No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Outcomes of implants placed with three different flapless surgical procedures: A systematic review
Abstract
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.
... [16] Furthermore, there are limited data to support the idea that guided flapless surgery is significantly more accurate than non-guided ones. [17] Therefore, this SR and meta-analysis has assessed both the surgical interventions in respect to the effect on crestal bone loss and the implant survival rate. ...
... [5] Contrastingly, a SR found no difference between the "free-hand" flapless method and guided surgeries, whether or not they incorporate 3D planning. [17] This review suggested a disparity in study frequency-only four employing the "free-hand" approach compared to seventeen utilizing 3D guides-might underpin the apparent equivalence in surgical outcomes. [17] This review, along with others, noted no distinctions between flapless and open-flap methods in studies devoid of any surgical guides, though this finding may be skewed by the few studies (only four) that did not use guides. ...
... [17] This review suggested a disparity in study frequency-only four employing the "free-hand" approach compared to seventeen utilizing 3D guides-might underpin the apparent equivalence in surgical outcomes. [17] This review, along with others, noted no distinctions between flapless and open-flap methods in studies devoid of any surgical guides, though this finding may be skewed by the few studies (only four) that did not use guides. [16,[54][55][56][57] The prevalence of surgical guides remains high, with most studies deploying conventional templates for implant placement in both techniques. ...
Objectives
Dental implant procedures are crucial for replacing missing teeth, with various surgical techniques impacting the outcome. This systematic review and meta-analysis aimed to evaluate the effects of flapped and flapless surgical techniques on implant survival and marginal bone loss (MBL).
Methods
We included clinical studies with at least ten subjects, excluding review articles, editorials, and conference abstracts. Studies were sourced from PubMed, Medline, ERIC, and Wiley, published between 2000 and 2022. Data were analyzed using random-effects models to compare implant survival and MBL between flapped and flapless techniques.
Results
The review identified 21 studies meeting the inclusion criteria. Flapless techniques showed a higher implant survival rate with an approximate survival rate of 98.6% in prospective cohort studies and 95.9% in retrospective studies. MBL was consistently lower in the flapless group, averaging 0.6–2.1 mm, compared to 1.5–3 mm in the flapped group. Low-risk studies demonstrated more consistent and reliable results, supporting the efficacy of flapless procedures.
Conclusion
Flapless implant surgery offers a viable alternative to traditional flapped surgery, showing higher rates of implant survival and less MBL. However, successful outcomes depend on advanced imaging, precise surgical techniques, and adequate training. Further high-quality studies are needed to confirm these findings and refine clinical recommendations.
... Successful single implant placement in the esthetic zone, mainly in the maxillary zone comprises four areas: [1] peri-implant augmentation surgery, [2] implant placement accuracy (angulation >10° and labially positioned), [3] peri-implant soft tissue management, and [4] the quality of the prosthetic restoration [3,4]. There should also be sufficient space between implant and tooth (>1 mm) to allow reconstruction or preservation of the interdental papilla, otherwise there will be insufficient blood supply, which would cause loss of this tissue [3,4]. ...
... Successful single implant placement in the esthetic zone, mainly in the maxillary zone comprises four areas: [1] peri-implant augmentation surgery, [2] implant placement accuracy (angulation >10° and labially positioned), [3] peri-implant soft tissue management, and [4] the quality of the prosthetic restoration [3,4]. There should also be sufficient space between implant and tooth (>1 mm) to allow reconstruction or preservation of the interdental papilla, otherwise there will be insufficient blood supply, which would cause loss of this tissue [3,4]. ...
... Successful single implant placement in the esthetic zone, mainly in the maxillary zone comprises four areas: [1] peri-implant augmentation surgery, [2] implant placement accuracy (angulation >10° and labially positioned), [3] peri-implant soft tissue management, and [4] the quality of the prosthetic restoration [3,4]. There should also be sufficient space between implant and tooth (>1 mm) to allow reconstruction or preservation of the interdental papilla, otherwise there will be insufficient blood supply, which would cause loss of this tissue [3,4]. ...
Introduction: Osseointegration is nowadays considered highly predictable, so minimally invasive surgical approaches are sought in order to allow proper function and a good esthetic result. It is of great importance to determine whether the shape and surface of the implant is an important factor in conjunction with the surgical technique. Objective: To evaluate the use of tomographic surgical guidance for the placement of a V3 implant in edentulous space in the maxillary esthetic zone. Method: A 53-year-old male patient with a vestibularly collapsed edentulous area corresponding to the left upper lateral. The treatment used was the IN2GUIDE system and MIS V3 implant, with evaluation up to 90 days. Results: Bone loss at the level of the implant platform without receiving any type of load. Discussion: Bone and peri-implant soft tissue loss will be similar with any procedure.
... Flapless surgery can be performed either with 3D planned surgical guides, with computer-assisted navigation [14,15] or free-handed so-called mentally guided, albeit it is recommended only for experienced surgeons. Voulgarakis et al. [16] reported no differences for the three different techniques on survival rate, marginal bone loss and complications. Guided flapless surgery seems to be more accurate for ideal implant positioning [17]. ...
... Guided flapless surgery seems to be more accurate for ideal implant positioning [17]. However, increased efforts using 3D implant software, preoperative planning time, accuracy issues in transferring the implant planning to the surgical field and higher technical costs involved, are important drawbacks [16,18]. Free-handed flapless surgery is a more accessible implant treatment procedure although surgical experience with the technique is mandatory, and a correct estimation of the alveolar bone morphology during the drilling procedure is a prerequisite. ...
... Free-handed flapless surgery is a more accessible implant treatment procedure although surgical experience with the technique is mandatory, and a correct estimation of the alveolar bone morphology during the drilling procedure is a prerequisite. To date, little is known of the exact implant position when free-handed flapless surgery is performed [16]. This may increase the risk for perforations, dehiscence or fenestration resulting in surgical complications or compromised implant integration [16]. ...
Background:
Free-handed, flaplessly placed mini dental implants (MDIs) are a valuable, more affordable and minimally invasive treatment to support overdentures in fully edentulous jaws, especially for medically compromised patients. However, critical 3D radiographic evaluation is lacking. This multicenter prospective case series assessed clinical outcome and carried out 3D- cone-beam computerized tomography (CBCT) analysis of free-handed flaplessly placed one-piece maxillary MDIs by an experienced maxillofacial surgeon.
Methods:
Thirty-one patients suffering from an ill-fitting maxillary denture relating to compromised bone volume (as confirmed on CBCT), with a dentate mandible, were selected. They received 5-6 MDIs free-hand flaplessly placed and mentally guided with preoperative CBCT. Final connection and attachment activation took place six months later. After two years each implant was individually assessed with CBCT for perforations on eight sites. Implant survival, prosthetic failure, clinical stability and sinus/nasal complaints were registered after three years.
Results:
32/185 (17.3%) MDIs failed during the provisional loading with non-activated attachments; 17 replacements in 10 patients were performed. Of the 170 actively loaded 170 MDIs, 82.3% survived and 27/31 prostheses (87%) were fully functional. In total 98/170 MDIs showed no perforation. Based on 1360 CBCT observations, 231 perforations (16.9%) were registered. Of most perforations 37 (25%) were observed at the apical tip and 37 were positioned (21%) into the sinus/nasal cavity, although without clinical complaints.
Conclusions:
Given the compromised population, the minimally invasive procedure and the low treatment cost involved, a failure rate of 17% is substantial, however clinically acceptable given the critical bone condition. However, even in experienced surgical hands, freehanded and flapless placement yield a high risk for implant perforation, although this did not necessarily lead to complications.
... The use of the surgical guides in daily practice ensures accurate implant placement, increases the probability of successful treatment outcomes, allows predictable flapless surgery and immediate loading, and reduces the risk for technical and biological complications [13,39,40]. However, static implant-guided surgery is not without possible risks related to deviations between the planned implant position and the final clinical outcome [41]. One of the major risks of inaccuracy is guide fracture during drilling for implant bed preparation. ...
... One of the major risks of inaccuracy is guide fracture during drilling for implant bed preparation. In a systematic review of complications associated with guided implant surgery, Voulgarakis et al. identified the fracture of the surgical guide as a common intraoperative complication, with an incidence rate between 6.7% and 9.7% [41]. ...
Static guided surgery for dental implant insertion is a well-documented procedure requiring the manufacturing of a custom-made surgical guide, either teeth-supported, mucosal-supported, bone-supported, or mixed (teeth-mucosal-supported), depending on the clinical situation. The guidance of the surgical drills during implant bed preparation could be undertaken using a sequence of different diameters of metal drill sleeves or, with the sleeves incorporated in the surgical guide, shank-modified drills, both clinically accepted and used with good results. Despite the great number of advantages associated with the use of guided surgery, one of the major risks is guide fracture during drilling for implant bed preparation. Therefore, the aim of the present study was to evaluate the surgical guides without metal sleeves and to simulate, with the aid of Finite Element Analysis (FEA), the use of such dentally supported guides for implant insertion. The FEA is performed in CATIA v5 software after defining the surgical guide mesh material and bone properties. A maximum stress of 6.92 MPa appeared on the guide at the special built-in window meant to allow cooling during drilling, and the maximum value of the guide displacement during drilling simulation was 0.002 mm. Taking into consideration the limits of the current research, the designed tooth-supported surgical guide can withstand the forces occurring during the surgery, even in denser bone, without the risk of fracture.
... Although SGS is regarded as a highly accurate method, it does suffer from certain limitations [12,13]. SGS requires a wide mouth-opening range to introduce specific instruments into the oral cavity, especially when treating posterior regions; the guide interferes with irrigation during osteotomy; it may fracture during surgery; and last-minute planning modifications are not possible, among other issues [9,14,15]. ...
... With no surgical template and no need for specific instrumentation, limited mouth opening is no longer a problem [21]. However, the technique demands a considerable learning curve and higher economic costs, and provides a limited vision of the surgical field, all of which are factors for improvement in future developments [15,22,23]. ...
(1) Background: Dynamic guided surgery is a computer-guided freehand technology that allows highly accurate procedures to be carried out in real time through motion-tracking instruments. The aim of this research was to compare the accuracy between dynamic guided surgery (DGS) and alternative implant guidance methods, namely, static guided surgery (SGS) and freehand (FH). (2) Methods: Searches were conducted in the Cochrane and Medline databases to identify randomized controlled clinical trials (RCTs) and prospective and retrospective case series and to answer the following focused question: “What implant guidance tool is more accurate and secure with regard to implant placement surgery?” The implant deviation coefficient was calculated for four different parameters: coronal and apical horizontal, angular, and vertical deviations. Statistical significance was set at a p-value of 0.05 following application of the eligibility criteria. (3) Results: Twenty-five publications were included in this systematic review. The results show a non-significant weighted mean difference (WMD) between the DGS and the SGS in all of the assessed parameters: coronal (n = 4 WMD = 0.02 mm; p = 0.903), angular (n = 4 WMD = −0.62°; p = 0.085), and apical (n = 3 WMD = 0.08 mm; p = 0.401). In terms of vertical deviation, not enough data were available for a meta-analysis. However, no significant differences were found among the techniques (p = 0.820). The WMD between DGS and FH demonstrated significant differences favoring DGS in three parameters as follows: coronal (n = 3 WMD = −0.66 mm; p =< 0.001), angular (n = 3 WMD = −3.52°; p < 0.001), and apical (n = 2 WMD = −0.73 mm; p =< 0.001). No WMD was observed regarding the vertical deviation analysis, but significant differences were seen among the different techniques (p = 0.038). (4) Conclusions: DGS is a valid alternative treatment achieving similar accuracy to SGS. DGS is also more accurate, secure, and precise than the FH method when transferring the presurgical virtual implant plan to the patient.
... Lin et al. [6] and Lemos et al. [7] could not establish a significant difference in the survival rate or crestal bone loss between the two techniques. Although freehand implant placement is not considered as accurate as guided flapless surgery as reported by Nickenig et al. in 2010, [8] a review by Voulgarakis et al. in 2014 [9] suggested that the surgical guides did not significantly influence the outcome. ...
... Lin et al. [6] Chrcanovic et al. [5] Vohra et al. [20] Romero-Ruiz et al. [21] Llamas-Monteagudo et al. [22] Zhuang et al. [23] Yadav et al. [24] Cai et al. [25] Data inadequate for crestal bone loss Arisan et al. [26] Berdougo et al. [27] Bashutski et al. [28] Voulgarakis et al. [9] Meizi et al. [29] Yadav et al. (2018) [30] Gupta et al. [31] Retrospective studies Nickenig et al. [8] Rousseau et al. [32] De Bruyn et al. [33] Nguyen et al. [34] Yue et al. [35] Immediate implant placement Stoupel et al. [36] Mazzocco et al. (2017) [37] Other outcome comparison studies Danza and Carinci [38] Lindeboom and van Wijk [2] Kaur et al. [39] Nonsubmerged Lesser loss of bone was found with flapless surgery as also better soft-tissue changes were seen Kumar et al. [41] 0.6495±0.17 (T) 0.9575±0.29 (C) ...
Aim: To compare the crestal bone level of flapless technique of dental implant placement with the flap technique.
Setting and Design: This Systematic review and Meta-analysis was conducted according to the Preferred Reporting Items For Systematic Review and Meta-Analyses (PRISMA) Guidelines and registered with PROSPERO.
Materials and Methods: Electronic search of Medline and Google scholar databases for articles from 2010 till March 2020 was performed. Studies comparing the crestal bone level with both the techniques were included. After the collection of data, the risk of bias was assessed for each study.
Statistical Analysis Used: Meta-analysis was executed using RevMan 5 software version 5.3.
Results: 23 studies were included. Statistically significant difference in crestal bone level was found between flapless and flap surgery with mean difference of −0.14 (flapless placement versus flap surgery; 95% CI: −0.24 to −0.03; P = 0.01FNx01). The difference in crestal bone level between the 2 groups was not statistically significant with a mean difference of –0.05(Guided flapless placement versus flap surgery; 95% CI: −0.10 to 0.00; P=0.06). Meta-analysis of the freehand flapless surgery with flap surgery generated a mean difference of −0.20 which was found to be statistically significant (Freehand flapless placement versus flap surgery; 95% CI: −0.37 to −0.03; P=0.02FNx01).
Conclusions: Flapless placement of implant can positively influence crestal bone loss in comparison with conventional flap technique.
... There are a variety of flapless implant surgical techniques which can be used for flapless implant surgery, these include, free hand, CBCT guided and CBCT guided and navigated flapless implant surgery. A systematic review by Voulgarakis et al., 89 This systematic review concluded that there are several methods to facilitate implant placement via a flapless approach and that none of the methods demonstrated has advantages over the other with regard to implant survival and marginal bone loss. 89 However, D'hase et al., 54 suggested that free hand flapless implant surgery can only be advocated in specific pre-planned cases by experienced surgeons where there is adequate bone volume. ...
... A systematic review by Voulgarakis et al., 89 This systematic review concluded that there are several methods to facilitate implant placement via a flapless approach and that none of the methods demonstrated has advantages over the other with regard to implant survival and marginal bone loss. 89 However, D'hase et al., 54 suggested that free hand flapless implant surgery can only be advocated in specific pre-planned cases by experienced surgeons where there is adequate bone volume. 54 ...
Flapless implant surgery is increasing in popularity, particularly due to advances and increased usage of cone beam computed tomography (CBCT) and dental implant treatment planning software allowing three-dimensional assessment of the implant site. It is the aim of the article to provide an overview of flapless implant surgery and CBCT guided flapless implant surgery and summarise the literature with regard to the effectiveness of this surgical technique.
... The reasons for exclusion are presented in Table 1. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Finally, a total of 18 studies published between 2005 and 2015 fulfilled the inclusion criteria applied in this systematic review. ...
... Follow-up less than 12 months Ozan et al (2007) 24 Nickenig et al (2010) 25 Katsoulis et al (2012) 31 Danza et al (2011) 32 Meloni et al (2013) 33 Pozzi et al (2014) 34 Systematic review Voulgarakis et al (2014) 35 Chrcanovic et al (2014) 36 Tahmaseb et al (2014) 2 Moraschini et al (2015) 20 full-text articles excluded (Table 1) 14 studies included for data extraction and analysis 4 studies identified through hand searching 18 studies included for data extraction and analysis provisionals in all cases. 41,43,44,47,50,51,55 Definitive prostheses were placed 2 to 7 months after surgery. ...
Purpose:
The radiologic outcomes of implants placed using static computer-guided surgery have not yet been systematically investigated. The purpose of this study was to evaluate the marginal bone loss (MBL) around dental implants inserted with static computer assistance in healed sites.
Materials and methods:
An electronic search of publications in English from three databases (from 2000 to March 2015), including PubMed, Web of Science, and Cochrane Oral Health Group Trials Register, and a hand search of peerreviewed journals for relevant articles were performed. Only clinical human studies, either randomized or nonrandomized, with at least 10 cases and a minimum follow-up time of 12 months, reporting on MBL were included.
Results:
The search strategy resulted in 18 publications, with 2,675 implants inserted with static computer assistance in healed sites. The pooled mean MBL at 1-year follow-up was 1.06 mm (95% CI: 0.83 to 1.30 mm; heterogeneity: random-effects model, I² = 99.38%; P < .01). Moreover, when considering studies with a 3-year follow-up only (n = 5; 748 implants), the pooled MBL was 1.48 mm (95% CI: 0.81 to 2.15 mm; heterogeneity: random-effects model, I² = 99%; P < .01).
Conclusion:
Within the limitations of this review, the MBL around dental implants placed in healed sites with computer-guided surgery seems to be a well-functioning one-stage alternative to extended two-stage conventional procedures if patients are appropriately selected and an appropriate width of bone is available for implant placement. However, current evidence is limited by the quality of available studies and the lack of comparative long-term clinical trials.
... On the one hand, it has been established that survival and marginal bone loss of flapless implantation is comparable with the flap surgery approach [22]. On the other hand, Voulgarakis et al. reported bone perforation and implant misplacement to be frequently reported with flapless surgery [23], especially in large edentulous regions without anatomic landmarks for surgical reference. However, in their literature review they could not Fig. 1 -Kaplan-Meier-curves for implant survival. ...
... identify an advantage of guided 3D navigation over free-hand flapless implantation regarding implant survival, marginal bone loss, or complications [23]. Despite this fact, it is possible that misplacing might have been a reason for some of the implant losses in the present study. ...
Purpose:
The purpose of this study was to assess the survival of mini dental implants (MDI) and to measure prosthetic maintenance needs in a dental practice-based setting.
Methods:
Patients with mandibular removable dentures were provided with MDI to improve denture retention. Complications and maintenance were analyzed by use of patient records and evaluated with Kaplan-Meier curves and the log rank test at a significance level of 0.05.
Results:
Ninety-nine MDI were placed in 25 patients (mean age: 72 years). Two MDI fractured during placement and eight implants failed during the first weeks. No more implants were lost for up to seven years, resulting in 92% survival. Implant survival differed significantly depending on whether the maxilla was provided with complete dentures (94.9%) or with partial dentures (81%). All prostheses were in use at the time of data extraction. Denture base fractures were observed in six cases, an incidence of fractures of 24%. Some minor intervention was necessary: one resin tooth fractured, retention rings were changed in five cases, and repeated relining was required for 16% of the dentures.
Conclusions:
After mid-term observation, survival of MDI was good. However, the incidence of denture base fractures and of minor prosthetic complications should not be under-estimated.
... In a systematic review, Voulgarakis et al 18 assessed the differences in outcome between flapless dental implants inserted "free-hand," without 3D computer-guided surgery, or with a 3D computer-guided surgery: The "free-hand" modality rendered 89.3% to 100% survival rates and a marginal bone loss of 0.09 to 1.4 mm between 1 and 4 years; the insertion without 3D computerguided surgery achieved 91% to 100% survival rates and 0.89 mm of bone loss between 2 and 10 years; and the insertion with a 3D computer-guided surgery rendered 89% to 100% survival rate together with a 0.55 to 2.6 mm of bone loss between 1 and 5 years of follow-up. The authors 18 concluded that none of the identified methods demonstrated advantages over the others. ...
... The "free-hand" method was used in the current study with comparable outcomes (survival and marginal bone loss) to those obtained in the systematic review. 18 Nevertheless, this "freehand" method implies a greater demand, as it does not allow visualizing the ridge and therefore does not allow positioning the implant as well as with the flap approach. 19 This was the probable cause for the implant failure registered in this study on the flapless group. ...
Purpose:
The aim of this prospective clinical study was to evaluate the 3-year outcome of fixed partial prostheses supported by implants with immediate provisionalization without occlusal contacts inserted in predominantly soft bone with flap and flapless protocols.
Materials and methods:
Forty-one patients partially rehabilitated with 72 NobelSpeedy implants (51 maxillary; 21 mandibular) were consecutively included and treated with a flapless surgical protocol (n = 20 patients; 32 implants) and flapped surgical protocol (n = 21 patients; 40 implants). Primary outcome measure was implant survival; secondary outcome measures were marginal bone resorption (comparing the bone levels at 1 and 3 years with baseline) and the incidence of biological, mechanical, and esthetic complications. Survival was computed through life tables; descriptive statistics were applied to the remaining variables of interest.
Results:
Eight patients with eight implants dropped out of the study. One implant failed in one patient (flapless group) giving an overall cumulative survival rate (CSR) of 98.6%. No failures were noted with the flapped protocol (CSR 100%), while for the implants placed with the flapless surgical technique, a 96.9% CSR was registered. The overall average marginal bone resorption at 3 years was 1.37 mm (SD = 0.94 mm), with 1.14 mm (SD = 0.49 mm) and 1.60 mm (SD = 1.22 mm) for the flap and flapless groups, respectively. Mechanical complications occurred in nine patients (n = 5 patients in the flapless group; n = 4 patients in the flap group). Implant infection was registered in three implants and three patients (flapless group), who exhibited inadequate oral hygiene levels.
Conclusions:
Partial edentulism rehabilitation through immediate provisionalization fixed prosthesis supported by dental implants inserted through flap or flapless surgical techniques in areas of predominantly soft bone was viable at 3 years of follow-up. The limitations and risks of the "free-hand" method in flapless surgery should be considered when planning implant-supported fixed prosthetic reconstructions.
... Furthermore, the early complication incidence rate could be as high as 9.1% and 18.8% for surgical and prosthodontic complications, respectively [7]. Concerning the clinical outcome, the survival of dental implants using guided surgery was reported in a range between 89% and 100% [8][9][10]. ...
Background/Objectives: The insertion of dental implants using dynamic 3D navigated surgery while applying immediate function protocols for full-arch rehabilitations warrants further research. This study aimed to evaluate the outcomes of All-on-4® rehabilitations using 3D Dynamic navigated surgery (X-Guide™). Methods: This study included 10 patients (women: 7; men: 3; average age: 59.9 years) rehabilitated with full-arch prostheses through the All-on-4® concept, with 48 dental implants inserted using navigated surgery. The primary outcome evaluation was prosthetic/implant cumulative survival (CS), estimated using life tables. Secondary outcome evaluations were marginal bone resorption (MBR), biological complications, and mechanical complications. The evaluation parameters were measured between 1 and 3 years. Results: No patients were lost to follow-up. Two implants (4.2%) were lost in one patient (10%) with smoking habits, resulting in an implant CS rate of 95.8%. The average MBR was 0.51 mm ± 0.62 mm at the 1-year follow-up. The incidence rate of mechanical complications was 40% (n = 4 patients), all occurring in provisional prosthesis. No biological complications were registered. The patients maintained their prostheses in function throughout the follow-up of the study. Conclusions: Within the limitations of this study and based on the results, it can be concluded that the insertion of dental implants assisted by dynamic navigation for full-arch rehabilitation through the All-on-4® concept may be a valid treatment alternative in the short-term follow-up. However, more studies are necessary to validate this treatment modality.
... 18 It is also beneficial in subjects on anticoagulant drugs and/or medically compromised patients. [19][20][21] The main strengths of the present study were the study design and choice of surgical technique for the implant placement. However, the study also reported certain limitations, such as a smaller sample size and a shorter follow-up period. ...
... Voulgarakis et al. 121 The implant survival, as reported in the three reviews, ranges from 89% to 100%, albeit that the follow-up time is rather short, ranging from 6 to 48 months. It can be concluded, based on a total of 35 clinical trials, that freehand surgery is comparable with guided flapless surgery in terms of implant survival, marginal bone remodeling and peri-implant variables. ...
Guided implant surgery helps to plan and place dental implants in a prosthetically driven position.
... Considering the survival of the implant with guided flapless surgery, the results of 4 systematic reviews suggest that conventional surgery (free-hand) is comparable with flapless static computer-aided implant surgery in terms of implant survival, marginal bone remodeling, and peri-implant variables [25][26][27][28]. Additionally, surgical and prosthetic complications have been reported in the literature, and the most frequently observed are fracture of the surgical guide, early loss of the implant due to loss of primary stability, changes in surgical planning, and fracture of the prosthesis, the most frequently observed [24,[29][30][31]. ...
Objectives
The study was aimed at comparing implants installed with guided and conventional surgery.Material and methodsTwenty-nine total edentulous patients were selected, and maxillary contralateral quadrants were randomly assigned to static computer-aided implant surgery (S-CAIS): flapless computer-guided surgery, and conventional surgery (CS): flap surgery with conventional planning. Tomography scans were performed at baseline and 10 days after the surgery for deviation measurement, and radiography was done at baseline and after 6 and 12 months, for peri-implant bone level (PIBL) analysis. Peri-implant fluid and subgingival biofilm were collected to evaluate bone markers and periodontal pathogens.ResultsS-CAIS showed less linear deviation at the apical point and the midpoint and less angular deviation (p < 0.05), with greater depth discrepancy in the positioning of the platform (p < 0.05). Higher values of vertical PIBL were observed for the S-CAIS group at baseline (p < 0.05), while lower values of horizontal PIBL were observed for CS (p < 0.05). Bone markers and Tf presented higher levels in CS (p < 0.05). Flapless S-CAIS allowed smaller linear and angular deviations than the conventional technique.Conclusion
However, PIBL was higher in S-CAIS; the conventional technique led to a greater angiogenic and bone remodeling activity by elevating the angiogenic levels and bone markers.Clinical relevanceEvaluating the different implant insertion techniques can guide clinical and surgical regarding the accuracy, the release pattern of bone markers, and the peri-implant bone level.Trial registrationReBEC-RBR-8556fzp.
... As an example, the full search strategy for one of the databases of interest is displayed in in order to identify any other publications and ensure a thorough screening process. Additionally, cross-referencing of cited references in 22 systematic reviews on the topic (Bover-Ramos et al., 2018;Carbajal Mejia, Wakabayashi, Nakano, & Yatani, 2016;Colombo et al., 2017;D'Haese et al., 2012;D'Haese, Van De Velde, Komiyama, Hultin, & De Bruyn, 2017;Hultin, Svensson, & Trulsson, 2012;Joda et al., 2018;Jung et al., 2009;Laederach, Mukaddam, Payer, Filippi, & Kuhl, 2017;Laleman et al., 2016;Moraschini, Velloso, Luz, & Barboza, 2015;Pozzi et al., 2016;Raico Gallardo et al., 2017;Schneider, Marquardt, Zwahlen, & Jung, 2009;Schnitman, Hayashi, & Han, 2014;Seo & Juodzbalys, 2018;Sigcho Lopez, Garcia, Da Silva Salomao, & Cruz Lagana, 2019;Van Assche et al., 2012;Vercruyssen, Hultin, et al., 2014;Voulgarakis, Strub, & Att, 2014;Widmann & Bale, 2006;Zhou et al., 2018) was conducted for additional article identification. ...
Objective:
To analyze the outcomes of static computer‐aided implant placement (sCAIP) compared to partially guided (PGIP) and free‐handed (FHIP) implant placement.
Material and Methods:
This study was registered in PROSPERO (CRD42019131397). A comprehensive literature search was performed by two independent examiners. Only randomized controlled trials (RCTs) were selected. Treatment modalities included sCAIP, PGIP and FHIP. Data pertaining to the outcomes of interest were extracted. Random‐effects meta‐analyses were feasible for a subset of outcomes.
Results:
From an initial list of 2,870 records, fourteen articles for a total of ten RCTs were selected. Data from 7 of these studies allowed for the conduction of three meta‐analyses comparing accuracy of implant placement across modalities. Survival rate up to 12 months post‐loading was high (>98%) and comparable between treatments (low quality evidence). No tangible differences in terms of patient perception of intra‐ or postoperative discomfort were observed (low quality evidence). Quantitative analyses revealed significantly lower angular (MD = 4.41° , 95% CI 3.99 – 4.83, p < 0.00001), coronal (MD = 0.65 mm, 95% CI 0.50 – 0.79, p < 0.00001) and apical (MD = 1.13 mm, 95% CI 0.92 – 1.34, p < 0.00001) deviation values for sCAIP as compared to FHIP (8 studies, 383 patients, 878 implants, high quality evidence). A similar discrepancy, in favor of sCAIP, was observed for angular deviation only as compared to PGIP (MD = 2.11° , 95% CI 1.06 – 3.16, p < 0.00001).
Conclusions:
sCAIP is associated with superior accuracy compared to PGIP and FHIP.
... These included six reviews but one only included immediate implant placement and restoration 27 and another was irrelevant to the topic. 28 The four reviews [29][30][31][32] included in this study are summarized in Table 1. ...
Background
The advent of computer‐guided surgery removed the need for complex surgical interventions such as extensive flap elevations, second stage implant exposure, and complications usually associated with conventional protocols.
Purpose
(a) Analyze available literature reporting on applicability, accuracy, clinical outcome of flapless surgery with or without computer guidance. (b) Evaluate quality of studies, in terms of scientific level of evidence and ethical committee approval.
Materials and methods
A PUBMED search was performed in July 2018. A first search was based on a general search string limited to “Dental Implants” and “flapless surgery.” A second search focused on accuracy of computer‐guided surgery using search string “Surgery, Computer‐Assisted” or “guided surgery,” and “Dental implants.” The following inclusion criteria were applied: (a) studies in English; (b) human studies (excluding cadaver); (c) systematic reviews; (d) systematic reviews with meta‐analysis. Reviews not mentioning accuracy were excluded in search 2.
Results
Nine reviews included in total. Implant survival ranged between 89% and 100%. Early surgical and prosthetic complications reported in 9.1% to 36.4% of reviewed papers. Tooth‐supported guides show more accuracy than bone or mucosa‐supported guides. Fully guided surgery yields higher accuracy, with lower values for horizontal coronal, horizontal apical and angular deviation (1.00, 1.23, and 3.13°mm, respectively) than those placed with half guided surgery (1.44, 1.91, and 4.30 mm, respectively). Thirty‐four of 71 human studies included in nine reviews, mentioned ethical committee approval or compliance with Declaration of Helsinki.
Conclusions
Guided flapless surgery is comparable to free‐hand surgery in terms of implant survival, marginal bone remodeling, and peri‐implant variables. Clinicians advised to take care in all steps of the protocol, and include safety margins around virtually planned implants. Regarding compliance with research ethics, we should question whether scientific reports of clinical trials performed without an ethical umbrella are trustworthy. Compliance of ethics standards is imperative for submitted research papers.
... 3 This approach with limited gum removal can be applied with a circular scalpel at the drill insertion area or directly with the drill, initiating bone drilling. 4 This technique decreases pain, bone loss, inflammatory process related to mucoperiosteal detachment, and improves postoperative phase and patient comfort. 5 It avoids suture use, requires shorter surgical time, shorter healing time, enhances recovery, and produces less bleeding, thus facilitating immediate loading. ...
Objectives The aim of this research was to develop a sensor of approximation by reflectance for guided surgery with dental implants without flap detachment, and verify the effectiveness of this system.
Materials and Methods Ten models of total edentulous arches were divided into two groups. Two implants of 3.5 × 11.5 mm (NeoDent) were inserted in each model; in Group 1 (G1), a stereolithographic guide NeoGuide system was used. In Group 2 (G2), the experimental approximation sensor was used for the insertion of the implants. The evaluation of the results was performed by overlapping the virtual planning images with the tomographies of the models of the implants inserted.
Results There were no statistically significant differences between the guide and the sensor groups. The averages and standard deviations observed at the angulation of the guide was 4.15 (2.65 degrees) and 5.48 (2.85 degrees) at the sensor. The linear deviations at the cervical level were 0.002 (1.37) and 0.11 (1.47) mm and at the apical level 0.19 (1.28) and 0.21 (1.42) mm, respectively.
Conclusions The use of a guide is important for the stabilization of the drills; the greatest challenge is to control the apical position of the implants, especially in highly reabsorbed edges. The experimental sensor can become an auxiliary tool to the stereolithographic guides; however, several difficulties must still be overcome to recommend the use of a sensor.
... proaches, respectively, there was a rational to evaluate patient-reported outcomes. In the present study, no differences between both procedures were observed, which is in accordance with a systematic review (Voulgarakis, Strub, & Att, 2014). That review analysed three different flapless surgeries: free hand without a surgical guide; use of a surgical guide based on the prosthetic position and reverse planning; and stereolithographic surgical guide based on virtual planning. ...
Abstract
Aim: Our objective was to compare guided virtual surgery to conventional surgery in terms of angular deviation of single dental implants placed in the posterior mandible.
Materials and Methods: Patients with bilateral homologous single teeth missing in the posterior mandible were eligible for this split-mouth randomized clinical trial. Cone beam computed tomography (CBCT) was performed for virtual planning of implant position and manufacturing of the stereolithographic guides. One week after the surgery, a second CBCT scan was superimposed to the initial planning. Primary endpoint was the angular deviation between virtual and clinical implant position. Secondary endpoints were linear deviations and patient-reported outcomes collected with a questionnaire.
Results: Data from 12 patients were available for analysis. Angular deviation was significantly lower using stereolithographic guides as compared to conventional guides (2.2±1.1° vs 3.5±1.6°, p=0.042). Linear deviations were similar for both techniques in the coronal (2.34±1.01 vs 1.93±0.95 mm) and apical (2.53±1.11 vs 2.19±1.00 mm) dimensions (p˃0.05). The selection of the surgical technique had no significant impact on the patient-reported outcomes.
Conclusion: Our data suggest that the angular discrepancy between the virtual and the clinical implant position is slightly lower when using stereolithographic guides as compared to conventional guides.
... proaches, respectively, there was a rational to evaluate patient-reported outcomes. In the present study, no differences between both procedures were observed, which is in accordance with a systematic review (Voulgarakis, Strub, & Att, 2014). That review analysed three different flapless surgeries: free hand without a surgical guide; use of a surgical guide based on the prosthetic position and reverse planning; and stereolithographic surgical guide based on virtual planning. ...
Aim:
Our objective was to compare guided virtual surgery to conventional surgery in terms of angular deviation of single dental implants placed in the posterior mandible.
Materials and methods:
Patients with bilateral homologous single teeth missing in the posterior mandible were eligible for this split-mouth randomized clinical trial. Cone beam computed tomography (CBCT) was performed for virtual planning of implant position and manufacturing of the stereolithographic guides. One week after the surgery, a second CBCT scan was superimposed to the initial planning. Primary endpoint was the angular deviation between virtual and clinical implant position. Secondary endpoints were linear deviations and patient-reported outcomes collected with a questionnaire.
Results:
Data from 12 patients were available for analysis. Angular deviation was significantly lower using stereolithographic guides as compared to conventional guides (2.2±1.1° vs 3.5±1.6°, p=0.042). Linear deviations were similar for both techniques in the coronal (2.34±1.01 vs 1.93±0.95 mm) and apical (2.53±1.11 vs 2.19±1.00 mm) dimensions (p˃0.05). The selection of the surgical technique had no significant impact on the patient-reported outcomes.
Conclusion:
Our data suggest that the angular discrepancy between the virtual and the clinical implant position is slightly lower when using stereolithographic guides as compared to conventional guides.
... An obvious advantage of MDIs is the reduced cost, especially when compared to treatments in which an augmentation procedure is needed to allow the placement of regular diameter implants. Due to the combination of a short surgical procedure, minimally invasive flapless approach, and reduced component costs, MDIs are especially useful in medically compromised, frail, anxious, or low-income patients 13 . ...
Studies on flaplessly placed, one-piece mini dental implants (MDIs) supporting overdentures in the maxilla are scarce. This prospective multicenter cohort study evaluated the outcomes (over 2 years) of five to six MDIs placed in the maxilla for overdentures. Study patients were ≥50 years old, with an edentulous maxilla and dentate/fixed prosthesis in the mandible. Dentures were provisionalized with the final connection at 6 months. Implant/prosthetic survival was evaluated, and postoperative discomfort and patient satisfaction were assessed (rating scale). Of 185 MDIs placed in 31 patients, 32 failed in 16 patients (17.3%); 22/83 in female patients and 10/102 in male patients. Kaplan-Meier analysis showed survival percentages of 86.3% (6 months), 84.0% (1year), and 82.3% (2 years). Two patients lost five or six MDIs resulting in two prosthetic failures (6.5%). Implant loss was significantly affected by sex, but not by smoking or location. The worst treatment combination was a torque value >25N·cm with an antagonist implant overdenture. The mean pain score was 4.1±2.8 on day 1 and 1.1±1.7 on day 7. The mean final satisfaction score was 8.6±1.7. The majority (96%) of the patients would recommend this treatment. Despite higher MDI failure in the maxilla compared to the mandible, prosthetic survival was acceptable and patient satisfaction was high, suggesting this to be a valuable treatment alternative.
... In recent implant dentistry, computer-assisted surgery (CAS) is becoming more popular and achieves prosthetically driven implant placement [14] CAS was first introduced by Van Steenberghe et al. [ 15,16] The key to computer planning is transferring the planning to the patient using a surgical template that allows placement of the implant directly through the tissue without the reflection of the flap [17][18][19] Furthermore, immediate restoration is possible because of precise fit, excellent primary stability achieved, and the ability to make a pre-implant model [20] This procedure allows restoratively driven implant placement and restoration to provide a more natural environment for soft tissue formation [21,22]. Nevertheless this approach will be promising future for esthetic zone areas without any intervention for alveolar bone exposure or soft tissue reflection. ...
... There are a few reviews assessing implant survival with flapless and guided surgery. Voulgarakis et al. (59) evaluated the outcome of three treatment protocols, namely freehand surgery, guided surgery with a prosthetic stent and guided surgery with stereolithographic computer-guided navigation. They included 23 studies with a prospective or retrospective design but randomized control trials were not available and the significant heterogeneity of the studies excluded a meta-analysis. ...
The invention of computerized axial tomography (now known as computerized tomography) and developments of interactive software to allow virtual planning, with the aim to guide the surgery precisely toward a specific target, has dramatically improved general, as well as oral, surgery. Virtual dental implant planning allows for a prosthetically driven approach, resulting in the best possible design of the prosthesis, better esthetics, optimized occlusion and loading. This approach has also changed the surgical paradigm of using extensive flaps to obtain a proper view of the surgical area because flapless implant surgery, with or without immediate loading, has become more predictable. Two types of guided implant surgery protocols – static and dynamic – are described in the literature. The static approach, better known as computer-guided surgery, refers to the use of a tissue-supported surgical template. This reproduces the virtual implant position directly from computerized tomographic data and this information can be converted to guide templates to be used during surgery, with or without raising a mucoperiosteal flap. Dynamic guided surgery, also called navigation, reproduces the virtual implant position directly from computerized tomographic data and uses motion-tracking technology to guide the implant osteotomy preparation. As the technology developed further, different levels of evidence were presented that showed various degrees of accuracy. Several protocols for guided surgery are available in the literature and are distinguished by different guide production techniques, methods of support and drilling/placement protocols. Currently, implant planning software using cone-beam computerized tomography data has made it possible to plan the optical implant position virtually the optimal implant position, taking the surrounding vital anatomic structures and future prosthetic requirements into consideration. This paper summarizes the evolution and ongoing trends in digital and virtual planning and in implant surgery. The purpose of this overview was to clarify the different concepts in guided surgery and their respective advantages, disadvantages and limitations. The outcome of guided surgery is assessed in terms of implant survival, precision and complications. Clinical cases are given to demonstrate briefly the workflow and clinical guidelines for safe use of these approaches.
... 7 According to a systematic review, fracture of the interim prosthesis was the most common postoperative technical complication, followed by the need for extensive adjustment of the immediately loaded interim prosthesis due to misfit. [5][6][7][8][9][10] Assuming that prosthetic complications such as extensive occlusal adjustments and misfit of the prosthesis are related to prosthesis fabrication before surgery, a new technique has been described based on the virtual position of the implants. 2 Accordingly, the planning of the prosthesis was based on presurgical information, but the prosthetic framework was fabricated in the immediate postsurgical period with transverse laser-welded titanium bars, taking into account the postoperative position of the implants. ...
Statement of problem:
Extensive occlusal adjustments and misfit of the prosthesis to prosthetic components are frequent problems related to fixed interim prosthesis fabrication with immediate dental implant loading.
Purpose:
The purpose of this clinical trial was to evaluate a prosthetic guide made with a rapid prototype model based on virtual surgical planning. This prosthetic guide was used to fabricate fixed interim prostheses that would allow immediate implant loading after computer-guided implant installation.
Material and methods:
Nine interim prostheses were made for 9 participants showing total maxillary or mandibular edentulism. The virtual prosthetic guide was planned using computer-assisted design (CAD) software and was fabricated with rapid prototyping equipment (selective laser sintering). The prosthetic guide had 3 portions: the occlusal portion, which had occlusal registration; the connection portion, which had the information of the position and angulation of the abutment/implant projection; and the mucosa portion, which had the registration of the alveolar mucosa architecture. The prosthetic guide was used by a dental technician to fabricate prostheses. A single trained examiner evaluated the passive fit of the interim prostheses, the average time required for installing the interim prosthesis and for occlusal adjustments, the satisfaction of the patient with the prosthesis; and the screws, torque, occlusion, and prosthesis status.
Results:
Passive fit was achieved between the prosthetic components and prostheses in 7 participants. The average time required for installing the fixed interim prostheses was 64.44 minutes. All participants reported being more pleased with the fixed interim prosthesis than with the prosthesis worn before implant placement. Prosthesis fractures were observed in 3 participants (2 in the maxilla and 1 in the mandible); all fractures occurred 3 months or more after delivery. No further complication was observed during 6 months of follow-up.
Conclusions:
The prosthetic guide enabled fabrication of interim immediate prostheses that were easily seated and adjusted to accommodate any shifts in implant position occurring during computer-guided surgery. Immediate implant loading could be achieved in a reasonable operative time.
The aim of this review is to evaluate the clinical outcomes of flapless extraction of impacted mandibular third molars compared to traditional flap-based techniques, with a focus on patient satisfaction, complication rates, and overall surgical efficiency. The extraction of impacted mandibular third molars (wisdom teeth) is a common procedure in oral and maxillofacial surgery, traditionally performed using a flap-based technique. While this method provides clear access to the impacted tooth, it is often associated with significant postoperative morbidity, such as pain, swelling, and extended recovery time. Recent innovations have introduced flapless extraction as a minimally invasive alternative, aiming to minimize tissue trauma and preserve periosteal integrity. This technique, however, presents its own set of challenges, including limited visibility and technical demands.
This review analyzes the current literature on flapless extraction techniques, drawing from retrospective studies, randomized controlled trials, and clinical case reports. The data include comparisons of postoperative outcomes between flapless and traditional methods, emphasizing factors such as operative time, postoperative discomfort, and the frequency of complications. Findings indicate that flapless extraction generally results in reduced postoperative pain, swelling, and faster recovery times compared to traditional flap-based techniques. Patients who undergo flapless extraction report higher satisfaction due to less postoperative discomfort and a quicker return to normal function. However, the technique poses challenges in cases of deeply impacted teeth, where the lack of a flap may hinder complete access and increase the risk of complications. Flapless extraction represents a promising evolution in the surgical removal of impacted mandibular third molars, offering several advantages over traditional methods, particularly in reducing postoperative morbidity. However, the technique requires precise surgical skill and is not suitable for all cases. Careful case selection is crucial, and continued research is needed to further validate its efficacy and safety in complex scenarios.
Objectives
To assess postoperative bleeding in patients undergoing immediate implant placement after tooth extraction without discontinuing or adjusting the dosage of oral antithrombotic drugs.
Materials and methods
Patients from February 2020 to August 2022 were selected who had undergone flapless immediate implant placements after tooth extraction and were on antithrombotics. A total of 27 patients were included. The patients were on different types of anticoagulants: vitamin K antagonists (one patient), non‐vitamin K oral anticoagulants (NOACs) (five), antiplatelet agents (15), dual antiplatelet therapy (five), and combination of anticoagulant and antiplatelet agents (one).
Results
One patient taking an anticoagulant (NOACs: apixaban) and antiplatelet agent (clopidogrel) showed mild bleeding at the implant placement site in the lower right canine area, and gauze compression was applied to control the bleeding. No special treatment was required for the other patients. There were no implant failures after surgery.
Conclusions
This study shows that the flapless immediate implant placements after tooth extraction for patients taking antithrombotics can be safely executed under adequate hemostasis without medication cessation. However, when anticoagulants and antiplatelets are taken together, it is speculated that surgeons may need careful hemorrhage management. Future research should include larger patient cohorts to yield more comprehensive evidence.
Among the common procedures in clinical practice in the field of dentistry is prosthetic rehabilitation through the insertion of dental implants. In order to obtain the best aesthetic and functional results, the oral surgeon who deals with implantology must be able to position the dental implants correctly; a crucial role is therefore played by the diagnostic and treatment planning phases, where attention must be paid to anatomical constraints and prosthetic constraints in the alveolar bone site. The parameters, such as bone quality, bone volume, and anatomical restrictions, can be processed and simulated using implant planning software. The simulation of the virtual positioning of the implant can lead to the construction of a three-dimensional model of the implant positioning guide, which can be used during the implant surgery. The aim of this systematic review is to evaluate survival rates, early and late failure rates, peri-implant bone remodeling, and possible implant-prosthetic complications related to implants placed using digitally designed surgical guides. This systematic review was written following the indications of PRISMA and envisaged the use of 3 databases: Scopus, PubMed, and Cochrane Library. Results: Only 9 of the 2001 records were included, including 2 retrospective studies and 7 prospective studies. Conclusion: On the basis of the studies selected in this review, it can be seen that the implant survival obtained with the use of guided implant surgery shows high percentages. Many recorded failures occurred early, due to a lack of osseointegration, and the variables that come into play in the survival of the implants are many.
Introduction: Accuracy in guided implant surgery means that pre-determined position of the implant by the software matches the position of the implant in the patient's mouth. The aim of this study was to evaluate the impact of initial prediction by navigation in the DIOnavi system on the accuracy of implant placement. Materials & Methods: In this interventional study, two samples of 17 and 25 patients) in total 42 patient) requesting navigation method for implant placement were selected. First, a cone beam computed tomography (CBCT) was taken from each patient and then its virtual model was prepared using the DIO NAVI system (South Korean DIO company. Two to three months following the implant placement by the surgeon, the CBCT from the same section was obtained again and the thickness of the buccal bone on the implant, the thickness of the lingual bone on the implant, the distance of the implant apex to the apical anatomic regions (Nasal cavity, Maxillary sinus and Mental foramen), Implant depth from crest edge and implant distance from adjacent teeth if present in the two obtained images were compared. Data were analyzed using paired t test and Pearson Correlation Coefficient (α = 0.05). Results: The mean of all measurements in both groups in the initial prediction was significantly related to after surgery (r = 0.99, p value < 0.001) and in the group of 17, 98% and in the group of 25, 97.4% of the variances of the means of the total measurements were explained by the initial prediction. Conclusion: The accuracy of implant placement with the help of dionavi system is estimated to be more than 97%.
Background:
The conventional implant approach involves flap elevation, which may result in increased soft tissue and bone loss and postoperative morbidity. The flapless surgical technique, aided by three-dimensional medical imaging equipment, is regarded as a possible alternative to the conventional approach to alleviate the above issues. Several studies have been performed regarding the role of flapless implant surgery. However, the results are inconsistent and there is no robust synthesis of long-term evidence to better inform surgeons regarding which type of surgical technique is more beneficial to the long-term prognosis of patients in need of implant insertion.
Aim:
To compare the long-term clinical performance after flapless implant surgery to that after the conventional approach with flap elevation.
Methods:
PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and grey literature databases were searched from inception to 23 September 2019. Randomised controlled trials (RCTs) and cohort studies comparing the long-term clinical performance after flapless implant surgery to that after the conventional approach over a follow-up of three years or more were included. Meta-analyses were conducted to estimate the odds ratios (ORs) or mean differences (MDs) and their 95% confidence intervals (CIs) between the long-term implant survival rate, marginal bone loss, and complication rate of the flapless and conventional groups. Subgroup analyses were carried out to account for the possible effects of the guided or free-hand method during flapless surgery.
Results:
Ten articles, including four RCTs and six cohort studies, satisfied the eligibility criteria and nine of them were included in the meta-analysis. There was no significant difference between the long-term implant survival rate [OR = 1.30, 95%CI (0.37, 4.54), P = 0.68], marginal bone loss [MD = 0.01, 95%CI (-0.42, 0.44), P = 0.97], and complication rate [OR = 1.44, 95%CI (0.77, 2.68), P = 0.25] after flapless implant surgery and the conventional approach. Moreover, subgroup analyses revealed that there was no statistically significant difference between the implant survival rate [guided: OR = 1.52, 95%CI (0.19, 12.35), P = 0.70]; free-hand: n = 1, could not be estimated), marginal bone loss [guided: MD = 0.22, 95%CI (-0.14, 0.59), P = 0.23; free-hand: MD = -0.27, 95%CI (-1.10, 0.57), P = 0.53], or complication rate [guided: OR = 1.16, 95%CI (0.52, 2.63), P = 0.71; free-hand: OR = 1.75, 95%CI (0.66, 4.63), P = 0.26] in the flapless and conventional groups either with use of the surgical guide or by the free-hand method.
Conclusion:
The flapless surgery and conventional approach had comparable clinical performance over three years or more. The guided or free-hand technique does not significantly affect the long-term outcomes of flapless surgery.
Ideal implant placement may reduce surgical complications, such as nerve injury and lingual cortical plate perforation, and minimize the likelihood of functional and prosthetic compromises. Guided implant surgery (GIS) has been used as the means to achieve ideal implant placement. GIS refers to the process of digital planning, custom‐guide fabrication, and implant placement using the custom guide and an implant system–specific guided surgery kit. GIS includes numerous additional steps beyond the initial prosthetic diagnosis, treatment planning, and fabrication of surgical guide. Substantial errors can occur at each of these individual steps and can accumulate, significantly impacting the final accuracy of the process with potentially disastrous deviations from proper implant placement. Pertinent overall strategies to reduce or eliminate these risks can be summarized as follows: complete understanding of the possible risks is fundamental; knowledge of the systems and tools used is essential; consistent verification of both diagnostic and surgical procedures after each step is crucial; proper training and surgical experience are critical. This review article summarizes information on the accuracy and efficacy of GIS, provides insight on the potential risks and problems associated with each procedural step, and offers clinically relevant recommendations to minimize or eliminate these risks.
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.
Background:
During implantation planning, dentists should be able to make an informed decision regarding whether to use an implant template to assist the surgery.
Purpose:
The aim of this meta-analysis was to assess the results of implantation with or without an implant template based on the accuracy, survival rate, and other considerations.
Materials and methods:
In January 2018, a systematic review was undertaken for randomized controlled trials and retrospective and prospective cohort studies with relevance to implant accuracy and the survival rate between the implant template and free-hand method. The odds ratios (ORs) of the survival rate and the mean difference of accuracy deviation from the selected papers were estimated by meta-analysis.
Results:
Of the 362 screened articles, 6 studies were included in the meta-analysis. Comparison of the survival rate of implant surgery with or without an implant template revealed no significant result (OR = 1.71, 95% confidence interval [CI] 0.65-4.51). Significant differences in accuracy were observed in angular (mean difference = -5.45 degrees, 95% CI -0.66 to -4.24 degrees) and apical deviation (mean difference = -0.83 mm, 95% CI -1.12 to -0.54).
Conclusions:
With the technology of computer-aided surgical template, implant placement can be more accurate than free-hand operation. No significant difference is observed in the survival rate between template and free-hand.
This review elucidates the advantages and disadvantages of the different implant navigation methods to assist the precise surgical placement of dental implants. Implant navigation surgery can be classified into: dynamic and static navigation, and static navigation can further be divided into full (FG)- and half-guided (HG) implant surgery. The HG implant placement includes the drilling-guided, pilot-drill guided, and the non-computed guided approaches. In dynamic navigation, the bone drilling and the implant placement are completely tracked with a specific software; while the static navigation refers to the use of static surgical templates. The FG associated with flapless surgery and teeth/crown supported guides has demonstrated the highest accuracy, followed by the drilling and pilot HG surgery that may provide comparable results, while the non-computer HG and FH implant placement provide the least accuracy in transmitting the implant positioning from the pre-surgical planning to the patient. Additionally, flapless implant surgery is related to reduced pain, less analgesic consumption, less swelling, shorter chair-time, and reduced risk of hemorrhage while achieving greater patient satisfaction. Nevertheless, other methods such as non-computer HG and FH implant surgery procedures require more surgical experience to overcome their limitations. There is still limited evidence to support dynamic surgery, and further investigations are needed.
No consensus has been reached regarding the influence of the flapless and open-flap surgical techniques on the placement of dental implants. This systematic review compared the effects of flapless implant placement and implant placement with elevation of the mucoperiosteal flap in terms of marginal bone loss, implant survival rate and complications rates. This review followed PRISMA guidelines and was registered in PROSPERO with the registration number CRD42017071475. Two independent reviewers performed a comprehensive search of the PubMed/MEDLINE, Scopus, and Cochrane Library databases for studies published until December 2017. The search identified 559 references. After a detailed review, 24 studies were assessed for eligibility. A total of 1025 patients who had received a total of 1873 dental implants were included. There were no significant differences between the flapless and open-flap surgical techniques in terms of implant survival rates (P=0.34; risk ratio (RR): 1.36; confidence interval (CI): 0.72-2.56), marginal bone loss (P=0.23; MD: -0.20; CI: -0.52-0.13), or complication rates (P=0.67; RR: 1.10; CI: 0.70-1.73). The current meta-analysis showed that the implant survival rate, marginal bone levels, and complications of flapless surgery were similar to those of open-flap surgery over a mean follow-up period of 21.62 months.
Vor oraler Rehabilitation durch implantatgetragenen Zahnersatz wird inzwischen regelhaft ein digitales Volumentomogramm (DVT) angefertigt, anhand dessen das Knochenangebot dreidimensional bewertet werden kann. Nach dem Konzept des „backward planning“ werden, ausgehend von der angestrebten Versorgung, die notwendigen präprothetischen Maßnahmen gezielt geplant. Prinzipiell gibt es unterschiedliche Vorgehensweisen, eine virtuelle Planung in die Realität umzusetzen. Die Navigation ist ein Verfahren, bei dem in Echtzeit die 3‑D-Position des Bohrers durch meist optische Systeme permanent überprüft wird und die korrekte Position und Achsneigung „chair-side“ auf einem Bildschirm kontrolliert werden kann. Neben der navigationsgestützten kann die schablonengeführte Implantologie angewandt werden, bei der die Informationen über vorab geplante 3‑D-Positionierung eines Implantats in Bohrhülsen, die sich in einer Bohrschablone befinden, enthalten sind und durch starre Führung der Bohrer und Implantatinsertion umgesetzt werden. Die virtuell festgelegte Position wird dadurch reproduzierbar auf den Patienten übertragen. Zu unterscheiden sind bei der Anfertigung die separate Erstellung von Röntgen- und Bohrschablonen sowie die Herstellung der Bohrschablonen mit moderner 3‑D-Drucktechnik. Die geführte Implantologie gilt insbesondere bei limitiertem Knochenangebot als sicheres und präzises Verfahren. Sowohl die navigierte als auch die schablonengeführte Implantologie dienen dem Ziel, vitale Strukturen zu schonen, postoperative Komplikationen zu verringern und zu einem funktionell und ästhetisch optimalen Ergebnis zu gelangen. Eine präzise Planung, unter Einbeziehung chirurgischer und prothetischer Aspekte, beeinflusst in der Implantologie die Langzeitprognose wesentlich.
Purpose:
The objective of this study was to compare the implant stability and osseointegration of implants using a flap or flapless technique.
Material and methods:
Mandibular premolars and molars were extracted from both sides in 6 dogs. After 8 weeks, 4 fixtures were implanted using either a flap or flapless technique. Implant stability quotient was measured on insertion and at 2, 4, and 8 weeks later. The animals were killed while the tissues were histologically analyzed.
Results:
Implant stability increased for 8 weeks, and no statistically significant differences were observed between the surgical protocols. Bone-implant contact showed 60.27% ± 30.99% for flapless surgery and 59.73% ± 17.12% for flap surgery. And the results of new bone formation area from total area showed 56.07% ± 27.78% for flapless surgery and 57.00% ± 14.66% for flap surgery. There were no statistically significant differences.
Conclusion:
This study showed no significant difference in implant stability as well as osseointegration regardless of flap or flapless technique.
Objectives:
The objective of this systematic review was to perform a comprehensive overview of systematic reviews and meta-analyses of surgical and patient factors affecting marginal bone loss around osseointegrated dental implants in humans.
Material and methods:
Electronic databases were searched for systematic reviews and meta-analyses published up to November 2015.
Results:
Of the 41 articles selected, 11 evaluated implant factors, 10 evaluated patient factors, 19 evaluated surgical protocol-related factors, and one evaluated all three factors. The chosen studies were AMSTAR rated for quality. The following parameters have statistically significant effect on marginal bone loss: (1) marginal bone loss was significantly more in patients with periodontitis than in periodontally healthy patients; (2) significantly greater in generalized aggressive periodontitis patients compared with chronic periodontitis patients; (3) significantly less in alveolar socket preservation techniques; (4) significantly more in alveolar ridge augmentation sites; (5) significantly more in men than in women; (6) significantly more in smokers than in nonsmokers; and (7) smokers also have significantly more marginal bone loss in the maxilla than in the mandible.
Conclusion:
Knowledge of the surgical and patient factors that affect marginal bone loss can aid the clinician in making informed choices in selecting implant treatment options that will enhance the longevity and long-term success of their implant-supported cases.
Placing implants without raising a soft tREFIID flap in the absence of proper imaging, planning, and placement frequently leads to complications. Accurate imaging in the form of a cone beam computerized tomogram along with digital planning software and a printed three-dimensional surgical template can improve the chances of success when using this approach. However in most cases, flap elevation leads to fewer problems.
Background:
A microvascular fibular flap is the main option for the reconstruction of mandibular defects. This paper introduces an innovative strategy for the accurate fabrication of fibular flaps.
Methods:
Nine patients with mandibular tumors were included in this study. The mandibular reconstruction planning was performed using MIMICS 10.01. One reconstruction plate was preformed. During the operation, the fibular flap was fabricated and implanted using the BrainLab navigation system. Six to 12 months after surgery, computed tomography data were acquired and compared with preoperative planning.
Results:
The osteotomy of the fibular flap and the mandible was easily performed, using the navigation and the osteotomy template respectively. The preformed plate accurately determined the position of the flap. The treatment outcome was consistent with the preoperative planning using 3D analysis.
Conclusions:
Combination of the intraoperative navigation and preformed plate technique demonstrated great practical value in mandibular reconstruction with microvascular fibular flaps.
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.
The desire for implant-supported prostheses is steadily increasing in edentulous patients. For the clinician, the restoration of edentulous jaw is a challenge in implant prosthodontics because of alveolar atrophy and changes in the maxillomandibular relationship. Three-dimensional imaging shows the extent of the residual bone volume. In this case report, an augmentation procedure was avoided with the help of virtual planning. With the full guided method a total of ten implants were placed using flapless surgery in the edentulous maxilla and mandible. Because of existing primary stability, the implants were immediately loaded with the definitive prostheses.
The quality assurance is a recent discipline in the medical domain, all the more in odontology. Its implementation passes in our discipline essentially by the application of rules of requirements towards medical devices used within dental surgeries. Implants, abutments, implant’s prosthesis but also the surgical guides are examples applied to the domain. This surgico-prosthetic technique owes be executed in the best conditions with an optimal requirement: every act which can have consequences on the patient and/or the future of the treatment. To meet the requirements of quality assurance of the treatment, it seems that the static surgical guides can be a way to improve the placement of implants thus impacting on the quality of the organized therapeutics. At first, the notions of quality assurance and medical devices are handed in light, in particular through the filter of the oral implantology. Then, the quality of the treatment is discussed: historic bases until the knowledge of today. It is important to master the evolution of this technique and tools associated to understand and thus use tools diagnoses and therapeutic at our disposal today. The last time of this work establishes) the evaluation of the current tools implantologie (CAD-CAM, stereolithography, surgery guides static, IT) through a study on anatomical subjects. This study estimates the precision of the implant’s positioning with conventional said guides and guides of static guided surgery. This precision is estimated by comparison of the preliminary images of planning and the post operative threedimensional examinations
To evaluate the reliability and accuracy of computer-designed surgical guides in osseointegrated oral implant rehabilitation.
Six implant rehabilitations, with a total of 17 implants, were completed with computer-designed surgical guides, performed with the master model developed by muco-compressive and muco-static impressions. In the first case, the surgical guide had exclusively mucosal support, in the second case exclusively dental support. For all six cases computer-aided surgical planning was performed by virtual analyses with 3D models obtained by dental scan DICOM data. The accuracy and stability of implant osseointegration over two years post surgery was then evaluated with clinical and radiographic examinations. Radiographic examination, performed with digital acquisitions (RVG - Radio Video graph) and parallel techniques, allowed two-dimensional feedback with a margin of linear error of 10%.
Implant osseointegration was recorded for all the examined rehabilitations. During the clinical and radiographic post-surgical assessments, over the following two years, the peri-implant bone level was found to be stable and without appearance of any complications. The margin of error recorded between pre-operative positions assigned by virtual analysis and the post-surgical digital radiographic observations was as low as 0.2mm.
Computer-guided implant surgery can be very effective in oral rehabilitations, providing an opportunity for the surgeon: (a) to avoid the necessity of muco-periosteal detachments and then (b) to perform minimally invasive interventions, whenever appropriate, with a flapless approach.
Diagnostics imaging is an essential component of patient selection and treatment planning in oral rehabilitation by means of osseointegrated implants. In 2002, the EAO produced and published guidelines on the use of diagnostic imaging in implant dentistry. Since that time, there have been significant developments in both the application of cone beam computed tomography as well as in the range of surgical and prosthetic applications that can potentially benefit from its use. However, medical exposure to ionizing radiation must always be justified and result in a net benefit to the patient. The as low a dose as is reasonably achievable principle must also be applied taking into account any alternative techniques that might achieve the same objectives. This paper reports on current EAO recommendations arising from a consensus meeting held at the Medical University of Warsaw (2011) to update these guidelines. Radiological considerations are detailed, including justification and optimization, with a special emphasis on the obligations that arise for those who prescribe or undertake such investigations. The paper pays special attention to clinical indications and radiographic diagnostic considerations as well as to future developments and trends.
Computer-aided dental implant placement seems to be useful for placing implants by using a flapless approach. However, evidence supporting such applications is scarce. The aim of this study is to evaluate the accuracy of and complications that arise from the use of selective laser sintering surgical guides for flapless dental implant placement and immediate definitive prosthesis installation.
Sixty implants and 12 prostheses were installed in 12 patients (four males and eight females; age range: 41 to 71 years). Lateral (coronal and apical) and angular deviations between virtually planned and placed implants were measured. The patients were followed up for 30 months, and surgical and prosthetic complications were documented.
The mean ± SD angular, coronal, and apical deviations were 6.53° ± 4.31°, 1.35 ± 0.65 mm, and 1.79 ± 1.01 mm, respectively. Coronal and apical deviations of <2 mm were observed in 82.67% and 58.33% of the implants, respectively. The total complication rate was 34.41%; this rate pertained to complications such as pulling of the soft tissue from the lingual surface during drilling, insertion of an implant that was wider than planned, implant instability, prolonged pain, midline deviation of the prosthesis, and prosthesis fracture. The cumulative survival rates for implants and prostheses were 98.33% and 91.66%, respectively.
The mean lateral deviation was <1.8 mm, and the mean angular deviation was 6.53°. However, 41.67% of the implants had apical deviation >2 mm. The complication rate was 34.4%. Hence, computer-aided dental implant surgery still requires improvement and should be considered as in the developmental stage.
To assess the literature on accuracy and clinical performance of computer technology applications in surgical implant dentistry.
Electronic and manual literature searches were conducted to collect information about (1) the accuracy and (2) clinical performance of computer-assisted implant systems. Meta-regression analysis was performed for summarizing the accuracy studies. Failure/complication rates were analyzed using random-effects Poisson regression models to obtain summary estimates of 12-month proportions.
Twenty-nine different image guidance systems were included. From 2,827 articles, 13 clinical and 19 accuracy studies were included in this systematic review. The meta-analysis of the accuracy (19 clinical and preclinical studies) revealed a total mean error of 0.74 mm (maximum of 4.5 mm) at the entry point in the bone and 0.85 mm at the apex (maximum of 7.1 mm). For the 5 included clinical studies (total of 506 implants) using computer-assisted implant dentistry, the mean failure rate was 3.36% (0% to 8.45%) after an observation period of at least 12 months. In 4.6% of the treated cases, intraoperative complications were reported; these included limited interocclusal distances to perform guided implant placement, limited primary implant stability, or need for additional grafting procedures.
Differing levels and quantity of evidence were available for computer-assisted implant placement, revealing high implant survival rates after only 12 months of observation in different indications and a reasonable level of accuracy. However, future long-term clinical data are necessary to identify clinical indications and to justify additional radiation doses, effort, and costs associated with computer-assisted implant surgery.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
To evaluate the clinical outcome of fully edentulous patients in the maxilla, who were treated with immediately loaded implant-supported cross-arch bridges using computer-aided implant surgery.
The clinical outcome of 15 consecutive patients (5 males and 10 females) with a mean age of 52 years (range 40 to 70), with edentulous arches and treated with implant-supported cross-arch bridges was evaluated. Two computed tomography scans were performed, the first with the patient wearing the denture/radiographic guide and the radiographic index, and the second of the denture alone. The guided flapless surgical procedure was performed under local anaesthesia. Ninety implants were placed. The implant length ranged from 10 to 13 mm and the implant diameter was either 4.3 or 5 mm. All implants were immediately loaded with screw-retained provisional acrylic prostheses prepared in advance and delivered immediately after surgery. Clinical and radiographic follow-up visits were scheduled at 6, 12 and 18 months from surgery; implant survival rate, marginal bone levels, patient satisfaction and any complications were recorded.
After the follow-up period of 18 months, two patients each lost one implant. After 18 months, patients lost, on average, 1.6 mm of peri-implant marginal bone. A patient satisfaction questionnaire at 18 months revealed a very high level of satisfaction with the treatment.
Although limited by the number of patients, it can be concluded that software- and computed tomography-guided surgical planning for completely edentulous arches provides reliable results with high success rates.
Computer planned flapless surgery and immediate loading are the most recent topics in implantology. One new computer-planned implant system uses a three-dimensional parallelometer able to transfer the implant position from the virtual project to the master model. The aim of this study was to verify if the new medical device gives an advantage in term of implant failures and/or crestal bone remodeling.
A retrospective study was planned to analyze a series of 193 immediately loaded fixtures inserted by means of flapless surgery. From those sixty six implants were inserted with computer planning whereas 127 were inserted "free-hand". Several variables related to patient, anatomy, implant, surgery and prosthesis were investigated. To detect the clinical outcome implant' failure and peri-implant bone resorption were considered. Kaplan-Meier algorithm and Cox regression were then performed to detect those variables statistically associated with the clinical outcome.
Implant length and diameter ranged from 10 to 16 mm and from 3.75 to 6.0 mm, respectively. Implants were inserted to replace 46 incisors, 30 cuspids, 75 premolars and 42 molars. The mean follow-up period was 15 months. Seven implants were lost (survival rate 96.4%) but no studied variable has a statistical impact on failures. On the contrary, implants inserted in sites with completed bone healing, wide diameter fixtures and implants inserted in totally edentulous jaw had a significantly lower crestal bone resorption. The other variables (age, gender, upper/lower jaws, tooth site, implant' type and length, number of prosthetic units antagonist condition) did not have impact on crestal remodeling.
Computer-planned and cast model transferred implantology is a reliable technology that provides a slightly higher clinical outcome than "free hand" technique at least in healed sites, wider implants and totally edentulous jaws.
The aim of this study was to compare the surgical and post-operative outcomes of a computer-aided implant surgery performed by bone- and mucosa-supported stereolithographic (SLA) guides against the standard technique.
Multiple- and single-type SLA guides from two commercial manufacturers were produced and a total of 341 implants were placed to 52 patients using the standard technique (Control group), bone- (bone-supported guide [BSG] group) and mucosa-supported SLA guides (Flapless group) in 21, 16 and 15 patients, respectively. Surgical duration (min), number of analgesics (tablets) as well as hemorrhage, difficulty in mouth opening (or trismus) and other incidences were recorded. Pain and swelling was assessed using the visual analog scale (VAS). Parametric and non-parametric tests were used for statistical analysis (P<.05).
The mean surgery duration (23.53+/-5.48 min) and the number of analgesics consumed (four tablets) in the Flapless group were lower than those in the control (68.71+/-11.4 min and 10 tablets) and BSG groups (60.94+/-13.07 min and 11 tablets, P<0.01). The change in pain scores (VAS) and the number of analgesics consumed in time were statistically significant (P<0.01 and 0.05, respectively) and the Flapless group reported a lower pain score than the BSG (P<0.01) and Control groups (P<0.001). The Flapless group experienced less hemorrhage (chi(2)=4.12, P=0.041 on the day of surgery) and fewer instances of trismus (chi(2)=6.91, P=0.031 the day after surgery). The differences in early-term failures were not statistically significant between the groups (log-rank test: P=0.782).
The use of mucosa-supported single SLA guides for flapless implant placement may help reduce the surgery duration, pain intensity, related analgesic consumption and most other complications typical in the post-implant surgery period. However, there are particular drawbacks in both guide types and further studies are required to confirm the prosthodontic conformity and long-term success of implants placed using computer-assisted techniques.
The aim of this study was to present the preliminary results of 33 edentulous maxillary patients treated using the Nobelguide (Nobel Biocare AB, Göteborg, Sweden) technique.
Thirty-three patients were treated according to the conventional protocol of the Nobelguide technique in two clinical centers. This group of patients received 211 implants. Monitoring was carried out for over 12-51 months, depending on the patient. The Nobelguide protocol was used for all patients.
Of the 211 implants loaded, four were lost (1.9%). The implant survival rate was therefore 98.1%. The prosthetic survival rate was 100%. There were some per-operative complications (four) and some postoperative complications (10 fractures of resin).
These preliminary results seemed rather promising. These were the first cases of experienced surgeons who needed to learn a new implant placement protocol. It was clear that analysis and understanding of the system were essential in order to obtain such a success. Only one implant was replaced without there being any impact on the prosthesis survival rate which is 100%.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Flapless implant placement using guided surgery is widespread, although clinical publications on the precision are lacking.
The purpose of this study was to evaluate the accuracy of mucosal-supported stereolithographic guides in the edentulous maxillae.
Seventy-eight OsseoSpeed™ implants (Astra Tech AB, Mölndal, Sweden) of 3.5 to 5 mm width and 8 to 15 mm length were installed consecutively in 13 patients. Implants were functionally loaded on the day of surgery, and implant location was assessed with a computed tomography scan. Mimics 9.0 software (Materialise N.V., Leuven, Belgium) was used to fuse the images of the virtually planned and actually placed implants, and the locations, axes, and interimplant distances were compared.
One implant was lost shortly after insertion because of abscess formation caused by remnants of impression material. Seventy-seven implant locations were analyzed. The deviation at the entrance point ranged between 0.29 mm and 2.45 mm (SD: 0.44 mm), with a mean of 0.91 mm. Average angle deviation was 2.60° (range 0.16-8.86°; SD: 1.61°). At the apical point, the deviation ranged between 0.32 mm and 3.01 mm, with a mean of 1.13 mm (SD: 0.52 mm). The mean deviation of the coronal and apical interimplant distance was respectively 0.18 mm (range 0.07-0.32 mm; SD: 0.15) and 0.33 mm (range 0.12-0.69 mm; SD: 0.28). These deviations are lower than the global coronal and apical deviations.
The present study is the first to investigate the accuracy of stereolithographic, full, mucosally supported surgical guides in the treatment of fully edentulous maxillae. Clinicians should be warned that angular and linear deviations are to be expected. Short implants show significantly lower apical deviations compared with longer ones. Reasons for implant deviations are multifactorial; however, it is unlikely that the production process of the guide has a major impact on the total accuracy of a mucosal-supported stereolithographic guide.
Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.
Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.
The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
To compare the efficacy of immediate functionally loaded implants placed with a flapless procedure (test group) versus implants placed after flap elevation and conventional load-free healing (control group) in partially edentulous patients.
Forty patients were randomized: 20 to the flapless immediately loaded group and 20 to the conventional group. To be immediately loaded, implants had to be inserted with a minimum torque > 45 Ncm. Implants in the immediately loaded group were provided with full acrylic resin temporary restorations the same day. Implants in the conventional group were submerged (anterior region) or left unsubmerged (posterior region) and were left load-free for 3 months (mandibles) or 4 months (maxillae). Provisional restorations were replaced with definitive single metal-ceramic crowns 1 month postloading. Outcome measures were prosthesis and implant failures, biological and prosthetic complications, postoperative edema, pain, and use of analgesics. Independent sample chi2 tests, Mann-Whitney tests, t tests, and paired t tests were used with a significance level of .05.
Fifty-two implants were placed in the flapless group and 56 in the conventionally loaded group. In the flapless group, 1 flap had to be raised to control the direction of the bur and 1 implant did not reach the planned primary stability and was treated as belonging to the conventional group. After 3 years no dropouts or failures occurred. There was no statistically significant difference for complications; however, patients in the conventional group had significantly more postoperative edema and pain and consumed more analgesics than those in the flapless group. Osstell values were significantly higher at baseline in the flapless group (P = .033). When comparing baseline data with years 1, 2, and 3 within each group, mean Osstell values of the flapless group did not increase, whereas there were statistically significant increases in the Periotest values.
Implants can be successfully placed flapless and loaded immediately without compromising success rates; the procedure decreases treatment time and patient discomfort.
The aim of this prospective study was to evaluate the concept of intraoral welding as a suitable technique for the placement of a final restoration for the edentulous maxilla on the same day as surgery.
Twenty patients with edentulous maxillae received a fixed restoration supported by an intraoral welded titanium bar. Final abutments were connected to the implants and welded to a titanium bar using an intraoral welding unit. This framework was used as a support for the final restoration, which was fitted on the same day as implant placement. Mean marginal bone loss and radiographically detectable alteration of the welded framework were assessed using periapical radiographs immediately after surgery and at 6- and 12-month follow-up examinations.
Ten males and 10 females, with an average age of 51.8 years (SD = 15.1 years; N = 20), were consecutively treated with 153 immediately loaded implants. No fractures or radiographically detectable alterations of the welded framework were evident. All implants osseointegrated and were clinically stable at the time of the 12-month follow-up. Mean marginal bone loss was 0.43 mm (SD = 0.13 mm; N = 153) between 0 and 6 months and 0.14 mm (SD = 0.055 mm; N = 153) between 6 and 12 months. Therefore, the accumulated mean marginal bone loss was 0.57 mm (SD = 0.21 m; N = 153).
On the same day of surgery, it is possible to successfully rehabilitate the edentulous maxilla with a fixed, permanent prosthesis supported by an intraoral welded titanium framework. More expanded investigations over longer time periods are required to better determine the long-term success of this approach.
To systematically scrutinize the current scientific literature regarding the clinical advantages of computer guidance of implant placement.
Four electronic databases were searched using specified indexing terms. The reference lists of publications were also searched manually. For inclusion, publications had to meet pre-established criteria.
The searches yielded 1028 titles and abstracts. After data extraction and interpretation, 28 publications and 2 systematic reviews remained for inclusion. Fifteen studies were prospective observational and four were retrospective observational. Nine studies included a control group (controlled clinical trials) of which seven were prospective and two retrospective. Only three of the prospective studies were randomized (RCT's). A total of 852 patients were treated with 4032 implants using computer-guided implant surgery. The number of patients included in each study ranged from 6 to 206. The age ranged from 16 to 92 years and the follow-up period varied between 1 and 49 months.
The limited scientific evidence available suggests that guided placement has at least as good implant survival as conventional protocols. However, several unexpected procedure-linked adverse events during guided implant placement indicate that the clinical demands on the surgeon were no less than those during conventional placement. A clinical advantage with flapless guided surgery is that the technique is likely to decrease pain and discomfort in the immediate postoperative period.
To assess the accuracy of static computer-guided implant placement.
Electronic and manual literature searches were conducted to collect information on the accuracy of static computer-guided implant placement and meta-regression analyses were performed to summarize and analyse the overall accuracy. The latter included a search for correlations between factors such as: support (teeth/mucosa/bone), number of templates, use of fixation pins, jaw, template production, guiding system, guided implant placement.
Nineteen accuracy studies met the inclusion criteria. Meta analysis revealed a mean error of 0.99 mm (ranging from 0 to 6.5 mm) at the entry point and of 1.24 mm (ranging from 0 to 6.9 mm) at the apex. The mean angular deviation was 3.81° (ranging from 0 to 24.9°). Significant differences for all deviation parameters was found for implant-guided placement compared to placement without guidance. Number of templates used was significant, influencing the apical and angular deviation in favour for the single template. Study design and jaw location had no significant effect. Less deviation was found when more fixation pins were used (significant for entry).
Computer-guided implant placement can be accurate, but significant deviations have to be taken into account. Randomized studies are needed to analyse the impact of individual parameters in order to allow optimization of this technique. Moreover, a clear overview on indications and benefits would help the clinicians to find the right candidates.
Purpose:
Immediate loading has become a widely reported practice in implant dentistry. The aim of this study is to report on the 10-year clinical and radiographic outcomes of an immediate-loading treatment protocol that included flapless surgery.
Materials and methods:
Forty-six patients were treated with 97 immediately loaded Mk IV implants (Nobel Biocare) with machined surface in the maxilla. Presurgically, a three-dimensional model of each patient's soft tissue and underlying alveolar bone anatomy was created and a surgical template was fabricated. A circular mucotome was used to punch out a 5-mm hole in the mucosa to avoid flap elevation. Control examinations were performed on the day of surgery and at 1, 2, 3, 6, 8, and 10 years after surgery.
Results:
All prepared implant sites had intact buccal and lingual bone walls. The prefabricated provisional restorations showed excellent fit. Nine implants failed within 8 weeks of loading, resulting in a cumulative survival rate of 91% after 10 years of loading. The survival rates were 94% for implants supporting partial prostheses and 81% for implants supporting single restorations. Average marginal bone resorption was 1 mm during the first year, 0.4 mm during the second year, and 0.1 mm during the third year and after 10 years.
Conclusions:
The unchanged survival rate and the low average bone loss after 10 years confirm the feasibility of an immediate loading treatment protocol in the maxilla that included flapless surgery.
Objectives
The study was designed to evaluate the clinical use of the NobelGuide concept over a follow-up period of 12months with respect to implant success and survival rates, development of soft tissue condition and recording of potential surgical and prosthetic complications. In addition, radiological assessment of peri-implant bone levels was performed at the 1-year follow-up post-implant placement. Material and methodsThirty patients (male/female=15/15) with partially dentate and edentulous mandibles and maxillae were included. All patients were planned and operated on using the computer-aided, template-guided treatment concept NobelGuide. Overall, 163 implants (NobelReplace((R)) Tapered Groovy) were placed (mandible/maxilla=107/56 implants). Recall appointments were performed after 1-2weeks, 1, 3, 6 and 12months after implant placement. Clinical parameters of the soft tissue conditions [e.g. bleeding on probing (BoP), pocket probing depth 3mm (PPD), marginal plaque index (mPI)] and the dentist's esthetic and functional evaluation using a visual analogue scale (VAS) were documented. Marginal bone level was evaluated on radiographs made at implant insertion and at the 1-year follow-up. ResultsAll 30 patients with 161 implants completed the 1-year follow-up resulting in a cumulative survival rate of 98.8% (two implant losses). Clinical parameters improved in a majority of the implants. The mean marginal bone level at implant insertion and at 1-year follow-up was reported with 0.17mm (SD 1.24; n=125) and -1.39mm (SD 1.27; n=110), respectively. The mean change in bone level from implant insertion to 1year was -1.44mm (SD 1.35; n=98). Conclusions
The 1-year follow-up showed a cumulative survival rate and success rate of 98.8% and 96.3%, respectively. Immediate or delayed loading of implants using a flapless, guided surgery approach (NobelGuide) appears to be a viable concept demonstrating good clinical and radiographic outcomes at the 1-year time point.
Objectives:
Flapless implant surgery is fast gaining popularity because of several advantages, such as reduced surgical time, postoperative bleeding, and swelling. Studies have shown that flap elevation results in some amount of bone loss. The aim of the current study was to compare the amount of bone loss in procedures using the flapless technique and those where flap elevation was done. Papillary fill was also compared in both techniques, which is unique to this study.
Study design:
Forty patients, selected according to certain inclusion and exclusion criteria, were randomly assigned to 1 of 2 groups: Flap (F), or Flapless (FL). The amount of crestal bone loss was measured from standardized radiographs at baseline, 6 months, 1 year, and 2 years after implant placement. Papillary fill was evaluated using the Papillary presence index, which was measured 6 months after loading.
Results:
The bone loss was greater for the F group during all time periods and the mean papillary fill was greater for the FL group.
Conclusions:
In conclusion, the results of the current study show that flapless implant surgery results in less crestal bone loss both during the healing period and after loading. In addition, it can produce better papillary fill. The cases selected for this study were ideal cases in terms of bone volume and the operator was well experienced, however. Care should be taken during case selection for flapless implant surgery.
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.
Long healing periods and submerged implant placement are commonly used in the maxilla. This extends the time of oral handicap and makes the use of immediate loading protocols an attractive option. The current clinical literature on direct loading of dental implants in the maxilla is limited.
The purpose of this prospective clinical study was to evaluate the clinical outcome and stability of directly loaded Brånemark System® or Replace Select® Tapered implants (Nobel Biocare AB, Göteborg, Sweden) after using a modified surgical protocol and inclusion by primary implant stability. In addition, a reference group treated according to a two-stage protocol was used for comparison.
Twenty patients planned for prosthetic rehabilitation with implant-supported bridges in the edentulous maxilla participated in the study group. The final decision on immediate loading was made after implant placement using insertion torque and resonance frequency analysis (RFA) as acceptance criteria. All patients were included, and 123 oxidized implants (TiUnite™, Nobel Biocare AB) were placed using a surgical protocol for enhanced primary stability. A screw-retained temporary bridge was delivered within 12 hours and a final bridge within 3 months of implant placement. The patients were monitored through clinical and radiographic follow-up examinations from implant placement to at least 12 months. Marginal bone level was measured at bridge delivery and after 12 months of loading. Additional RFA measurements were made after 6 months of loading. A reference group comprising 20 patients with 120 implants treated according to a two-stage protocol was used for comparison.
One (0.8%) of the 123 implants in the study group failed, and no implant was lost in the reference group. The cumulative survival rates after 12 months of loading were thus 99.2% and 100% for immediate and delayed loading protocols, respectively. The marginal bone resorption was 0.78 (SD 0.9) in the study group and 0.91 (SD 1.04) in the reference group. RFA showed a mean value of 62.9 (SD 4.9) implant stability quotient (ISQ) at placement and 64.5 (SD 4.8) ISQ after 6 months for immediately loaded implants (not significant). The corresponding figures for the reference groups were 61.3 (SD 8.8) ISQ and 62.6 (SD 7.0) ISQ (not significant). There were no statistically significant differences between the groups at any time point.
The use of six to seven implants for immediate loading of a fixed provisional bridge is a viable option for implant treatment of the edentulous maxilla, at least when good primary implant stability can be ensured.
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: Early loading of implant-supported prostheses in the edentulous mandible is widely accepted, but do the clinical results replicate those of delayed loading?
Purpose: The aim of this study was to evaluate clinical outcome and patient satisfaction with early or delayed loading in patients treated with fixed prostheses, using three different implant systems.
Materials and Methods: One hundred and nine consecutively treated patients received 490 implants supporting fixed prostheses; 82 patients with Brånemark System® implants (Nobel Biocare AB, Göteborg, Sweden), 16 with Astra Tech® implants (Astra Tech AB Dental Implant system, Mölndal, Sweden), and 11 with ITI® MonoType® implants (ITI Dental Implant System®, Institute Straumann AG, Waldenburg, Switzerland). Prostheses were placed within 2 to 3 weeks in 55 patients; 54 patients underwent a two-stage procedure. Data were collected from patient records and radiographs; 83 patients attended a clinical examination and received a questionnaire.
Results: All patients had fixed prostheses at follow-up with a mean observation time of 3.5 years. Cumulative survival rates (CSRs) were 92.5% of prostheses and 94.4% of implants for early loading, and 98.0 and 97.9% for delayed loading. The mean radiographic bone loss after the first year was small, and at 5 years less than 0.2 mm for both groups. With early loading, significantly more prostheses (p < .05) needed adjustment or replacement.
Conclusion: Statistically significantly more prostheses needed adjustment or replacement in the early group. The present study suggested lower CSRs for prostheses and implants in the early loading group after 5 years; the difference was not statistically significant. Larger study samples are needed to verify statistically small differences between treatment techniques.
Flapless, free-handed implant surgery offers advantages for patient comfort, but studies on long-term clinical success based on marginal bone loss are scarce.
Aim: The aim of this study was to compare single implants installed with a flap (F) or flapless (FL) surgery with respect to survival and marginal bone preservation after at least 3 years.
Materials and Methods: Fifty-three TiUnite (TM) Branemark implants, installed in 49 patients (27 females; 22 males; mean age 53 years) were examined. Then, 25 F and 28 FL were delayed loaded; bone level from the abutment-implant level was measured on intraoral radiographs. From 44 (21 F, 23 FL), 31 (18F, 13FL), and 36 (18 F, 18 FL) implants, radiographs were available at baseline and after 1 and 3 years of function.
Results: The overall survival rate was 100% and the overall mean bone loss after an average of 38 months was 1.35 mm (SD 0.91; range 0-3.7). Both F and FL showed increasing bone loss during the first year with a higher bone loss for FL than for F sites (p < .01). Afterward, no further bone loss occurred and both groups were statistically equal (p > .7). On individual implant level, nearly 80% in both F and FL were considered a success showing bone loss between 1.5 and 1.9 mm.
Conclusions: Single implants yield an excellent prognosis with stable bone levels irrespective of the surgical technique, and free-handed flapless surgery is a viable alternative to more extensively planned guided surgery. Proper case selection and clinical experience are considered prerequisites for a predictable treatment outcome.
Background:
The introduction of digital planning programs has made it possible to place dental implants in preplanned positions and being immediately functionally loaded by using prefabricated prostheses.
Purpose:
The aim of this multicenter study was to describe the 1-year results of digitally planned, immediately loaded edentulous maxillae.
Materials and methods:
A total of 312 implants (Brånemark System, TiUnite RP, Nobel Biocare, Göteborg, Sweden) in 52 patients from eight Scandinavian clinics were digitally planned, surgically as well as prosthetically, by using the NobelGuide (Nobel Biocare AB, Göteborg, Sweden) and received prefabricated, immediately loaded fixed prosthetic constructions in the maxillae. Individual implant stability was manually tested at 1-year follow-up.
Results:
All patients received a Procera Implant Bridge (Nobel Biocare AB); however, in two cases, the bridges were reconstructed due to misfit. In five patients, difficulties in getting the surgical guide completely in position, and in five patients, getting the prostheses completely seated, were noted. All but four patients fulfilled the 1-year follow-up. Two implants were lost during the study period, resulting in a cumulative survival rate of 99.4%. The mean marginal bone resorption from implant placement to the 1-year follow-up was 1.3 mm (SD 1.28). More than 2 mm of marginal resorption was noted in 19% of the implants at this instant. The most frequently reported complications during the first year were gingival hyperplasia and prosthesis-related problems (prosthesis screw loosening, occlusal fractures, and occlusal adjustments).
Conclusion:
The 1-year results in this multicenter are promising regarding implant and bridge stability; however, the study is planned to be running for at least 3 years.
Background: Evaluation of the clinical conditions following computer guided treatment planning and flapless surgery is still limited.
Objectives: The objective was to evaluate the soft tissue conditions and marginal bone changes after 1 year of function around immediately loaded implants inserted in edentate jaws following computer guided treatment planning and flapless surgery.
Material and Methods: Twenty-nine edentate jaws (19 maxillae, 10 mandibles) treated with 165 implants using the Teeth-in-an-Hour™ protocol were included. In these patients, peri-implant soft tissue conditions and radiographic marginal bone changes were evaluated after ≥1 year of functional loading (mean: 19 months).
Results: The mean probing depth at case level was 2.6 mm (SD: 0.6). Bleeding on probing was recorded as a mean of 81.9% (SD: 23.0). Plaque index showed a wide range of 0–100%. The mean marginal bone change of measured sites evaluated on intraoral radiographs was −1.2 mm (SD: 1.4). A marginal bone loss more than 1.5 mm or 2.0 mm was observed in 42% and 27% of the measured sites, respectively. A pressure-like-ulcer was found in 9 cases. Implants with marginal bone loss of >1.5 mm were more frequently observed in cases with an ulcer than cases where no ulcer was found.
Conclusion: Although the mean marginal bone loss after function in the present study was within the range of other reports presenting mean bone loss data after immediate implant loading, our patients showed a wide range of bone loss with several sites, where the bone loss was greater than the commonly used successful level (>1.5 mm).
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.
Dentin hypersensitivity (DH) is a commonly occurring dental condition, and bioactive glasses (BG) are used in dentifrice formulations for treating DH by forming a surface layer of hydroxycarbonate apatite (HCA) on the tooth, thereby occluding exposed dentinal tubules. Fluoride-containing BG, however, form fluorapatite, which is more stable toward acid attack, and provide a more sustainable option for treating DH.
Melt-derived multi-component BG (SiO(2)-P(2)O(5)-CaO-CaF(2)-SrO-SrF(2)-ZnO-Na(2)O-K(2)O) with increasing CaF(2)+SrF(2) content (0-32.7 mol%) were prepared. Apatite formation, occlusion of dentinal tubules in dentin discs and ion release in Tris buffer were characterized in vitro over up to 7 days using X-ray diffraction, infrared spectroscopy, scanning electron microscopy and inductively coupled plasma emission spectroscopy.
The fluoride-containing bioactive glasses formed apatite from as early as 6h, while the fluoride-free control did not form apatite within 7 days. The glasses successfully occluded dentinal tubules by formation of apatite crystals and released ions such as fluoride, strontium and potassium.
Fluoride significantly improved apatite formation of the BG, allowing for treatment of DH by occlusion of dentinal tubules. The BG also released therapeutically active ions, such as strontium and fluoride for caries prevention, zinc for bactericidal properties and potassium, which is used as a desensitizing agent in dentifrices.
Clinical data are scarce on flapless-guided surgery in the mandible using the all-on-four concept. In addition, limited documentation exists on the latter under immediate loading conditions with a pre-fabricated implant bridge. The aim was to provide detailed documentation focusing on clinical and radiographic outcome and complications.
Sixteen systemically healthy non-smoking patients (10 women, 6 men, average age 59 years) with sufficient bone volume in the mandible were operated via flapless-guided surgery using the all-on-four concept. Clinical and radiographic data and complications were registered at 3, 6 and 12 months.
The overall implant survival rate was 90% with a trend for higher failure of short implants (P = 0.098). The mean bone level after 12 months of function was 0.83 mm with a maximum of 1.07 mm. Technical complications were common (15/16 patients). These mainly related to a misfit between the pre-fabricated prosthesis and abutment(s) (13/16 patients).
If immediate loading of implants is pursued fabrication of the implant bridge should be based on actual impression of the implants at the time of surgery and not on their virtual position.
In order to minimise publication bias, authors of systematic reviews often spend considerable time trying to obtain unpublished data. These include data from studies conducted but not published (unpublished data), as either an abstract or full-text paper, as well as missing data (data available to original researchers but not reported) in published abstracts or full-text publications. The effectiveness of different methods used to obtain unpublished or missing data has not been systematically evaluated.
To assess the effects of different methods for obtaining unpublished studies (data) and missing data from studies to be included in systematic reviews.
We identified primary studies comparing different methods of obtaining unpublished studies (data) or missing data by searching the Cochrane Methodology Register (Issue 1, 2010), MEDLINE and EMBASE (1980 to 28 April 2010). We also checked references in relevant reports and contacted researchers who were known or who were thought likely to have carried out relevant studies. We used the Science Citation Index and PubMed 'related articles' feature to identify any additional studies identified by other sources (19 June 2009).
Primary studies comparing different methods of obtaining unpublished studies (data) or missing data in the healthcare setting.
The primary outcome measure was the proportion of unpublished studies (data) or missing data obtained, as defined and reported by the authors of the included studies. Two authors independently assessed the search results, extracted data and assessed risk of bias using a standardised data extraction form. We resolved any disagreements by discussion.
Six studies met the inclusion criteria; two were randomised studies and four were observational comparative studies evaluating different methods for obtaining missing data.Methods to obtain missing dataFive studies, two randomised studies and three observational comparative studies, assessed methods for obtaining missing data (i.e. data available to the original researchers but not reported in the published study).Two studies found that correspondence with study authors by e-mail resulted in the greatest response rate with the fewest attempts and shortest time to respond. The difference between the effect of a single request for missing information (by e-mail or surface mail) versus a multistage approach (pre-notification, request for missing information and active follow-up) was not significant for response rate and completeness of information retrieved (one study). Requests for clarification of methods (one study) resulted in a greater response than requests for missing data. A well-known signatory had no significant effect on the likelihood of authors responding to a request for unpublished information (one study). One study assessed the number of attempts made to obtain missing data and found that the number of items requested did not influence the probability of response. In addition, multiple attempts using the same methods did not increase the likelihood of response. METHODS TO OBTAIN UNPUBLISHED STUDIES: One observational comparative study assessed methods to obtain unpublished studies (i.e. data for studies that have never been published). Identifying unpublished studies ahead of time and then asking the drug industry to provide further specific detail proved to be more fruitful than sending of a non-specific request.
Those carrying out systematic reviews should continue to contact authors for missing data, recognising that this might not always be successful, particularly for older studies. Contacting authors by e-mail results in the greatest response rate with the fewest number of attempts and the shortest time to respond.
Background:
Checking reference lists to identify relevant studies for systematic reviews is frequently recommended by systematic review manuals and is often undertaken by review authors. To date, no systematic review has explicitly examined the effectiveness of checking reference lists as a method to supplement electronic searching.
Objectives:
To investigate the effectiveness of checking reference lists for the identification of additional, relevant studies for systematic reviews. Effectiveness is defined as the proportion of relevant studies identified by review authors solely by checking reference lists.
Search strategy:
We searched the databases of The Cochrane Library (Issue 3, 2008), Library and Information Science abstracts (LISA) (1969 to July 2008) and MEDLINE (1966 to July 2008). We contacted experts in systematic review methods and examined reference lists of articles.
Selection criteria:
Studies of any design which examined checking reference lists as a search method for systematic reviews in any area. The primary outcome was the additional yield of relevant studies (i.e. studies not found through any other search methodologies); other outcomes were publication types identified and data pertaining to the costs (e.g. cost-effectiveness, cost-efficiency) of checking reference lists.
Data collection and analysis:
We summarized data descriptively.
Main results:
We included 12 studies (in 13 publications) in this review, but interpretability and generalizability of these studies is difficult and the study designs used were at high risk of bias. The additional yield (calculated by dividing the additional 'unique' yield identified by checking reference lists by the total number of studies found to be eligible within the study) of relevant studies identified through checking reference lists ranged from 2.5% to 42.7%. Only two studies reported yield information by publication type (dissertations and systematic reviews). No cost data were reported although one study commented that it was impossible to isolate the time spent on reference tracking since this was done in parallel with the critical appraisal of each paper, and for that particular study costs were not specifically estimated.
Authors' conclusions:
There is some evidence to support the use of checking reference lists for locating studies in systematic reviews. However, this evidence is derived from weak study designs. In situations where the identification of all relevant studies through handsearching and database searching is difficult, it would seem prudent that authors of reviews check reference lists to supplement their searching. The challenge, therefore, is for review authors to recognize those situations.
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.
To compare the effective dose levels of cone beam computed tomography (CBCT) for maxillofacial applications with those of multi-slice computed tomography (MSCT).
The effective doses of 3 CBCT scanners were estimated (Accuitomo 3D, i-CAT, and NewTom 3G) and compared to the dose levels for corresponding image acquisition protocols for 3 MSCT scanners (Somatom VolumeZoom 4, Somatom Sensation 16 and Mx8000 IDT). The effective dose was calculated using thermoluminescent dosimeters (TLDs), placed in a Rando Alderson phantom, and expressed according to the ICRP 103 (2007) guidelines (including a separate tissue weighting factor for the salivary glands, as opposed to former ICRP guidelines).
Effective dose values ranged from 13 to 82 microSv for CBCT and from 474 to 1160 microSv for MSCT. CBCT dose levels were the lowest for the Accuitomo 3D, and highest for the i-CAT.
Dose levels for CBCT imaging remained far below those of clinical MSCT protocols, even when a mandibular protocol was applied for the latter, resulting in a smaller field of view compared to various CBCT protocols. Considering this wide dose span, it is of outmost importance to justify the selection of each of the aforementioned techniques, and to optimise the radiation dose while achieving a sufficient image quality. When comparing these results to previous dosimetric studies, a conversion needs to be made using the latest ICRP recommendations.
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.
Background: ‘Immediate’ implants are placed in dental sockets just after tooth extraction. ‘Immediate‐delayed’ implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. ‘Delayed’ implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique.
Objectives: To evaluate success, complications, aesthetics and patient satisfaction between ‘immediate’, ‘immediate‐delayed’ and ‘delayed’ implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique.
Search strategy: The Cochrane Oral Health Group’s Trials Register (to 2 June 2010), CENTRAL ( The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 – 2 June 2010) and EMBASE via OVID (1980 – 2 June 2010) were searched. Several dental journals were handsearched.
Selection criteria: Randomized controlled trials (RCTs) comparing immediate, immediate‐delayed and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading.
Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient.
Main results: Fourteen eligible RCTs were identified but only 7 trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and an independent blinded assessor judged the level of the peri‐implant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients).
Authors’ conclusions: There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on a few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants. On the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques are superior to the others.
Many studies have shown success with implants placed in grafted bone, and there is an emerging desire to simplify the treatment process by placing implants via a flapless approach using navigation or computer-aided design/computer-assisted manufacture techniques. This paper reports a preliminary study of laboratory and clinical procedures that may enable flapless implant placement in patients treated previously with extensive onlay grafting of the severely resorbed maxilla, thereby avoiding secondary exposure of the grafted site. Six patients received 39 implants, with a cumulative survival rate of 97.7% over an average of 48.8 months; all prosthetic reconstructions are successful to date.
Dental implants can be placed in sockets just after tooth extraction (immediate implants) or after a couple of weeks up to a couple of months (immediate-delayed implants) or thereafter (delayed implants). This review looked at which was the best time to place dental implants and whether it would be advantageous to augment sites with gaps present at implant placement. It also tried to determine the most effective bone augmentation procedure. The seven identified studies included too few patients to answer the questions. Four studies evaluated which is the best time to place implants. One study evaluated whether bone grafting is advantageous at implant placement and two studies evaluated which are the best grafting techniques. There is currently too little evidence to draw any reliable conclusions, however, the aesthetic outcome could be slightly better when placing implants early after tooth extraction, though early placed implants might be at a higher risk of failure. There is not enough evidence supporting or refusing the need of bone augmentation when extracted teeth are immediately replaced with dental implants, nor it is known whether any augmentation procedure is better than the others. Bone substitutes (anorganic bovine bone) can be used instead of self generated (autogenous) bone graft.
Osseointegrated dental implantation is traditionally performed by a flap approach that involves soft tissue flap reflection, but this technique is associated with several drawbacks. Conversely, the flapless method requires only minimal removal of soft tissue but is not suitable for all patients. The objective of this study was to compare the flapless (FL) method of implant placement with the traditional flap (TR) method with regard to achievement of success, change in bone level, and overall safety.
In this single-center, open, retrospective, investigator-driven, nonrandomized, comparative study, patients were pre- or intraoperatively assigned to the FL or TR treatment. The primary success criteria were the absence of mobility, radiolucency, pain, and infection.
The FL method was applied to 174 implants (46%) in 121 patients and the TR method to 203 implants (54%) in 98 patients. At visit 1, implantation was rated successful in 171/174 (98.3%) implants with the FL method and in 200/203 (98.5%) with the TR method. Success rate remained constant until visit 2. The difference between the 2 groups in the rate of success was not significant. Similarly, no significant difference was observed for mean time to last follow-up for success.
Based on pre- or intraoperative decision-making, patients eligible for FL surgery can benefit from a less straining procedure without affecting the high success rate of dental implant surgery. The FL approach is a predictable procedure when patient selection and surgical technique are appropriate.
To evaluate and compare the outcome of dental implants placed using a flapless protocol and immediate loading with a conventional protocol and loading after 6 weeks.
Fourteen patients with bilateral maxillary edentulous areas were treated using Straumann SLA-implants. Using a randomized split-mouth design, implants were placed in one side of the maxilla using a stereolithographic surgical guide for flapless surgery and immediately loaded on temporary abutments with a bridge (test). Implants in the other side were placed using the conventional protocol and loaded after 6 weeks of healing (control). Clinical and radiographic evaluation of peri-implant tissues was performed at time of implant surgery, and after 1 week, 6 weeks, 3, 6, 12 and 18 months.
A total of 70 implants were placed (36 test and 34 control). One implant (test) was lost after 3 months, resulting in a survival rate of 97.3% for the test implants and 100% for the control implants. Marginal bone levels were not statistically significantly different between the test and control implants but at baseline the marginal bone level was significantly lower compared to the other evaluation periods (P < 0.05). The mean bone level for test and control implants was 1.95 mm ± 0.70 and 1.93 mm ± 0.42 after 18 months, respectively. There was a significant change in height of the attached mucosa at implants placed with a conventional flap between post-operative and 1 week and between 1 week and 6 weeks. Statistically significant differences were found between the test side and the control side for opinion about speech, function, aesthetics, self-confidence and overall appreciation the first 6 weeks.
Implants can successfully integrate in the posterior maxilla using a flapless approach with immediate loading similar to a conventional protocol. The mucosal tissues around implants placed with a conventional flap changed significantly compared with flapless placed implants.
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.
Despite several reports on the clinical outcomes of flapless implant surgery, limited information exists regarding the clinical conditions after flapless implant surgery.
The objective of this study was to evaluate the soft tissue conditions and marginal bone changes around dental implants 1 year after flapless implant surgery.
For the study, 432 implants were placed in 241 patients by using a flapless 1-stage procedure. In these patients, peri-implant soft tissue conditions and radiographic marginal bone changes were evaluated 1 year after surgery.
None of the implants were lost during follow-up, giving a success rate of 100%. The mean probing depth was 2.1 mm (SD 0.7), and the average bleeding on probing index was 0.1 (SD 0.3). The average gingival index score was 0.1 (SD 0.3), and the mean marginal bone loss was 0.3 mm (SD 0.4 mm; range 0.0-1.1 mm). Ten implants exhibited bone loss of >1.0 mm, whereas 125 implants experienced no bone loss at all.
The results of this study demonstrate that flapless implant surgery is a predictable procedure. In addition, it is advantageous for preserving crestal bone and mucosal health surrounding dental implants.
It was proposed that technologies derived from computer-aided design (CAD)/computer-aided manufacturing (CAM) and computed tomography may be useful for flapless implant treatment procedures. However, most of the studies examining the effectiveness of this method were performed in fully edentulous patients, with little or no attention paid to partially edentulous patients. The aims of this study were 1) to evaluate the concept of computer-assisted implant placement including a treatment planning procedure based on computed tomography scan images by use of a flapless surgical approach in partially edentulous cases and 2) to validate the reliability of this concept in a prospective 12-month clinical study.
Sixteen patients with partially edentulous areas in their mandibles were included in this study. A total of 57 implants were inserted by use of a CAD/CAM drill template, specially designed for flapless implant surgery. To assess the degree of pain and discomfort, the patients were examined at 2 days and 1 week after surgery. Patient satisfaction and implant functionality were further evaluated at follow-up intervals of 1, 3, 6, and 12 months postoperatively. A specially designed visual analog scale was used for data acquisition.
The mean pain score on the visual analog scale at follow-up was within the range for little or no pain. Two implants failed early in 1 patient. All of the other implants were in a good functional state throughout the study. The mean marginal bone loss after 1 year of follow-up was 0.6 mm (SD, 0.2) mesially and 0.5 mm (SD, 0.1) distally.
This prospective study showed that the use of CAD/CAM technology and flapless implant surgery may be considered reliable for partial edentulous patients.
The aim of this systematic review was to analyze the dental literature regarding accuracy and clinical application in computer-guided template-based implant dentistry.
An electronic literature search complemented by manual searching was performed to gather data on accuracy and surgical, biological and prosthetic complications in connection with computer-guided implant treatment. For the assessment of accuracy meta-regression analysis was performed. Complication rates are descriptively summarized.
From 3120 titles after the literature search, eight articles met the inclusion criteria regarding accuracy and 10 regarding the clinical performance. Meta-regression analysis revealed a mean deviation at the entry point of 1.07 mm (95% CI: 0.76-1.22 mm) and at the apex of 1.63 mm (95% CI: 1.26-2 mm). No significant differences between the studies were found regarding method of template production or template support and stabilization. Early surgical complications occurred in 9.1%, early prosthetic complications in 18.8% and late prosthetic complications in 12% of the cases. Implant survival rates of 91-100% after an observation time of 12-60 months are reported in six clinical studies with 537 implants mainly restored immediately after flapless implantation procedures.
Computer-guided template-based implant placement showed high implant survival rates ranging from 91% to 100%. However, a considerable number of technique-related perioperative complications were observed. Preclinical and clinical studies indicated a reasonable mean accuracy with relatively high maximum deviations. Future research should be directed to increase the number of clinical studies with longer observation periods and to improve the systems in terms of perioperative handling, accuracy and prosthetic complications.
In implant dentistry today, precise preoperative planning of both the implant placement and the restoration is a critical prerequisite to succeeding in the oral rehabilitation of patients with dental implants. Modern three-dimensional imaging techniques such as digital volume tomography allow the acquisition of radiologic data with very low levels of radiation and excellent image accuracy, and also allow the processing of these data with various types of software applications. Formerly, only the position of the implant collar or the axis of the osteotomy could be transferred into the clinical setting; it is now possible to predetermine the precise three-dimensional position of the planned implant before the actual implant insertion, and to transfer this position to the surgical site. Thus, the restoration can be fabricated before surgery and can be placed into the patient's mouth immediately after surgery. Treatment planned in this way is fast, minimally invasive, and most importantly, predictable. This increases the quality of both the surgical procedure and the restoration. For three-dimensional navigation in implant dentistry there are static systems based on both surgical guides and optical, dynamic navigation systems. This article is an overview of the latest systems for guided implant insertion and their fields of application.
The aim of this retrospective multicenter clinical study was to compare the survival rate of dental implants placed with two different surgical procedures: (1) a flapless surgical procedure using an image-guided system (IGS flapless protocol) and (2) the conventional technique (open flap without IGS) with a computed tomography scan.
Between 2001 and 2004, 552 implants were placed in 169 patients by six practitioners who used both protocols to restore completely and partially edentulous arches: 271 of them were placed with the IGS flapless protocol (test group) and 281 with the conventional procedure (control group). Each implant was categorized as "survival" or "failure" after 1 to 4 years of follow-up after prosthesis implantation. A preoperative classification was used to evaluate the anatomic features of each case. There was initially no possible comparison between these two groups because of the indication bias relative to the retrospective clinical study data characteristics. After a classic logistic regression analysis, propensity scores were used to reduce this bias: prognosis variables were included in a regression logistic model to define the probability for each implant to be treated with the IGS flapless protocol. Implants showing the same probability were categorized into three classes. The implants were then compared with each other within the same class.
After the follow-up period, the cumulative survival rate was 98.57% in the control group and 96.30% in the test group. Whatever the statistical method used, no statistical differences between the two protocols were shown. Transmucosal implant placement showed a survival rate of 97%. Even though the initial conditions were less favorable, the survival rate in the test group was comparable with the standard protocol group.
Passing an implant through the gum does not interfere with osseointegration. The IGS flapless procedure makes it possible to use the flapless procedure, even though anatomic conditions were initially unfavorable.
The placement of implants using a minimally invasive flapless approach has the potential to reduce operative bleeding and postoperative discomfort and minimize crestal bone loss. This article presents follow-up data on a prospective clinical study of implants placed using a flapless procedure.
The original study reported on 57 patients (33 female patients with an age range of 24 to 86 years; 24 male patients with an age range of 27 to 81 years) recruited from three clinical centers (Tucson, Arizona; Gothenburg, Sweden; and Tel Aviv, Israel) who received 79 implants. After an average of 3 years and 8 months, the patients were contacted and invited to return to their respective clinics for reexamination. Thirty-seven patients with 52 implants returned for a follow-up examination; the remaining 20 patients (27 implants) were not available for reexamination and were considered study drop-outs.
The cumulative survival rate at the 3- to 4-year follow-up examination remains at 98.7%, reflecting the loss of one implant. The mean probing depth at abutment connection was 2.2 mm, as reported in the initial study (examination 2 at approximately 2 years postplacement); it was 2.4 mm at the 3- to 4-year second follow-up examination. This change was not clinically or statistically significant. Bleeding score changes also were not significant between the two intervals. The average crestal bone level was -0.7 mm at examination 2 and -0.8 mm at examination 3, a change that approached significance (P <0.06).
Minimally invasive flapless surgery offers patients the possibility of high implant predictability with clinically insignificant crestal bone loss for up to 4 years. Proper diagnosis and treatment planning are key factors in achieving predictable outcomes.
The aim of this study was to compare the clinical success and bone healing of implants placed in fresh extraction sockets using a flapless procedure compared to those placed with flap elevation.
Twenty teeth in 20 patients were selected for this study and were scheduled for tooth extraction and immediate implant placement. Ten implants were placed with flap elevation (control group), and 10 implants were placed without flap elevation (test group). All the sites selected showed a complete bone defect at the facial wall. All the implants included in this study were 2-stage implants placed at the level of palatal/lingual bone in augmented bone. Each surgical site was protected with a collagen membrane and, subsequently, a standardized radiograph was taken to evaluate the distance between the implant shoulder and the first bone-implant contact (DIB). Six months after placement, both control and test implants underwent a second-stage surgery and a clinical examination to determine the implant stability quotient, DIB, and the distance between implant shoulder and the crestal bone at the midbuccal aspect (DIC).
One implant failed in the test group. Only 1 implant (test group) showed bone growth over the implant neck at the re-entry procedure. Implant stability quotient (ISQ) and DIB did not show any significant differences between the control and test group; however, a higher DIC was found in the test sites compared to the control sites.
Data from this study showed that immediate implants with and without a mucoperiosteal flap elevation can be successfully used even in the presence of bone defects requiring augmentation procedures. It was also noted that the bone regenerated reached a higher coronal level in the group with flap elevation than in the group without flap elevation.
The aim of this randomized controlled clinical trial was to compare the efficacy of implants placed with a flapless procedure and restored immediately (test group) or early (6 weeks) (control group) in partially edentulous patients up to 1 year after loading. Both groups were nonocclusally loaded. Ten patients were included in each group. No patients dropped out and no failures were recorded. Two complications occurred in the early loading group, but both were resolved. It can be concluded that the use of a flapless technique for placing implants in conjunction with nonocclusal immediate loading in select patients can provide excellent clinical results. These preliminary findings should be confirmed by larger randomized clinical trials.
It has been suggested that for success with immediate loaded dental implants it is necessary that, prior to their placement, bone quantity and quality as well as the biomechanical environment in which the implants are to function be evaluated. However, conventional techniques currently used for immediate implant placement lack sufficient precision and are usually accomplished by opening flap procedures. The purpose of this paper is to report the benefit of sophisticated pre-operative diagnostic implant planning and a flapless surgical approach with immediate loading.
The report describes the use of computed tomography (CT) for three-dimensional (3D) evaluations of bone implant sites, an interactive software program for 3D planning and the fabrication of stereolithographic models as custom surgical templates. The degree of patient satisfaction was evaluated by periodic recall and by adopting a specially designed analogue scale in each visit.
The mean amount of bone loss around the implants was 0.5 +/- 0.1 mm and the satisfactoriness scale was rated high (i.e. 81), at the end of 1 year.
The use of stereolithographic appliances in accordance with flapless surgery makes immediate placement of the implants more predictable.