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Proceedings of the fifth ITI Consensus Conference

Introduction and Participants

Table of Contents

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Stephen Chen, David Cochran, Daniel Buser
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Conference Participants

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Group 1: Contemporary Surgical and Radiographic Techniques in Implant Dentistry

Horizontal Ridge Augmentation in Conjunction with or Prior to Implant Placement in the Anterior Maxilla: A Systematic Review

Ulrike Kuchler, Thomas von Arx

Purpose: To systematically review clinical studies examining the survival and success rates of implants in horizontal ridge augmentation, either prior to or in conjunction with implant placement in the anterior maxilla.

Materials and Methods: A literature search was undertaken up to September 2012 including clinical studies in English with ≥ 10 consecutively treated patients and a mean follow-up of at least 12 months. Two reviewers screened the pertinent articles and extracted the data. Key words focused on the outcome parameters (implant success, implant survival, horizontal bone gain, and intra- and postoperative complications) in studies utilizing either a simultaneous approach (ridge augmentation performed at the time of implant placement) or a staged approach (ridge augmentation performed prior to implant placement) were analyzed.

Results: A total of 13 studies met the inclusion criteria, with 2 studies in the simultaneous group and 11 studies in the staged group. In the simultaneous group, survival rates of implants were 100% in both studies, with one study also reporting a 100% implant success rate. No data on horizontal bone gain were available. In the staged group, success rates of implants placed in horizontally augmented ridges ranged from 96.8% to 100% (two studies), and survival rates ranged from 93.5% to 100% (five studies). However, follow-up periods differed widely (up to 4.1 years). Mean horizontal bone gain determined at reentry (implant placement) ranged from 3.4 to 5.0 mm with large overall variations (0 to 9.8 mm, five studies). Intraoperative complications were not reported. Postsurgical complications included mainly mucosal dehiscences (five studies), and, occasionally, complete failures of block grafts were described in one study.

Conclusions: Staged and simultaneous augmentation procedures in the anterior maxilla are both associated with high implant success and survival rates. The level of evidence, however, is better for the staged approach than for the simultaneous one.

Int J Oral Maxillofac Implants 2014;29(suppl):14–24. doi: 10.11607/ jomi.2014suppl.g1.1

Key words: anterior maxilla, bone gain, esthetic zone, horizontal ridge augmentation, implant success, implant survival, surgical complications

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Computer Technology Applications in Surgical Implant Dentistry: A Systematic Review

Ali Tahmaseb, Daniel Wismeijer, Wim Coucke, Wiebe Derksen

Purpose: To assess the literature on the accuracy and clinical performance of static computer-assisted implant surgery in implant dentistry.

Materials and Methods: Electronic and manual literature searches were applied to collect information about (1) the accuracy and (2) clinical performance of static computer-assisted implant systems. Meta-regression analysis was performed to summarize the accuracy studies. Failure/complication rates were investigated using a generalized linear mixed model for binary outcomes and a logit link to model implant failure rate.

Results: From 2,359 articles, 14 survival and 24 accuracy studies were included in this systematic review. Nine different static image guidance systems were involved. The meta-analysis of the accuracy (24 clinical and preclinical studies) revealed a total mean error of 1.12 mm (maximum of 4.5 mm) at the entry point measured in 1,530 implants and 1.39 mm at the apex (maximum of 7.1 mm) measured in 1,465 implants. For the 14 included survival studies (total of 1,941 implants) using static computer-assisted implant dentistry, the mean failure rate was 2.7% (0% to 10%) after an observation period of at least 12 months. In 36.4% of the treated cases, intraoperative or prosthetic complications were reported, which included: template fractures during the surgery, change of plan because of factors such as limited primary implant stability, need for additional grafting procedures, prosthetic screw loosening, prosthetic misfit, and prosthesis fracture.

Conclusion: Different levels of quantity and quality of evidence were available for static computer-assisted implant placement, with tight-fitting high implant survival rates after only 12 months of observation in different indications achieving a variable level of accuracy. Future long-term clinical data are necessary to identify clinical indications; detect accuracy; assess risk; and justify additional radiation doses, effort, and costs associated with computer-assisted implant surgery.

Int J Oral Maxillofac Implants 2014;29 (suppl):25–42. doi: 10.11607/jomi.2014suppl.g1.2

Key words: guided surgery, dental implants, computer planning

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Systematic Review on Success of Narrow-Diameter Dental Implants

Marc O. Klein, Eik Schiegnitz, Bilal Al-Nawas


Purpose: The aim of this systematic review was to determine the survival and success rates of narrow- diameter implants (NDI) in different clinical indications compared to standard diameter implants.

Materials and Methods: Implant diameters were categorized into categories 1 (< 3.0 mm), 2 (3.00 to 3.25 mm), and 3 (3.30 to 3.50 mm). Retro- and prospective studies with more than 10 patients and a follow-up time of 1 year or more were included.

Results: A literature search from 1995 to 2012 revealed 10 articles reporting on implant diameters < 3 mm (Category 1), 12 articles reporting on implant diameters 3 to 3.25 mm (Category 2), and 16 articles reporting on implant diameters 3.3 to 3.5 mm (Category 3). The quality of the studies was mostly low with a high risk of bias. Dental implants < 3.0 mm (mini-implants) were one-piece in the edentulous arch and non-loaded frontal region with survival rates between 90.9% and 100%. For dental implants with a diameter between 3.0 and 3.25 mm, most were two-piece implants inserted into narrow tooth gaps without loading and in the frontal region. Survival rates for these implants ranged between 93.8% and 100%. Implants of 3.3 to 3.5 mm were two-piece and were also used in the load-bearing posterior region. Survival rates were between 88.9% and 100%, and success rates ranged between 91.4% and 97.6%. A meta-analysis was conducted for NDI (3.3 to 3.5 mm), which showed no statistically significant difference in implant survival compared to conventional implants with an odds ratio of 1.16 (0.7 to 1.69).

Conclusions: Narrow-diameter implants of 3.3 to 3.5 mm are well documented in all indications including load-bearing posterior regions. Smaller implants of 3.0 to 3.25 mm in diameter are well documented only for single-tooth non-load-bearing regions. Mini-implants < 3.0 mm in diameter are only documented for the edentulous arch and single-tooth non-load-bearing regions, and success rates are not available. Long-term follow-up times > 1 year and information on patient specific risk factors (bruxism, restoration type) are also missing.

Int J Oral Maxillofac Implants 2014;29 (suppl):43–54. doi: 10.11607/jomi.2014suppl.g1.3

Key words: dental implant, diameter, mini-implants, small diameter, systematic review

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Cone Beam Computed Tomography in Implant Dentistry: A Systematic Review Focusing on Guidelines, Indications, and Radiation Dose Risks

Michael M. Bornstein, William C. Scarfe, Vida M. Vaughn, Reinhilde Jacobs

Purpose: The aim of the paper is to identify, review, analyze, and summarize available evidence in three areas on the use of cross-sectional imaging, specifically maxillofacial cone beam computed tomography (CBCT) in pre- and postoperative dental implant therapy: (1) Available clinical use guidelines, (2) indications and contraindications for use, and (3) assessment of associated radiation dose risk.

Materials and Methods: Three focused questions were developed to address the aims. A systematic literature review was performed using a PICO-based search strategy based on MeSH key words specific to each focused question of English-language publications indexed in the MEDLINE database retrospectively from October 31, 2012. These results were supplemented by a hand search and gray literature search.

Results: Twelve publications were identified providing guidelines for the use of cross-sectional radiography, particularly CBCT imaging, for the pre- and/or postoperative assessment of potential dental implant sites. The publications discovered by the PICO strategy (43 articles), hand (12), and gray literature searches (1) for the second focus question regarding indications and contraindications for CBCT use in implant dentistry were either cohort or case-controlled studies. For the third question on the assessment of associated radiation dose risk, a total of 22 articles were included. Publication characteristics and themes were summarized in tabular format.

Conclusions: The reported indications for CBCT use in implant dentistry vary from preoperative analysis regarding specific anatomic considerations, site development using grafts, and computer-assisted treatment planning to postoperative evaluation focusing on complications due to damage of neurovascular structures. Effective doses for different CBCT devices exhibit a wide range with the lowest dose being almost 100 times less than the highest dose. Significant dose reduction can be achieved by adjusting operating parameters, including exposure factors and reducing the field of view (FOV) to the actual region of interest.

Int J Oral Maxillofac Implants 2014;29 (suppl):55–77. doi: 10.11607/jomi.2014suppl.g1.4

Key words: cone beam computed tomography, contraindications, dental implants, effective dose, guidelines, indications, radiation dose.

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Consensus Statements and Recommended Clinical Procedures Regarding Contemporary Surgical and Radiographic Techniques in Implant Dentistry

Michael M. Bornstein, Bilal Al-Nawas, Ulrike Kuchler, Ali Tahmaseb
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Group 2: Restorative Materials and Techniques for Implant Dentistry

Clinical Performance of Screw- Versus Cement-Retained Fixed Implant-Supported Reconstructions— A Systematic Review

Julia-Gabriela Wittneben, Christopher Millen, Urs Brägger

Purpose: To assess the survival outcomes and reported complications of screw- and cement-retained fixed reconstructions supported on dental implants.

Materials and Methods: A Medline (PubMed), Embase, and Cochrane electronic database search from 2000 to September 2012 using MeSH and free-text terms was conducted. Selected inclusion and exclusion criteria guided the search. All studies were first reviewed by abstract and subsequently by full-text reading by two examiners independently. Data were extracted by two examiners and statistically analyzed using a random effects Poisson regression.

Results: From 4,324 abstracts, 321 full-text articles were reviewed. Seventy-three articles were found to qualify for inclusion. Five-year survival rates of 96.03% (95% confidence interval [CI]: 93.85% to 97.43%) and 95.55% (95% CI: 92.96% to 97.19%) were calculated for cemented and screw-retained reconstructions, respectively (P = .69). Comparison of cement and screw retention showed no difference when grouped as single crowns (I-SC) (P = .10) or fixed partial dentures (I-FDP) (P = .49). The 5-year survival rate for screw-retained full-arch reconstructions was 96.71% (95% CI: 93.66% to 98.31). All-ceramic reconstruction material exhibited a significantly higher failure rate than porcelain-fused-to-metal (PFM) in cemented reconstructions (P = .01) but not when comparing screw-retained reconstructions (P = .66). Technical and biologic complications demonstrating a statistically significant difference included loss of retention (P ≤ .01), abutment loosening (P ≤ .01), porcelain fracture and/or chipping (P = .02), presence of fistula/suppuration (P ≤ .001), total technical events (P = .03), and total biologic events (P = .02).

Conclusions: Although no statistical difference was found between cement- and screw-retained reconstructions for survival or failure rates, screw-retained reconstructions exhibited fewer technical and biologic complications overall. There were no statistically significant differences between the failure rates of the different reconstruction types (I-SCs, I-FDPs, full-arch I-FDPs) or abutment materials (titanium, gold, ceramic). The failure rate of cemented reconstructions was not influenced by the choice of a specific cement, though cement type did influence loss of retention.

Int J Oral Maxillofac Implants 2014;29(suppl):84–98. doi: 10.11607/jomi.2014suppl.g2.1

Key words: cement, dental implants, fixed dental prostheses, prosthodontics, screw, single crown

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Systematic Review of the Survival Rate and Incidence of Biologic, Technical, and Esthetic Complications of Single Implant Abutments Supporting Fixed Prostheses

Anja Zembic, Sunjai Kim, Marcel Zwahlen, J. Robert Kelly

Purpose: To assess the 5-year survival rate and number of technical, biologic, and esthetic complications involving implant abutments.

Materials and Methods: Electronic (Medline) and hand searches were performed to assess studies on metal and ceramic implant abutments. Relevant data from a previous review were included. Two reviewers independently extracted the data. Failure and complication rates were analyzed, and estimates of 5-year survival proportions were calculated from the relationship between event rate and survival function. Multivariable robust Poisson regression was used to compare abutment characteristics.

Results: The search yielded 1,558 titles and 274 abstracts. Twenty-four studies were selected for data analysis. The survival rate for ceramic abutments was 97.5% (95% confidence interval [CI]): 89.6% to 99.4%) and 97.6% (95% CI: 96.2% to 98.5%) for metal abutments. The overall 5-year rate for technical complications was 11.8% (95% CI: 8.5% to 16.3%), 8.9% (95% CI: 4.3% to 17.7%) for ceramic and 12.0% (95% CI: 8.5% to 16.8%) for metal abutments. Biologic complications occurred with an overall rate of 6.4% (95% CI: 3.3% to 12.0%), 10.4% (95% CI: 1.9% to 46.7%) for ceramic, and 6.1% (95% CI: 3.1% to 12.0%) for metal abutments.

Conclusions: The present meta-analysis on single-implant prostheses presents high survival rates of single implants, abutments, and prostheses after 5 years of function. No differences were found for the survival and failure rates of ceramic and metal abutments. No significant differences were found for technical, biologic, and esthetic complications of internally and externally connected abutments.

Int J Oral Maxillofac Implants 2014;29(suppl):99–116. doi: 10.11607/jomi.2014suppl.g2.2

Key words: biologic complications, ceramics, complication rates, esthetic complications, failures, implant abutments, implant prostheses, metal, survival, systematic review, technical complications, titanium, zirconia

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CAD/CAM Technology for Implant Abutments, Crowns, and Superstructures

Theodoros Kapos, Christopher Evans

Purpose: The aim of this systematic review was to compare implant prostheses fabricated by computer- assisted design and computer-assisted manufacturing (CAD/CAM) with conventionally fabricated implant prostheses when assessing esthetics, complications (biologic and mechanical), patient satisfaction, and economic factors.

Materials and Methods: Electronic searches for clinical studies focusing on long-term follow-up were performed using the PubMed and Ovid search engines. Concentrating on the restorative aspect of the CAD/CAM technology applicable to implant dentistry, pertinent literature was divided into articles related to implant abutments, crowns, and frameworks.

Results: A total of 18 articles satisfied the inclusion criteria. Two articles reported on CAD/CAM crowns, six on abutments, and 10 on implant- supported CAD/CAM frameworks. The mean survival rate for CAD/CAM crowns was 98.85% and for CAD/CAM abutments 100%. The mean survival rate for CAD/CAM frameworks was 95.98%.

Conclusion: Based on the current literature, CAD/CAM fabricated crowns, abutments, and frameworks demonstrate survival rates comparable to conventionally fabricated prostheses. Implant survival appears unaffected by fabrication technique. Since this technology encompasses several manufacturing variations, a new definition might be necessary to accurately define the processes under which the CAD/CAM restorations are fabricated. “Complete CAD/CAM product” where no or minimal manual intervention is employed could be a possible term.

Int J Oral Maxillofac Implants 2014;29(suppl):117–136. doi: 10.11607/jomi.2014suppl.g2.3

Key words: abutment, CAD/CAM, crown, dental prosthesis implant-supported, implant-supported framework, implant superstructure

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Consensus Statements and Recommended Clinical Procedures Regarding Restorative Materials and Techniques for Implant Dentistry

Daniel Wismeijer, Urs Brägger, Christopher Evans, Theodoros Kapos, J. Robert Kelly, Christopher Millen, Julia-Gabriela Wittneben, Anja Zembic, Thomas D. Taylor
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Group 3: Optimizing Esthetic Outcomes in Implant Dentistry

The Influence of Restorative Procedures on Esthetic Outcomes in Implant Dentistry: A Systematic Review

William C. Martin, Adrien Pollini, Dean Morton

Purpose: The objectives of this review were to (1) identify if prosthodontic parameters influence the esthetic outcome of implant-supported restorations and (2) make clinically relevant recommendations based upon the findings.

Materials and Methods: Electronic and manual searches of dental literature were performed to collect information on esthetic outcomes based on objective criteria. The prosthodontic parameters included optimal three-dimensional implant position, the utilization of provisional restorations, the timing of provisional restoration with regard to implant placement, the choice of prosthodontic platform size and form, the abutment and definitive restoration material, and the mode of prosthesis retention. Regions including maxillary and mandibular anterior teeth and premolars were considered. All levels of evidence, including case studies, were accepted.

Results: From 472 titles, 152 full-text articles were evaluated and 58 records included for data extraction (15 randomized controlled trials, 6 cohort studies, and 37 case series studies). Considerable heterogeneity in study design was found. A meta-analysis of controlled studies was not possible. It was consistently reported that facial malpositioning of implants increases the likelihood of mucosal recession. No studies directly compared esthetic outcomes associated with the use or non-use of provisional restorations. The literature contains a greater number of case series studies evaluating esthetic outcomes for protocols including, rather than excluding, provisional restorations. It is not possible to identify any significant variation in esthetic outcomes based on the character of the abutment platform from the current literature. Based on the findings, no significant difference can be established between all-ceramic and metal-ceramic prostheses with regard to esthetic indices over short observation periods. No firm conclusions relating esthetic benefits for cement in comparison to screw retention can be identified.

Conclusions: There is a need for RCTs comparing accepted procedures in routine practice. The utilization of provisional restorations remains strongly recommended in order to trial the planned definitive restoration, to facilitate maturation of healing tissues and for patient convenience. Implant positioning according to the planned prosthesis remains a requirement to achieve a long-lasting esthetic outcome. The majority of studies reported on single-tooth replacement, and many of the outcomes may not be relevant or applicable to the large number of esthetic indications involving more than one tooth.

Int J Oral Maxillofac Implants 2014;29(suppl):142–154. doi: 10.11607/jomi.2014suppl.g3.1

Key words: abutment material, final restoration material, implant position, implant restoration mode of retention, implant-supported provisional restoration, restorative implant platform size and form, timing of provisional restoration

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Soft Tissue Augmentation Procedures for Mucogingival Defects in Esthetic Sites

Robert A. Levine, Guy Huynh-Ba, David L. Cochran

Purpose: This systematic review was performed to address the focus question: “In adult patients with soft tissue deficiencies around maxillary anterior implants, what is the effect on esthetic outcomes when a soft tissue procedure is performed?” In addition, this paper reviews the importance of presurgical esthetic risk assessment (ERA) starting with comprehensive team case planning prior to surgical intervention and a restorative-driven approach.

Materials and Methods: A thorough Medline database search performed on related MeSH terms yielded 1,532 titles and selected abstracts that were independently screened. Out of the 351 abstracts selected, 123 full-text articles were obtained for further evaluation. At each level, any disagreements were discussed until a consensus was reached.

Results: A total of 18 studies were included in this systematic review of esthetic outcomes following soft tissue procedures around implants with soft tissue deficiencies. A preliminary analysis of the included studies showed that the vast majority were case series studies with most not providing objective outcomes of their results. Moreover, only one randomized controlled trial was identified. Therefore, quantitative data analysis and subsequent meta-analysis could not be performed. The included studies were grouped according to the intervention on the peri-implant soft tissue performed and six groups were identified. The periodontal procedures performed around dental implants gave initial good results from the inflammation involved in wound healing, but in virtually all cases significant recession occurred as healing resolved and the tissues matured.

Conclusions: Although success of implant therapy is similar in the anterior maxilla and other areas of the mouth, the majority of studies evaluating this therapy in the esthetic zone are lacking literature support, few in number, devoid of long-term follow-up and number of patients, and are subject to inclusion bias. The use of the ERA tool for all esthetic zone cases can benefit both the clinician and the patient to avoid any miscommunication and problems of expectation upon completion. All the available knowledge on this topic, including the approaches described in this paper, is based on a very limited literature support and thus should be addressed with caution. These concerns should encourage long-term good clinical trials for better assessment of those issues.

Int J Oral Maxillofac Implants 2014;29(suppl):155–185. doi: 10.11607/jomi.2014suppl.g3.2

Key words: keratinized mucosa, mucogingival surgery, peri-implant mucosa, recession

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Esthetic Outcomes Following Immediate and Early Implant Placement in the Anterior Maxilla—A Systematic Review

Stephen T. Chen, Daniel Buser

Purpose: The objectives of this systematic review are (1) to quantitatively estimate the esthetic outcomes of implants placed in postextraction sites, and (2) to evaluate the influence of simultaneous bone augmentation procedures on these outcomes.

Materials and Methods: Electronic and manual searches of the dental literature were performed to collect information on esthetic outcomes based on objective criteria with implants placed after extraction of maxillary anterior and premolar teeth. All levels of evidence were accepted (case series studies required a minimum of 5 cases).

Results: From 1,686 titles, 114 full-text articles were evaluated and 50 records included for data extraction. The included studies reported on single-tooth implants adjacent to natural teeth, with no studies on multiple missing teeth identified (6 randomized controlled trials, 6 cohort studies, 5 cross-sectional studies, and 33 case series studies). Considerable heterogeneity in study design was found. A meta-analysis of controlled studies was not possible. The available evidence suggests that esthetic outcomes, determined by esthetic indices (predominantly the pink esthetic score) and positional changes of the peri-implant mucosa, may be achieved for single-tooth implants placed after tooth extraction. Immediate (type 1) implant placement, however, is associated with a greater variability in outcomes and a higher frequency of recession of > 1 mm of the midfacial mucosa (eight studies; range 9% to 41% and median 26% of sites, 1 to 3 years after placement) compared to early (type 2 and type 3) implant placement (2 studies; no sites with recession > 1 mm). In two retrospective studies of immediate (type 1) implant placement with bone graft, the facial bone wall was not detectable on cone beam CT in 36% and 57% of sites. These sites had more recession of the midfacial mucosa compared to sites with detectable facial bone. Two studies of early implant placement (types 2 and 3) combined with simultaneous bone augmentation with GBR (contour augmentation) demonstrated a high frequency (above 90%) of facial bone wall visible on CBCT. Recent studies of immediate (type 1) placement imposed specific selection criteria, including thick tissue biotype and an intact facial socket wall, to reduce esthetic risk. There were no specific selection criteria for early (type 2 and type 3) implant placement.

Conclusions: Acceptable esthetic outcomes may be achieved with implants placed after extraction of teeth in the maxillary anterior and premolar areas of the dentition. Recession of the midfacial mucosa is a risk with immediate (type 1) placement. Further research is needed to investigate the most suitable biomaterials to reconstruct the facial bone and the relationship between long-term mucosal stability and presence/absence of the facial bone, the thickness of the facial bone, and the position of the facial bone crest.

Int J Oral Maxillofac Implants 2014;29(suppl):186–215. doi: 10.11607/jomi.2014suppl.g3.3

Key words: bone grafts, CBCT, contour augmentation, early implant placement, esthetics, GBR, immediate implant

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Consensus Statements and Recommended Clinical Procedures Regarding Optimizing Esthetic Outcomes in Implant Dentistry

Dean Morton, Stephen T. Chen, William C. Martin, Robert A. Levine, Daniel Buser
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Group 4: Implant Loading Protocols

Loading Protocols for Single-Implant Crowns: A Systematic Review and Meta-Analysis

Goran I. Benic, Javier Mir-Mari, Christoph H.F. Hämmerle

Purpose: To test whether or not immediate loading of single-implant crowns renders different results from early and conventional loading with respect to implant survival, marginal bone loss, stability of peri-implant soft tissue, esthetics, and patient satisfaction.

Materials and Methods: An electronic search of Medline and Embase databases including studies published prior to August 1, 2012, was performed and complemented by a manual search. Randomized controlled trials (RCTs) comparing different loading protocols of single- implant crowns with a follow-up after restoration of at least 1 year were included. A meta-analysis yielded odds ratios (OR) and standardized mean differences (SMD) together with the corresponding 95% confidence intervals (95% CI).

Results: The search provided 10 RCTs comparing immediate and conventional loading and 1 RCT comparing immediate and early loading. When assessing the implant survival at 1 year of loading, the meta-analysis of 10 studies found no significant differences between immediate and conventional loading (OR = 0.75; 95% CI: 0.32 to 1.76). The total difference of marginal bone loss during the first year of function between immediate and conventional loading protocols in 7 RCTs did not reach statistical significance (SMD = –0.05 mm; 95% CI: –0.41 to 0.31 mm). There were no significant differences between immediate and conventional loading regarding implant survival and marginal bone loss at 2, 3, and 5 years of loading. Three RCTs comparing the change of papilla level between immediate and conventional loading identified no significant differences. One study investigated the recession of the buccal mucosa after implant placement and found significantly inferior soft tissue loss for immediate loading as compared to conventional loading. Two RCTs investigated the recession of the buccal mucosa after insertion of the definitive crown and found no differences between immediate and conventional loading. The esthetics and the patient satisfaction were assessed in one and two RCTs, respectively. There were no significant differences between immediate and conventional loading.

Conclusions: Immediately and conventionally loaded single-implant crowns are equally successful regarding implant survival and marginal bone loss. This conclusion is primarily derived from studies evaluating implants inserted with a torque ≥ 20 to 45 Ncm or an implant stability quotient (ISQ) ≥ 60 to 65 and with no need for simultaneous bone augmentation. Immediately and conventionally loaded implants do not appear to differently affect the papilla height during the first year of loading. Due to the heterogeneity of the time point of baseline measurements and contradictory findings in the studies, it is difficult to draw clear conclusions regarding the recession of the buccal mucosa. With respect to the assessment of esthetic outcomes and patient satisfaction, the data available remain inconclusive.

Int J Oral Maxillofac Implants 2014;29(suppl):222–238. doi: 10.11607/jomi.2014suppl.g4.1

Key words: bone, crowns, dental implants, early, esthetics, function, immediate, loading, meta-analysis, papilla, restoration, satisfaction, soft tissue, survival, systematic review

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Implant Loading Protocols for Partially Edentulous Patients with Extended Edentulous Sites— A Systematic Review and Meta-Analysis

Alexander Schrott, Martine Riggi-Heiniger, Katsuichiro Maruo, German O. Gallucci

Purpose: The aim of this study was to systematically review the evidence for immediate implant loading in partially edentulous patients with extended edentulous sites and evaluate potential treatment modifiers.

Materials and Methods: An electronic search was performed in Medline, Embase, and Central to identify studies investigating the outcome of implants subjected to immediate loading (IL) (less than 1 week), early loading (EL) (1 week to 2 months), or conventional loading (CL) (more than 2 months) with implant-supported fixed dental prostheses (IFDPs) in partially edentulous patients with extended edentulous sites, ie, at least two adjacent teeth are missing. Only human studies with at least 10 cases and a minimum follow-up time of 12 months, reporting on solid-screw–type implants with rough surfaces and a diameter of at least 3 mm, were included. Weighted means of implant survival rates and risk ratios for implant survival at 1 year using meta-analytic tools were calculated to perform the following comparisons: IL vs EL, IL vs CL, and IL in the maxilla vs mandible. Noncomparative studies reporting on IL and EL protocols were summarized through descriptive methods.

Results: The search provided 3,872 titles, 837 abstracts, and 444 full-text articles. A total of 24 publications that comprised six comparative studies (five randomized controlled trials, one nonrandomized controlled trial) and 18 noncomparative studies were included for analysis. The comparison of weighted mean survival rates revealed no statistically significant difference between IL (97.9%) and EL (97.8%, P = .9405), and between IL (100%) and CL (99.3%, P = .3280). Meta-analysis showed no statistically significant difference in implant survival at 1 year between IL and EL (RR 0.90; 95% CI 0.30, 2.70; P = .502). A meta-analysis comparing IL and CL could not be performed due to the low number of failures. No statistically significant difference was found for IL implants placed in the maxilla vs the mandible (RR 1.55; 95% CI 0.49, 4.84; P > .05). Due to the small number of IL implants placed in the anterior, a comparison between implant survival in anterior vs posterior zones was not performed. Treatment modifiers were bone quality, primary stability, insertion torque, ISQ values, implant length, the need for substantial bone augmentation, the timing of implant placement, and the presence of parafunctional and smoking habits.

Conclusions: IL presents similar implant survival rates as EL or CL for partially edentulous patients with extended edentulous sites in the posterior zone, as long as strict inclusion/exclusion criteria are followed. There is a lack of evidence for IL of multiple implants in the anterior zone of partially edentulous patients. Preliminary evidence suggests that IL may be equally successful in either the maxilla or mandible. Further research is needed before IL in partially edentulous patients with extended edentulous sites can be recommended in everyday practice.

Int J Oral Maxillofac Implants 2014;29(suppl):239–255. doi: 10.11607/jomi.2014suppl.g4.2

Key words: conventional loading, dental implants, early loading, fixed dental prostheses, immediate loading, meta-analysis, partial edentulism, systematic review

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Implant Loading Protocols for Edentulous Patients with Fixed Prostheses: A Systematic Review and Meta-Analysis

Panos Papaspyridakos, Chun-Jung Chen, Sung-Kiang Chuang, Hans-Peter Weber

Purpose: To report on the effect of immediate implant loading with fixed prostheses compared to early and conventional loading on implant and prosthesis survival, failure, and complications.

Materials and Methods: An electronic and manual search was conducted to identify randomized controlled clinical trials (RCTs) as well as prospective and retrospective studies involving rough surface implants and implant fixed complete dental prostheses for edentulous patients.

Results: The 62 studies that fulfilled the inclusion criteria featured 4 RCTs, 2 prospective case-control studies, 34 prospective cohort studies, and 22 retrospective cohort studies. These studies yielded data from 2,695 patients (2,757 edentulous arches) with 13,653 implants. Studies were grouped according to the loading protocol applied; 45 studies reported on immediate loading, 8 on early loading, and 11 on conventional loading. For the immediate loading protocol with flap surgery, the implant and prosthesis survival rates ranged from 90.1% to 100% and 93.75% to 100%, respectively (range of follow-up, 1 to 10 years). When immediate loading was combined with guided flapless implant placement, the implant survival rates ranged from 90% to 99.4%. For the early loading protocol, the implant and prosthesis survival rates ranged from 94.74% to 100% and 93.75% to 100%, respectively (range of follow-up, 1 to 10 years). For the conventional loading protocol, the implant and prosthesis survival rates ranged from 94.95% to 100% and 87.5% to 100%, respectively (range of follow-up, 2 to 15 years). No difference was identified between maxilla and mandible.

Conclusions: When selecting cases carefully and using dental implants with a rough surface, immediate loading with fixed prostheses in edentulous patients results in similar implant and prosthesis survival and failure rates as early and conventional loading. For immediate loading, most of the studies recommended a minimal insertion torque of 30 Ncm. The estimated 1-year implant survival was above 99% with all three loading protocols. Caution is necessary when interpreting these results, as there are many confounding factors that affect treatment outcomes with each of the loading protocols.

Int J Oral Maxillofac Implants 2014;29(suppl):256–270. doi: 10.11607/jomi.2014suppl.g4.3

Key words: dental implants, edentulous patients, fixed prosthesis, immediate loading, loading protocols

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Loading Protocols for Implant-Supported Overdentures in the Edentulous Jaw: A Systematic Review and Meta-Analysis

Martin Schimmel, Murali Srinivasan, François R. Herrmann, Frauke Müller

Purpose: High survival rates have frequently been reported for immediately loaded implants. The aim of this systematic review was to compare immediately loaded with early and conventional loaded implants for overdenture treatment with regard to their 1-year survival rates.

Materials and Methods: Systematic database (Medline, Embase, CENTRAL) and hand searches were performed to identify prospective studies reporting on loading protocols for two-piece implants with micro-rough surfaces and diameters > 3 mm. Studies were grouped according to loading protocol, jaw, number of implants per jaw, and splinting. Meta- analyses of comparative reports were performed based on the calculated risk difference (RD). Descriptive analyses included the remainder prospective studies. Two investigators extracted the data independently. Kappa statistics served to evaluate the inter-investigator agreement.

Results: Of the 3,142 identified articles, 58 were included for data extraction. They comprised 11 studies comparing loading protocols as well as a further 47 prospective reports. Comparative studies were only available for mandibular overdentures. The meta-analysis revealed a statistical tendency to support conventional over immediate loading (RD: –0.03, 95% confidence interval: –0.06, 0.00). The descriptive analysis of studies with lower evidence demonstrated partially contradictory findings. There, reported survival rates for immediately loaded implants lay between 81.6% and 100%, but depended on the number of implants placed. Most investigators preferred verifying an initial high insertion torque (≥ 35 Ncm) or ISQ value (≥ 60) before considering an implant for an immediate or early loading protocol.

Conclusions: Although all three loading protocols provide high survival rates, early and conventional loading protocols are still better documented than immediate loading and seem to result in fewer implant failures during the first year. Only a few prospective case series are available to document immediate loading of implants supporting an overdenture in the edentulous maxilla.

Int J Oral Maxillofac Implants 2014;29(suppl):271–286. doi: 10.11607/jomi.2014suppl.g4.4

Key words: dental implants, edentulism, loading protocol, meta-analysis, overdenture, systematic review

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Consensus Statements and Clinical Recommendations for Implant Loading Protocols

German O. Gallucci, Goran I. Benic, Steven E. Eckert, Panos Papaspyridakos, Martin Schimmel, Alexander Schrott, Hans-Peter Weber
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Group 5: Prevention and Management of Biologic and Technical Implant Complications

The Effects of Anti-infective Preventive Measures on the Occurrence of Biologic Implant Complications and Implant Loss: A Systematic Review

Giovanni E. Salvi, Nicola U. Zitzmann

Purpose: To systematically appraise whether anti-infective protocols are effective in preventing biologic
implant complications and implant loss after a mean observation period ≥ 10 years after loading.

Materials and Methods: An electronic search of Medline via PubMed and Embase via Ovid databases complemented by manual search was conducted up to October 31, 2012. Studies were included provided that they were published in English, German, French, or Italian, and conducted on ≥ 20 partially and fully edentulous patients with dental implants and regular (≥ 1?/year) supportive periodontal therapy (SPT) over a mean observation period ≥ 10 years. Assessment of the identified studies and data extraction were performed independently by two reviewers. Authors were contacted if required. Collected data were reported by descriptive methods.

Results: The initial electronic search resulted in the identification of 994 titles from Medline via PubMed and
531 titles from Embase via Ovid databases, respectively. After elimination of duplicate titles and exclusion
of 60 full-text articles, 143 articles were analyzed, resulting in 15 studies eligible for qualitative analysis.
The implant survival rate ranged from 85.7% to 99.2% after a mean observation period ≥ 10 years. One
comparative study assessed the effects of regular SPT on the occurrence of biologic complications and implant loss. Overall, regular diagnosis and implementation of anti-infective therapeutic protocols were effective in the management of biological complications and prevention of implant loss. Residual probing depths at the end of active periodontal therapy and development of reinfection during supportive periodontal therapy (SPT) represented a significant risk for the onset of peri-implantitis and implant loss. Comparative studies indicated that implant survival and success rates were lower in periodontally compromised vs noncompromised patients.

Conclusions: In order to achieve high long-term survival and success rates of dental implants and their
restorations, enrollment in regular SPT including anti-infective preventive measures should be implemented.

Therapy of peri-implant mucositis should be considered as a preventive measure for the onset of peri-implantitis.Completion of active periodontal therapy should precede implant placement in periodontally compromised patients.

Int J Oral Maxillofac Implants 2014;29(suppl):292–307. doi: 10.11607/jomi.2014suppl.g5.1

Key words: bone loss, complication, dental implants, implant loss, implant survival, peri-implantitis,
prevention, prophylaxis, supportive periodontal therapy

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Improvements in Implant Dentistry over the Last Decade: Comparison of Survival and Complication Rates in Older and Newer Publications

Bjarni E. Pjetursson, Asgeir G. Asgeirsson, Marcel Zwahlen, Irena Sailer

Purpose: The objective of this systematic review was to assess and compare the survival and complication
rates of implant-supported prostheses reported in studies published in the year 2000 and before, to those
reported in studies published after the year 2000.

Materials and Methods: Three electronic searches complemented by manual searching were conducted to identify 139 prospective and retrospective studies on implant-supported prostheses. The included studies were divided in two groups: a group of 31 older studies published in the year 2000 or before, and a group of 108 newer studies published after the year 2000. Survival and complication rates were calculated using Poisson regression models, and multivariable robust Poisson regression was used to formally compare the outcomes of older and newer studies.

Results: The 5-year survival rate of implant-supported prostheses was significantly increased in newer studies compared with older studies. The overall survival rate increased from 93.5% to 97.1%. The survival rate for cemented prostheses increased from 95.2% to 97.9%; for screw-retained reconstruction, from 77.6% to 96.8%; for implant-supported single crowns, from 92.6% to 97.2%; and for implant-supported fixed dental prostheses (FDPs), from 93.5% to 96.4%. The incidence of esthetic complications decreased in more recent studies compared with older ones, but the incidence of biologic complications was similar. The results for technical complications were inconsistent. There was a significant reduction in abutment or screw loosening by implant-supported FDPs. On the other hand, the total number of technical complications and the incidence of fracture of the veneering material was significantly increased in the newer studies. To explain the increased rate of complications, minor complications are probably reported in more detail in the newer publications.

Conclusions: The results of the present systematic review demonstrated a positive learning curve in implant dentistry, represented in higher survival rates and lower complication rates reported in more recent clinical studies. The incidence of esthetic, biologic, and technical complications, however, is still high. Hence, it is important to identify these complications and their etiology to make implant treatment even more predictable in the future.

Int J Oral Maxillofac Implants 2014;29(suppl):308–324. doi: 10.11607/jomi.2014suppl.g5.2

Key words: biologic complications, dental implants, esthetic complications, failures, fixed dental prosthesis,
implant dentistry, marginal bone loss, single crowns, survival, success, systematic review, technical complications

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The Therapy of Peri-implantitis: A Systematic Review

Lisa J. A. Heitz-Mayfield, Andrea Mombelli

Purpose: To evaluate the success of treatments aimed at the resolution of peri-implantitis in patients with osseointegrated implants.

Materials and Methods: The potentially relevant literature was assessed independently by two reviewers to identify case series and comparative studies describing the treatment of peri-implantitis with a follow-up of at least 3 months. Medline, Embase, and The Cochrane Library were searched. For the purposes of this review, a composite criterion for successful treatment outcome was used which comprised implant survival with mean probing depth < 5 mm and no further bone loss.

Results: A total of 43 publications were included: 4 papers describing 3 nonsurgical case series, 13 papers describing 10 comparative studies of nonsurgical interventions, 15 papers describing 14 surgical case series, and 11 papers describing 6 comparative studies of surgical interventions. No trials comparing nonsurgical with surgical interventions were found. The length of follow-up varied from 3 months to 7.5 years. Due to the heterogeneity of study designs, peri-implantitis case definitions, outcome variables, and reporting, no metaanalysis was performed. Eleven studies could be evaluated according to a composite success criterion. Successful treatment outcomes at 12 months were reported in 0% to 100% of patients treated in 9 studies and in 75% to 93% of implants treated in 2 studies. Commonalities in treatment approaches between studies included (1) a pretreatment phase, (2) cause-related therapy, and (3) a maintenance care phase.

Conclusions: While the available evidence does not allow any specific recommendations for the therapy of peri-implantitis, successful treatment outcomes at 12 months were reported in a majority of patients in 7 studies. Although favorable short-term outcomes were reported in many studies, lack of disease resolution as well as progression or recurrence of disease and implant loss despite treatment were also reported. The reported outcomes must be viewed in the context of the varied peri-implantitis case definitions and severity of disease included as well as the heterogeneity in study design, length of follow-up, and exclusion/inclusion criteria.

Int J Oral Maxillofac Implants 2014;29(suppl):325–345. doi: 10.11607/jomi.2014suppl.g5.3

Key words: peri-implantitis, systematic review, treatment, therapy

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Consensus Statements and Clinical Recommendations for Prevention and Management of Biologic and Technical Implant Complications

Lisa J. A. Heitz-Mayfield, Ian Needleman, Giovanni E. Salvi, Bjarni E. Pjetursson
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ITI International Team for Implantology
ITI Headquarters
Peter Merian-Strasse 88
4052 Basel

Phone +41 61 270 83 83
Fax +41 61 270 83 84
E-Mail headquarters@iti.org 

ITI International Team for Implantology | Peter Merian-Strasse 88 | 4052 Basel | Switzerland | Phone +41 61 270 83 83 | Fax +41 61 270 83 84 | headquarters@iti.org

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