What are the gapsfuture plans for filling these gapswhat areas need looking at IMPLANTSPROSTHETICS

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What are the gaps/future plans for filling these
gaps/what areas need looking atIMPLANTS/PROSTHETI
CS
Evidence for up-to-date clinical dental practice
a review of 10 years of the Cochrane Oral
Health Group30th-31st May 2006, Manchester

• MARCO ESPOSITO
• Senior Lecturer in Oral and Maxillofacial
  Surgery, School of Dentistry, and Editor of the
  Cochrane Oral Health Group, The University of
  Manchester, UK Assoc Prof in Biomaterials,
  Göteborg University, Sweden

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AN OVERVIEW

• From 11 Cochrane reviews on osseointegrated
  dental implants and 1 review on prosthetics
• Updated to March 2006
• http//www.cochrane.orghttp//www.cochrane-oral.m
  an.ac.uk

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• We shall discuss specifically the gaps of the
  topics covered in the Cochrane reviews, since we
  know what has been done in these fields.
• It can difficult to discuss the gaps not knowing
  what has been done (importance of the systematic
  reviews).
• However, additional gaps can be addressed by the
  participants.

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1 BONE AUGMENTATION PROCEDURES

• A) to test whether and when bone augmentation
  procedures are necessary.
• B) to test which is the most effective bone
  augmentation technique for specific clinical
  indications.
• Trials were divided into 3 broad categories
  according to different clinical indications
• major vertical and/or horizontal bone
  augmentation
• implants placed in extraction sockets
• treatment of fenestration around implants.

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1 BONE AUGMENTATION PROCEDURES

• Last literature search October 2005
• 13 RCTs with 330 participants (17 RCTs excluded)
• Bone augmentation of athrophic edentulous
  mandibles (1 trial)
• Stellingsma 2003 short implant vs sandwich bone
  graft
• Sinus lifting (3 trials)
• Wannfors 2000 1-stage block vs 2-stage
  particulated bone
• Hallman 2002 1-stage particulated bone vs
  80Bio-Oss/20bone vs 100 Bio-Oss
• Szabó 2005 2-stage particulated bone vs 100
  tricalciumphosphates (Cerasorb)

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DESCRIPTION OF STUDIES

• Vertical augmentation (2 trials)
• Chiapasco 2004 bone titanium barrier vs
  distraction osteogenesis
• Merli submitted particulated bone resorbable
  barrier plates vs titanium barrier
• Immediate implants in fresh extraction sockects
  (4 trials)
• Cornelini 2004 resorbable barrier Bio-Oss
• Chen1 2005 non-resorbable vs resobable
  particulated bone
• Chen2 2005 particulated bone vs control
• Chen manuscript Bio-Oss vs Bio-Oss resorbable
  barrier
• Fenestrations and dehiscence around implants (3
  trials)
• Dahlin 1991 non-resorbable barrier vs control
• Carpio 2000 GBR bone/Bio-Oss resobable vs
  non-resorbable
• Jung 2003 resorbable barrier Bio-Oss rhBMP-2
  (placebo)

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Titanium reinforced barriers for vertical
GBRpreoperative postoperative
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CONCLUSIONS

• In atrophic edentulous mandibles there are more
  implant failures, complications, pain, cost and
  longer treatment time using sandwich bone
  grafts than short implants.
• Sinus lifting with 100 bone substitutes (Bio-Oss
  and Cerasorb) might work with sinus floor lt 5 mm.
• It is possible to augment bone vertically,
  however complications are frequent and it is
  unclear which is the most effective technique.

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CONCLUSIONS

• It unclear whether augmentation procedures are
  needed in postextractive sockets and which is the
  most effective augmentation procedure. In sites
  treated with Bio-Oss barriers, the gingival
  margins may be positioned 1.2 mm higher than in
  sites treated with barriers alone.
• GBR allows bone augmentation at fenestrated
  implant, but it is unclear whether it is needed,
  and which is the most effective technique.
• Complications with GBR procedures are common.
  There might be an association between bone
  retrieved with bone filters also using a
  dedicated suction device and infective
  complications.

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Where are the gaps

• When bone augmentation procedures are actually
  needed?
• Which procedures are associated with the least
  discomfort and complications for the patients,
  without jeopardizing (ideally improving) success
  rates?
• Sinus lift use of 100 bone substitutes.
• Vertical augmentation bone blocks, particulated
  bone/bone substitutes and GBR, osteodistraction,
  active molecules, split-crest techniques (only
  for horizontal augmentation).
• Postextractive implants grafting or not, what
  to graft (bone or slow resorbable bone
  substitutes), membranes?
• Duration of follow-up.

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What trials are needed
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2 Various implant characteristics/systems

• Is a surface modification, an implant shape, a
  material or an implant system more effective than
  the others?
• Last literature search February 2005.
• 12 RCTs with 512 participants and 12 different
  implant systems (19 RCTs excluded). 4 RCTs with a
  5-year follow-up.
• Minor statistically significant differences in
  marginal bone loss and in the occurrence of
  perimplantitis (20 risk reduction to have
  perimplantitis at 3 years around implants with a
  machined surface). No statistically significant
  difference in failure rates.
• We do not know whether any implant system is
  superior to the others. It does not mean that
  they are all the same!

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Where are the gaps

• Is the material, the macrodesign, the surface
  characteristics or a combination of those
  characteristics relevant for the success?
• HA-coated implants?
• No statistically significant difference but not a
  single study was powered to detect any!
• Duration of follow-up
• Constant changes of surface characteristics
  (mostly for marketing reasons!)
• Is it better to have an early failure today or a
  perimplantitis tomorrow? IN MEDIO STAT VIRTUS
  Virtue stands in the middle?!

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What trials are needed
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3 Immediate, early or conventional loading

• Is there any difference if implants are
  immediately or early loaded?
• Last literature search February 2004.
• 5 RCTs with 124 participants (2 RCTs excluded).
• For good quality mandibles we do not know
  whether a difference does exist. It does not mean
  that the techniques provide the same results!

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Where are the gaps

• Other clinical indications (fully edentulous
  maxillas, partial edentulism)?
• More failures can be acceptable?
• Factors affecting success of immediate loading.
• Immediate loading is more interesting for the
  patients than early loading.

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What trials are needed
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4 Maintenance

• Which is the most effective maintenance technique
  or regimen?
• Last literature search June 2004.
• 5 RCTs with 127 participants (9 RCTs were
  excluded) electric (1 RCT) and sonic (1 RCT) vs
  manual toothbrush phosphoric acid gel vs
  debridement (1 RCT) subgingival vs chlorhexidine
  mouthrinses (1 RCT) adjunctive Listerine
  mouthrinse vs placebo (1 RCT). Follow-up 6
  weeks-5 months.
• Adjunctive Listerine mouthrinse reduces dental
  plaque and marginal bleeding.

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Where are the gaps

• The longest follow-up was of 5 months!

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What trials are needed
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5 Surgical techniques

• Is there any surgical technique associated to
  higher success rates?
• Last literature search September 2002.
• 4 RCTs (5 RCTs excluded). 2 RCTs compared 2
  versus 4 implants with mandibular overdentures
  (170 participants) 2 RCTs compared a crestal
  surgical incision with a vestibular incision (20
  participants).
• We do not know whether a surgical technique is
  superior, however, 2 mandibular implants are
  sufficient to hold an overdenture. It does not
  mean that all techniques are the same!

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Where are the gaps

• 1-stage versus 2-stage techniques.
• How many implants for overdentures.
• Incision techniques.
• Techniques to reconstruct the papillas.
• Techniques to increase the keratinized tissues.
• Flapless implant placement.
• Computer guided surgery.

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What trials are needed
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6 Immediate, immediate-delayed and delayed
implants in extraction sockets

• How long time we need to wait to insert an
  implant in postextractive sockets?
• Last literature search March 2006.
• 1 RCT with 46 participants immediate delayed (ca
  10 days) vs delayed (ca 3 months) implants.
  Follow-up (loading) 1 year and half.
• Patients treated with immediate-delayed implants
  were more satisfied, and the peri-implant tissues
  position was judged to be more appropriate in
  relation to the neighbouring teeth by and
  independent and masked assessor.

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Where are the gaps

• When placing the implants?
• Immediate is better than immediately-delayed for
  the patients.
• How to place the implants (subcrestally, slightly
  lingually)?
• Are bone augmentation procedures needed?
• What type of bone augmentation procedures are
  needed?
• How closing the flaps (1- or 2-stage procedure)?

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What trials are needed
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7 Treatment of perimplantitis

• Which is the most effective treatment for
  perimplantitis?
• Last literature search March 2006.
• 5 RCTs with 106 participants (2 RCTs excluded)
• local antibiotics vs debridement (2 RCT)
• mechanical (Vector) vs manual debridement (1
  RCT)
• laser vs debridement and Chlorhexidine
  irrigation/gel (1 RCT)
• systemic antibiotics 2 different local
  antibiotics resective surgery modification of
  the surface topography.
• Follow-up 3 months 2 years

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7 PERIMPLANTITIS
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7 Treatment of perimplantitis

• No difference between more complex procedures and
  conventional debridement in light forms of
  perimplantitis.
• The adjunctive use of local antibiotics
  (doxycycline) to debridement showed an
  improvement of about 0.6 mm for PAL and PPD,
  after 4 months in patients affected by severe
  forms of perimplantitis (bone loss gt 50).

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Where are the gaps

• Length of the follow-up (1-5 years minimum).
• To start with the simpler procedures.
• To include enough patients to detect a
  difference.
• Clearly define whether early or more advanced
  forms of perimplantitis are treated.

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What trials are needed
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8 Preprosthetic surgery vs implants

• Which intervention is more effective
  preprosthetic surgery and denture vs an implant
  supported prosthesis?
• Last literature search October 2005.
• 1 RCT with 60 participants.
• Patients treated with preprosthetic surgery and
  dentures are less satisfied than patients who
  received a mandibular overdenture on implants.

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Where are the gaps

• .?

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What trials are needed
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9 Use of prophylactic antibiotics

• Does the use of prophylactic antibiotics decrease
  postoperative complications and early failures?
• Last literature search March 2006.
• 0 RCT.

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Where are the gaps
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What trials are needed
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10 Zygomatic implants

• Zygomatic implants with and without bone grafting
  versus conventional implants in augmented bone.
• Last literature search March 2006.
• 0 RCT.

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Where are the gaps

• Zygomatic implants can be associated with
  frequent short and long-term complications (wrong
  positioning, chronic sinusitis) and are very
  difficult to be placed.
• It is extremely difficult to remove them.
• Computer guided surgery?
• Long follow-up (1-5 years minimum)

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What trials are needed
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11 Hyperbaric oxygen therapy

• Does hyperbaric oxygen (HBO) therapy decrease
  implant failures and complications in irradiated
  patients?
• Last literature search March 2006.
• 0 RCT.

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Where are the gaps
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12 Denture chewing surface designs

• Which denture chewing surface design should be
  used?
• Last literature search April 2004.
• 1 cross-over RCT with 30 participants (1 RCT
  excluded) lingualised (maxillary anatomic and
  mandibular non-anatomic) vs zero-degree teeth.
• Patients preferred dentures with lingualised
  teeth.

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Where are the gapsANY OTHER SUGGESTED TOPIC

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THANK YOU

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