI(-29.33, -3.13), P<0.01]. Conclusion: The present meta-analysis confirmed the effectiveness of flapless technique in dental implant. The implant survival rates of the different between the two techniques are comparable; however, the flapless technique significantly reduced the duration of implant procedure and occurrence of postoperative pain and edema. ©, 2015, Editorial Board of Medical Journal of Wuhan University. All right reserved.
The aim of this study is to examine the clinical outcomes of implants inserted using split mouth study and to measure patients’ satisfaction using visual analogue scale in flapless and conventional flap techniques in post menopause women age 50 years or over. Materials and methods: This study is a retrospective split mouth study of flapless vs flap technique involving the study of dental records of 16 postmenopause of patients undergoing bilateral implant surgery in the posterior maxilla. A total of 45 implants with no augmentative procedures were selected from 16 patients for the study. The patients were divided into two groups: the control group had 21 implants placed by full flap technique, and the test group consisted of 24 implants inserted using flapless procedure. Only those patients with comprehensive clinical record were included in this study. The treatment outcomes were measured using key words: implant survival, Visual Analogue Scale (VAS), Periotest, x-ray assessment. Results and Discussion: The results showed that flapless surgery had comparable, similar results as compare to flap surgery: survival rate (95.8% and 95.2%), Using visual analogue scale (VAS=0 to 10), flapless surgery revealed to have less: pain, swelling, bleeding and speech impairment and had better overall satisfaction at one day and one week than flap technique than the flap counterpart (*P<0.05). No significant difference in bone resorption at 3 months. After one year, bone change in the flap group vs the flapless group was statistically significant [-0.53 (±0.57) vs +0.08 (±0.49), **P<0.005]. No significant difference in Periotest value (PTV). Conclusion: This study showed that implant flapless surgery is a minimal invasive, effective, and novel technique that can render a significantly better early stage satisfaction outcome as compare to the traditional flap method. Flapless implantation resulted in minimal bone loss, less pain, less complications, and comparable good PTV.
The aim of this study is to perform a comprehensive evaluation of clinical procedures used in dental implant treatment in posterior maxilla using flapless technique; to assess osseo-integration of surface-treated implants in the posterior maxilla of osteoporotic (OP) rats, and the conservative regeneration of poor quality bone in (OP) rats with simvastatin. Materials and methods: This comprehensive consists of a systematic review of the literature on dental implant flapless technique, a retrospective study of 1241 dental implants using flapless technique, and an osseo-integration study on osteoporotic (OP) rats. The osseo-integration study used a cohort of sixty-four female Sprague-Dawley rats, aged 3 months old, split into three groups: Sham-operated (SHAM; n=20), ovariectomized (OVX; n=20) and ovariectomized treated with simvastatin (OVX+SIM; n=20). Eighty-four days following ovariectomy, screw-shaped titanium implants were immediately placed into the posterior maxilla. Simvastatin was fed orally at 5 mg/kg each day after the implant placement in the OVX+SIM group. The animals were sacrificed at either 28 or 56 days for histological analysis. The osseo-integration indices used were: bone formation rate (BFR), bone to implant contact (BIC), and bone density (BD). Results and Discussion: The systematic review showed flapless surgery had comparable, similar & high survival rate compare with flap surgery, and its cumulative 5 and 10 years implant survival rate of 97.9% and 96.5% respectively and complication rate of 6.0%. The osseo-integration indices (BFR, BIC and BD) in the three groups showed significant variations among the SHAM > OVX+SIM > OVX group, which suggested that simvastatin could encourage bone regeneration and mineralization in OVX rats. Conclusion: This study shows that implant flapless surgery has been proven to be a successful procedure, osteoporosis reduced osseo-integration, and simvastatin can positively influence on bone regeneration through the osseointegration indices, and successfully promoted osseointegration in the posterior maxilla in OP rats.
The aim of this systematic review was to evaluate the outcomes of flapless surgery for implants placed using either free-hand or guided (with or without 3D navigation) surgical methods. Literature searches were conducted to collect information on survival rate, marginal bone loss, and complications of implants placed with such surgeries. Twenty-three clinical studies with a minimum of 1year follow-up time were finally selected and reviewed. Free-hand flapless surgery demonstrated survival rates between 98.3% and 100% and mean marginal bone loss between 0.09 and 1.40mm at 1-4 years after implant insertion. Flapless guided surgery without 3D navigation showed survival rates between 91% and 100% and mean marginal bone loss of 0.89mm after an observation period of 2-10 years. The survival rates and mean marginal bone loss for implants placed with 3D guided flapless surgery were 89-100% and 0.55-2.6mm, respectively, at 1-5 years after implant insertion. In 17 studies, surgical and technical complications such as bone perforation, fracture of the surgical guide, and fracture of the provisional prosthesis were reported. However, none of the identified methods has demonstrated advantages over the others. Further studies are needed to confirm the predictability and effectiveness of 3D navigation techniques.
Background:
The clinical outcomes of implants placed using the flapless approach have not yet been systematically investigated. Hence, the present systematic review and meta-analysis aims to study the effect of the flapless technique on implant survival rates (SRs) and marginal bone levels (MBLs) compared with the conventional flap approach.
Methods:
An electronic search of five databases (from 1990 to March 2013), including PubMed, Ovid (MEDLINE), EMBASE, Web of Science, and Cochrane Central, and a hand search of peer-reviewed journals for relevant articles were performed. Human clinical trials with data on comparison of SR and changes in MBL between the flapless and conventional flap procedures, with at least five implants in each study group and a follow-up period of at least 6 months, were included.
Results:
Twelve studies, including seven randomized controlled trials (RCTs), one cohort study, one pilot study, and three retrospective case-controlled trials (CCTs), were included. The SR of each study was recorded, weighted mean difference (WMD) and confidence interval (CI) were calculated, and meta-analyses were performed for changes in MBL. The average SR is 97.0% (range, 90% to 100%) for the flapless procedure and 98.6% (range, 91.67% to 100%) for the flap procedure. Meta-analysis for the comparison of SR among selected studies presented a similar outcome (risk ratio = 0.99, 95% CI = 0.97 to 1.01, P = 0.30) for both interventions. Mean differences of MBL were retrieved from five RCTs and two retrospective CCTs and subsequently pooled into meta-analyses; however, none of the comparisons showed statistical significance. For RCTs, the WMD was 0.07, with a 95% CI of -0.05 to 0.20 (P = 0.26). For retrospective CCTs, the WMD was 0.23, with a 95% CI of -0.58 to 1.05 (P = 0.58). For the combined analysis, the WMD was 0.03, with a 95% CI of -0.11 to 0.18 (P = 0.67). The comparison of SR presented a low to moderate heterogeneity, but MBL presented a considerable heterogeneity among studies.
Conclusion:
This systematic review revealed that the SRs and radiographic marginal bone loss of flapless intervention were comparable with the flap surgery approach.
To assess the marginal soft tissue healing process after flap or flapless surgery in immediate implant placement in a dog model.
This study was carried out on five Beagle dogs. Four implants were placed in the lower jaw in each dog immediately after tooth extraction. Flap surgery was performed before the extraction on one side (control) and flapless on the other (test). After 3 months of healing, the dogs were sacrificed and prepared for histological analysis.
Ten implants were placed in each group. Two failed (one of each group). The length of the junctional epithelium in the flapless group was 2.54 mm (buccal) and 2.11 mm (lingual). In the flap group, the results were very similar: 2.59 mm (buccal) and 2.07 mm (lingual), with no significant differences observed between the groups. The length of the connective tissue in the flapless group was 0.68 mm (buccal) and 0.54 mm (lingual), and 1.09 mm at the buccal and 0.91 mm at the lingual aspect in the flap group, with no significant differences between groups. The difference between the mean distance from the peri-implant mucosa margin to the first bone-implant contact at the buccal aspect was significant between both groups (3.02 mm-flapless and 3.69 mm flap group). However, this difference was mostly due to the Pm3 group (flapless: 2.95/flap: 3.76) because no difference could be detected in the Pm4 group. Both groups showed minimal recession, with no significant differences between groups (flapless group - 0.6 mm buccal and 0.42 mm lingual; flap group - 0.67 and 0.13 mm).
The clinical evaluation of immediate implant placement after 3 months of healing indicated that buccal soft tissue retraction was lower in the flapless group than in the flap group, without significant differences. The mean values of the biological width longitudinal dimension at the buccal aspect were higher in the flap group than in the flapless group, this difference being mostly due to the Pm3, probably because of a thinner biotype in this region.
The survival rate of dental implants is markedly influenced by the quality of the bone into which they are placed. The purpose of this study was to determine the trabecular bone density at potential dental implant sites in different regions of the Chinese jawbone using computed tomography (CT) images. One hundred and fifty-four potential implant sites (15 in the anterior mandible, 47 in the anterior maxilla, 55 in the posterior mandible, and 37 in the posterior maxilla) were selected from the jawbones of 62 humans. The data were subjected to statistical analysis to determine any correlation between bone density (in Hounsfield units, HU) and jawbone region using the Kruskal-Wallis test. The bone densities in the four regions decreased in the following order: anterior mandible (530 +/- 161 HU, mean +/- s.d.) approximately equal anterior maxilla (516 +/- 132 HU) > posterior mandible (359 +/- 150 HU) approximately equal posterior maxilla (332 +/- 136 HU). The CT data demonstrate that trabecular bone density varies markedly with potential implant site in the anterior and posterior regions of the maxilla and mandible. These findings may provide the clinician with guidelines for dental implant surgical procedures (i.e., to determine whether a one-stage or a two-stage protocol is required).
A total of 2895 threaded, cylindrical titanium implants have been inserted into the mandible or the maxilla and 124 similar implants have been installed in the tibial, temporal or iliac bones in man for various bone restorative procedures. The titanium screws were implanted without the use of cement, using a meticulous technique aiming at osseointegration--a direct contact between living bone and implant. Thirty-eight stable and integrated screws were removed for various reasons from 18 patients. The interface zone between bone and implant was investigated using X-rays, SEM, TEM and histology. The SEM study showed a very close spatial relationship between titanium and bone. The pattern of the anchorage of collagen filaments to titanium appeared to be similar to that of Sharpey's fibres to bone. No wear products were seen in the bone or soft tissues in spite of implant loading times up to 90 months. The soft tissues were also closely adhered to the titanium implant, thereby forming a biological seal, preventing microorganism infiltration along the implant. The implants in many cases had been allowed to permanently penetrate the gingiva and skin. This caused no adverse tissue effects. An intact bone-implant interface was analyzed by TEM, revealing a direct bone-to-implant interface contact also at the electron microscopic level, thereby suggesting the possibility of a direct chemical bonding between bone and titanium. It is concluded that the technique of osseointegration is a reliable type of cement-free bone anchorage for permanent prosthetic tissue substitutes. At present, this technique is being tried in clinical joint reconstruction. In order to achieve and to maintain such a direct contact between living bone and implant, threaded, unalloyed titanium screws of defined finish and geometry were inserted using a delicate surgical technique and were allowed to heal in situ, without loading, for a period of at least 3--4 months.
To document the literature regarding outcomes of implant restorations in the anterior maxilla to formulate consensus statements with regard to esthetics in implant dentistry, to provide guidelines to clinicians, and to articulate remaining questions in this area to be addressed by future research.
The following areas of the recent literature were scrutinized: treatment outcomes of implant therapy for partial edentulism (including maxillary anterior tooth replacement); anterior maxillary single-tooth replacement; effect of implant design, diameter, and surface characteristics; soft tissue stability/contours around anterior implant restorations; ceramic abutments; influence of surgical techniques; and finally, evaluation of patient satisfaction.
The use of dental implants in the esthetic zone is well documented in the literature, and numerous controlled clinical trials show that the respective overall implant survival and success rates are similar to those reported for other segments of the jaws. However, most of the published studies do not include well-defined esthetic parameters. Currently, the literature regarding esthetic outcome is inconclusive for the routine implementation of certain surgical approaches, such as flapless surgery and immediate implant placement with or without immediate loading/restoration in the anterior maxilla. Considering anterior single-tooth replacement in sites without tissue deficiencies, predictable treatment outcomes, including esthetics, can be achieved because of tissue support provided by adjacent teeth. The replacement of multiple adjacent missing teeth in the anterior maxilla with fixed implant restorations is poorly documented. In this context, esthetic restoration is not predictable, particularly regarding the contours of the interimplant soft tissue.
This review has demonstrated that scientific documentation of esthetically relevant and reproducible parameters is rather scarce. Most of the reported outcome analyses primarily focus on implant survival. Elements of anterior implant success such as maintenance or reestablishment of harmoniously scalloped soft tissue lines and natural contours should be included in future studies.
Placing implants in periodontally compromised sites is generally considered a risk factor. Good results have been reported when rehabilitating partial or complete edentulous sites in patients with a history of periodontitis. However, there is a need for more documentation of this treatment modality.
The purpose of this study was to report, retrospectively, on the placement of implants in periodontally compromised areas of the maxilla and mandible without a prior healing period and in immediate function. This study also presents a prospective preliminary 1-year report using a standardized clinical protocol, including a regenerative surgical procedure, control of the inflammatory response, a maintenance protocol, and use of an implant with an oxidized surface.
The clinical study encompassed 184 consecutively included patients with 433 implants (165 with a machined surface and 268 with an oxidized surface) placed in immediate function (140 in the maxilla and 293 in the mandible) supporting 218 fixed prostheses. Two groups were defined: the Retrospective group (using an unstandardized surgical technique and a majority of machined surface implants) with a retrospective approach and the Prospective group (using standardized surgical and maintenance protocols and oxidized surface implants) with a prospective approach. The 2 groups were evaluated for implant survival, clinical implant stability, bone resorption, absence of radiolucent areas around implants on the radiographs, and patient-reported function of the implants. Definitive prostheses were placed 6 months after the surgery. The data was analyzed using descriptive statistics.
Thirteen implants were lost in 9 patients, providing a cumulative survival rate of 91% at 5 years for the Retrospective group. In the Prospective group, a 100% cumulative survival rate was recorded after 1 year. The average bone resorption (SD) was 1.2 mm (0.9 mm) and 1.1 mm (1.1 mm) after the first year for the Retrospective and Prospective groups, respectively, and 1.7 mm (1.0 mm) for the Retrospective group after the fifth year of function.
The cumulative survival rate of 91% at 5 years for the Retrospective group is low compared to protocols for noncompromised situations, but the use of a standardized protocol together with oxidized surface implants seems to improve the treatment outcome and bring the survival rate to levels comparable to noncompromised situations.
Osteoporosis is a disease that influences the quality of bone tissue. At present, osteoporosis represents a contraindication or a risk factor for osseointegration. The aim of this report was to evaluate the bone-to-implant contact of 2 loaded implants retrieved after prosthetic failure in a woman with type 1 osteoporosis. Histologically, only one implant was osseointegrated, and it appeared surrounded by healthy bone tissue. The bone-to-implant contact presented a mean of 51.25%. No foreign body reaction was found at the bone-to-implant contact, although epithelial downgrowth was observed at the interface. Data from this case report demonstrate that the peri-implant bone histology of the dental implant retrieved from an osteoporotic patient presented no alteration. However, the role of osteoporosis in the long-term success of dental implants needs further investigation.
Immediate loading of dental implants shortens the treatment time and makes it possible to give the patient an esthetic appearance during the whole treatment period.
The aim of the present study was to evaluate an immediate-loading treatment protocol, which included flapless surgery, implants placed in predetermined positions and connected to prefabricated provisional restorations, and the 3-year clinical results.
A total of 97 Brånemark System Mk IV implants (Nobel Biocare AB, Gothenburg, Sweden) with a machined surface were inserted in the maxillas of 46 patients. A presurgical three-dimensional model of the patients' soft tissue and underlying alveolar bone anatomy was created, which allowed the clinician to place the implants in predetermined positions and connect them to prefabricated provisional restorations. A surgical template with drilling guides corresponding to each implant was used. The apical part of the master guide was equipped with a circular "mucotome," which punched out a 5 mm hole in the mucosa to eliminate the need for flap elevation. The patients received 25 fixed partial prostheses and 27 single-tooth restorations. Bone quality and quantity were assessed. Radiographic examinations were performed on the day of surgery/loading and at the 1-, 2-, and 3-year follow-up visits.
All implant sites showed intact buccal and lingual bone walls during surgery, confirming the accuracy of the bone-mapping procedure. The prefabricated temporary restorations fitted, meaning that the implants were positioned clinically in the same way as on the cast. Nine implants in eight patients failed during the first 8 weeks of loading. This resulted in a cumulative survival rate of 91% after 3 years of prosthetic load. The survival rate of splinted implants was 94%. The number of failed implants was significantly higher in cases of single-tooth replacements and placement in soft bone sites and smokers. The failed implants were successfully replaced according to a two-stage protocol. All patients finally received the expected restoration. The marginal bone resorption was on average 1.0 mm during the first year of loading, 0.4 mm during the second year, and 0.1 mm during the third year.
The study confirmed the feasibility of an immediate-loading treatment protocol in the maxilla, which included flapless surgery, implants and abutments placed in predetermined positions, and prefabricated provisional restorations. All failures occurred within the first 2 months of loading. The unchanged survival rate and the low average bone loss found during the following 34-month study period indicate a good long-term prognosis for the performed immediate-loading treatment.
Background:
Immediate loading of osseointegrating implants shortens the treatment time and makes it possible to give the patient an esthetic appearance during the whole treatment period. A previous retrospective clinical study showed a success rate of 94.2% after 1 year of immediate loading of fixed partial constructions in the maxilla supported by machined-surface implants. The recently introduced Brånemark System TiUnite (Nobel Biocare AB, Gothenburg, Sweden) surface has been shown to better maintain primary implant stability and to help achieve secondary stability earlier compared with the machined surface.
Purpose:
The aim of the present study was to compare TiUnite and machined-surfaced Brånemark System implants when applying immediate loading of partial fixed bridges in the posterior mandible.
Materials and methods:
Forty-four patients were randomized for test and control therapy. In the test group, 22 patients received 66 Brånemark System TiUnite surface implants supporting 24 fixed partial bridges, all of which were connected on the day of implant insertion. In the control group, 22 patients received 55 Brånemark System machined-surface implants supporting 22 fixed partial bridges, which also were connected on the day of implant insertion. All constructions were two- to four-unit bridges. Bone quality and quantity were assessed. Radiographic examinations were performed on the day of surgery/loading and at the 1-year follow-up visit.
Results:
Three TiUnite and eight machined-surface implants failed during the first 7 weeks of loading. This resulted in a cumulative success rate of 95.5% for TiUnite surface implants after 1 year of prosthetic load in the posterior mandible. The corresponding cumulative success rate for machined-surface implants was 85.5%. When using the machined-surface implants, the number of failed implants was significantly higher in smokers and in bone quality 4 sites. Such findings were not seen with the use of TiUnite implants, despite the fact that there were more smokers and more implants placed in bone quality 4 in this group. The marginal bone resorption after 1 year of loading was on average 0.9 mm (SD 0.7 mm) with the TiUnite implants and 1.0 mm (SD 0.9 mm) with the machined implants.
Conclusions:
The present study demonstrated a 10% higher success rate following immediate loading of partial fixed bridges in the posterior mandible supported by TiUnite surface implants compared with success with machined implants. When using the machined implants, the number of failed implants was significantly higher in smokers and in bone quality 4 sites. Such findings were not seen following the use of TiUnite implants.
1.Reduction of residual ridges (RRR) needs to be recognized for what it is: a major unsolved oral disease which causes physical, psychologic, and economic problems for millions of people all over the world.2.RRR is a chronic, progressive, irreversible, and disabling disease, probably of multifactorial origin. At the present time, the relative importance of various cofactors is not known.3.Much is known about the pathology and the pathophysiology of this oral disease, but we need to know much more about its pathogenesis, epidemiology, and etiology.4.The ultimate goal of research of RRR is to find better methods of prevention or control of the disease.5.Over 25 million Americans are estimated to be totally edentulous. The need for the delivery of more prosthodontic care in this country alone is staggering.6.More research in RRR with new methods and new thinking are badly needed in order to provide the best possible oral health care for millions of edentulous patients.
The aim of this article was to review the current literature with regard to the efficacy and effectiveness of flapless surgery for endosseous dental implants. The available data were evaluated for short- and long-term outcomes.
A MEDLINE search was conducted on studies published between 1966 and 2008. For the purpose of this review, only clinical (human) studies with five or more subjects were included, and clinical opinion papers were excluded. Clinical studies or reports were further rated in terms of the level or weight of evidence using criteria defined by the Oxford Center for Evidence-Based Medicine in 2001.
The available data on flapless technique indicate high implant survival overall. The prospective cohort studies demonstrated approximately 98.6% (95% CI: 97.6 to 99.6) survival, suggesting clinical efficacy, while the retrospective studies or case series demonstrated 95.9% (95% CI: 94.8 to 97.0) survival, suggesting effective treatment. Six studies reported mean radiographic alveolar bone loss ranging from 0.7 to 2.6 mm after 1 year of implant placement. Intraoperative complications were reported in four studies, and these included perforation of the buccal or lingual bony plate. Overall, the incidence of intraoperative complications was 3.8% of reported surgical procedures.
Flapless surgery appears to be a plausible treatment modality for implant placement, demonstrating both efficacy and clinical effectiveness. However, these data are derived from short-term studies with a mean interval of 19 months, and a successful outcome with this technique is dependent on advanced imaging, clinical training, and surgical judgment.
With the introduction of in-office cone beam computed tomography (CT), improved access to conventional CT scanning, and dental implant treatment planning software allowing on-the-spot 3-dimensional evaluations of potential implant sites, the use of "flapless" implant surgery has gained popularity among surgeons. Although the flapless approach was initially suggested for and embraced by novice implant surgeons, the successful use of this approach often requires advanced clinical experience and surgical judgment. This article reviews the advantages and disadvantages of and indications and contraindications for flapless dental implant surgery, with special emphasis on requirements for establishing or maintaining long-term health and stability of the peri-implant soft tissues. Prerequisites for surgeons wishing to use the flapless tissue punch approach in dental implant surgery are outlined and put into perspective relative to conventional open-flap surgery techniques and other minimally invasive procedures currently used in implant surgery. Procedures for single- and multiple-tooth applications are illustrated.
Purpose: The aim of this study was to examine healing over time after implant body placement in a senile osteoporosis model and a control group.
Materials and Methods: In this study, 16-week-old male mice were used. The senile osteoporosis model consisted of senescence-accelerated prone 6 mice and the control group consisted of senescence-accelerated resistant 1 mice. Titanium-coated plastic implants were used as experimental implants whose dimensions were 3.0 mm in length, 1.1 mm in apical diameter, and 1.2 mm in coronal diameter. Bone samples were collected at 5, 7, 14, 21, and 28 days after implant placement. A micro-quantitative computed tomography (QCT) system was used to scan these samples and a phantom in order to quantitate bone mineral measurements. Bone mineral density (BMD) of each sample was measured. Each sample was also examined by light microscopy after QCT imaging. At 14 and 28 days after implant placement, the bone-implant contact (BIC) ratios were calculated from light microscopy images and were divided into cortical bone and bone marrow regions.
Results: When BMD was compared between the osteoporosis and control groups using micro-QCT, the osteoporosis group had a significantly lower BMD in the region 0–20 µm from the implant surface in the bone marrow region at 14 days onward after implant placement. Compared with the control group, the osteoporosis model also had significantly lower BMD in all regions 0–100 µm from the implant surface in the bone marrow region at 14 days after placement. However, in the cortical bone region, no statistically significant difference was observed in the regions at the bone-implant interface. Light microscopy revealed osseointegration for all implants 28 days after implant placement. The osteoporosis model tended to have lower BICs compared with that of the control group, although this did not reach statistical significance.
Discussion: Our results showed that osseointegration was achieved in the osteoporosis model. However, the BMD was 30–40% lower than that of the control group in the region closest to the implant surface in bone marrow region. Peri-implant BMD was lower in a relatively large area in the osteoporosis model during an important time for osseointegration. Therefore, this result suggests that osteoporosis might be considered as a risk factor in implant therapy.
Conclusion: The osteoporosis model had a lower BMD than the control group in the region closest to the implant during an important time for osseointegration. This result suggests that senile osteoporosis might be a risk factor in implant therapy. However, the osteoporosis model and the control group had no difference in peri-implant BMD in the cortical bone region. This suggests that risk might be avoided by implant placement that effectively uses the cortical bone.
The aim of this study was to investigate the consequences of different flapless procedures for the installation of dental implants on peri-implant bone response.
After bilateral extraction of the mandibular second and third premolars and a 3-month healing period, 30 SLActive(®) implants were installed for 3 months in 10 Beagle dogs according to three different surgical approaches, i.e.: (1) flapped (F), (2) tissue punch flapless (P), and (3) direct flapless (DF).
At harvesting, 29 implants were analysed. Micro-computed tomography and histomorphometrical evaluation (which also included the mobile implants) showed comparable results in bone volume (F=55 ± 9, P=51 ± 4, DF=54 ± 5) and crestal bone level (F=3420 ± 762, P=5358 ± 1681, DF=3843 ± 433). However, the implants inserted using the punch approach revealed a significantly lower first bone contact (F=3420 ± 762, P=5358 ± 1681, DF=3843 ± 433) and bone-to-implant contact percentage (F=70 ± 12, P=48 ± 23, DF=73 ± 12). Considering the gingival response, the barrier epithelium was also significantly deeper around the implants installed using the punch approach (F=1383 ± 332, P=2278 ± 1154, DF=1107 ± 300).
The results indicate that a flapless surgical technique can be used for the installation of oral implants. In addition, using a tissue punch wider than the implant diameter should be avoided, as it can jeopardize the outcome of the implantation procedure.
The present study aims to identify radiographic methods revealing data that are most representative for the true peri-implant bone as assessed by histology.
Eighty implants were placed in 10 minipigs. To assess matching between different image modalities, measurements conducted on intra-oral digital radiographs (IO), cone beam computer tomography (CBCT) and histological images were correlated using Spearman's correlation. Paired tests (Wilcoxon test) were used to determine changes in the bone parameters after 2 and 3 months of healing.
Significant correlations between bone defect depth on IO and histological slices (r= + 0.7, P<0.01), as well as on CBCT images and histological slices (r= + 0.61, P<0.01), were found. CBCT and IO images deviate, respectively, 1.20 and 1.17 mm from the histology regarding bone defects. No significant correlations were detected between fractal analysis on CBCT, intra-oral radiography and histology. For bone density assessment, significant but weaker correlations (r= + 0.5, P<0.01) were found for intra-oral radiography vs. histology. Significant marginal bone-level changes could be observed after 3 months of healing using intra-oral radiography.
This study allowed linking radiographic bone defect depth to the histological observations of the peri-implant bone. Minute bone changes during a short-term period can be followed up using digital intra-oral radiography. Radiographic fractal analysis did not seem to match histological fractal analysis. CBCT was not found to be reliable for bone density measures, but might hold potential with regard to the structural analysis of the trabecular bone.
To compare the remodeling of the alveolar process at implants installed immediately into extraction sockets by applying a flap or a "flapless" surgical approach in a dog model.
Implants were installed immediately into the distal alveoli of the second mandibular premolars of six Labrador dogs. In one side of the mandible, a full-thickness mucoperiosteal flap was elevated (control site), while contra-laterally, the mucosa was gently dislocated, but not elevated (test site) to disclose the alveolar crest. After 4 months of healing, the animals were sacrificed, ground sections were obtained and a histomorphometric analysis was performed.
After 4 months of healing, all implants were integrated (n=6). Both at the test and at the control sites, bone resorption occurred with similar outcomes. The buccal bony crest resorption was 1.7 and 1.5 mm at the control and the test sites, respectively.
"Flapless" implant placement into extraction sockets did not result in the prevention of alveolar bone resorption and did not affect the dimensional changes of the alveolar process following tooth extraction when compared with the usual placement of implants raising mucoperiosteal flaps.
To report the outcome of an implant therapy protocol using 4 or 6 implants supporting immediately loaded fixed prostheses following 3D software planning and flapless guided surgery.
A total of 30 patients (24 women, 6 men), mean age of 53 years (range 35-84 years) were treated with 195 immediately loaded implants (97 NobelSpeedy Groovy and 98 Brånemark MKIII Groovy) supporting 25 maxillary and 17 mandibular fixed full-arch acrylic prostheses and followed for 1 year. The Procera Software v1.6 and v2.0 was used to plan implant position and to obtain a surgical template for the guided flapless implant placement. To perform immediate loading, the implants had to be inserted with torque of at least 35 Ncm. Provisional prostheses were made before surgery using software planning and were placed in the same session as the implants. Definitive restorations were delivered 6-12 months after surgery. Outcome measures were failures of the prosthesis and of the implants, marginal bone level changes, complications, clinical time and patient satisfaction.
Four patients with full edentulism and 26 with advanced periodontitis were enrolled in this study. A total of 195 implants were immediately loaded (128 implants were placed in the maxilla and 67 implants were placed in the mandible). Four implants out of 195 failed in three patients during the healing period: 2 in the maxilla (1 straight and 1 tilted), and 2 in the mandible (both of them tilted). Three of them were successfully replaced. One year after loading there were no dropouts and no failure of the definitive prosthesis occurred. In three cases, the surgical template fractured during surgery. In one patient, a new impression had to be taken to fit the provisional prosthesis onto the implants. Three patients were subjected to surgery and systemic antibiotics to treat apically infected implants.
The 'all-on-four' and 'all-on-six' treatment protocol combined with computer-guided flapless implant surgery could be a viable and predictable treatment. Some complications occurred that were successfully treated. However, this technique could be sensitive to the experience of the surgeon and a learning curve is required.
The aim of this case series was to evaluate the Procera Software v1.6 and the surgical templates for flapless implant placement and immediate loading in atrophic fully edentulous maxillae.
The Procera Software was used to plan the exact position of the implants, and surgical templates were made to guide flapless implant placement. To allow for immediate loading, implants had to be placed with an insertion torque > 30 Ncm. Provisional cross-arch prostheses, produced before surgery using the software planning, were delivered immediately after implant placement, and replaced by final restorations after 6 months. Outcome measures were: prosthetic and implant failures, complications, post-operative pain and swelling, consumption of analgesics, and patient satisfaction. The followup stopped at 8 months post-loading.
Thirteen consecutive patients with atrophic maxillae were treated with 89 implants (6 to 8 implants per patient). Two flaps had to be elevated in two patients. One template fractured during surgery. Three implants in two patients were not loaded immediately. In four patients, impressions had to be taken to fit the provisional prostheses onto the implants. Five implants failed in four patients. One patient dropped out, due to financial reasons, with the provisional prosthesis still in function. Eight months after loading, all prostheses were successful and 11 out of 12 patients reported their quality of life and lifestyle had improved.
This software-based treatment planning may be useful in planning and treating challenging cases such as flapless implant placement and immediate loading of maxillary cross-arch bridges, but a learning curve is necessary.
Assess the interaction between fibrinolysis and in-hospital percutaneous coronary intervention (PCI) in patients with inferior myocardial infarction (MI), particularly those with electrocardiographic evidence of right ventricular infarction (RVI).
Retrospective observational study.
Consecutive patients with inferior MI identified from an MI registry between January 1998 and January 2004.
Propensity analyses and multiple regression analysis were used to determine the mortality benefit of PCI.
In-hospital morbidity and mortality.
In total, 465 patients with inferior MI received fibrinolytic therapy (median pain-to-needle time of 167 minutes; IQR 100-311 minutes). The main predictors of PCI were recurrent chest pain, peak creatine kinase, age, reinfarction, presence of heart failure and male gender. Significant independent predictors of in-hospital mortality were age > or = 75 years, RVI, initial systolic blood pressure < or = 80 mmHg, female gender and no in-hospital PCI. In-hospital PCI was performed in 184/465 (40%) patients; 55 (30%) had rescue PCI performed < or = 6 hours post fibrinolysis, 45 (24%) within 6-24 hours and 84 (46%) > or = 24 hours. In-hospital PCI was associated with reduced in-hospital mortality (PCI: 9 [5%] vs. no PCI: 40 [14%]; p < 0.001) mainly in those with RVI (PCI: 8 [8%] vs. no PCI 33 [23%]; p = 0.002) compared with no RVI (PCI: 1 [1%] vs. no PCI 7 [5%]; p = 0.1).
A strategy of timely fibrinolysis combined with in-hospital PCI including rescue PCI may result in a significant reduction in in-hospital mortality and morbidity in patients with inferior MI, particularly those with RVI.
To analyze computer-assisted diagnostics and virtual implant planning and to evaluate the indication for template-guided flapless surgery and immediate loading in the rehabilitation of the edentulous maxilla.
Forty patients with an edentulous maxilla were selected for this study. The three-dimensional analysis and virtual implant planning was performed with the NobelGuide software program (Nobel Biocare, Göteborg, Sweden). Prior to the computer tomography aesthetics and functional aspects were checked clinically. Either a well-fitting denture or an optimized prosthetic setup was used and then converted to a radiographic template. This allowed for a computer-guided analysis of the jaw together with the prosthesis. Accordingly, the best implant position was determined in relation to the bone structure and prospective tooth position. For all jaws, the hypothetical indication for (1) four implants with a bar overdenture and (2) six implants with a simple fixed prosthesis were planned. The planning of the optimized implant position was then analyzed as follows: the number of implants was calculated that could be placed in sufficient quantity of bone. Additional surgical procedures (guided bone regeneration, sinus floor elevation) that would be necessary due the reduced bone quality and quantity were identified. The indication of template-guided, flapless surgery or an immediate loaded protocol was evaluated.
Model (a) - bar overdentures: for 28 patients (70%), all four implants could be placed in sufficient bone (total 112 implants). Thus, a full, flapless procedure could be suggested. For six patients (15%), sufficient bone was not available for any of their planned implants. The remaining six patients had exhibited a combination of sufficient or insufficient bone. Model (b) - simple fixed prosthesis: for 12 patients (30%), all six implants could be placed in sufficient bone (total 72 implants). Thus, a full, flapless procedure could be suggested. For seven patients (17%), sufficient bone was not available for any of their planned implants. The remaining 21 patients had exhibited a combination of sufficient or insufficient bone.
In the maxilla, advanced atrophy is often observed, and implant placement becomes difficult or impossible. Thus, flapless surgery or an immediate loading protocol can be performed just in a selected number of patients. Nevertheless, the use of a computer program for prosthetically driven implant planning is highly efficient and safe. The three-dimensional view of the maxilla allows the determination of the best implant position, the optimization of the implant axis, and the definition of the best surgical and prosthetic solution for the patient. Thus, a protocol that combines a computer-guided technique with conventional surgical procedures becomes a promising option, which needs to be further evaluated and improved.
An investigation of factors controlling healing and long term stability of intra-osseous titanium implants to restore masticatory function in dogs revealed that an integrity of the good anchorage of the implant requires: (1) Non-traumatic surgical preparation of soft and hard tissues and a mechanically and chemically clean implant. (2) Primary closure of the mucoperiosteal flap, to isolate the implant site from the oral cavity until a biological barrier has been reestablished. (3) Oral hygiene to prevent gingival inflammation. Provided these precautions are taken, it is possible to subject dental prostheses, connected to the implants, to unlimited masticatory load. With these precautions such implants were found to tolerate ordinary use in dogs for periods of more than 5 years without signs of tissue injury or other indications of rejection phenomena.
Macroscopic clinical investigation, stereomicroscopy, roentgenography and light microscopy of the implant site in situ and after removal from the body showed that the soft and hard tissues had accepted the implant and incorporated it without producing signs of tissue injury. In fact the bone appeared to grow into all the minute pits and impressions in the surface of the titanium implant, without any shielding layer of buffer tissue at all.
These findings indicate that dental prostheses can be successfully anchored intra-osseously in the dog suggesting that its possible clinical use in oral rehabilitation should be given unprejudiced consideration.
A classification of the edentulous jaws has been developed based on a randomised cross-sectional study from a sample of 300 dried skulls. It was noted that whilst the shape of the basalar process of the mandible and maxilla remains relatively stable, changes in shape of the alveolar process is highly significant in both the vertical and horizontal axes. In general, the changes of shape of the alveolar process follows a predictable pattern. Such a classification serves to simplify description of the residual ridge and thereby assist communication between clinicians; aid selection of the appropriate surgical prosthodontic technique; offer an objective baseline from which to evaluate and compare different treatment methods; and help in deciding on interceptive techniques to preserve the alveolar process. An awareness of the pattern of resorption that takes place in various parts of the edentulous jaws, enables clinicians to anticipate and avert future problems.
The success of osseointegration depends in part on the state of the host bed. Concerns have therefore been raised about osteoporosis, a condition believed to be associated with a decrease in bone quality and quantity. However, the orthopedic literature indicates that osteoporotic fractures heal readily and that the level of bone mass and estimates of the parameters associated with bone remodeling present considerable overlap between patients with osteoporosis and control subjects. It also appears that osteoporosis, as diagnosed at one particular site of the skeleton, is not necessarily seen at another distant site. Although the prevalence of osteoporosis increases among the elderly and after menopause, the results of this study indicate that implant failure rate is not correlated with age and sex. A review of the literature and of results of a series of patients treated does not provide a compelling theoretical or practical basis to expect osteoporosis to be a risk factor for osseointegrated dental implants.
This article is a retrospective clinical analysis of implants placed with a flapless approach.
Seven hundred seventy implants were placed in 359 patients to restore both completely edentulous and partially edentulous arches with fixed prostheses or removable complete dentures. Each patient was examined after 3 months, 6 months, 1 year, and then once every year. Prostheses were removed, if possible, and implant mobility was assessed, periapical radiographs were obtained, and periodontal probing was performed. Implants were considered failed if they had mobility or pain, had to be removed, or if they showed more than 0.5 mm of bone loss per year and signs of active peri-implantitis.
The cumulative success rate for implants placed using a flapless 1-stage surgical technique after a 10-year period varied from 74.1% for implants placed in 1990 to 100% at 2000.
Since flapless implant placement is a generally "blind" surgical technique, care must be taken when placing implants. Angulation of the implants affected by drilling is critical to avoid perforation of the cortical plates, both lingual or buccal, especially on the lingual in the mandibular molar area and the anterior maxilla. There should be no problem if the patient has been appropriately selected and an appropriate width of bone is available for implant placement. There is a learning curve to every surgical procedure, after which it becomes routine. There are many advantages for the patient as well as for the surgeon, since the procedure is less time consuming, bleeding is minimal, implant placement is expedited, and there is no need to place and remove sutures.
Flapless implant surgery is a predictable procedure if patient selection and surgical technique are appropriate.
Implant dentistry has evolved into the mainstream of restorative practices all over the world. Maintenance of bone after tooth loss to improve or maintain facial esthetics and improved retention, function, and performance of removable restorations are only some of the advantages for the edentulous patient. No longer are implants considered only when traditional restorations cannot be fabricated. Evidence-based reports indicate implant restorations last longer than those on teeth and the abutment teeth are at less risk of loss or complication.
This mixed-longitudinal study of edentulous individuals covering 25 years of complete denture wearing revealed a continued reduction of the residual ridges throughout the observation period. The reduction of the lower ridge was particularly marked, the mean reduction in anterior ridge height being approximately four times as great as that of the upper ridge. The magnitude and pattern of alveolar bone loss showed great individual variation. Correlations between the shape of the mandible and the anterior mandibular bone loss indicated a pronounced resorption in subjects with a marked mandibular base bend, and a less marked resorption in subjects with a flattened mandibular base. These findings suggest that careful examination of the mandibular shape can provide valuable information on the response of the residual ridges to the wearing of dentures. Regarding the clinical consequences of the alveolar bone loss it should be emphasized that by regular control and prosthetic measures marked instability of the dentures and undesirable changes in jaw and occlusal relationships can be prevented. As the rate of resorption is most rapid during the first year of denture wear, regular control during the first year and thereafter at least once a year is advisable. However, with the continuing resorption over years, the prosthetic replacement of the lost tissues will give rise to increasing treatment problems and may cause the patient extreme difficulties in management of the dentures. The continuing resorption, especially of the lower ridge, therefore, constitutes a serious prosthodontic problem.
Based on three-dimensional implant planning software for computed tomographic (CT) scan data, customized surgical templates and final dental prostheses could be designed to ensure high precision transfer of the implant treatment planning to the operative field and an immediate rigid splinting of the installed implants, respectively.
The aim of the present study was to (1) evaluate a concept including a treatment planning procedure based on CT scan images and a prefabricated fixed prosthetic reconstruction for immediate function in upper jaws using a flapless surgical technique and (2) validate the universality of this concept in a prospective multicenter clinical study.
Twenty-seven consecutive patients with edentulous maxillae were included. Treatments were performed according to the Teeth-in-an-Hour concept (Nobel Biocare AB, Göteborg, Sweden), which includes a CT scan-derived customized surgical template for flapless surgery and a prefabricated prosthetic suprastructure.
All patients received their final prosthetic restoration immediately after implant placement, that is, both the surgery and the prosthesis insertion were completed within approximately 1 hour. In the 24 patients followed for 1 year, all prostheses and individual implants were recorded as stable.
The present prospective multicenter study indicates that the prefabrication, on the basis of models derived from three-dimensional oral implant planning software, of both surgical templates for flapless surgery and dental prostheses for immediate loading is a very reliable treatment option. It is evident that the same approach could be used for staged surgery and in partial edentulism.
Placement of implants with a minimally invasive flapless approach has the potential to minimize crestal bone loss, soft tissue inflammation, and probing depth adjacent to implants and to minimize surgical time.
The aim of this multicenter study was to evaluate implant placement using a minimally invasive one-stage flapless technique up to 2 years.
Fifty-seven patients ranging in age from 24 to 86 years were recruited from three clinical centers (Tucson, AZ, USA; Tel Aviv, Israel; Göteborg, Sweden). Seventy-nine implants were placed. A small, sharp-tipped guiding drill was used to create a precise, minimally invasive initial penetration through the mucosa and into bone (Nobel Biocare, Yorba, Linda, CA, USA). Implants were placed according to the manufacturer's instructions, with minimal countersinking. The parameters evaluated were total surgical time, implant survival, bone quality and quantity, implant position by tooth type, depth from mucosal margin to bone crest, implant length, probing depth, inflammation, and crestal bone changes. At 2 years, for 79 implants placed in 57 patients, the cumulative success rate using a minimally invasive flapless method was 98.7%, indicating the loss of 1 implant. Changes in crestal bone for 77 baseline and follow-up measurements were insignificant (radiograph 1: mean 0.7 mm, SD 0.5 mm, range 2.8 mm, minimum 0.2 mm, maximum 3.0 mm; radiograph 2: mean 0.8 mm, SD 0.5 mm, range 3.4 mm, minimum 0.12 mm, maximum 3.5 mm). Using descriptive statistics for 78 patients (one implant lost), mean changes for probing depth and inflammation were clinically insignificant. The average time for implant placement was 28 minutes (minimum 10 minutes, maximum 60 minutes, SD 13.1 minutes). Average depth from mucosal margin to bone was 3.3 mm ( SD 0.7 mm, minimum 2 mm, maximum 5 mm, range 3 mm). Thirty-two implants were placed in maxillae and 47 in mandibles.
The results of this study demonstrate that following diagnostic treatment planning criteria, flapless surgery using a minimally invasive technique is a predictable procedure. The benefits of this procedure are lessened surgical time; minimal changes in crestal bone levels, probing depth, and inflammation; perceived minimized bleeding; and lessened postoperative discomfort.
The aim of this study was to compare the pain experienced after implant placement with 2 different surgical procedures: a flapless surgical procedure using an image-guided system based on a template and an open-flap procedure.
The study population consisted of 60 patients who were referred for implant placement. One group consisted of 30 patients who were referred for the placement of 80 implants and treated with a flapless procedure. The other group consisted of 30 patients who were referred for the placement of 72 implants with a conventional procedure. Patients were selected randomly. They were requested to fill out a questionnaire using a visual analog scale (VAS) to assess the pain experienced and to indicate the number of analgesic tablets taken every postoperative day from the day of the surgery (DO) to 6 days after surgery (D6).
The results showed a significant difference in pain measurements, with higher scores on the VAS with open-flap surgery (P < .01). Pain decreased faster with the flapless procedure (P = .05). The number of patients who felt no pain (VAS = 0) was higher with the flapless procedure (43% at DO versus 20%). With the flapless procedure, patients took fewer pain tablets (P = .03) and the number of tablets taken decreased faster (P = .04).
Minimally invasive procedures may be requested by patients to reduce their anxiety and the pain experienced and thus increase the treatment acceptance rate.
With the flapless procedure, patients experienced pain less intensely and for shorter periods of time.
Flapless implant surgery has been suggested as one possible treatment option for enhancement of implant esthetics.
Twenty-four patients with a missing tooth in the premaxillary region were randomly assigned to one of two groups (12 each): immediate loading (IL) or delayed loading (DL) (loading after 4 months). An endosseous implant was placed in each patient via a flapless surgery. Clinical measurements including the papillary index (PPI) (0, no papilla; 1, less than half; 2, more than half but not complete fill; 3, complete fill; and 4, overfill), marginal levels of the soft tissue (ML), probing depths (PDs), modified bleeding index (mBI), modified plaque index (mPI), and the width of the keratinized mucosa (WKM) were performed at baseline (at the time of loading) and at 2, 4, and 6 months.
The soft tissue profile remained stable up to 6 months, without significant differences between the two groups (mean PPI and ML at 6 months, 2.16 and 0.30 mm, respectively). Mean PPI in the IL group significantly increased from 1.50 at baseline to 2.09 at 2 months, and the significance remained up to 6 months (2.30 at 6 months) (P <0.05), whereas in the DL group, no significant changes were found from baseline to 6 months in mean PPI (2.06 at both time points). Mean PPI increased over time when two treatment groups were combined; however, no statistical significance was found. In ML, the difference at baseline between the two groups (-0.28 mm for DL versus 0.17 mm for IL; P <0.05) was no longer significant at 2 months (0 versus 0.08 mm for DL and IL, respectively) and thereafter (P >0.05). No significant differences were detected between groups at each time and over time in the other clinical parameters, PD, mBI, mPI, and WKM (P >0.05).
The results of this study indicate that creeping attachment (i.e., soft tissue recovery) might occur within 2 months after IL. The study suggests that flapless implant surgery provides esthetic soft tissue results in single-tooth implants either immediately or delayed loaded. Other long-term randomized controlled clinical trials with a large sample size and comparison group (i.e., implant surgery with flap) are recommended to verify the conclusions drawn in this preliminary study.
To evaluate success rates and complications of implants placed with a flapless technique and immediately loaded in fully edentulous maxillae.
Implants were placed in fully edentulous maxillae with a minimum insertion torque of 45 Ncm in underprepared sites to allow maximum stability at insertion using a flapless technique. Implants were immediately loaded. Outcome measures were prosthesis and implant success, biologic and prosthetic complications, pain, and edema evaluation. Stability of individual implants was assessed both manually and with Osstell at baseline and after 12 months of loading. A single sample t test was used with a significance level of .05.
Thirty-three consecutively treated edentulous patients received 202 implants in the maxilla. In 10 patients, 53 implants were immediately inserted in fresh extraction sockets. At implant insertion, a flap had to be elevated to control the direction of the drill in 5 patients. Three implants in 2 patients did not reach sufficient stability and were left to heal for 45 to 90 days. All restorations (21 fixed prostheses and 12 overdentures) were delivered the same day of the surgery. Twenty-six patients experienced no or slight postoperative pain; 7 experienced moderate to severe pain. No or slight edema was recorded for 19 patients and moderate to severe edema for 14 patients. Two implants failed in 2 patients but were successfully replaced the same day they were removed. No major complications occurred. Five patients experienced biologic complications, eg, peri-implantitis; 10 experienced prosthetic complications. No prosthesis failed; however, 1 patient was unsatisfied with his overdenture and requested a fixed alternative. There was a highly significant difference (P < .001) between the stability at implant insertion and after 12 months.
Implants placed in the edentulous maxilla with a flapless procedure can be successfully loaded the same day of surgery.
The use of short implants (7-8.5 mm) has historically been associated with lower survival rates than for longer implants. However, recent clinical studies indicate that short implants may support most prosthetic restorations quite adequately, but still clinical documentation is sparse.
The purpose of this study was to report on the placement of short Brånemark implants, testing the hypothesis that short implants in atrophied jaws might give similar long-term implant survival rates as longer implants used in larger bone volumes.
This retrospective clinical study included 237 consecutively treated patients with 408 short Brånemark implants supporting 151 fixed prostheses. One hundred thirty-one of the implants were 7-mm long, and 277 were 8.5-mm long. Final abutments were delivered at the time of surgery, and final prostheses were delivered 4 to 6 months later.
One hundred and twenty six of the 7-mm implants (96%) have passed the 1-year follow-up; 110 (84%), the 2-year follow-up; and 88 (67%), the 5-year follow-up. Five implants failed in four patients before the 6-month follow-up, giving a cumulative survival rate of 96.2% at 5 years. The average bone resorption was 1 mm (SD=0.6 mm) after the first year and 1.8 mm (SD=0.8 mm) after the fifth year of function. Two hundred sixty nine of the 8.5-mm implants (97%) have passed the 1-year follow-up; 220 (79%), the 2-year follow-up; and 142 (51%), the 5-year follow-up. Eight implants failed in seven patients before the 6-month follow-up, giving a cumulative survival rate of 97.1% at 5 years. The average bone resorption was 1.3 mm (SD=0.8 mm) after the first year and 2.2 mm (SD=0.9 mm) after the fifth year of function.
The cumulative survival rates of 96.2 and 97.1% at 5 years for implants of 7.0- and 8.5-mm length, respectively, indicate that one-stage short Brånemark implants used in both jaws is a viable concept.
There is a need for clinical evidence for the of use of computer tomography and CAD-CAM technology for surgical planning and fabrication of a custom surgical template in the rehabilitation of complete edentulous jaws with a prosthesis supported by 4 implants placed in immediate function.
The purpose of this study was to report on the preliminary clinical outcomes of survival and bone loss for prosthodontic rehabilitation using computer-guided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture.
This clinical study included 23 consecutively treated patients (18 maxillae and 5 mandibles). Ninety-two implants were placed supporting fixed complete dentures followed between 6 and 21 months (mean of 13 months). Recall examinations included clinical evaluation of implant mobility, patient-reported discomfort, suppuration, and infection. The radiographic assessment included the determining of the marginal bone level at 6 and 12 months. A cumulative implant survival rate was calculated, and data were analyzed with descriptive statistics.
The overall cumulative implant survival rate at 1 year was 97.8%, with 97.2% and 100% in the maxilla and the mandible, respectively. The average marginal bone loss was 1.9 mm at the 1-year follow-up.
The results of this study indicate that, within the limitations of this preliminary study, this treatment modality for completely edentulous jaws is predictable with a high survival rate.
Data available regarding the treatment outcome for completely edentulous jaws by means of a prefabricated fixed complete denture placed immediately after flapless implant insertion using a surgical guide are only short term.
The purpose of this study was to follow the survival of implants inserted in completely edentulous jaws using a flapless procedure and immediately loaded with prefabricated fixed complete dentures for several years. A second purpose was to investigate whether there is a difference in marginal bone remodeling in smoking (S) and nonsmoking (NS) patients.
During a 5-year period (mean time of follow-up 2.2 years), 30 consecutive patients, 12 women, 38-74 years of age (average 56 years) were treated for complete edentulism in 1 arch in the Department of Periodontology at the University Hospitals in Leuven. The S group included 13 and the NS group 17 patients. Descriptive statistics were used to analyze the data. Two outcome parameters were analyzed: the cumulative survival rate (CSR) of individual implants and the marginal bone remodeling for up to 5 years in the 2 groups.
Nine (4.9%) implants failed. Eight of the failures occurred in 3 smoking patients. The absolute survival rate for all patients was 95%, while the cumulative survival rate (CSR) after 5 years was 91.5%. For the NS group, the CSR was 98.9%, while for the S it was 81.2%. The mean marginal bone resorption was - 2.6 and - 1.2 mm in the S and NS groups, respectively.
The present findings indicate that the treatment protocol described results in good implant survival rate even after several years. Smoking may eventually compromise the efficacy of this treatment concept.
The objective of this clinical study was to compare the survival rates of early loaded implants placed using flapless and flapped surgical techniques and to determine the bone density in the implant recipient sites using computerized tomography (CT). The study population consisted of 12 patients who were referred implant placement. One group consisted of five patients referred for the placement of 14 implants and treated with a flapless procedure. The other group consisted of seven patients referred for the placement of 45 implants with a conventional flapped procedure. Patients were selected randomly. CT machine was used for pre-operative evaluation of the jaw bone and the mean bone density value of each implant recipient site was recorded in Hounsfield units (HU). All implants were placed using CT-guided surgical stents. The early loading protocols included 2 months of healing in the mandible and 3 months of healing in the maxilla. Single-implant crowns, implant-supported fixed partial dentures, and implant-retained over dentures were delivered to the patients. Of 59 implants placed, one was lost in the conventional flapped group within the first month of healing, meaning overall implant survival rate of 98.3% average 9 months later. The highest average bone density value (801 +/- 239 HU) was found in the anterior mandible, followed by 673 +/- 449 HU for the posterior maxilla, 669 +/-346 HU for the anterior maxilla and 538 +/- 271 HU for the posterior mandible. The results of this study show that the early loading of implants placed utilizing flapless surgical technique with CT-guided surgical stents may be possible.
The present retrospective clinical study was undertaken to evaluate the survival rate and marginal bone conditions around Nobel Direct one-piece implants. The purpose was also to compare the results with when these implants are used for immediate/early loading with implants allowed to heal before loading.
Forty-three consecutive patients previously treated with 117 Nobel Direct implants at four different centres were evaluated. The implants had been used in both jaws for treatment after loss of single and multiple teeth. Immediate/early loading (within 2 weeks) with a provisional crown/bridge was applied to 95 implants, while 22 implants healed unloaded for 6 weeks to 6 months before loading. Calculations of marginal bone loss were performed in radiographs taken at placement and after an average of 10.2 months (range 1-18 months) of loading.
Six (5.1%) of the 117 implants were removed during the follow up. All failed implants belonged to the immediate/early loading group giving a failure rate of 6.3% for this group and 0% for two-stage implants. The failure rate was higher for flapless (7.9%) than for flap surgery (0%). The marginal bone loss was -2.4 mm (SD 1.5) for all implants, while 37.6% showed more than 3 mm of loss during the follow up. Bone loss increased with time of follow up. Implants subjected to immediate/early loading showed more bone loss than two-stage implants: -2.6 mm (SD 1.5) vs. -1.6 mm (SD 1.1). Moreover, 41.3% of immediately loaded and 22.7% of two-stage implants presented with more than 3 mm of bone loss.
This short-term retrospective analysis showed a poor clinical outcome of Nobel Direct implants. Extensive marginal bone loss (>3 mm) was found around more than 1/3 of the implants evaluated. Less resorption and no failures were experienced when implants were allowed to heal from 6 weeks to 6 months before occlusal loading. Within the limitations of the present study design, data indicate that immediate loading, the use of this implant for multi-unit constructions and flapless surgery are risk factors for failure of Nobel Direct implants.
Osteoporosis is a metabolic bone disease that leads to bone fragility and an increase in the risk of bone fracture. Nowadays, osteoporosis may represent a contraindication or a risk factor for osseointegration; however, this field still is controversial in the literature. This article sought to evaluate the bone-to-implant contact of a loaded implant that had been retrieved (due to prosthetic failure) from a woman with Type 1 osteoporosis. Histologically, the implant was osseointegrated and appeared to be surrounded by healthy bone tissue. The bone-to-implant contact demonstrated a mean of 40.07% (+/- 1.07%). No foreign body reaction was found at the bone-to-implant contact, although epithelial downgrowth was observed at the interface. Data from this case report demonstrate that the peri-implant bone histology is not altered even when a patient has been diagnosed with osteoporosis.
Evaluation of human bone
- Ja Shibli
- Pa Grande
- S Avila
- G Iezzi
- Piattelli
Shibli JA, Grande PA, d'Avila S, Iezzi G, Piattelli A. Evaluation of human bone