The International Journal of Oral & Maxillofacial Implants, 06/2003

Purpose: Our primary aim was to use a rabbit guided bone augmentation model to evaluate whether use of autogeneic bone grafts or bovine bone mineral (BBM) combined with a space-making barrier enhances bone augmentation compared with a barrier alone. Materials and Methods: Sixteen rabbits were studied. In each rabbit, 2 titanium cylinders, each with 1 titanium lid, were placed subcutaneously in perforated slits made in the cortical bones, with their open ends facing the parietal bones. One cylinder was left empty and the other was filled with either autogeneic skull bone chips or BBM. Bone labels were injected after 4 and 11 weeks. After 12 weeks, the animals were sacrificed to obtain ground sections for histology and histomorphometry. Results: Significantly more tissue was augmented in the 2 test groups than in the control group. Most of the autografts were resorbed, leaving only minute amounts in the upper third of the cylinders. Slender new bone trabeculae were distributed mainly from the contiguous bone plate that had no contact with the remaining graft material. In the BBM group, most of the BBM remained evenly distributed in the cylinder. In the upper third of the cylinder, the BBM was surrounded by soft connective tissue, while in the lower two thirds, mainly mineralized bone enclosed the BBM. Equal amounts of mineralized bone were found in both test groups. Comparisons of contact between bone and BBM on one hand and bone and bone cylinder wall on the other revealed that the greatest bone contact was with the BBM in the lower third of the cylinder. In the middle and upper third of the cylinder, bone-BBM contact and bone-cylinder wall contact were similar. Fluorescent label intensity was higher in the autograft group than in the BBM group. In all 3 groups the intensity of the early label was similar to that of the late label, indicating that the graft materials do not seem to retard mineralization. Discussion: BBM was found to promote as much new bone as did autogeneic bone. In addition, BBM appears to have at least the same osteoconductive properties as titanium, provided BBM is contained in a stable environment. Conclusions: Placement of autogeneic bone or BBM in conjunction with a stiff space-making barrier generated more tissue than a barrier only. In this model, autogeneic bone chips and BBM augmented similar amounts of new mineralized bone. (More than 50 references)

Purpose: The objective of this study was to evaluate the qualitative and quantitative differences that could appear in newly formed peri-implant bone around Screw-Vent implants placed in rabbit tibiae when treated with local administration of growth hormone (GH). Materials and Methods: Eight New Zealand rabbits were randomly divided into 2 groups: the experimental group, which received 4 IU of GH in the form of lyophilized powder added to the ostectomy site before implant placement, and the control group, which did not receive GH before implant placement. Animals were sacrificed 2 weeks later, and histologic sections were obtained for histomorphometry and observation under light microscopy. Results: The sections in the GH-treated group presented enhanced growth of new trabeculae from the periosteal tissue, and the bone-to-implant contact in the experimental group was significantly greater (P .05). Discussion: Local administration of GH stimulated a more dramatic effect than that seen previously with systemic GH administration, prompting growth from both the periosteum and endosteum. Conclusions: Local administration of GH at the time of implant placement could enhance peri-implant bone reaction.

Purpose: Polychromatic sequence labeling of bone was used to study the effect of periodontal infection on the immediate placement of Frialit-2 implants. Materials and Methods: In the surgical first phase, periodontitis was induced with ligatures involving the mandibular premolars of 5 mongrel dogs, and the contralateral teeth were used as controls (received only prophylaxis). After 3 months, the second phase was initiated and 40 implants were placed in the alveoli of both experimental and control teeth. During the healing period, fluorescent bone markers were injected to study bone formation around the implants. The dyes were injected in the following sequence: oxytetracycline hydrochloride at 3 days after implant placement, calcein green 4 weeks after implant placement, oxytetracycline 8 weeks after implant placement, and alizarin red S 3 days before sacrifice. Following a healing period of 12 weeks, the animals were euthanized and the hemimandibles were removed, dissected, fixed, and prepared for histomorphometic analysis of the percentage of each bone marker present. Results: Fluorescence microscopy showed a similar sequence of bone remodeling (Mann-Whitney test) for both groups: experimental group, 9% bone formation at 3 days, 29% at 4 weeks, 21.6% at 8 weeks, and 52% at 12 weeks; control group, 14% at 3 days, 35.2% at 4 weeks, 32.3% at 8 weeks, and 45.8% at 12 weeks. Discussion: Remodeling in both groups had similar characteristics in the degree of bone formation. Conclusions: It was concluded that periodontal disease does not affect bone remodeling around immediate implants. Although the healing in periodontally infected sites was slower initially, it reached the levels of the non-diseased sites after 12 weeks.

Purpose: In general, both chemical composition and surface features of implants affect cell response. The aim of this study was to evaluate the effect of titanium (Ti) passivation on the response of rat bone marrow cells, considering cell attachment, cell morphology, cell proliferation, total protein content, alkaline phosphatase (ALP) activity, and bonelike nodule formation. Materials and Methods: Cells were cultured on both commercially pure titanium (cpTi) and titanium-aluminium-vanadium alloy (Ti- 6Al-4V) discs, either passivated or not. For attachment evaluation, cells were cultured for 4 and 24 hours. Cell morphology was evaluated after 4 days. After 7, 14, and 21 days, cell proliferation, total protein content, and ALP activity were evaluated. Bonelike nodule formation was evaluated after 21 days. Data were compared by analysis of variance and the Duncan multiple range test. Results: Cell attachment, cell morphology, cell proliferation, total protein content, ALP activity, and bonelike nodule formation all were unaffected by Ti composition or passivation. Discussion and Conclusion: Although the protocol for passivation used here could interfere with the pattern of ions released from Ti-6Al-4V and cpTi surfaces, the present study did not show any effect of this surface treatment on in vitro biocompatibility of Ti as evaluated by osteoblast attachment, proliferation, and differentiation.

Purpose: Submerged and nonsubmerged ITI solid-screw titanium implants were followed retrospectively from 1989 to 1993 and prospectively from 1994 on to analyze long-term prognosis in partially and fully edentulous patients. Material and Methods: A total of 468 implants were consecutively inserted in 191 patients from 1989 to 1998. Two hundred twenty-eight successfully integrated fixedrestoration implants and 238 with removable restorations were restored following a healing period of 4 to 6 months (9 months in sinus floor elevation sites). From 1994 on all implants inserted were documented annually up to 9 years. During examination the clinical status of the implants was analyzed and evaluated according to predefined criteria of success and this allowed the calculation of 10-year cumulative survival and success rates for 468 implants. Results: Two implants (0.43%) did not successfully integrate during the healing period, and 8 implants (1.7%) were classified as failures during follow-up (1 late failure under load, 7 with a progressive bone loss from 1 to 3 threads). Including 68 implants in subjects who dropped out (with a dropout rate of 14.4%), the 10-year cumulative survival and success rates were 99.2% and 96.4%, respectively. Discussion: Over the course of this long-term study, osseointegrated implants, once used as a last possible solution, became nearly standard in cases of single-tooth implants because of the high rate of long-term success. Life table analysis not only determines whether an implant is functioning, it also makes a statement about its clinical status according to strict success criteria. Conclusion: The study demonstrated that ITI solid-screw titanium implants achieved success rates above 95% in a clinical center for an observation period of up to 10 years. (More than 50 references)

Purpose: Two treatment concepts for implant-supported bar retention of mandibular overdentures-2 intramobile cylinder (IMZ) implants and a Dolder bar and 4 titanium plasma-sprayed (TPS) screw implants and an angulated bar-were compared in a randomized controlled clinical trial with respect to postprosthetic efficacy and safety. Materials and Methods: Four hundred twenty-five patients with edentulous mandibles were enrolled; 212 were randomized to TPS implants (control group) and 213 to IMZ implants (test group). Endpoints were occurrences of postprosthetic integration deficiency (ID), functional deficiency (FD), and complications. The trial was sized to detect a 10% difference in 5-year ID-free postprosthetic system lifetime with a power of 80%. Results: With 340 protocol-completed cases, the trial achieved its predetermined power. The 2 systems did not show statistically significant differences in occurrences of postprosthetic ID and FD; 5-year occurrence-free postprosthetic system lifetime probabilities were estimated as 42.5% with IMZ and 42.8% with TPS, for ID; and as 82.6% with IMZ and 87.2% with TPS, for FD. However, at 3 to 6 months after surgery, mean Periotest values were significantly higher (P = .0001 without adjustment) with IMZ implants (5.6, SD 4.2) than with TPS implants (0.8, SD 4.3). TPS implants showed a higher incidence of inflammation and recession, while IMZ implants had a higher incidence of implant fracture after functional loading. Discussion: The system- wise approach overcomes potential bias with implant-wise analyses. A combination of radiographic and clinical criteria distinguishes between desirable integration and functional anchorage. The in situ survival rates at 5 years in this study (95% for IMZ, 92% for TPS) match rates reported in the literature. Conclusion: This study demonstrated equivalent efficacy of 2 IMZ cylinders and 4 TPS screws in implant-supported, bar-retained mandibular overdentures and indicated a higher rate of complications with the TPS screw implants.

Purpose: This study sought to identify the types, frequencies, and risk factors associated with complications following placement of dental implants. It was hypothesized that one or more factors could be identified that are associated with an increased risk for complications and may be modified by the clinician to enhance outcome. Materials and Methods: A retrospective cohort study design was used that included patients who received Bicon implants (Bicon, Boston, MA) between 1992 and 2000. Predictor variables were grouped into demographic, medical history, implant-specific, anatomic, prosthetic, and reconstructive categories. Complications were grouped into inflammatory, prosthetic, operative, and major or minor categories. Cox proportional hazards regression models were developed to identify risk factors for complications. Results: The sample was composed of 677 patients. The overall frequency of implant complications was 13.9% (10.2% inflammatory, 2.7% prosthetic, 1.0% operative), of which 53% were minor. The multivariate Cox model revealed that smoking, use of 1-stage implants, and reconstructive procedures were statistically associated with an increased risk for overall complications (P = .05). The median duration of follow-up was 13.1 months (range 0 to 85.6 months). Discussion: A lower frequency of complications was found compared to mean frequencies calculated from past reports. Investigations examining the influence of smoking and reconstructive procedures on implant complications are recommended. Conclusion: Of the 3 factors associated with an increased risk for complications, tobacco use and implant staging may be modified by the clinician to enhance outcome.

Purpose: The aim of this randomized study was to evaluate and compare the long-term success rates of cylindric, screw-type titanium implants with a larger diameter (5.9 mm) that were placed in fresh extraction sockets in association with resorbable bone substitutes or a resorbable membrane. Materials and Methods: Eighty-three partially edentulous adult patients, selected from among those treated in 1997 and 1998 at the San Raffaele Institute in whom 1 or more implants had been placed into fresh posterior mandibular or maxillary sockets, were included in the study. A total of 111 implants were placed, 36 in mandibles and 75 in maxillae. Fifty-six implants were placed in combination with resorbable hydroxyapatite (HA group) and 55 with a resorbable membrane (MR group). Intraoral radiographs and follow-up examinations, including verification of implant stability via the Periotest, were carried out at secondstage surgery 3, 6, 9, and 12 months later; and then annually up to 4 years after placement of the definitive restoration. The radiographic examination was conducted by means of a standardized procedure to verify osseointegration. Results: There was 100% attendance at the follow-up examination after 4 years. At second-stage surgery, which was performed after 4 to 6 months' healing time, none of the implants showed any signs of mobility, peri-implantitis, or bone loss. Two implants failed in the MR group, one at 3 months and one at 9 months after placement; 1 implant failed in the HA group at 4 months after placement. After 4 years, the implant success rate was 97.3% (108 of 111 implants were considered successful). The success rate did not differ significantly between the HA group (98.2%) and the MR group (96.4%). Discussion: The use of larger-diameter implants served to minimize the anatomic discrepancies that would have evolved when substituting a molar with a standard-diameter implant. According to the accepted criteria for success, the 5-year success rate should be at least 85%; therefore both methods may be considered satisfactory. Conclusion: Implants placed in combination with a resorbable allogeneic material or with a resorbable membrane provided predictable long-term results when restored with a fixed partial denture.

Purpose: The purpose of this study was to compare internal Morse taper connections in 2 separate modes: repeated torque/reverse-torque values and compressive bending at a 30-degree off-axis angle. Materials and Methods: Three sample groups (n = 12 in each group)-a solid-screw implant paired with a 5.5-mm solid abutment (SSI), a synOcta implant with a 5.5-mm solid abutment (SOI), and a syn- Octa implant with a synOcta 5.5-mm solid abutment (SOSA)-were torqued to 35 Ncm, and the reverse torque to remove the abutment was recorded. This was repeated for 3 trials. Additionally, the sample groups were loaded 30 degrees off-axis, and the ultimate compressive values were recorded. Results: There was a significant difference in the initial reverse-torque values. The SOSA setup showed significantly lower torque than the SOI and SSI setups (P .05). In addition, the compressive bending test showed that the SOSA setup was significantly different (P .05) from the SSI and SOI setups. Radiographic survey of the test groups following compressive bending revealed no implant fractures, but bending of the implant-abutment complex occurred. Discussion: The alteration within the Morse taper did not reduce the strength of the implant-abutment connection, ie, the reduction in surface area did not significantly reduce the torque properties or tensile properties. The new 2-piece synOcta 5.5-mm solid abutment was shown to have a stronger implant-abutment connection when torqued down a second time. Conclusions: In this in vitro study, alteration of the Morse taper with an internal octagon indexing did not significantly reduce the strength of the implant connection. Sufficient strength was exhibited, which would indicate this implant-abutment design for anterior as well as posterior edentulous sites.

Purpose: In patients with atrophic mandibles, elevation of the floor of the mouth often prevents intraoral rectangular radiography for longitudinal follow-up studies, while extraoral techniques such as panoramic radiographs tend to produce distorted views of the interforaminal region. In this study, intraoral rectangular radiographs and panoramic radiographs were compared for their accuracy in evaluating peri-implant bone loss. Materials and Methods: In a recall program, 22 patients with 88 screw-type implants (44 MKII and 44 Frios) were followed. Interforaminal marginal bone loss was evaluated by extraoral orthopantomograms and by intraoral rectangular radiographs. In addition, pocket depth, Periotest readings, and bleeding on probing were recorded. For statistical analysis, the Spearman coefficient of correlation was used. The effects on bone loss and clinical variables were computed with a mixed model and the Bland and Altman method. Results: Computed as least square means, the mean difference between panoramic radiographs (2.4 ± 0.2 mm for MKII implants and 1.6 ± 0.2 mm for Frios implants) and intraoral radiographs (2.6 ± 0.2 mm and 1.4 ± 0.2 mm, respectively) was 0.2 mm (range, 0.1 to 0.8 mm). Discussion: In this study, the 2 imaging techniques were comparable clinically in terms of the precision with which they could be used to measure marginal bone loss. Conclusion: For highly atrophic mandibles with unfavorable imaging conditions, rotational panoramic radiographs can be a useful alternative to intraoral small-format radiographs for evaluating periimplant bone loss.

Purpose: The aim of this prospective randomized clinical trial was to evaluate 10 years of treatment of patients receiving a mandibular implant-retained overdenture (IRO) or a conventional complete denture (CD). Materials and Methods: One hundred twenty-one edentulous patients were treated with an IRO (2 endosseous implants, n = 61) or a conventional CD (n = 60). Clinical aspects and patient satisfaction were evaluated. One year after placement of the denture, unsatisfied patients of the CD group were given the opportunity to receive implants. Results: In the IRO group, 4 implants were lost during the first year and 4 implants were lost during the next 4 years. Between 5 and 10 years, no implants were lost (survival rate: 93%). In the CD group, 24 patients (40%) chose an IRO between 1 and 10 years. Discussion: Patients in the IRO group were significantly more satisfied than patients in the CD group after 1 year (satisfaction score 8.3 versus 6.6 on a scale of 1 to 10), after 5 years (7.4 versus 6.4), and after 10 years (7.7 versus 6.8). Conclusion: The mean satisfaction score of the CD group (including patients who later received implants) was still lower than that of the IRO group, in spite of the opportunity for retreatment with IROs. Endosseous implants had a high survival rate after 10 years of follow-up. Keywords: clinical trial, complete denture, dental implants, overdenture

Purpose: The purpose of this study was to assess the reliability of the planning software of an imageguided implant placement system based on a mechanical device coupled with a template stabilized on soft tissue during surgery. Materials and Methods: Thirty consecutive partially or completely edentulous patients were treated with the image-guided system. For each patient, a study prosthesis was fabricated and duplicated in acrylic resin and served as a scanning template. Axial images were obtained from a computerized tomographic scan and transferred to planning software that provides real 3- dimensional information to plan implant position. Once the final position of the implant was defined, preoperative data such as the size of implants and anatomic complications were recorded using the planning software. The scanning template was then drilled in that exact position by a drilling machine. During surgery, the drilled template was used as a drill guide. After implant placement, intraoperative data were recorded and statistically compared with the preoperative data using the Kendall correlation coefficient for qualitative data and the Kappa concordance coefficient for quantitative data. Results: Agreement between the preoperative and intraoperative data was high for both implant size and anatomic complications. The Kendall correlation coefficient was 0.8 for the diameter and 0.82 for the length. The Kappa concordance coefficient was 0.87 for both dehiscence and bone graft, 0.88 for osteotomy, and 1.0 for fenestration. Discussion: In the few instances where planning was not perfect, implant placement was completed in a clinically acceptable manner. Conclusion: The results suggest that the image-guided system presented is reliable for the preoperative assessment of implant size and anatomic complications. It may also be reliable for flapless surgery.

Purpose: Bone resorption following tooth loss often limits the quantity of bone available for implant placement. The purpose of the present study was to evaluate the clinical outcome of 10-mm or shorter machined-surface implants when used exclusively in the treatment of various forms of edentulism. Materials and Methods: Two hundred sixty-nine screw-type Brånemark System implants (Nobel Biocare), 10 mm or shorter, were placed in 111 consecutively treated patients. Of the total, 88.8% were placed in the mandible and 11.2% were placed in the maxilla; 95.2% were used to treat partially edentulous situations, including single-tooth losses, of which 96.6% were in the premolar and molar regions. The patients were followed for periods of 12 to 92 months. Results: Of the 269 placed implants, 12 were lost. The overall survival rate was 95.5%. Bone quality 2 and 3 (Lekholm-Zarb classification of 1985) was found in 88.8% of the treated sites. There was no statistical difference in the survival rate of the 10-mm implants when compared to the shorter series (P > .05) or between the various implant diameters. The mean marginal bone loss was 0.71 ± 0.65 mm. Discussion: The failure rate of 4.5% compares favorably with that of implants of different shape, surface characteristics, and length. Bone quality appeared to be the critical factor in implant survival, rather than bone quantity, in this patient series. Conclusions: This study supports the survival of short, machined-surface implants when used for the treatment of partial edentulism in bone of good quality.

Zygomatic implants have been in use since the 1990s for the treatment of patients with severely resorbed maxillae. Here, the authors present a modification of the standard zygomatic implant technique that uses up to 3 implants on each side of the maxilla for support of a dental prosthesis.

Dental implants have become an accepted treatment modality for aging patients with either completely or partially edentulous arches. However, growing patients with congenitally missing primary and/or permanent teeth often need dental implant treatment, even before puberty, for optimum functional and/or psychosocial development. From a developmental perspective, dental implants cannot accompany the physiologic differentiation of the alveolar bone because of the difference in anchorage between an osseointegrated dental implant and a tooth in bone. Nevertheless, reports in the literature suggest that dental implants can be used successfully in partially and completely edentulous arches affected by congenital disorders such as ectodermal dysplasia. In this case report, a multidisciplinary team approach, which included an orthodontist, an oral surgeon, and prosthodontists, in the treatment of a patient with oligodontia is discussed. The orthodontic and prosthodontic treatment sequence, growth analysis from age 14 to 18 years, and successful therapy of an implant associated with late failure is presented.