The International Journal of Oral & Maxillofacial Implants, Supplement/2004

Purpose: The aim of this article was to review the current literature with regard to survival and success rates, along with the clinical procedures and outcomes associated with immediate and delayed implant placement. Materials and Methods: A MEDLINE search was conducted of studies published between 1990 and June 2003. Randomized and nonrandomized clinical trials, cohort studies, case-control studies, and case reports with a minimum of 10 cases were included. Studies reporting on success and survival rates were required to have follow-up periods of at least 12 months. Results: Thirty-one articles were identified. Most were short-term reports and were not randomized with respect to timing of placement and augmentation methods used. All studies reported implant survival data; there were no reports on clinical success. Peri-implant defects had a high potential for healing by regeneration of bone, irrespective of healing protocol and bone augmentation method. Sites with horizontal defects (HD) of 2 mm or less healed by spontaneous bone fill when implants with rough surfaces were used. In the presence of HDs larger than 2 mm, or when socket walls were damaged, concomitant augmentation procedures with barrier membranes and bone grafts were required. Delayed implant placement allowed for resolution of local infection and an increase in the area and volume of soft tissue for flap adaptation. However, these advantages were diminished by simultaneous buccolingual ridge resorption and increased requirements for tissue augmentation. Discussion: Immediate and delayed immediate implants appear to be predictable treatment modalities, with survival rates comparable to implants in healed ridges. Relatively few long-term studies were found. Successful clinical outcomes in terms of bone fill of the peri-implant defect were well established. However, there was a paucity of data on long-term success as measured by peri-implant tissue health, prosthesis stability, and esthetic outcomes. Conclusions: Short-term survival rates and clinical outcomes of immediate and delayed implants were similar and were comparable to those of implants placed in healed alveolar ridges.

High clinical success rates have been reported when implants are placed according to standard indications. This has encouraged efforts to improve the success rates for implants placed in more demanding clinical situations. One of these indications is tooth replacement with implants placed into extraction sockets. Although the first clinical procedures for the placement of implants immediately following tooth removal were described long ago, it is only recently that the details of such clinical approaches have been studied in greater detail. One of the aims of the present consensus meeting was to scrutinize the available literature to identify predictable and successful procedures for replacing extracted teeth with implant-supported reconstructions. In addition, where the data from the literature were inconclusive or absent, the clinical experience of the members of the consensus group was used as the basis for the recommendations.

Purpose: To document the literature regarding outcomes of implant restorations in the anterior maxilla to formulate consensus statements with regard to esthetics in implant dentistry, to provide guidelines to clinicians, and to articulate remaining questions in this area to be addressed by future research. Materials and Methods: The following areas of the recent literature were scrutinized: treatment outcomes of implant therapy for partial edentulism (including maxillary anterior tooth replacement); anterior maxillary single-tooth replacement; effect of implant design, diameter, and surface characteristics; soft tissue stability/contours around anterior implant restorations; ceramic abutments; influence of surgical techniques; and finally, evaluation of patient satisfaction. Results: The use of dental implants in the esthetic zone is well documented in the literature, and numerous controlled clinical trials show that the respective overall implant survival and success rates are similar to those reported for other segments of the jaws. However, most of the published studies do not include well-defined esthetic parameters. Currently, the literature regarding esthetic outcome is inconclusive for the routine implementation of certain surgical approaches, such as flapless surgery and immediate implant placement with or without immediate loading/restoration in the anterior maxilla. Considering anterior single-tooth replacement in sites without tissue deficiencies, predictable treatment outcomes, including esthetics, can be achieved because of tissue support provided by adjacent teeth. The replacement of multiple adjacent missing teeth in the anterior maxilla with fixed implant restorations is poorly documented. In this context, esthetic restoration is not predictable, particularly regarding the contours of the interimplant soft tissue. Discussion and Conclusions: This review has demonstrated that scientific documentation of esthetically relevant and reproducible parameters is rather scarce. Most of the reported outcome analyses primarily focus on implant survival. Elements of anterior implant success such as maintenance or reestablishment of harmoniously scalloped soft tissue lines and natural contours should be included in future studies.

The placement of dental implants in the anterior maxilla is a challenge for clinicians because of patients' exacting esthetic demands and difficult pre-existing anatomy. This article presents anatomic and surgical considerations for these demanding indications for implant therapy. First, potential causes of esthetic implant failures are reviewed, discussing anatomic factors such as horizontal or vertical bone deficiencies and iatrogenic factors such as improper implant selection or the malpositioning of dental implants for an esthetic implant restoration. Furthermore, aspects of preoperative analysis are described in various clinical situations, followed by recommendations for the surgical procedures in single-tooth gaps and in extended edentulous spaces with multiple missing teeth. An ideal implant position in all 3 dimensions is required. These mesiodistal, apicocoronal, and orofacial dimensions are well described, defining "comfort" and "danger" zones for proper implant position in the anterior maxilla. During surgery, the emphasis is on proper implant selection to avoid oversized implants, careful and low-trauma soft tissue handling, and implant placement in a proper position using either a periodontal probe or a prefabricated surgical guide. If missing, the facial bone wall is augmented using a proper surgical technique, such as guided bone regeneration with barrier membranes and appropriate bone grafts and/or bone substitutes. Finally, precise wound closure using a submerged or a semi-submerged healing modality is recommended. Following a healing period of between 6 and 12 weeks, a reopening procedure is recommended with a punch technique to initiate the restorative phase of therapy.

The purpose of this article is to review and project treatment procedures for areas of esthetic concern. The authors were participants in a consensus conference sponsored by ITI and held in August 2003 in Gstaad, Switzerland. This article deals with the basic prosthetic/restorative aspects in implant esthetics. It is based on a literature review performed by 16 participants from Group 2 (Buser et al) in this section of the Journal.

The group was asked to come to a consensus position related to the esthetic dimension of implant dentistry in the anterior maxilla, based on its discussion of and subsequent deliberation on 3 previously written position papers regarding the following fields: (1) outcome analysis of implant restorations located in the anterior maxilla; (2) anatomical and surgical considerations of implant therapy in the anterior maxilla; and (3) practical prosthodontic procedures related to anterior maxillary fixed implant restorations. These reports were critically reviewed and thoroughly discussed within the group, leading to a first draft of consensus statements. These were subsequently presented during a plenary session that included the members of the other 3 consensus groups. After their respective input, the statements were refined and then presented again to the plenary session for final approval.

Primary stability and postponement of loading of dental implants for approximately 3 to 6 months have been considered for years the "conditio sine qua non" to allow osseointegration of dental implants. However, in recent years, an increasing number of publications on immediate and early loading of dental implants in completely edentulous patients have appeared in the literature, and high survival rates were generally reported. Nevertheless, much controversy still exists over the reliability of the reported data, frequently because the publications are of insufficient methodologic quality (insufficient follow-up, inadequate sample size, absence of randomization, lack of well-defined exclusion and inclusion criteria, lack of well-defined success criteria, etc). The objective of this study was to review the literature to evaluate the reliability of early and immediate loading of implants placed in the edentulous mandible and maxilla and rehabilitated either with implant-supported overdentures or with implant-supported fixed prostheses.

Purpose: The objective of this consensus committee report was to review the available literature published predominantly in refereed journals to summarize findings, data, and conclusions as they related to reduced healing times and protocols for single-tooth and partial-arch clinical situations. Early loading of dental implants has been defined as restoration of implants in or out of occlusion at least 48 hours after implant placement, but at a shorter time interval than conventional healing. Immediate loading or restoration has been defined as attachment of a restoration in or out of direct occlusal function within 48 hours of surgical placement, Materials and Methods: Six articles addressing early loading, with a mixture of single-tooth and partial-arch clinical conditions and including some controlled cohort studies, were reviewed. Immediate loading or restoration of dental implants in single-tooth and partial-arch applications, was extensively reviewed. An attempt was made to isolate and categorize similar case types to discern trends and relevant factors. Variables that were considered included single- or multiple-tooth conditions, immediate or delayed placement in extraction sockets, effect of implant surface and geometry, bone quality, implant stability, surgical technique, occlusal design, effect of cigarette smoking, and stability of results. Results: Combined data from 6 early loading studies on single-tooth and partial-arch applications revealed 1,046 implants with a survival rate of 98.2%. Long-term data for most of the early loading studies were not yet available. Most of the publications on immediate loading or restoration of dental implants were written as case series rather than scientific studies. Discussion and Conclusions: In general, most publications indicated that with attention to appropriate factors, implant survival with immediate restoration was comparable to the results with conventional and early loading protocols. It should be recognized that, with few exceptions, these conclusions may be misleading statistical phenomena of the authors, as most publications were written by exceptionally experienced, highly skilled practitioners working under tightly controlled clinical conditions on a relatively small, statistically inconclusive number of implants and patients.

The use of dental implants to assist in the treatment of partial and complete edentulism is well documented. Most of the implant literature, however, reports results associated with implant survival and success when there has been adherence to rigid placement and loading protocols. Conventionally, these protocols call for the undisturbed healing of the implant-3 months in the mandible and 4 to 6 months in the maxilla. This article evaluates the literature and develops protocols for clinical procedures for the early or immediate restoration or loading of dental implants. Criteria are established for defining immediate loading, immediate restoration, early loading, and early restoration as compared to conventional protocols. The review assesses factors that influence accelerated loading and restoration decisions, including bone quality and quantity, implant design, splinting of implants, and prosthetic design. Conclusions and recommendations are made based on the experience of the consensus group charged with considering these procedures and on the current literature published on these protocols.

The group was asked to develop evidence-based reviews on topics related to various loading protocols for dental implants. Three reviews were prepared: the first addressed the literature related to different loading protocols for partially edentulous cases, the second examined the literature for loading protocols in completely edentulous cases, and the third addressed clinical procedures for the various loading protocols. Drafts of the manuscripts were prepared and distributed to the members of the group prior to the conference. The overall objective of the literature review was to determine whether a procedure could be recommended as a standard based on the available evidence. The second objective was to identify whether patients perceived a benefit associated with these procedures. The literature included full-length articles in English on endosseous root-form titanium implants. For edentulous patients, a minimum follow-up of 1 year was required. The volume of literature found was moderate, but the level of evidence was limited at best for the procedures considered. The predominant literature was case reports. The primary goal was to identify survival of the implants and success or failure of the procedure(s), and to relate these to the implant and/or prosthesis. A secondary goal was to identify possible risk factors for the procedures. At the consensus conference, the authors presented their manuscripts to the group for discussion. There was discussion concerning how the authors approached writing the draft, how the literature was searched and reviewed, what the major findings were, and finally, what conclusions could be drawn. Following these presentations, group members addressed several aspects of each review, including: • Did the review adequately address the topic? • Has any evidence been published since the review that has a significant impact on the topic? • Do the section members agree with the findings of the review's authors? • What open questions remain in this area, and what might be investigated in the future regarding this topic? • What recommendations can be made for patient treatment with regard to loading protocols? During the discussion, several statements were made regarding immediate or early restoration and/or loading of implants in edentulous and partially edentulous patients. These are listed below, along with issues that were identified throughout the discussions.

Purpose: To review the literature on clinical, radiographic, and biochemical parameters used for monitoring peri-implant conditions. Materials and Methods: A MEDLINE search was conducted that included articles published in English until the end of August 2003. Results from human and experimental animal studies are presented. Results: The parameters that may be used to assess the presence of peri-implant health and the severity of peri-implant disease include plaque assessment, mucosal conditions, peri-implant probing depth, width of the peri-implant keratinized mucosa, peri-implant sulcus fluid analysis, suppuration, implant mobility and discomfort, resonance frequency analysis, and radiographic evaluation. Discussion: Based on the analysis of the available evidence, it appears reasonable to use a number of clinical and radiographic parameters to discriminate between peri-implant health and disease. Conclusions: Systematic and continuous monitoring of peri-implant tissues during maintenance care is recommended for the early diagnosis of peri-implant disease.

Purpose: To review the literature on the treatment of peri-implant diseases. Specific emphasis was placed on the use of antimicrobial therapy, defined as local or systemic administration of antiseptic and/or antibiotic agents. Materials and Methods: A search of MEDLINE, the Cochrane Controlled Trials Register, and The Cochrane Health Group Specialized Register was conducted, and articles published in English until July 31, 2003, were included. The results of experimental animal studies and human research are presented. Results: A variety of antimicrobial treatment regimens in combination with nonsurgical or surgical debridement with and without regenerative therapy were reported. Use of antimicrobials varied between studies with respect to type of drug, dosage, delivery system, duration, and commencement of antibiotic administration. Patient compliance and adverse effects related to the antimicrobials were mostly not mentioned. Discussion: While the majority of the case reports and studies presented showed positive outcomes following antimicrobial treatment, there were no nonmedicated controls included, so the relative effect of the antimicrobial agent(s) cannot be evaluated. Conclusions: Although antimicrobials are widely used for the treatment of peri-implant diseases, evidence of their benefit is limited, and randomized, controlled human trials should be initiated where ethically possible. In addition, prospective cohort studies designed to monitor consecutive cases treated using specific treatment protocols are required.

Surgical treatment of peri-implantitis lesions can be performed in cases with considerable pocket formation (larger than 5 mm) and bone loss after the acute infection has been resolved and proper oral hygiene has been instituted. A literature review was conducted to ascertain current knowledge about surgical treatment options for peri-implantitis around commercially pure titanium implants. Recently reported animal studies involving implants with a rough surface indicate that considerable bone regeneration and re-osseointegration can be obtained by using membrane-covered autogenous bone graft particles. However, comparisons of the treatment outcomes in studies involving humans and animals are difficult because of differences in implant type, graft type, and evaluation protocols. In addition, different treatment procedures, including implant surface decontamination methods, have been used. Therefore, further long-term studies in humans involving sufficient numbers of subjects are needed to provide a solid basis for recommendations regarding the surgical treatment of peri-implantitis. Moreover, the encouraging treatment outcomes of regenerative procedures recently revealed in animal experiments and applied in the treatment of peri-implantitis around implants with sandblasted/acid-etched surfaces have not yet been documented for implants with other surfaces, especially turned surfaces. Numerous implant surface decontamination methods have been suggested as part of the surgical treatment of peri-implantitis. Decontamination of affected implants with titanium plasma-sprayed or sandblasted/acid-etched surfaces may most easily and effectively be achieved by applying gauze soaked alternately in chlorhexidine and saline.

Introductory remarks The working group based its discussion on 2 systematic reviews published in 2002, 2 systematic reviews published in 2004 on related topics, and 3 traditional reviews prepared specifically for this consensus workshop (see reference list). After extensive discussion, the previously unpublished reviews were amended where indicated, and consensus was reached that the reviews were both comprehensive and complete in covering the available published literature up to August of 2003. Hence, the papers were accepted and formed the basis for the consensus report on implant survival and complications. Subsequent to the consensus meeting, the quoted literature was updated up to December 2003. For the purpose of clarification and understanding of the evaluated literature, the working group adopted a glossary of terms.