When loading immediately, early or conventionally? Short implants or longer implants i augmented in t d bone? b ? MARCO A CO ESPOSITO S OS O
CLINICAL QUESTION Is possible to achieve predictable success rates loading i the implants i immediately or early?
E Esposito, it Grusovin, G i Achille, A hill Worthington, W thi t Coulthard Interventions for replacing missing teeth: p different times for loadingg dental implants The Cochrane Library 2008, issue 4 Last literature search: June 2008
2008; 1: 259-276
OBJECTIVES To compare: 1) immediately vs conventionally loaded implants 2) early vs conventionally loaded implants 3) immediately vs early loaded implants 4) immediately occlusally vs non-occlusally loaded implants • • •
Immediate loading: g implant p loaded within 1 week after its placement g implant p loaded between 1 week and 2 months Earlyy loading: Conventional loading: implant loaded after 2 months
INCLUSION CRITERIA •T Types off studies: t di all ll RCTs RCT with ith a follow f ll up off at least 4 months after loadingg • Types of interventions: trials comparing the same dental implants loaded at different times Occlusally and non-occlusally loaded implants were considered
OUTCOME MEASURES • Prosthesis failure • Implant failure: mobility and removal of stable implants dictated by progressive marginal bone loss • Radiographic g p marginal g bone level changes g on intraoral radiographs taken with a parallel techniq e technique
DESCRIPTION OF STUDIES Of the 30 potentially eligible RCTs, 22 trials were included and 8 excluded because: • • • •
Various additional confounding factors Not RCT Insufficient data presented Comparisons outside the scope of the review
4 trials 2 trials 1 trial 1 trial
DESCRIPTION OF STUDIES RCTs conducted in Italy RCT conducted RCTs d d iin N New Z Zealand l d RCTs conducted in Turkey y RCTs conducted in Sweden RCTs conducted in Germany RCTs conducted in USA RCTs conducted in Egypt RCTs conducted in several countries
11 3 2 1 1 1 1 1
Total number of treated patients
1024
RCTs supported by the manufacturer
13
Immediate vs conventional loadingg ((12 trials)) 1) Chiapasco 2001 2) Romeo 2002 3) Cannizzaro 2003 4) Hall 2006 5) Oh 2006 6)) Romanos 2006 7) Assad 2007 8) Turkyilmaz 2007 9) Crespi 2008 10) Donati 2008 11) Gungu 2008
edentulous mandibles edentulous mandibles partial edentulism single implants in anterior maxillas single implants in anterior maxillas mandibular distal p partial edentulism edentulous mandibles edentulous mandibles single post-extractive implants in aesthetic maxilla single implants in anterior jaws including premolars single mandibular first molars
12) Schincaglia 2008 single implants in mandibular molar sites
Early vs conventional loading (3 trials) 1) Payne 2002 2) Tawse-Smith 2002 3) Fischer 2004
edentulous mandibles edentulous mandibles edentulous maxillas
Immediate vs early loading (6 trials) 1) T Testori t i 2007 2)) Cannizzaro 2008a 3) Cannizzaro 2008b 4) C Cannizzaro i 2008 2008c 5)) Merli 2008 6) Zollner 2008 N-O N O = Non Non-occluding occluding
partial ti l edentulism d t li (N-O) (N O) edentulous mandibles edentulous maxillas single i l 7 mm long l implants i l t partial edentulism ((N-O)) p posterior jaws (N-O)
Occlusal vs non-occlusal loading (1 trial) 1) Lindeboom 2006 single implants and anterior (including premolars) maxillas
METHODOLOGICAL QUALITY ALLOCATION CONCEALMENT: • Adequate 9 trials • Inadequate 5 trials • Unclear 8 trials BLINDING: • Yes • Partly (radiographs) • No • Unclear
12 trials 4 trials 4 trials 2 trials
WITHDRAWALS: Clear explanation 21 trials (Zollner unclear) RISK OF BIAS: low for 6 trials
high for 16 trials
Immediate vs conventional loading prosthetic failures Study or Subgroup Cannizzaro 2003 Donati 2008 Güncü 2008 Hall 2006 Oh 2006 Schincaglia 2008 Total (95% CI)
log[risk ratio]
Immediate loading Conventional loading SE Total Total Weight
-1.1 1.6 1 43 1.43 15 1.5 0.7673 1.093 0.995 1.645 1.955 1.48 1.099 1.6
14 84 13 13 12 15 151
Heterogeneity: Tau² = 0.00; Chi² = 2.23, df = 5 (P = 0.82); I² = 0% Test for overall effect: Z = 1.49 (P = 0.14)
14 53 13 12 12 15
risk ratio IV, Random, 95% CI
13.5% 15 4% 15.4% 29.0% 12.8% 15.8% 13.5%
0.33 [0.01, 7.66] 4 18 [0 4.18 [0.22, 22 79 79.04] 04] 2.15 [0.25, 18.35] 2.70 [0.11, 67.98] 7.06 [0.39, 128.48] 3.00 [0.13, 69.06]
119 100.0%
2.41 [0.76, 7.63]
risk ratio IV, Random, 95% CI
0.001 0.1 1 10 1000 Favours immediate Favours conventional
Immediate vs conventional loading implant p failures Study or Subgroup Cannizzaro 2003 Chiapasco 2001 Donati 2008 Güncü 2008 Hall 2006 Oh 2006 Romeo 2002 Schincaglia 2008 Total (95% CI)
log[risk ratio]
SE Weight
-1.1 1.6 0 1.342 1.43 1.5 0.7673 1.093 0.995 1.645 1.955 1.48 -0.1086 1.6 1 099 1.099 16 1.6
risk ratio IV, Random, 95% CI
10.2% 14.5% 11.6% 21.8% 9.6% 11.9% 10.2% 10 2% 10.2%
0.33 [0.01, 7.66] 1.00 [0.07, 13.88] 4.18 [[0.22, 79.04]] 2.15 [0.25, 18.35] 2.70 [0.11, 67.98] 7.06 [0.39, 128.48] 0.90 [0.04, 20.64] 3 00 [0 3.00 [0.13, 13 69 69.06] 06]
100.0%
1.92 [0.70, 5.22]
Heterogeneity: Tau² = 0.00; Chi² = 2.84, df = 7 (P = 0.90); I² = 0% Test for overall effect: Z = 1.27 (P = 0.20)
risk ratio IV, Random, 95% CI
0.001
0.1 1 10 1000 Favours immediate Favours conventional
I Immediate di t vs conventional ti l loading l di radiographic di hi peri-implant i i l t marginal i l bone b level l l changes h
Study or Subgroup Cannizzaro 2003 C Crespi i 2008 Güncü 2008 Hall 2006 Schincaglia 2008 Turkyilmaz 2007
Mean Difference
SE
Immediate loading Conventional loading Total Total Weight
0.02 0.047 -0.14 0 14 0.164 0 164 -0.23 0.1484 -0.14 0.568 -0.43 0.1777 0 0.114
Total (95% CI) Heterogeneity: Tau² = 0.01; Chi² = 8.57, df = 5 (P = 0.13); I² = 42% Test for overall effect: Z = 1.39 (P = 0.16)
Mean Difference IV, Random, 95% CI
14 20 11 12 14 10
13 20 11 12 15 10
37.4% 13.3% 13 3% 15.2% 1.5% 11.8% 20.8%
0.02 [-0.07, 0.11] -0.14 0 14 [[-0.46, 0 46 0 0.18] 18] -0.23 [-0.52, 0.06] -0.14 [-1.25, 0.97] -0.43 [-0.78, -0.08] 0.00 [-0.22, 0.22]
81
81 100.0%
-0.10 [-0.24, 0.04]
Mean Difference IV, Random, 95% CI
-2 -1 0 1 2 Favours immediate Favours conventional
Early vs conventional loading prosthetic and implant p p failures Study or Subgroup Tawse-Smith 2002
Early loading Conventional loading Events Total Events Total Weight 5
24 24
Total (95% CI)
5 Total events Heterogeneity: Not applicable Test for overall effect: Z = 1.52 ((P = 0.13))
Study or Subgroup Fischer 2004 Tawse-Smith 2002 Total (95% CI)
1
24 100.0%
5.00 [[0.63,, 39.67]]
24 100.0%
5.00 [0.63, 39.67]
16 24 40
Risk Ratio M-H, Random, 95% CI
1 0.001
Early loading Conventional loading Events Total Events Total Weight 1 5
Risk Ratio M-H, Random, 95% CI
2 1
8 24
Risk Ratio M-H, Random, 95% CI
48.9% 51.1%
0.25 [0.03, 2.36] 5.00 [0.63, 39.67]
32 100.0%
1.15 [0.06, 22.33]
Total events 6 3 Heterogeneity: g y Tau² = 3.36;; Chi² = 3.76,, df = 1 (P ( = 0.05); ); I² = 73% Test for overall effect: Z = 0.10 (P = 0.92)
0.1 1 10 Favours early Favours conventional
Risk Ratio M-H, Random, 95% CI
0 001 0.001
0.1 0 1 1 10 Favours early Favours conventional
Early vs conventional loading radiographic peri-implant marginal bone level changes
Immediate vs early loading prosthetic failures Study or Subgroup Cannizzaro 2008a Cannizzaro 2008d Testori 2007 Zöllner 2008 Total (95% CI)
log[Risk Ratio]
SE
-1.609 1.5 0 1.45 1.172 1.61 -0.478 0.63
Immediate Early Total Total Weight
Risk Ratio IV, Random, 95% CI
30 30 25 138
30 30 27 128
11.6% 12.4% 10.1% 65.9%
0.20 [0.01, 3.78] 1.00 [0.06, 17.15] 3.23 [0.14, 75.76] 0.62 [0.18, 2.13]
223
215 100.0%
0.68 [0.25, 1.86]
Heterogeneity: Tau² = 0.00; Chi² = 1.69, df = 3 (P = 0.64); I² = 0% Test for overall effect: Z = 0.75 (P = 0.45)
Risk Ratio IV, Random, 95% CI
0.001
0.1 1 10 Favours immediate Favours early
Immediate i vs early loading i i l t failures implant f il Study or Subgroup Cannizzaro 2008a Cannizzaro 2008b Cannizzaro 2008d Testori 2007 Zöllner 2008 Total (95% CI)
log[Risk Ratio]
Immediate Early SE Total Total Weight
-1.609 1.5 -0 693 1.2 -0.693 12 0 1.45 1.172 1.61 -0.478 0.63
Risk Ratio IV, Random, 95% CI
30 15 30 25 138
30 15 30 27 128
9.8% 15 4% 15.4% 10.5% 8.5% 55.7%
0.20 [0.01, 3.78] 0 50 [0 0.50 [0.05, 05 5 5.25] 25] 1.00 [0.06, 17.15] 3.23 [0.14, 75.76] 0.62 [0.18, 2.13]
238
230 100.0% 100 0%
0 65 [0 0.65 [0.26, 26 1 1.63] 63]
Heterogeneity: Tau² = 0.00; Chi² = 1.75, df = 4 (P = 0.78); I² = 0% Test for overall effect: Z = 0.92 (P = 0.36)
Risk Ratio IV, Random, 95% CI
0.001
0.1 1 10 Favours immediate Favours early
Immediate i vs early loading i radiographic di hi peri-implant i i l t marginal i l bone b level l l changes h
Occlusaly vs non-occlusally loaded Lindeboom 2006 (48 patients) compared 24 non-occlusally IL with 24 occlusally l ll IL maxillary ill single i l implants i l No statistically significant differences 3 implants lost in the non-occlusally IL group 2 implants lost in the occlusally IL group
RESULTS No statistically significant differences - Slight tendency to have less failures for conventionally loaded implants - Slight tendency to have less failures for immediately than early loaded implants
Ottoni 2005 (CCT split-mouth) split mouth) Failures of single implants: 10 out of 23 (44%) immediately y non-occlusally y loaded 1 out of 23 (4%) conventionally loaded
For immediate loadingg a strong g correlation between failures and insertion torque Torque = 20 Ncm: 9 ffailures i out off 10 implants i Torque > 32 Ncm: 1 failure out of 10 implants
CONCLUSIONS - It is p possible to successfully y load implants p immediately y or early in selected patients, though not all clinicians were able to achieve optimal results - High insertion torque values (above 30 Ncm) seem to be a prerequisite for implant success - If it is decided to load the implants early, it might be better to do it immediately (within 1 week)
Examples of clinical trials on immediate versus early loading
Immediate vs early loading Testori JOMI 2007 – Galli COIR 2008 – Capelli 2010 Aims: to compare non-occlusal immediate vs early (2 months) l di in loading i partial ti l edentulism d t li (multicenter ( lti t RCT) Outcome measures: - Failure of the prosthesis - Failure of the implant 2010; 3: 209-219 - Any complications - Radiographic R di hi marginal i l bone b level l l changes h (blind (bli d assessment) t) - Peri-implant soft tissues level changes (blind assessment)
Materials and methods • Osseotite tapered FNT implants (Biomet 3i) • To be immediately loaded: – single implants insertion torque > 30 Ncm – splinted implants insertion torque > 20 Ncm
• 2 months th after ft implant i l t placement l t full f ll occluding l di provisional restorations were provided • Follow-up 5 years
Immediate non-occlusal loading g
Results Immediate (n=25) Early (n=27) Females l
12
17
Mean age at implant insertion (range)
51.6 (27-74)
51.3 (34-73)
S k Smokers
9
4
Total number of inserted implants
52
52
Implants inserted in mandibles
38
21
Implants inserted in anterior areas (canine to canine)
3
3
Implants inserted in fresh extraction sockets
6
9 (1 grafted)
Number of patients receiving 1 implant
7
10
Number of p patients receiving g 2 implants p
10
9
Number of patients receiving 3 implants
7
8
Number of p patients receiving g 4 implants p
1
0
Results Tactile bone density Hard d Medium Soft
Immediate (n=52) 1 43 8
Early (n=52) 2 40 10
Insertion torque 20 Ncm N 30 Ncm 40 Ncm 50 Ncm 60 Ncm
Immediate (n=52) 3 6 18 22 3
Early (n=52) 4 14 20 14 0
Results 1 drop-out (EL) moved after 1 year 1 single implant failed (IM) 2 months after placement 1 complication (EL): iatrogenic peri-implantitis No statistically differences between the 2 procedures
Iatrogenic peri peri-implantitis implantitis (EL) detected 33 months after loading
Bio-Oss + BioGide
At suture removal
After 2 y year ((5th y year after loading) g)
Radiographic results Baseline
2 months*
14 months*
60 months*
N Mean (SD) N Mean (SD) N Mean (SD)
N Mean (SD)
Immediate loading
25 0.03 ((0.09)) 25 0.56 ((0.50)) 24 1.14 ((0.58))
24 1.18 ((0.56))
E l loading Early l di
27 0.07 0 07 (0.16) (0 16) 27 0.67 0 67 (0.47) (0 47) 27 1.18 1 18 (0 (0.54) 54)
26 1.28 1 28 (0 (0.50) 50)
*All changes from baseline statistically different (p<0.001) (p ) No significant differences between groups
Peri-implant Peri implant soft tissues
Immediate loading Early loading
8-14 months
8-60 months
N Mean Diff (SD)
N Mean Diff (SD)
24 27
24 26
0.13 0.01
(0.40) (0.37)
N diff No difference b between t groups After 5 years buccal soft tissues of IL receded significantly (0.2 (0 2 mm) from baseline (= delivery of the final restorations 8 months after implant placement)
0.20 0.20* 0.05
(0.40) (0.37)
Immediate vs early loading of 7 mm long implants Cannizzaro 2008: 1: 127-139
Aims: to compare immediate vs early loaded (6 weeks) 7 mm long single implants placed flapless (split-mouth RCT) Outcome measures: - Failure F il off the th crown/implant /i l t (blind (bli d assessment) t) - Any complications - Radiographic marginal bone level changes (blind assessment) - Patient preference
Materials and methods • Biomet 3i 7 mm Nanotite parallel walled implants with external connection • Sites prepared with conical drills • To be immediately loaded: insertion torque > 40 Ncm • Follow-up: 9 months
Drill sequence to place a 5 mm diameter implant HARD BONE
high
MEDIUM QUALITY BONE
Drill sequence to place a 5 mm diameter implant in soft bone
Immediate
Early
p Total number of inserted implants
29
31
Number of implants inserted in maxilla
17 (56.7%)
16 (53.3%)
Implants inserted in fresh extraction sockets
9 (30%)
9 (30%)
Number of elevated flaps
8 (26.7%)
5 (16.7%)
Number of implants placed originally with less than 40 Ncm
7 (23.3%)
4 (13.3%)
Sites receiving 4 mm diameter implants
8 (26.7%)
12 (40%)
Sites receiving 5 mm diameter implants
13 (43.3%)
12 (40%)
Sites receiving 6 mm diameter implants
9 (30%)
6 (20%)
Implants in incisor sites
2 (6.7%)
1 (3.3%)
I l Implants i canine in i sites i
2 (6.7%) (6 7%)
2 (6.7%) (6 7%)
Implants in premolar sites
11 (36.7%)
14 (46.7%)
Implants in molar sites
15 (50%)
13 (43.3%) (43 3%)
Number of implants placed in hard bone quality
9 (30%)
9 (30%)
Number of implants placed in medium bone quality
16 (53.3%) (53 3%)
18 (60%)
Number of implants placed in soft bone quality
5 (16.7%)
3 (10%)
Results 13 flaps had to be elevated 11 iimplants l t did nott reach h planned l d insertion i ti torque: t 8 immediately replaced by larger ones 2 loaded anyway 1, randomised to IL, was early loaded instead
No drop drop-out out One implant failed in each group
N statistically No i i ll differences diff between b the h 2 procedures d Complication type
Immediate (n = 30)
Early (n = 30)
Peri-implant soft tissue complication
1
0
Peri-implantitis
1
2
Repeated crown dis-cementation (new crown)
1
0
Fracture of the ceramic of definitive crown*
1
0
Patient unsatisfied with esthetic ((new crown))
1
0
Improper contact points* (crown adjustment)
0
2
T t l number Total b off complications li ti
5
4
*One O e pat patient e t experienced e pe e ced 1 complication co p cat o at both bot implants p a ts All complications were successfully treated
Radiographic g p marginal g bone levels Immediate loading Early loading (n = 29) (n = 29)
Mean difference
0.03 ((0.92))
0.13 ((0.23))
-0.10 ((0.26))
6 months post-loading 0.34 (0.35)
0.41 (0.41)
-0.07 (0.47)
Mean changes at 6 months
-0.28 (0.36)
-0.03 (0.41)
At loadingg
-0.31 (0.35)
Patient preference at 3 months after loading: 17 patients had no preference 10 patients preferred immediate loading 3 patients preferred early loading
CONCLUSIONS No differences in success and stability of periimplant tissues when loading implants immediately or early Even 7 mm short implants can be loaded immediately when inserted with high torque
Wh loading implants earl Why early then?
CLINICAL QUESTION In atrophic jaws is better to use short implants i (5-8 ( 8 mm)) or augmenting to insert longer implants? Mandibles: Maxillas:
3 RTCs 2 RTCs
MANDIBULAR ATROPHY IN EDENTULOUS PATIENTS Mobile prosthesis
Fixed prosthesis
How can we place implants in this patient?
Bone augmentation procedures
Short implants
Esposito, Grusovin, Felice, Karatzopoulos Worthington Karatzopoulos, Worthington, Coulthard Interventions for replacing p g missing g teeth: horizontal and vertical bone augmentation techniques for dental implant treatment The Cochrane Library 2009 2009, issue 4 Last literature search: June 2009
2009; 2: 167-184
Stellingsma 2003 mandibles of 6-12 mm height - 2 year follow-up • 20 patients: “sandwich” graft from iliac crest + 4 implants > 11 mm long • 20 patients: 4 short implants (8-11 mm) • 20 patients: Bosker staple plate (intervention of no interest)
Felice 2009-2010
2009: 2: 7-20
7 mm long implants versus longer implants in vertically augmented posterior mandibles Outcome measures (assessed blindly): - Failure of the prosthesis - Failure of the implant - Any complications - Time needed to fully recover mental nerve sensitivity - Marginal M i l bone b level l l changes h
Study design Patients with 7-8 mm of bone above the alveolar inferior canal at least 55.5 canal, 5 mm thick thick, requiring 2 to 3 implants
randomised to
Felice 2009-2010
7 mm long implants
10 mm or longer implants after vertical augmentation with Bio-Oss blocks
Materials and methods • Biomet 3i Nanotite parallel walled implants external connection
• Bio Bio-Oss Oss bone blocks and Bio-Gide resorbable barriers
• Follow-up 1 year after loading
Augmentation procedure: i t interpositional iti l Bio-Oss Bi O block bl k
Interpositional Bio Bio-Oss Oss blocks
10 mm or longer implants p submerged for 4 months After 5 months
Prosthetic procedures p Provisional acrylic bridges replaced by definitive ones after 4 months
Patient and intervention characteristics Augmented (n=30) Short implants (n=30)
Females
15
23
M Mean age att implant i l t insertion i ti (range) ( )
55 (43 (43-67) 67)
56 (40 (40-83) 83)
Smokers
11 light
11 light + 1 heavy
Total number of inserted implants
61
60
Number of implants placed < 25 Ncm torque
12 (6 patients)
4 (2 patients)
Mean length of placed implants
11.2 mm
7 mm
Results 1 drop-out (short implant group) Bio-Oss blocks fractured at placement in 3 p p patients No augmentation obtained in 2
Most of the short implants (26 patients) become exposed during the submerged phase since placed supracrestally
Results Augmented (n=30)
Short implants (n=30)
Failure of the augmentation procedure
2
Not applicable
Failure to place the prosthesis when planned
3
1
Failure of the implants
3
1
Complications
4
0
Transient postoperative paraesthesia of the lip/chin
16
2
Results â&#x20AC;˘ No permanent paraesthesia of the alveolar inferior nerve â&#x20AC;˘ 28/30 patients with short implants (93%) had not i impaired i d alveolar l l inferior i f i nerve sensitivity iti it versus 14/30 in the augmented group (43%) â&#x20AC;˘ Patients subjected to vertical augmentation recovered full mental nerve sensitivity significantly l later than h those h treated d with i h short h iimplants l
Augmentation complications • 4 dehiscence occurred during g graft g healingg – 1 healed after resuturing – 2 associated i t d with ith partial ti l loss l off the th graft ft (1 iimplant l t failed) f il d)
Dehiscence at implant placement, the site was infected
RESULTS: mean peri peri-implant implant bone levels
Short implants
Implant placement 0.79 mm
Loading
1 year after loading 1.37 mm 1.79 mm
Long implants
0.65 mm
1.21 mm 1.65 mm
Significant bone loss from baseline (1 mm) No differences between groups
META-ANALYSIS
inlay grafting vs short implants More - failures f il - complications (including (i l di 1 potentially lethal sublingual haemorrage)
- pain - costs t - time if grafting fti
Bone grafts Short implants Study or Subgroup Events Total Events Total Weight 1.1.1 Prosthetic failure Felice 2009a Stellingsma 2003 Subtotal (95% CI)
3 1
30 19 49
1 0
30 57.5% 19 42.5% 49 100.0%
Odds Ratio M-H, Random, 95% CI
Odds Ratio M-H, Random, 95% CI
3.22 [0.32, 32.89] 3.16 [0.12, 82.64] 3.20 [0.48, 21.25]
Total events 4 1 Heterogeneity: Tau² = 0.00; Chi² = 0.00, df = 1 (P = 0.99); I² = 0% Test for overall effect: Z = 1.21 (P = 0.23) 1.1.2 Implant failure Felice 2009a St lli Stellingsma 2003 Subtotal (95% CI)
3 5
30 19 49
1 0
30 55.2% 19 44.8% 44 8% 49 100.0%
3.22 [0.32, 32.89] 14.79 14 79 [0 [0.76, 76 289 289.43] 43] 5.74 [0.92, 35.82]
Total events 8 1 Heterogeneity: Tau² = 0.00; Chi² = 0.65, df = 1 (P = 0.42); I² = 0% Test for overall effect: Z = 1.87 (P = 0.06) 1 1 3 Major complications 1.1.3 Felice 2009a Stellingsma 2003 Subtotal (95% CI)
4 6
30 20 50
0 2
30 40.7% 20 59.3% 50 100.0%
10.36 [0.53, 201.45] 3.86 [0.67, 22.11] 4.97 [1.10, 22.40]
Total events 10 2 Heterogeneity: Tau² = 0.00; Chi² = 0.33, df = 1 (P = 0.57); I² = 0% Test for overall effect: Z = 2.09 (P = 0.04) 1.1.4 Experienced the operation negatively Stellingsma 2003 Subtotal (95% CI)
10
20 20
Total events 10 Heterogeneity: Not applicable Test for overall effect: Z = 1.61 (P = 0.11)
5
20 100.0% 20 100.0%
3.00 [0.79, 11.44] 3.00 [0.79, 11.44]
20 100.0% 20 100.0%
22.67 [4.37, 117.47] 22.67 [4.37, 117.47]
20 100.0% 20 100.0%
0.11 [0.03, 0.46] 0.11 [0.03, 0.46]
5
1.1.5 Severe pain for > 1 week Stellingsma 2003 Subtotal (95% CI)
17
20 20
Total events 17 Heterogeneity: Not applicable Test for overall effect: Z = 3.72 (P = 0.0002)
4 4
1.1.6 No improvement of facial appearance (3 weeks) Stellingsma 2003 Subtotal (95% CI)
6
20 20
Total events 6 Heterogeneity: Not applicable Test for overall effect: Z = 3.01 (P = 0.003)
16 16
0.001
0.1 1 10 Favours bone grafts Favours short implants
1000
What does it happen using even shorter implants?
Felice, Checchi, Pistilli, Scarano, Pellegrino, Esposito; 2009; 2: 267-281
Esposito, Pistilli, Pellegrino, Felice Rehabilitation of posterior atrophic edentulous jaws: prostheses supported by 5 mm short implants or by longer implants in augmented bone? Oneyyear results from a pilot p randomized clinical trial submitted
15 patients with posterior bilateral mandibular edentulism with 5-7 mm of bone over the mandibular canal canal, at least 8 mm tick
1 to 3 implants p p per side ((split-mouth) p ) Follow-up: 1 year after loading Short implants (5x6 mm)
versus
implants > 10 mm in bone augmented with interpositional Bio-Oss blocks
1 implant failure (augmented side) 1 complication in each group Statistically > transient paresthesiae at augmented sides (10 vs 3)
What about the maxilla? Esposito, E i Grusovin, G i Rees, R Karasoulos, K l Felice, Alissa, Worthington, Coulthard Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus The Cochrane Library 2010, issue 3 Last literature search: January 2010 2010: 3: 7-26
C Cannizzaro, i F li Leone, Felice, L Vi l Esposito Viola, E i Early loading of hydroxyapatite coated implants in the atrophic posterior maxilla: lateral sinus lift with autogenous t bone b and d Bi Bio-Oss O versus crestal t l minii i sinus lift and 8 mm implants. A randomized controlled clinical trial
2009; 2: 25-38
Cannizzaro 2009: 3-6 mm sinus floor height 40 patients (20 in each group) early loading (45 days) 1 year follow-up after loading 8 mm long implants crestal sinus lift a togeno s bone autogenous
versus
10-16 mm long implants 1-stage lateral window sinus lift 50% Bio-Oss Bio Oss - 50% bone
No significant g differences - 5 failed implants in lateral approach (2 sinus infections = 4 implants lost) - 1 failed implant in crestal approach
What does it happen using even shorter implants?
Felice, Checchi, Pistilli, Scarano, Pellegrino, Esposito; 2009; 2: 267-281
Esposito, Pistilli, Pellegrino, Felice Rehabilitation of posterior atrophic edentulous jaws: prostheses supported by 5 mm short implants or by longer implants in augmented bone? Oneyyear results from a pilot p randomized clinical trial submitted
Bilateral posterior atrophy
4-6 mm sinus floor height; width > 8 mm 15 patients (split-mouth) 1-3 3 MegaGen eg Ge implant p per pe site s e 1 year follow-up after loading
5x6 mm implants
versus
lateral 2-stage sinus lift with Bio-Oss & implants > 10x4 mm
One failed implant per group â&#x20AC;&#x201C; no significant difference for complications
RESULTS at 1 year after loading peri-implant mean marginal bone levels mandible + maxilla Implant insertion 5 mm short implants 0.33 mm
1 y after loading 0.55 mm 1.30 mm
Long implants
0.56 mm 1.48 mm
0.32 mm
Loading
Significant bone loss from baseline: - 1 mm (short implants) - 1.2 mm (long implants) 0 2 mm more b 0.2 bone lloss att long l i l implants (significant) ( i ifi )
Conclusions Mandibles: in 5-8 mm bone height, 5-7 mm short implants provided better results at 1 year than vertical augmentation with interpositional blocks to insert implants at least 10 mm long Maxillae: yet insufficient data, though 5-8 mm short i l t seem to implants t provide id good d short-term h tt results lt Crestal sinus lift techniques ought to investigated in more details
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