Interventions for replacing missing teeth: treatment of perimplantitis

Background : One of the key factors for the long‐term success of oral implants is the maintenance of healthy tissues around them. Bacterial plaque accumulation induces inflammatory changes in the soft tissues surrounding oral implants and it may lead to their progressive destruction (perimplantitis) and ultimately to implant failure. Different treatment strategies for perimplantitis have been suggested, however it is unclear which are the most effective. Objectives : To identify the most effective interventions for treating perimplantitis around osseointegrated dental implants. Search strategy : We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomized controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 15 March 2006. Selection criteria : All RCTs of oral implants comparing agents or interventions for treating perimplantitis around dental implants. Data collection and analysis : Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. We contacted the authors for missing information. Results were expressed as random‐effects models using weighted mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals (CI). Heterogeneity was to be investigated including both clinical and methodological factors. Main results : Seven eligible trials were identified, but two were excluded. The following procedures were tested: (1) use of local antibiotics versus ultrasonic debridement; (2) benefits of adjunctive local antibiotics to debridement; (3) different techniques of subgingival debridement; (4) laser versus manual debridement and chlorhexidine irrigation/gel; (5) systemic antibiotics plus resective surgery plus two different local antibiotics with and without implant surface smoothening. Follow up ranged from 3 months to 2 years. No meta‐analysis was conducted due to different interventions tested and outcomes used. No side effects occurred in any of the trials. The only significant statistically differences were observed in a 4‐month follow‐up RCT evaluating the use of adjunctive local antibiotics to manual debridement in patients having lost at least 50% of the supporting bone around the implants. There were improved probing attachment levels (PAL) mean differences of 0.61mm (95% CI 0.40 to 0.82), and reduced probing pockets depths (PPD) mean differences of 0.59mm (95% CI 0.39 to 0.79) in those patients receiving adjunctive local antibiotics. This trial was judged to be at high risk of bias. Authors' conclusions : There is no reliable evidence suggesting which could be the most effective interventions for treating perimplantitis. This is not to say that currently used interventions are not effective. However, the use of local antibiotics in addition to manual subgingival debridement was associated with a 0.6mm additional improvement for PAL and PPD over a 4‐month period in patients associated with severe forms of perimplantitis. In three trials, the control therapy which basically consisted of a simple subgingival mechanical debridement seemed to be sufficient to achieve results similar to the more complex and expensive therapies. Smoothening of rough implant surfaces was not associated with statistically significant improvements of the clinical outcomes. However, sample sizes were small, therefore these conclusions have to be considered with great caution. More well‐designed RCTs are needed. Plain language summary : As with natural teeth, dental implants can be lost due to gum disease (perimplantitis). This review looked at which are the most effective treatments to arrest perimplantitis Five studies were included in the review and evaluated five different treatment modalities. In one small study of short duration (4 months) it was shown that the use of locally applied antibiotics in addition to the deep manual cleaning of the diseased implants decreased the depth of the pockets around the implants of an additional 0.6mm in patients affected by severe forms of perimplantitis. In conclusion, at present, there is no reliable evidence to determine which is the most effective way to treat perimplantitis. This is not to say that currently used interventions are not effective. The majority of trials testing more complex and expensive therapies did not show any statistically or clinically significant advantages over the deep mechanical cleaning around the affected implants.     

Interventions for replacing missing teeth: Antibiotics in dental implant placement to prevent complications: Evidence summary of Cochrane review

The failure of dental implant can occurs at the preoperative planning stage, at the surgical stage, and at the postoperative stage. The success of this treatment can be increased if the clinical implant practice guidelines are prepared based on the recommendations from the highest level of research evidence (i.e.,) from systematic review of randomized controlled trials (RCTs) with meta-analysis. The Cochrane reviews of interventions are basically systematic reviews of RCTs with meta-analysis but follow a systematic methodological approach following the guidelines from Cochrane handbook for Systematic Reviews of Intervention. They give the current best evidence as they are updated every 2 years which is being the minimum period for an update. This evidence summary recommends the use of antibiotics, single dose of 2 g of amoxicillin 1 h prior to implant surgery to prevent implant failure, based on the body of evidence from the Cochrane review that was first published in 2003, 2008, and then updated twice in 2010 and 2013. The included studies are not from our population for the research question asked in this updated Cochrane review; hence, the need to do primary research in our population to support the available evidence is mandatory.Key Words: Antibiotics, evidence summary, implant placement     

Intervention for replacing missing teeth: Alveolar ridge preservation techniques for dental implant site development - evidence summary of Cochrane review

The Cochrane reviews have transparent reporting of the methodology to clarify the reader the methods used for writing the review; hence, each review becomes a large volume of scientific literature. This evidence summary of the Cochrane review published in 2015 for the question, what are the clinical effects (preservation of both width and height of bone, esthetic outcomes, complications, and failure of implant) for different alveolar ridge preservation techniques (ARP) and materials used in patients planning implant placement following extraction after 6 months follow-up. This review provides evidence for efficacy of different ARP techniques, materials, and superiority of one over the other. It also tries to settle the controversy of timing of placement of implant after grafting. Of the 8 included studies from 50, two trials provide moderate evidence for xenografts versus extraction favoring xenografts in preserving the width and height of bone by 1.97 mm (2.48–1.46) and 2.60 mm (3.43–1.76), respectively in pooled estimates of meta-analysis. Using different material, five-trial were found; of which, two trials provide moderate evidence for alloplast versus xenografts favoring alloplast in preserving the width by 0.44 mm (0.90–0.02) and low-grade evidence for height of bone by 0.35 mm (0.86–0.16) in pooled estimates of meta-analysis. There is a paucity of randomized controlled trial to address other primary and secondary outcomes addressed in this review.Key Words: Alveolar ridge preservation, evidence summary, implant placement     

All-ceramic inlay-retained fixed dental prostheses for replacing posterior missing teeth: A systematic review

Purpose

To evaluate the current status of all-ceramic inlay-retained fixed dental prostheses (CIR-FDPs) for the replacement of posterior teeth.

Treatment planning for replacing missing teeth in UK general dental practice: current trends

Summary The aim of this study was to examine the confidence, barriers and attitudes towards the replacement of missing teeth by general dental practitioners (GDPs). The perceived impact of the recently introduced National Health Service (NHS) contract on the provision of prosthodontic treatments was also considered. Pre‐piloted postal questionnaires were mailed to 500 GDPs in Wales. Open‐ and closed‐ended questions were utilised to establish confidence, adequacy of training and attitudes towards treatments for replacing missing teeth. Two hundred and seventeen completed questionnaires were received (response rate = 43·4%). Many respondents described themselves as ‘confident’ or ‘very confident’ in the provision of removable partial dentures (RPDs) (acrylic = 100%, metal based = 99·5%), cantilever resin‐bonded bridges (94·4%) and conventional bridgework (98·6%). GDPs were ‘not confident’ providing fixed‐fixed resin‐bonded bridges (21·1%) or implants (81·4%). Financial barriers were identified to the provision of prosthodontic treatments, including comments such as “the new [National Health Service] contract does limit the treatments available”. Privately funded patients were more likely to be offered a fixed bridge or implant replacement of a missing upper first molar, whereas non‐privately funded patients were more likely to be offered no treatment (P < 0·01). Most respondents reported confidence at providing more routine forms of prosthodontic care such as RPDs and bridges. It appears that funding arrangements may have an impact on treatments offered to replace missing teeth, particularly under the current NHS contract.     

Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate,immediate‐delayed and delayed implants)

Background:  ‘Immediate’ implants are placed in dental sockets just after tooth extraction. ‘Immediate‐delayed’ implants are those implants inserted after weeks up to about a couple of months to allow for soft tissue healing. ‘Delayed’ implants are those placed thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential disadvantages are an increased risk of infection and failures. After implant placement in postextractive sites, gaps can be present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the best augmentation technique. Objectives:  To evaluate success, complications, aesthetics and patient satisfaction between ‘immediate’, ‘immediate‐delayed’ and ‘delayed’ implants. To evaluate whether and when augmentation procedures are necessary and which is the most effective technique. Search strategy:  The Cochrane Oral Health Group’s Trials Register (to 2 June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 – 2 June 2010) and EMBASE via OVID (1980 – 2 June 2010) were searched. Several dental journals were handsearched. Selection criteria:  Randomized controlled trials (RCTs) comparing immediate, immediate‐delayed and delayed implants, or comparing various bone augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional loading. Data collection and analysis:  Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Trial authors were contacted for any missing information. Results were expressed as random‐effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). The statistical unit of the analysis was the patient. Main results:  Fourteen eligible RCTs were identified but only 7 trials could be included. Four RCTs evaluated implant placement timing. Two RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT compared immediate‐delayed versus delayed implants in 46 patients. After 2 years patients in the immediate‐delayed group perceived the time to functional loading significantly shorter, were more satisfied and an independent blinded assessor judged the level of the peri‐implant marginal mucosa in relation to that of the adjacent teeth as more appropriate (RR = 1.68; 95% CI 1.04 to 2.72). These differences disappeared 5 years after loading but significantly more complications occurred in the immediate‐delayed group (RR = 4.20; 95% CI 1.01 to 17.43). One RCT compared immediate with immediately delayed implants in 16 patients for 2 years and found no differences. Three RCTs evaluated different techniques of bone grafting for implants immediately placed in extraction sockets. No statistically significant difference was observed when evaluating whether autogenous bone is needed in postextractive sites (1 trial with 26 patients) or which was the most effective augmentation technique (2 trials with 56 patients). Authors’ conclusions:  There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate‐delayed or delayed implants, therefore these preliminary conclusions are based on a few underpowered trials often judged to be at high risk of bias. There is a suggestion that immediate and immediate‐delayed implants may be at higher risks of implant failures and complications than delayed implants. On the other hand the aesthetic outcome might be better when placing implants just after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques are superior to the others.     

Injectable bone applied for ridge augmentation and dental implant placement: human progress study

PURPOSE: The aim of this study was to clinically evaluate the success of implants placed in conjunction with a new material, tissue-engineered bone, and the stability of the regenerated bone after functional loading on a long-term basis. METHODS: The tissue-engineered bone was applied to 14 cases, in which 6 patients were with partially or totally edentulous arches scheduled for sinus floor grafting and 8 patients underwent concurrent onlay plasty. RESULTS: This study showed that the injectable bone formation induced bone in this anatomical site in 100% of the patients. The results also indicate that it might be possible to achieve the osseointegration of simultaneous implant placements with the grafts. CONCLUSIONS: It may be possible that injectable bone can shorten the period of implant treatment and reduce the patient's burden and expect good long-term prognosis.     

Intervention for replacing missing teeth: Partially absent dentition-Evidence summary of Cochrane review

Cochrane reviews are systematic reviews with meta analysis published by the Cochrane collaboration, in the Cochrane Database of Systematic Reviews (CDSR). These reviews provide the clinicians with the highest level of evidence as they use a highly structured and transparent systematic review model to address a specific research question.The management of partially absent dentition is routinely under taken by general dentist and Prosthodontist but clinical practice guidelines based on evidence to this common problem is yet to be summarized. This Cochrane systematic review aims to address the effect of different prosthesis for the treatment of partially absent dentition in the terms of, Long-term success, function, morbidity, and patient satisfaction. All randomized controlled trials were searched till March 18, 2011, based on the inclusion and exclusion criteria, 21 trials were included and 32 trials were excluded and, it was critically appraised using the Cochrane methodology for interventions. The summary of evidence from the study concludes that there is insufficient evidence to state the effectiveness of removable and fixed prosthesis in partially edentulous subjects in the following four outcomes. There were insufficient trials to perform a meta-analysis and sensitivity analysis.This evidence-based summary emphasizes and reinforces the need to reassess the quality of research currently pursued in our profession, to address the need to provide higher level of evidence for common conditions like partial edentulousness. The included studies are basically not from our population too, hence the urgency to address this critical issue.     

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对患者进行种植修复时,上下颌骨种植区垂直向和(或)水平向骨质的吸收,无疑给医生提出了一个难题。为确保种植区符合种植条件,必要的剩余牙槽骨尤为重要。本文对近年来改善颌骨种植区骨量不足的外科手术技术及其研究进展进行综述,为临床操作提供帮助。     

2种方法治疗种植体植骨术后早期感染的临床比较

目的 探讨种植体植骨术后早期感染的临床治疗方案.方法 种植体植骨术后早期感染患者16例,共计28枚种植体.共采取2种治疗方法,方法1:彻底清创同期植骨,共处理患者9例,种植体16枚;方法2:取出种植体,重新种植,共处理患者7例,种植体12枚.通过评价种植体的存留率,比较2种处理方法的临床效果.结果 2例2枚种植体按照方法1处理后未取得预期效果,最终种植体失败取出,其余种植体均成功.2种方法处理的种植体10年累计存留率分别为87.5％ (14/16)、100.0％ (12/12),差异无统计学意义(x2=9.393,P=0.263).结论 彻底清创同期植骨和取出种植体重新种植均能有效解决种植体植骨术后的早期感染问题.     

Vertical bone augmentation with dental implant placement: efficacy and complications associated with 2 different techniques. A retrospective cohort study

PURPOSE: To compare retrospectively the efficacy of and complications associated with 2 different techniques for vertical bone augmentation at implant placement: autogenous particulated bone grafts covered either by nonresorbable titanium-reinforced e-PTFE barriers or by resorbable collagen barriers supported by osteosynthesis plates. MATERIALS AND METHODS: Nineteen partially edentulous patients were consecutively treated: 11 patients had 18 implants treated for vertical bone augmentation with nonresorbable barriers, whereas 8 patients had 11 implants treated with resorbable barriers supported by osteosynthesis plates. Two independent assessors evaluated the amount of tissue regenerated and complications based on photographs and/or radiographs. RESULTS: No implants failed. In the group treated with nonresorbable barriers, complete bone regeneration was obtained for 12 of 18 implants. More than 50% of the planned regeneration was obtained for the remaining 6 implants. One patient had a dehiscence with suppuration that required an additional surgical intervention to remove the barrier. For resorbable barriers, complete regeneration was obtained for 10 of 11 implants. Dehiscences occurred in 2 patients. In 1 case no treatment was necessary. The other patient was treated with applications of chlorhexidine gel; more than 50% of the desired bone regeneration was obtained. DISCUSSION AND CONCLUSIONS: No statistically significant differences for the amount of regenerated tissue and complications were observed between the 2 techniques; however, the power of the study was too low to detect a difference, if any. Randomized clinical trials with a sufficient number of patients are needed to determine which could be the most effective technique for vertical ridge augmentation.     

正畸技术联合种植修复技术治疗先天缺牙错[牙合]的临床应用体会

目的：探讨正畸技术联合种植修复技术治疗先天缺牙错的临床应用效果。方法：7例先天缺牙患者采用正畸技术集中间隙后植入14枚XIVE柱状螺纹纯钛种植体,治疗完成后用活动保持器保持。结果：14枚种植体经过12-38个月的随访无一例失败,并且牙列的咬合关系保持良好。结论：正畸联合种植义齿修复是一种较好的治疗先天缺牙错[牙合]的临床方法。     

正畸种植联合治疗长期牙齿缺失

目的探讨正畸种植联合治疗长期牙齿缺失患者的临床疗效。方法收集15例长期牙齿缺失病例（21颗种植体）,利用正畸方法获得足够的种植修复空间后行缺牙区种植修复。结果15例患者均获得足够的种植修复空间,牙种植骨整合成功,获得良好的临床疗效。结论正畸联合种植修复是一种治疗患者长期牙齿缺失的有效方法。