When loading immediately, early or conventionally?conventionally?

Short implants or longer implantsi t d b ?

A CO S OS Oin augmented bone?MARCO ESPOSITO

CLINICAL QUESTIONCLINICAL QUESTIONIs possible to achieve predictable

i isuccess rates loading the implants immediately or early?immediately or early?

E it G i A hill W thi tEsposito, Grusovin, Achille, Worthington, CoulthardCoulthard

Interventions for replacing missing teeth:Interventions for replacing missing teeth: different times for loading dental implantsg p

The Cochrane Library 2008, issue 4

Last literature search: June 2008

2008; 1: 259-276

OBJECTIVESOBJECTIVESTo compare: 1) immediately vs conventionally loaded implants2) early vs conventionally loaded implants2) early vs conventionally loaded implants3) immediately vs early loaded implants4) immediately occlusally vs non-occlusally loaded

implants

• Immediate loading: implant loaded within 1 week after its g pplacement

• Early loading: implant loaded between 1 week and 2 monthsy g p• Conventional loading: implant loaded after 2 months

INCLUSION CRITERIAINCLUSION CRITERIA

T f t di ll RCT ith f ll f• Types of studies: all RCTs with a follow up of at least 4 months after loadingg

• Types of interventions: trials comparing the• Types of interventions: trials comparing the same dental implants loaded at different times

Occlusally and non-occlusally loaded implants were considered

OUTCOME MEASURESOUTCOME MEASURES

• Prosthesis failure

• Implant failure: mobility and removal of stable implants dictated by progressive marginal boneimplants dictated by progressive marginal bone loss

• Radiographic marginal bone level changes on g p g gintraoral radiographs taken with a parallel techniq etechnique

DESCRIPTION OF STUDIESDESCRIPTION OF STUDIES

Of the 30 potentially eligible RCTs, 22 trials were included and 8 excluded because:

• Various additional confounding factors 4 trialsVarious additional confounding factors 4 trials• Not RCT 2 trials• Insufficient data presented 1 trial• Comparisons outside the scope of the review 1 trialComparisons outside the scope of the review 1 trial

DESCRIPTION OF STUDIESRCTs conducted in Italy 11RCT d d i N Z l d 3RCTs conducted in New Zealand 3RCTs conducted in Turkey 2yRCTs conducted in Sweden 1RCTs conducted in Germany 1RCTs conducted in Germany 1RCTs conducted in USA 1RCTs conducted in Egypt 1RCTs conducted in several countries 1RCTs conducted in several countries 1

Total number of treated patients 1024RCTs supported by the manufacturer 13

Immediate vs conventional loading (12 trials)g ( )1) Chiapasco 2001 edentulous mandibles2) Romeo 2002 edentulous mandibles2) Romeo 2002 edentulous mandibles3) Cannizzaro 2003 partial edentulism4) Hall 2006 single implants in anterior maxillas4) Hall 2006 single implants in anterior maxillas5) Oh 2006 single implants in anterior maxillas6) Romanos 2006 mandibular distal partial edentulism) p7) Assad 2007 edentulous mandibles8) Turkyilmaz 2007 edentulous mandibles9) Crespi 2008 single post-extractive implants in aesthetic maxilla10) Donati 2008 single implants in anterior jaws including premolars11) Gungu 2008 single mandibular first molars12) Schincaglia 2008 single implants in mandibular molar sites

Early vs conventional loading (3 trials)Early vs conventional loading (3 trials)

1) Payne 2002 edentulous mandibles2) Tawse-Smith 2002 edentulous mandibles2) Tawse-Smith 2002 edentulous mandibles3) Fischer 2004 edentulous maxillas

Immediate vs early loading (6 trials)Immediate vs early loading (6 trials)

1) T t i 2007 ti l d t li (N O)1) Testori 2007 partial edentulism (N-O)2) Cannizzaro 2008a edentulous mandibles)3) Cannizzaro 2008b edentulous maxillas4) C i 2008 i l 7 l i l t4) Cannizzaro 2008c single 7 mm long implants5) Merli 2008 partial edentulism (N-O)) p ( )6) Zollner 2008 posterior jaws (N-O)

N-O = Non-occludingN O Non occluding

Occlusal vs non-occlusal loading (1 trial)Occlusal vs non-occlusal loading (1 trial)

1) Lindeboom 2006single implants and anterior (including premolars) maxillassingle implants and anterior (including premolars) maxillas

METHODOLOGICAL QUALITYALLOCATION CONCEALMENT:• Adequate 9 trials• Inadequate 5 trials• Unclear 8 trials

BLINDING:• Yes 12 trials• Yes 12 trials• Partly (radiographs) 4 trials• No 4 trials• No 4 trials• Unclear 2 trials

WITHDRAWALS: Clear explanation 21 trials (Zollner unclear)

RISK OF BIAS: low for 6 trials high for 16 trialsRISK OF BIAS: low for 6 trials high for 16 trials

Immediate vs conventional loading prosthetic failures

Study or SubgroupCannizzaro 2003Donati 2008

log[risk ratio]-1.11 43

SE1.61 5

Total1484

Total1453

Weight13.5%15 4%

IV, Random, 95% CI0.33 [0.01, 7.66]

4 18 [0 22 79 04]

Immediate loading Conventional loading risk ratio risk ratioIV, Random, 95% CI

Donati 2008Güncü 2008Hall 2006Oh 2006Schincaglia 2008

1.430.76730.9951.9551.099

1.51.0931.6451.481.6

8413131215

5313121215

15.4%29.0%12.8%15.8%13.5%

4.18 [0.22, 79.04]2.15 [0.25, 18.35]2.70 [0.11, 67.98]

7.06 [0.39, 128.48]3.00 [0.13, 69.06]

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 2.23, df = 5 (P = 0.82); I² = 0%Test for overall effect: Z = 1.49 (P = 0.14)

151 119 100.0% 2.41 [0.76, 7.63]

0.001 0.1 1 10 1000Favours immediate Favours conventional

Immediate vs conventional loadingImmediate vs conventional loading implant failuresp

risk ratio risk ratioStudy or SubgroupCannizzaro 2003Chiapasco 2001Donati 2008

log[risk ratio]-1.1

01.43

SE1.6

1.3421.5

Weight10.2%14.5%11.6%

IV, Random, 95% CI0.33 [0.01, 7.66]

1.00 [0.07, 13.88]4.18 [0.22, 79.04]

risk ratio risk ratioIV, Random, 95% CI

Güncü 2008Hall 2006Oh 2006Romeo 2002Schincaglia 2008

0.76730.9951.955

-0.10861 099

1.0931.6451.481.61 6

21.8%9.6%

11.9%10.2%10 2%

[ ]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 13 69 06]Schincaglia 2008

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 2.84, df = 7 (P = 0.90); I² = 0%Test for overall effect: Z = 1.27 (P = 0.20)

1.099 1.6 10.2%

100.0%

3.00 [0.13, 69.06]

1.92 [0.70, 5.22]

0.001 0.1 1 10 1000Favours immediate Favours conventionalFavours immediate Favours conventional

I di t ti l l diImmediate vs conventional loading di hi i i l t i l b l l hradiographic peri-implant marginal bone level changes

Study or SubgroupCannizzaro 2003C i 2008

Mean Difference0.020 14

SE0.0470 164

Total1420

Total1320

Weight37.4%13 3%

IV, Random, 95% CI0.02 [-0.07, 0.11]0 14 [ 0 46 0 18]

Immediate loading Conventional loading Mean Difference Mean DifferenceIV, Random, 95% CI

Crespi 2008Güncü 2008Hall 2006Schincaglia 2008Turkyilmaz 2007

-0.14-0.23-0.14-0.43

0

0.1640.14840.568

0.17770.114

2011121410

2011121510

13.3%15.2%1.5%

11.8%20.8%

-0.14 [-0.46, 0.18]-0.23 [-0.52, 0.06]-0.14 [-1.25, 0.97]

-0.43 [-0.78, -0.08]0.00 [-0.22, 0.22]

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)

81 81 100.0% -0.10 [-0.24, 0.04]

-2 -1 0 1 2Favours immediate Favours conventional

Early vs conventional loadingEarly vs conventional loadingprosthetic and implant failuresp p

Study or SubgroupTawse-Smith 2002

Events5

Total24

Events1

Total24

Weight100.0%

M-H, Random, 95% CI5.00 [0.63, 39.67]

Early loading Conventional loading Risk Ratio Risk RatioM-H, Random, 95% CI

Total (95% CI)Total eventsHeterogeneity: Not applicableTest for overall effect: Z = 1.52 (P = 0.13)

524

124 100.0%

[ , ]

5.00 [0.63, 39.67]

0.001 0.1 1 10Favours early Favours conventional( ) Favours early Favours conventional

Study or SubgroupFischer 2004

Events1

Total16

Events2

Total8

Weight48.9%

M-H, Random, 95% CI0.25 [0.03, 2.36]

Early loading Conventional loading Risk Ratio Risk RatioM-H, Random, 95% CI

Fischer 2004Tawse-Smith 2002

Total (95% CI)Total eventsHeterogeneity: Tau² = 3.36; Chi² = 3.76, df = 1 (P = 0.05); I² = 73%

15

6

1624

40

21

3

824

32

48.9%51.1%

100.0%

0.25 [0.03, 2.36]5.00 [0.63, 39.67]

1.15 [0.06, 22.33]

0 001 0 1 1 10g y ; , ( );

Test for overall effect: Z = 0.10 (P = 0.92)0.001 0.1 1 10

Favours early Favours conventional

Early vs conventional loadingradiographic peri-implant marginal bone level changes

Immediate vs early loadingprosthetic failuresprosthetic failures

Study or Subgroup log[Risk Ratio] SE Total Total Weight IV, Random, 95% CIImmediate Early Risk Ratio Risk Ratio

IV, Random, 95% CICannizzaro 2008aCannizzaro 2008dTestori 2007Zöllner 2008

-1.6090

1.172-0.478

1.51.451.610.63

303025

138

303027

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]

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 1.69, df = 3 (P = 0.64); I² = 0%Test for overall effect: Z = 0.75 (P = 0.45)

223 215 100.0% 0.68 [0.25, 1.86]

0.001 0.1 1 10Favours immediate Favours early

i iImmediate vs early loadingi l t f ilimplant failures

Study or SubgroupCannizzaro 2008aCannizzaro 2008b

log[Risk Ratio]-1.609-0 693

SE1.51 2

Total3015

Total3015

Weight9.8%

15 4%

IV, Random, 95% CI0.20 [0.01, 3.78]0 50 [0 05 5 25]

Immediate Early Risk Ratio Risk RatioIV, Random, 95% CI

Cannizzaro 2008bCannizzaro 2008dTestori 2007Zöllner 2008

Total (95% CI)

-0.6930

1.172-0.478

1.21.451.610.63

153025

138

238

153027

128

230

15.4%10.5%

8.5%55.7%

100 0%

0.50 [0.05, 5.25]1.00 [0.06, 17.15]3.23 [0.14, 75.76]

0.62 [0.18, 2.13]

0 65 [0 26 1 63]Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 1.75, df = 4 (P = 0.78); I² = 0%Test for overall effect: Z = 0.92 (P = 0.36)

238 230 100.0% 0.65 [0.26, 1.63]

0.001 0.1 1 10Favours immediate Favours early

i iImmediate vs early loadingdi hi i i l t i l b l l hradiographic peri-implant marginal bone level changes

Occlusaly vs non-occlusally loadedOcclusaly vs non-occlusally loadedLindeboom 2006 (48 patients) comparedLindeboom 2006 (48 patients) compared

24 non-occlusally IL with

24 l ll IL ill i l i l24 occlusally IL maxillary single implants

No statistically significant differences

3 implants lost in the non-occlusally IL group2 implants lost in the occlusally IL group

RESULTS

No statistically significant differences

- Slight tendency to have less failures for conventionally loaded implantsconventionally loaded implants

- Slight tendency to have less failures for immediatelySlight tendency to have less failures for immediately than early loaded implants

Ottoni 2005 (CCT split mouth)Ottoni 2005 (CCT split-mouth)Failures of single implants:Failures of single implants:10 out of 23 (44%) immediately non-occlusally loadedy y1 out of 23 (4%) conventionally loaded

For immediate loading a strong correlation g gbetween failures and insertion torque

20 9 f i f 10 iTorque = 20 Ncm: 9 failures out of 10 implantsTorque > 32 Ncm: 1 failure out of 10 implantsTorque > 32 Ncm: 1 failure out of 10 implants

CONCLUSIONSCONCLUSIONS- It is possible to successfully load implants immediately p y p yor early in selected patients, though not all clinicians were able to achieve optimal resultswere able to achieve optimal results

- High insertion torque values (above 30 Ncm) seem toHigh 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)better to do it immediately (within 1 week)

Examples of clinical trials on immediate versus early loading

Immediate vs early loadingImmediate vs early loadingTestori JOMI 2007 – Galli COIR 2008 – Capelli 2010

Aims: to compare non-occlusal immediate vs early (2 months) l di i ti l d t li ( lti t RCT)loading in partial edentulism (multicenter RCT)Outcome measures:- Failure of the prosthesis - Failure of the implantFailure of the implant- Any complications

R di hi i l b l l h (bli d t)2010; 3: 209-219

- Radiographic marginal bone level changes (blind assessment)- Peri-implant soft tissues level changes (blind assessment)

Materials and methodsMaterials and methods• Osseotite tapered FNT implants (Biomet 3i)Osseotite tapered FNT implants (Biomet 3i)

• To be immediately loaded:• To be immediately loaded: – single implants insertion torque > 30 Ncm – splinted implants insertion torque > 20 Ncm

2 th ft i l t l t f ll l di• 2 months after implant placement full occluding provisional restorations were provided

• Follow-up 5 years

Immediate non-occlusal loadingg

ResultsImmediate (n=25) Early (n=27)

lFemales 12 17Mean age at implant insertion (range) 51.6 (27-74) 51.3 (34-73)S k 9 4Smokers 9 4Total number of inserted implants 52 52Implants inserted in mandibles 38 21Implants inserted in mandibles 38 21Implants inserted in anterior areas (canine to canine) 3 3Implants inserted in fresh extraction sockets 6 9 (1 grafted)Implants inserted in fresh extraction sockets 6 9 (1 grafted)Number of patients receiving 1 implant 7 10Number of patients receiving 2 implants 10 9p g pNumber of patients receiving 3 implants 7 8

Number of patients receiving 4 implants 1 0p g p

ResultsResultsTactile bone density Immediate (n=52) Early (n=52)

dHard 1 2Medium 43 40Soft 8 10

Insertion torque Immediate (n=52) Early (n=52)20 N 3 420 Ncm 3 430 Ncm 6 1440 Ncm 18 2050 Ncm 22 1450 Ncm 22 1460 Ncm 3 0

ResultsResults1 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 proceduresNo statistically differences between the 2 procedures

Iatrogenic peri-implantitis (EL)Iatrogenic peri implantitis (EL) detected 33 months after loading

Bio-Oss + BioGide At suture removal After 2 year (5th year after loading)y ( y g)

Radiographic resultsRadiographic resultsBaseline 2 months* 14 months* 60 months*

N Mean (SD) N Mean (SD) N Mean (SD)Immediate 25 0.03 (0.09) 25 0.56 (0.50) 24 1.14 (0.58)

N Mean (SD)

24 1.18 (0.56)loading

( ) ( ) ( )

E l l di 27 0 07 (0 16) 27 0 67 (0 47) 27 1 18 (0 54)

( )

26 1 28 (0 50)Early loading 27 0.07 (0.16) 27 0.67 (0.47) 27 1.18 (0.54) 26 1.28 (0.50)

*All changes from baseline statistically different (p<0.001)(p )

No significant differences between groups

Peri-implant soft tissuesPeri implant soft tissues8-14 months 8-60 months

N Mean Diff (SD) N Mean Diff (SD)Immediate loading 24 0.13 (0.40) 24 0.20* (0.40)Immediate loading 24 0.13 (0.40) 24 0.20 (0.40)Early loading 27 0.01 (0.37) 26 0.05 (0.37)

N diff b tNo difference between groupsAfter 5 years buccal soft tissues of IL receded significantly (0 2 mm) fromreceded significantly (0.2 mm) from baseline (= delivery of the final restorations 8 months after implantrestorations 8 months after implant placement)

Immediate vs early loading of 7 mm long implantsCannizzaro 2008: 1: 127-139

Aims: to compare immediate vs early loaded (6 weeks) 7 mm longAims: to compare immediate vs early loaded (6 weeks) 7 mm long single implants placed flapless (split-mouth RCT)

Outcome measures:F il f th /i l t (bli d t)- Failure of the crown/implant (blind assessment)

- Any complications- Radiographic marginal bone level changes (blind assessment)- Patient preferencePatient preference

Materials and methods

• Biomet 3i 7 mm Nanotite• Biomet 3i 7 mm Nanotiteparallel walled implantswith 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 implantDrill sequence to place a 5 mm diameter implant

HARDBONE

high

MEDIUM QUALITY BONE

Drill sequence to place a 5 mm diameter implantin soft bone

Immediate EarlyTotal number of inserted implants 29 31pNumber 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 i i i 2 (6 7%) 2 (6 7%)Implants in canine sites 2 (6.7%) 2 (6.7%)Implants in premolar sites 11 (36.7%) 14 (46.7%)Implants in molar sites 15 (50%) 13 (43 3%)Implants in molar sites 15 (50%) 13 (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%) 18 (60%)Number of implants placed in medium bone quality 16 (53.3%) 18 (60%)Number of implants placed in soft bone quality 5 (16.7%) 3 (10%)

ResultsResults13 flaps had to be elevated13 flaps had to be elevated

11 i l t did t h l d i ti t11 implants did not reach planned insertion torque: 8 immediately replaced by larger ones2 loaded anyway1, randomised to IL, was early loaded instead1, randomised to IL, was early loaded instead

No drop-outNo drop out

One implant failed in each groupOne implant failed in each group

N i i ll diff b h 2 dNo statistically differences between the 2 proceduresComplication type Immediate (n = 30) Early (n = 30)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 b f li ti 5 4Total number of complications 5 4

*One patient experienced 1 complication at both implants O e pat e t e pe e ced co p cat o at bot p a tsAll complications were successfully treated

Radiographic marginal bone levelsg p gImmediate loading(n = 29)

Early loading(n = 29)

Meandifference(n 29) (n 29) difference

At loading 0.03 (0.92) 0.13 (0.23) -0.10 (0.26)g ( ) ( ) ( )

6 months post-loading 0.34 (0.35) 0.41 (0.41) -0.07 (0.47)

Mean changes at 6 months

-0.31 (0.35) -0.28 (0.36) -0.03 (0.41) at 6 months

Patient preference at 3 months after loading: 17 patients had no preference10 patients preferred immediate loading3 patients preferred early loading

CONCLUSIONSCONCLUSIONSNo differences in success and stability of peri-implant tissues when loading implantsimplant tissues when loading implants immediately or early

Even 7 mm short implants can be loaded immediately when inserted with high torqueimmediately when inserted with high torque

Wh loading implants earl then?Why loading implants early then?

CLINICAL QUESTIONCLINICAL QUESTIONIn atrophic jaws is better to use

i ( 8 )short implants (5-8 mm) or augmenting to insert longeraugmenting to insert longer implants?

Mandibles: 3 RTCsMandibles: 3 RTCsMaxillas: 2 RTCs

MANDIBULAR ATROPHY IN EDENTULOUS PATIENTS

Mobile prosthesis

Mobile prosthesis

Fixedprosthesis

Fixedprosthesis

How can we place implants in this patient?How can we place implants in this patient?

Bone augmentation proceduresBone augmentation procedures Short implantsShort implants

Esposito, Grusovin, Felice, Karatzopoulos Worthington CoulthardKaratzopoulos, Worthington, CoulthardInterventions for replacing missing teeth: p g ghorizontal and vertical bone augmentation

techniques for dental implant treatmenttechniques for dental implant treatment

The Cochrane Library 2009 issue 4The Cochrane Library 2009, issue 4

Last literature search: June 2009Last literature search: June 2009

2009; 2: 167-184

Stellingsma 2003Stellingsma 2003mandibles 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)

2009: 2: 7-20Felice 2009-2010

7 mm long implants versus longer implants in vertically7 mm long implants versus longer implants in vertically augmented posterior mandibles

Outcome measures (assessed blindly):- Failure of the prosthesis - Failure of the implant- Any complicationsAny complications- Time needed to fully recover mental nerve sensitivity

M i l b l l h- Marginal bone level changes

Study designStudy designPatients with 7-8 mm of bone above the alveolar inferior

canal at least 5 5 mm thick requiring 2 to 3 implantscanal, at least 5.5 mm thick, requiring 2 to 3 implants

randomised torandomised to

Felice 2009-2010

7 mm long implants 10 mm or longer implants after vertical augmentationafter vertical augmentation with Bio-Oss blocks

Materials and methods

• Biomet 3i Nanotite• Biomet 3i Nanotiteparallel walled implantsexternal connection

• Bio Oss bone blocks and• Bio-Oss bone blocks andBio-Gide resorbable barriers

• Follow-up 1 year after loading

Augmentation procedure: i t iti l Bi O bl kinterpositional Bio-Oss block

Interpositional Bio-Oss blocksInterpositional Bio Oss blocks

10 mm or longer implants psubmerged for 4 months

After 5 months

Prosthetic procedurespProvisional acrylic bridges replaced by definitive ones after 4 months

Patient and intervention characteristics

Augmented (n=30) Short implants (n=30)

Females 15 23

M t i l t i ti ( ) 55 (43 67) 56 (40 83)Mean age at implant insertion (range) 55 (43-67) 56 (40-83)

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)Number of implants placed 25 Ncm torque 12 (6 patients) 4 (2 patients)

Mean length of placed implants 11.2 mm 7 mm

ResultsResults1 drop-out (short implant group)

Bio-Oss blocks fractured at placement in 3 patientsp pNo augmentation obtained in 2

Most of the short implants (26 patients) become exposedMost of the short implants (26 patients) become exposed during the submerged phase since placed supracrestally

ResultsResults

Augmented Short implants(n=30) (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 2Transient postoperative paraesthesia of the lip/chin 16 2

ResultsResults• No permanent paraesthesia of the alveolar inferiorNo permanent paraesthesia of the alveolar inferior

nerve

• 28/30 patients with short implants (93%) had not i i d l l i f i iti itimpaired alveolar inferior nerve sensitivity versus 14/30 in the augmented group (43%)

• Patients subjected to vertical augmentation• Patients subjected to vertical augmentation recovered full mental nerve sensitivity significantly l h h d i h h i llater than those treated with short implants

Augmentation complicationsAugmentation complications• 4 dehiscence occurred during graft healingg g g

– 1 healed after resuturing2 i t d ith ti l l f th ft (1 i l t f il d)– 2 associated with partial loss of the graft (1 implant failed)

Dehiscence at implant placement, the site was infected

RESULTS: mean peri implant bone levelsRESULTS: mean peri-implant bone levels

Implantplacement

Loading 1 year after loading

Short implants 0.79 mm 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

Study or Subgroup1.1.1 Prosthetic failureFelice 2009aStellingsma 2003Subtotal (95% CI)

Events

31

Total

301949

Events

10

Total

301949

Weight

57.5%42.5%

100.0%

M-H, Random, 95% CI

3.22 [0.32, 32.89]3.16 [0.12, 82.64]3.20 [0.48, 21.25]

Bone grafts Short implants Odds Ratio Odds RatioM-H, Random, 95% CI

META-ANALYSISinlay grafting Total events

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 failureFelice 2009aSt lli 2003

4

35

3019

1

10

3019

55.2%44 8%

3.22 [0.32, 32.89]14 79 [0 76 289 43]

inlay grafting vs

short implantsMore

f il

Stellingsma 2003Subtotal (95% CI)Total eventsHeterogeneity: 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

5

8

1949

0

1

1949

44.8%100.0%

14.79 [0.76, 289.43]5.74 [0.92, 35.82]

short implants

- failures- complications(i l di 1

1.1.3 Major complicationsFelice 2009aStellingsma 2003Subtotal (95% CI)Total eventsHeterogeneity: Tau² = 0.00; Chi² = 0.33, df = 1 (P = 0.57); I² = 0%Test for overall effect: Z = 2.09 (P = 0.04)

46

10

302050

02

2

302050

40.7%59.3%

100.0%

10.36 [0.53, 201.45]3.86 [0.67, 22.11]4.97 [1.10, 22.40]

(including 1 potentially lethal sublingual

)

Test for overall effect: Z 2.09 (P 0.04)

1.1.4 Experienced the operation negativelyStellingsma 2003Subtotal (95% CI)Total eventsHeterogeneity: Not applicable

10

10

2020

5

5

2020

100.0%100.0%

3.00 [0.79, 11.44]3.00 [0.79, 11.44]

haemorrage)- pain

t

Test for overall effect: Z = 1.61 (P = 0.11)

1.1.5 Severe pain for > 1 weekStellingsma 2003Subtotal (95% CI)Total events

17

17

2020

4

4

2020

100.0%100.0%

22.67 [4.37, 117.47]22.67 [4.37, 117.47]

- costs- timeif fti

Heterogeneity: Not applicableTest for overall effect: Z = 3.72 (P = 0.0002)

1.1.6 No improvement of facial appearance (3 weeks)Stellingsma 2003Subtotal (95% CI)Total events

6

6

2020

16

16

2020

100.0%100.0%

0.11 [0.03, 0.46]0.11 [0.03, 0.46]

if grafting Total eventsHeterogeneity: Not applicableTest for overall effect: Z = 3.01 (P = 0.003)

6 16

0.001 0.1 1 10 1000Favours bone grafts Favours short implants

What does it happen using evenWhat does it happen using even shorter implants?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? One-

year results from a pilot randomized clinical trialy psubmitted

15 patients with posterior bilateral mandibular edentulism with 5-7 mm of bone over the mandibular canal at least 8 mm tick5-7 mm of bone over the mandibular canal, at least 8 mm tick

1 to 3 implants per side (split-mouth)p p ( 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 group1 complication in each groupStatistically > transient paresthesiae at augmented sides (10 vs 3)

What about the maxilla?E i G i R K l

What about the maxilla?Esposito, Grusovin, Rees, Karasoulos, Felice, Alissa, Worthington, CoulthardFelice, Alissa, Worthington, Coulthard

Interventions for replacing missing teeth: augmentation procedures of the

maxillary sinusmaxillary sinusThe Cochrane Library 2010, issue 3

Last literature search: January 2010

2010: 3: 7-26

C i F li L Vi l E iCannizzaro, Felice, Leone, Viola, EspositoEarly loading of hydroxyapatite coated implants inEarly loading of hydroxyapatite coated implants in

the atrophic posterior maxilla: lateral sinus lift with t b d Bi O t l i iautogenous bone and Bio-Oss versus crestal mini-sinus lift and 8 mm implants. A randomized

controlled clinical trial2009; 2: 25-382009; 2: 25-38

Cannizzaro 2009: 3-6 mm sinus floor height40 patients (20 in each group) early loading (45 days)1 year follow-up after loading

8 mm long implants8 mm long implantscrestal sinus lifta togeno s bone versus

10-16 mm long implants1-stage lateral window sinus lift

50% Bio Oss 50% boneautogenous bone versus 50% Bio-Oss - 50% bone

No significant differencesg- 5 failed implants in lateral approach (2 sinus infections = 4 implants lost)- 1 failed implant in crestal approach

What does it happen using evenWhat does it happen using even shorter implants?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? One-

year results from a pilot randomized clinical trialy psubmitted

Bilateral posterior atrophyBilateral posterior atrophy

4-6 mm sinus floor height; width > 8 mm15 patients (split-mouth) 1-3 MegaGen implant per site3 eg Ge p pe s e1 year follow-up after loading

5x6 mm implants versus lateral 2-stage sinus lift with Bio-Oss & implants > 10x4 mmBio-Oss & implants > 10x4 mm

One failed implant per group – no significant difference for complications

RESULTS at 1 year after loading peri-implant mean marginal bone levels

mandible + maxillaImplant insertion

Loading 1 y after loadinginsertion loading

5 mm short implants 0.33 mm 0.55 mm 1.30 mm

Long implants 0.32 mm 0.56 mm 1.48 mm

Significant bone loss from baseline: - 1 mm (short implants)- 1 mm (short implants) - 1.2 mm (long implants)

0 2 b l t l i l ( i ifi )0.2 mm more bone loss at long implants (significant)

ConclusionsMandibles: in 5-8 mm bone height, 5-7 mm short implants provided better results at 1 year than vertical augmentation with interpositional blocks to insertaugmentation with interpositional blocks to insert implants at least 10 mm long

Maxillae: yet insufficient data, though 5-8 mm short i l t t id d h t t ltimplants seem to provide good short-term results

Crestal sinus lift techniques ought to investigated in more detailsmore details

THANK YOUTHANK YOUComments to

espositomarco@hotmail.com