Purpose: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. Materials and methods: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. Results: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. Conclusion: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable. Keywords: diagnostic procedure, implant dentistry, lateral window technique, pterygoid implants, sinus floor elevation, transcrestal sinus floor elevation, zygomatic implants The authors report no conflicts of interest relating to this study.

The aim of the present study was to generate an international and multidisciplinary consensus on the clinical management of implant protrusion into the maxillary sinuses and nasal fossae. A total of 31 experts participated, 23 of whom were experts in implantology (periodontologists, maxillofacial surgeons and implantologists), 6 were otolaryngologists and 2 were radiologists. All the participants were informed of the current scientific knowledge on the topic based on a systematic search of the literature. A list of statements was created and divided into three surveys: one for all participants, one for implant providers and radiologists and one for otolaryngologists and radiologists. A consensus was reached on 15 out of 17 statements. According to the participants, osseointegrated implants protruding radiographically into the maxillary sinus or nasal fossae require as much monitoring and maintenance as implants fully covered by bone. In the event of symptoms of sinusitis, collaboration between implant providers and otolaryngologists is required. Implant removal should be considered only after pharmacological and surgical management of sinusitis have failed. Keywords: consensus, dental implants, maxillary sinus, nasal fossae Conflict-of-interest statement: The authors declare there are no conflicts of interest relating to this study.

Purpose: To investigate whether implant position (adjacent to teeth/implants vs most distal position in the arch) influences the clinical outcomes of short (≤ 6 mm) non-splinted implants.  Materials and methods: A systematic electronic search of human randomised clinical trials and prospective cohort studies was performed using the PubMed, Embase and Cochrane Central Register of Controlled Trials (Central) databases. A manual search of implant-related journals was also performed. A meta-analysis was conducted to compare survival rate, marginal bone loss and prosthetic complications based on implant position.  Results: Overall, 11 studies were included to give a total of 388 non-splinted short implants (269 adjacent, 119 distal) followed up over a period ranging from 12 to 120 months. No significant differences in survival were found when comparing adjacent and distal positioning for both arches, and no significant differences were found for marginal bone loss or prosthetic complications between groups regardless of position.  Conclusions: Short implants supporting single crowns presented similar outcomes when placed in the most distal position in the arch or between adjacent teeth or other implants. Conflict-of-interest statement: The authors do not have any financial interests, either direct or indirect, in the products mentioned in the present study. Keywords: dental implants, occlusal loading, short implants, single crown

The goal of this multicenter randomized controlled study was to evaluate the effectiveness of a newly developed ionic-sonic electric toothbrush in terms of plaque removal and reduction of gingival inflammation. A total of 78 subjects from three dental centers were invited to join the study. They were randomized to receive either a manual toothbrush (control group) or an ionic-sonic electric brush (test group). Full-mouth prophylaxis and oral hygiene instructions based on the stationary bristle technique were provided 1 week prior to the baseline visit. At baseline and at each follow-up appointment, Plaque Index (PI) and Gingival Index (GI) were recorded. In addition, probing depth (PD) and bleeding on probing were recorded at baseline and at the last appointment (week 5). At completion of the study, subjects in the test group were given a questionnaire regarding their satisfaction with the toothbrush. Sixty-four subjects completed the study (control: 28; test: 36). The mean age of the subjects was 36.90 ± 12.19 years. No significant difference between the baseline and 5-week PD was found. Plaque removal efficacy and reduction in gingival inflammation were more significant for the test group at week 2. Both the control and test groups showed statistically significant improvement in PI and GI from baseline to week 5. The ionic-sonic toothbrush was more effective than manual toothbrush after a 1-week application.

Purpose: To investigate the influence of vertical mucosal thickness on marginal bone loss around implants with short and long prosthetic abutments and the marginal bone loss progression rate up to 18 months after prosthetic loading. Materials and methods: Internal hex platform-switched implants were placed equicrestally using a two-stage protocol in the posterior mandible of two groups of patients with different vertical mucosal thickness, thin (≤ 2.0 mm) and thick (> 2.0 mm). Elevated prosthetic abutments of different heights (1 mm or 3 mm) were randomly assigned for single screw-retained crowns in both groups. Mesial and distal marginal bone loss were measured at implant placement (T0) and crown delivery (after 4 months [T1]), and after 6 (T2), 12 (T3) and 18 months (T4) of functional loading. Results: Eighty implants were placed in eighty patients. Three patients dropped out at T2. At T4, 74 out of 77 implants were functioning, resulting in a 96% survival rate. Marginal bone loss (mean ± SE) at T2 was significantly greater in the 1-mm abutment groups (0.61 ± 0.09 mm with thin mucosa; 0.64 ± 0.07 mm with thick mucosa) than in the 3-mm abutment groups (0.32 ± 0.07 mm with thin mucosa; 0.26 ± 0.04 mm with thick mucosa). The marginal bone loss pattern over 18 months of loading showed that the greatest amount of marginal bone loss occurred during the first 6 months of function. Conclusions: Internal hex platform-switched implants placed equicrestally and restored with 1-mm abutments presented greater marginal bone loss than identical implants with 3-mm abutments, with vertical mucosal thickness having no significant influence. Keywords: abutment height, marginal bone loss, platform switching, vertical mucosal thickness Conflict-of-interest statement: The authors have no direct or indirect financial interest in the products listed or information presented in this article.

Alveolar bone resorption and maxillary sinus pneumatization occurring after dental extraction in the posterior region of the maxilla may be problematic when planning implant-supported rehabilitation. Various regenerative options are available, including guided bone regeneration, bone block grafts, and lateral sinus augmentation. These procedures are associated with significant complication rates, high morbidity, increased therapy duration, and high cost. Less invasive approaches, such as transcrestal sinus floor elevation, and using short implants have been proposed in an attempt to reduce these drawbacks. The aim of this study is to analyze available evidence to suggest predictable options and identify minimally invasive management of implant-supported rehabilitation in the posterior maxilla. This article concerns biologic mechanisms regulating new bone formation after maxillary sinus augmentation and examines characteristics of available implants and grafting materials to help the clinician select the most rational and convenient surgical approach according to specific situations.

Insufficient crestal bone is a common feature encountered in the edentulous posterior maxilla due to atrophy of the alveolar ridge and maxillary sinus pneumatization. Numerous surgical techniques, grafting materials, and timing protocols have been proposed for implant-supported rehabilitation of posterior maxillae with limited bone height. In the majority of potential implant sites, residual bone height is less than 8 mm and the clinician has to select either a lateral or transcrestal sinus-elevation technique or placing short implants as the correct surgical option. Nevertheless, guidelines for selecting the best option remains mostly based on the personal experience and skills of the surgeon. The role of sinus anatomy in healing and graft remodeling after sinus floor augmentation is crucial. In addition to the evaluation of residual bone height, the clinician should consider that histologic and clinical outcomes are also influenced by the buccal-palatal bone wall distance. Therefore, three main clinical scenarios may be identified and treated with either a lateral or transcrestal sinus-elevation technique or short implants. This article introduces a new decision tree for a minimally invasive approach based on current evidence to help the clinician safely and predictably manage implant-supported treatment of the atrophic posterior maxilla.

Purpose: Piezoelectric bone surgery was introduced into clinical practice almost 20 years ago as an alternative method for cutting bone in dental surgical procedures, in an attempt to reduce the disadvantages of using conventional rotary instruments. The aim of this Consensus Conference was to evaluate the current evidence concerning the use of piezoelectric surgery in oral surgery and implantology. Materials and methods: Three working groups conducted three meta-analyses with trial sequential analysis, focusing on the use of piezoelectric surgery in impacted mandibular third molar extraction, lateral sinus floor elevation and implant site preparation. The method of preparation of the systematic reviews, based on comprehensive search strategies and following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, was discussed and standardised. Results: Moderate/low evidence suggests that piezoelectric surgery is significantly associated with a more favourable postoperative course (less pain, less trismus) after impacted mandibular third molar extraction than conventional rotary instruments. Moderate evidence suggests that implants inserted with piezoelectric surgery showed improved secondary stability during the early phases of healing compared with those inserted using a drilling technique. Strong/moderate evidence suggests that piezoelectric surgery prolongs the duration of surgery in impacted mandibular third molar extraction, sinus floor elevation and implant site preparation, but it is unclear whether the slight differences in duration of surgery, even if statistically significant, represent a real clinical advantage for either operator or patient. Weak evidence or insufficient data are present to draw definitive conclusions on the other investigated outcomes. Conclusions: Further well-designed trials are needed to fully evaluate the effects of piezoelectric surgery, especially in implant site preparation and sinus floor elevation. Keywords: impacted mandibular third molar extraction, implant site preparation, piezoelectric surgery, sinus augmentation, systematic review

Aims: To evaluate whether piezoelectric bone surgery (PBS) for lateral maxillary sinus floor elevation reduces risk of intraoperative complications, requires prolonged surgical time and improves the survival rate of dental implants in comparison with conventional rotary instruments. Materials and methods: This meta-analysis followed PRISMA guidelines and was registered in the PROSPERO database (CRD42019122972). The PubMed, Embase, Scopus and Open Grey databases were screened for articles published from 1 January 1990 to 31 December 2018. The selection criteria included randomised controlled trials (RCTs) and case-control studies (CCTs) comparing PBS with rotary instruments in lateral sinus augmentation and reporting intraoperative and postoperative outcomes (e.g. sinus membrane perforations, surgical time and implant failure rate). The risk of bias assessment was performed using the Cochrane Collaboration's tool for RCTs. A meta-analysis was performed, and the power of the meta-analytic findings was assessed via trial sequential analysis (TSA). Results: Four RCTs met the inclusion criteria and were included in the review. The meta-analysis showed that, although a lower incidence of membrane tearing occurred when using PBS, the difference between the two groups was not significant. However, the power of evidence for this outcome, as determined by the TSA, was weak. Moreover, there was moderate evidence suggesting that PBS prolongs the surgery duration (mean difference of 3.43 minutes), whilst insufficient data was present to assess if PBS improves the survival rate of implants inserted in augmented sinuses. Conclusions: The power of the evidence was too weak to confirm the above-mentioned findings and further well-designed randomised clinical trials are needed to draw definitive conclusions. Keywords: intraoperative complications, membrane perforation, piezosurgery, sinus floor elevation Conflict-of-interest statement: The authors report no conflicts of interest related to this study. This study received no external funding.