ID_Vol6_NR4_2011_EN_DE

Published by IF Publishing, Germany

Cranio-maxillofacial

Implant Directions®

Vol. 6 N� 4 December 2011

Full length Article»AntimicrobiAl Activity oF nAci solution As A medium For

preservAtion oF dentAl implAnts

Full length Article»peri - implAntitis And implAnt chArActeristics in dentAl

implAntology: A systemAtic review

Full length Article»soFortbelAstung bei totAlrehAbilitAtion des ober - und unterkieFers beim vorliegen einer Augeprägten Atrophie

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CMF.Impl.dir.ISSN 1864-1199e-ISSN 1864-1237

CMF. Impl. Dir. Vol. 6 No. 4 2011 89

Antimicrobial activity of NaCl solution as a

medium for preservation of dental implants.

Authors:

Daniil V Rublevsky – Postgraduate student Dental department Belorussian state medical [email protected] cell#+375291271544Dzerginskogo st. 83-7 Minsk Belarus

Alexey V Stugarev-Dentist/Private practice Mogilev Belarusvate practice Mogilev Belarus

Prof. Dr. Stefan K.A. IhdeInternational Implant Foundation MunichHead of Dental Implant FacultyLeopoldstr. 116DE- 80802 Munich/Germanyemail: [email protected]

Dr. Antonina IhdeLindenstr. 68CH-8738 Uetliburg/Switzerlandemail: [email protected]

Abstract

Implant infection and periimplantitis are recur-rent and serious problem in implantology. Multi-ple techniques have been discovered to prevent biofilm formation and avoid the failure of the implant in dental practice. We propose that use of NaCl solution as preservation medium for dental implants may be a simple and cost reduc-tive method of avoiding implant contamination before implantation procedure. Four strains of health relevant micro-organism were used

for testing the disinfection efficiency of various concentrations of NaCl solution. Freeze resis-tance of NaCl solution samples was tested at -19˚C. In Comparison group gamma-sterilization (25kGy) was applied. The results prove effective-ness of Gamma-sterilization technique; applica-tion of sodium chloride of physiologic concen-trations for storage of bone dental implants is questionable. Application of NaCl in higher con-centrations (8-9 %) seems to be a reasonable strategy for implant preservation and storage. Our data shows that it may be possible in the future to supply dental implants without them being radiated. This would save costs in produc-tion and allow a larger part of the population, to access dental implant treatment.

Keywords:

Dental,desinfection, implantation, sterilization, sodium chloride

Oral cavity is a particular area of the concern due to its high microbial contamination that makes minimization of bacterial adhesion prior to placing an implant difficult even under ideal circum-stances (Keefe Morrgan, Keefe Michael 2009). If bacteria adhesion occurs before fibro vascular ingrowths takes place, immune defense often cannot prevent surface colonization for certain bacterial species that form a protective biofilm layer. Inhibiting bacterial adhesion is essential to prevent implant-associated infection, because biofilm is extremely resistant to both the immune system and antibiotics. (Ewal A. and Ihde S. 2009; Stoodley P. et al 2002; Rice L.2006; Trampuz A. et al 2003). Therefore proper sterilization and storage of an implant material prior to implantation

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procedure on one hand and provision of antimicro-bial environment at the implant site by enhancing physic-chemical properties of the implant surface on the other hand are claimed to be compulsory conditions of successive implantation. ( Serro A.P., Saramago B.; Simichi A. et al 2011; Decraene V. et al 2008; Jones F.H.2001). Possibility of using NaCl solution of various concentrations (0,9; 2;4;8;9 vol %) as a medium for implant storage might be an option to other methods of avoiding the contamination of implant surface. This may be simple and cost-reductive possibility to keep the implant surface free of miclobial agents prior to implantation.

Material and methods

Testing strains.For testing the disinfection efficiency of various

concentrations of NaCl solution following health relevant micro-organism were used: Escherich-ia coli CCM 3954, Staphylococcus aureus CCM 2022, Pseudomonas aeruginosa CCM 3955, Candida albicans CCM 8215. Density 1 accord-ing to McFarland scale (approximately 108 KTJ/ml), 0.05 ml of micro-organism suspension was used for 5 ml of the solution tested. Esch-erichia coli is considered as a general indicator of environment cleanliness. S. aureus, P. aeru-ginosa and C. albicans are conditionally patho-genic micro-organisms with affinity towards mucous tissues. Test procedure.Physiologic solution (batch of 9g of NaCl into

1000 ml of H200) antimicrobial efficiency and disinfection characteristics of NaCl solu-tion of selected concentrations (2;4;8;9 vol %) were analyzed. A standard quantity of 24-hour

micro-organism suspension - density 1 accord-ing to McFarland scale (= about 108 KTJ/ml) was inoculated into a solution of the selected NaCl concentration (after 24 hours from the solution preparation), 0.05 ml of suspension per 5 ml of the solution tested was used. Further samples were taken from these samples after 24 hours, 5 days and 10 days, for the purpose of verification of presence of individual micro-organisms. If the presence of the micro-organ-ism is not confirmed, the result is expressed as “efficient” (confirmation of the disinfection effect of the solution). The test method was growing the extracts on agar (medium).Same procedure was applied for the control group where implants were sterilized with gamma-sterilisation (25kGy).Freeze resistance analysis.Since preservation conditions often require application of low temperature additionally the freeze resistance of the solution was tested. Freeze resistance of NaCl solution samples was tested at -19˚C. Samples were analyzed after 60, 120 min and 24 hours of application of the temperature.

Results

Gamma-sterilisation (25kGy) reduces bacterial activity at of all tested strains.Disinfection efficiency analysis of NaCl (0,9 %)

solution failed to reveal it’s antimicrobial prop-erties on the 1st, 4th and 6th day of the experi-ment. Table 1.


Test strainSolution activity time

1 day 4 days 6 days

Escherichia coliCCM 3954

inefficient inefficient inefficient

Staphylococcus aureusCCM 2022


Pseudomonas aeruginosaCCM 3955


Candida albicansCCM 8215


Fig 1. Antimicrobial efficiency of NaCl 0,9 % solution at 1st 4th and 6th day of experiment.

NaCl 2 % (vol %) concentration was ineffective in a time period of 10 days. The concentration of 4 % (vol %) NaCl solution after 5 days of application was efficient for S.aureus and P.aeruginosa ,inefficient for E.coli and Candida albicans. On the 10th day of experiment NaCl solution concentrations 8 % and 9 % ( vol %) demonstrated its effectiveness for all the tested strains of microorganisms. Table 2

Solution activity time

Sample no.: 857NaCI concentration 2 % (vol. %)

1 day 5 days 10 days

Escherichia coli CCM 3954 inefficient inefficient inefficient

Staphylococcus aureus CCM 2022 inefficient inefficient inefficient

Pseudomonas aeruginosa CCM 3955 inefficient inefficient inefficient

Candida albicans CCM 8215 inefficient inefficient inefficient



Escherichia coli CCM 3954 inefficient inefficient inefficient

Staphylococcus aureus CCM 2022 inefficient inefficient efficient

Pseudomonas aeruginosa CCM 3955 inefficient inefficient efficient

Candida albicans CCM 8215 inefficient inefficient inefficient



Escherichia coli CCM 3954 inefficient inefficient efficient



Candida albicans CCM 8215 inefficient inefficient efficient



Escherichia coli CCM 3954 inefficient inefficient efficient



Candida albicans CCM 8215 inefficient inefficient efficient

Fig 2 . Antimicrobial efficiency of NaCl solution (2, 4, 8, 9 vol %) at 1st 5th and 10th day of the experiment.

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Discussion

Because the implant doesn’t have its own blood supply, which exclude an opportunity of carrying intravenous antibiotics or host antibi-otics or other immune agents to fight bacteria, one of the main concerns is the risk of the expo-sure to micro-organisms that are in the region of the implant placement. Multiple techniques have been discovered to prevent biofilm forma-tion and avoid the failure of the implant. To date, different surface modifications strategies for dental implants have been investigated. One direction of modification is connected with the development of special implant shape (macro-scale), surface properties on micro and nano-metric scale. Surface porosity, procedures of sandblasting, acid etch, nanomodification pro-vide favorable conditions for rapid colonization of the implant surface by body cells. (Simichi A. el al 2011; Buser D. et al 2004 ; Sclafani A. and Romo T. 2000; Spector M. et al 1979). Chemi-cal modification by applying various antimicro-bial coatings was proposed to keep the implant surface free of microbial contaminants during surgery and first days after implant placement

when microorganisms and body cells compete for the colonization of the substrate. (Gristina A.G. 1987) Direct impregnation with the anti-biotics (Tasman AJ. et al 2000) coating with active antimicrobial metal such as copper and silver (Feng QL et al 2004; Furno F et al 1998) ,TiO2 films (Chung Cj et al 2007; Chung CJ et al 2009) and NO releasing materials (Smith D.J. et al 2003; Zhang H. et al 1996) ,nanos-tuctured coatings (Schrand A.M. et al 2007; Popat K.C. et al 2007) ,salt impregnation (Ewal A. and Ihde S. 2009) have been used. Ster-ilization is the last step of the processing of any implant material and it has an important clinical impact. The most commonly used ster-ilization processes for dental implant materials are steam autoclaving and γ-irradiation which are considered to be safe with respect to chem-ical contamination of the surface. Other mo-dalities of sterilization such as laser and ultra-violet light sterilization, glow plasma discharge, supercritical phase CO2 sterilization techniques have been introduced.( Hill C.M. et al 2000; Ar-onsson O.et al 1997; Schwartz Z. et al 2007)Together with satisfying antimicrobial effects

The results of the freeze resistance analysis are depicted in Table 3.

NaCI solutionconnentrations % (vol.)

Time of application of the temperature “-19˚C”

60 minutes 120 minutes 24 hours

2 frozen frozen frozen

4 frozen frozen frozen

8 partially frozen frozen frozen

9 liquid partially frozen frozen

Fig3. Freeze resistance of selected NaCl solution concentrations.

Solution with concentration 2 and 4 vol % of NaCl exhibited no freeze resistance already after an hour of temperature application. Only 9 % vol concentration of the solution demonstrated full and partial freeze resistance after 60 and 120 minutes of the experiment accordingly.


authors note some adverse effect of γ-irradiation such as an increase in the hydrophobicity of the implant surface ; the modification of Ti surfac-es was also discussed in literature (Serro A.P., Saramago B.). Most of the mentioned methods of sterilization are relatively expensive there-fore a simple cost –reductive way of keeping the surface of the implant free of microbial contaminant during storage period is needed. Sodium chloride solution is often used as a medium for storing the implant materials including Ti dental implants (Buser D. et al 2004; Aronsson O. et al 1997). Researchers describe enhanced “bone opposition” to the implants stored in 0,9 % NaCl. (Buser D. et al 2004) Saline solutions have a vast application in implant medicine including dentistry. (Dowden RV. 2010) Sodium chloride is used as implant preservation liquid which is used during packing the implant and it’s storage before implantation (Buser D. et al 2004). Most of the bacteria can’t survive in the environment with low water activity. NaCl provide special osmotic conditions that result in loss of water and subsequent collapse of micro-organisms. The osomolarity of the bone tissues is about double of that in the blood (Ewal A., Ihde S. 2009) so description physiologic corresponds only to blood but not to bone tissue. Thus the amount of NaCl inphysiologic solution is hypo-physiologic for bone and the storage of dental implants in 0,9 % NaCl can’t provide favorable osmotic conditions. Therefore NaCl solution of different concentrations was tested with the regards of its antimicrobial activity and low tem-perature resistance. An experiment revealed lack of antimicrobial activity of sodium chloride

solution in concentrations 0,9; 2 and 4 vol %. NaCl concentrations of 8 and 9 vol % dem-onstrated satisfactory disinfection efficacy. 9 % NaCl solution demonstrated decent freeze resistance. The results prove that application of sodium chloride of physiologic concentrations for storage of bone dental implants is question-able. Application of NaCl in higher concentra-tions (8-9 %) seems to be a reasonable strat-egy for implant preservation and storage. Gamma sterilization method is very fast and effective, but storage of the implants without salt solution bears the risk that sterilization might get lost over time Despite the proven antimicrobial activity of saline solution of mentioned concentrations, thorough cleaning of the implants before packaging is necessary, because presence of nei-ther vital nor killed bacteria on the implant is highly undesirable.

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Aronsson O, Lausmaa J.and. Kasemo B. Glow discharge plasma treatment for surface cleaning and modification of metallic biomaterials. J Biomed Mater Res 1997; 35: 49–73 Buser D.Broggini N. Wieland MSchenk RK. Denzer AJ Cochran DL. Enchanced bone apposition to a

chemically modified SLA titanium surface. J Dent res 2004;83:529-33Chung CJ, Lin HI, TsouHK, Shi ZY, He JL. An antimicrobial TiO2 coating for reduction hospital-

acquired infection. J Biomed Mater Res B 2007;85:220-4.Chung Cj, Lin HI, Chou CM, Hsieh PY, Hsiao CH, Shi ZY et al. Inactivation of Staphylococcus aureus

and Escherichia coli under various sources on photocatalytic titanium dioxide thin film. Surf Coat Tech 2009;203:1081-5.Decraene V. Ready D.Pratten J. Wilson M. Air-borne microbal contamination of surfaces in a UK

dental clinic. J Gen Appl Microbiol 2008;54:195-203.Dowden RV. Discussing the advantages of saline and silicone implants in clinical practice. Comment

on Aesthet Surg J. 2010; 30(4):557-70.Ewal A, Ihde S. Salt impregnation of implant materials. OOOE 2009:20:1-6 Feng QL, KimTN, Wu J, Park ES, Kim JO, Lim DY et al. Antibacterial effects of Ag-Hap thin films on

aluminia substrates. Thin Solid Films 1998;335:214-9.Furno F. MorleyKS. Wong B,SharpBl, Arnold PL et al. Silver nanoparticles and polymeric medical

devices: a new approach to prevention of infection? J Antimicrob Chemoth 2004;54:1019-24.Gristina AG. Biomaterial-centered infection: microbial adhesionversus tissue integration. Science

1987:237:1588-95.Hill CM, Kang QK, Wahl C, Jimenez A, Laberge M, Drews M, Matthews MA, An YH. Biocompatibility

of supercritical CO2-treated titanium implants in a rat model. Int J Artif Organs. 2006; 29(4):430-3.Jones F.H. Teeth and bones: applications of surface science to dental materials and related

biomaterials, Surf Sci Rep 2001;42: 75–205. Keefe Morrgan, Keefe Michael An evaluation of the effectiveness of different techniques for intraop-

erative infiltration of antibiotics into alloplastic implants for use in facial reconstruction. Arch Facial Plast Surg . Jul/Aug 2009;11(4):246-251.Popat KC, EltgrothM, La Tempa TJ, Grimes CA et al. Decreased Staphylococcus epidermidis

adhesion and increase osteoblast functionality on antibiotic – loaded titania nanotubes. Biomaterials 2007;28:4880-8. Rice L. Unmet medical needs in antibacterial therapy. Biochem Pharmacol 2006; 71:991-5Sclafani A. Romo T,Biology and chemistry of facial implants. Facial Plast Surg 2000; 16(1):3-6Schrand AM, Huang HJ, Carlson C, Schlager JJ, Osawa E, Hussain Sm et al. Are diamond nanopar-

ticles cytotoxic? J Phys Chem B 2007; 111:2-7.Schwartz Z, Lohmann CH, Blau G, Blanchard CR, Soskolne AW, Liu Y, Cochran DL, Dean DD, Boyan

BD. Re-use of implant cover screws changes their surface properties but not clinical. Clin Oral


Implants Res. 2000; 11(3): 183-94.Serro AP, Saramago B .Influence of sterilization on the mineralization of titanium implants induced by

incubation in various biological model fluids. SourceCentro de Química Estrutural, Instituto Superior Técnico, Av. Rovisco Pais, 1049-001 Lisboa, Portugal.Simichi A.,Tamijid E.,Pishbin F.,Boccaccini A. Recent progress in inorganic and composite

coatings with bacterial capability for orthopaedic applications. Nanomedicine: nanotechnology and Medicine2011;7:22-39.SmithDJ, Chakavarthy D, Pulfer S, Simmonas ML, Saavedra JE et al. Nitric oxide – releasing

polymers containing th [N(O)NO]-group. J Med Chem 1996;39:1148-56. Spector M. Harmon Sl. Kreutner A. Characteristics of tissue growth into Proplast and porous

polyethylene implants in bone. J Biomed Mater Res 1979;13(5):677-692 Stoodley P. Saver K. Davies DG, costerton JW. Biofilms as complex differentiated community .

Ann Rev Microbiol 2002: 56 : 187-209.Tasman AJ. Wallner F. Neumier R. Antibiotic impregnation of cartilage implants :diffusion kinetics of

fluoroquinolones. Laryngo Rhino-otologie; 2000:79:30-3 Trampuz A, Osmon D, Douglas R, Hanssen A, Steckelberg J, Patel R. Molecular and antibiofilm

approaches to prosthetic joint infection. CLIN orthop RELAT r 2003; 414:69-88.Zhang H, Annich GM,Miskulin J, Stankiewicz K, Osterholzer K et al. Nitric oxide – releasing fumed

silica particles :synthesis characterization and biomedical application.J Am ChemSoc 2003; 125:5015-24.

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Peri-implantitis and implant characteristics

in Dental Implantology: A Systematic Review

Authors:

Dr. med. dent. Sigmar KoppNiklotstrasse 39D-18273 Guestrow / GermanyPhone business: +49 3843 214553Phone home: +49 3843 843967Mobil phone: +49 172 301 31 58Fax.: +49 3843 22272e-mail: [email protected]

Dr. Thomas MaierBahnhofstrasse 7D-73447 Oberkochen / [email protected]

Prof. Dr. Stefan K.A. IhdeInternational Implant Foundation MunichHead of Dental Implant FacultyLeopoldstr. 116DE- 80802 Munich/Germanyemail: [email protected]

Abstract

Objective: To report outcomes of treatment for periimplantis and to determine the influence of implant characteristics.

Methods

A systematic review of literature was per-formed. The strength of literature was classified using the Grading of Recommendations Assess-ment, Development, and Evaluation (GRADE).

Results

103 articles were screened and 24 met the inclusion criteria. Treatment modalities were categorized into chemical, mechanical, and surgical interventions. Conflicting results were found regarding outcomes of various chemical treatments using antibacterials com-pared to mechanical debridement. Chemical treatments may have a beneficial effect upon gingival parameters. Only implant surface modification resulted in significantly improved gingival parameters. The influence of implant diameter was not significant. Different studies reported results without leading to a gener-able suggestion. In regards to surface struc-ture, implants with roughened surfaces lead to a greater incidence of periimplantitis than did turned or machined implants. These find-ings correspondences with the only significant periimplantitis treatment by surface modification.

Conclusions

The quality of evidence of treatment out-comes for peri-implant disease is “Low”; for the relationship between implant diameter and peri-implant disease is “Very Low”, and between implant surface structure and peri-implant disease is “Moderate” to “Low”. The small number of available studies limits conclusions for periimplant disease as well as prognostic factors such as implant diameter and surface structure.

Keywords Peri-implantitis, treatment, implant diameter,

implant surface structure

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Introduction

Inflammatory lesions that develop in the tissues around implants are collectively recog-nized as peri-implant diseases. Peri-implant dis-ease includes peri-implant mucositis and periim-plantitis. Peri-implant mucositis is a reversible inflammatory reaction in soft tissues surround-ing a functioning implant with no signs of loss of supporting bone. Peri-implantitis is described as inflammatory reactions associated with loss of supporting bone around an implant in function. [1] The clinical presence of peri-implant disease requires periodontal probing to identify bleed-ing and/or suppuration, while radiographs are required to detect the presence (periimplantitis) or absence external f of marginal or crater-like bone loss. The pathogenesis of peri-implantitis seems to be related to the peri-implant en-vironment and the soft tissue/implant inter-face, patient-related factors, and microbial fac-tors. Potential causes include bacterial biologic complications [2,3], mechanical overload [4], or a combination of these factors. It has been suggested that microbial colonization of the im-plant surface and infection of the peri-implant tis-sues may result in peri-implant bone destruction [1]. Some reports have indicated a healing po-tential of peri-implant tissues following suppres-sion of the peri-implant microbiota.[5] Because mechanical cleansing around implants is hampered by threads and often a rough sur-face structure, the use of mechanical debride-ment alone might not be sufficient to suppress the microflora to a level associated with heal-ing and healthy peri-implant tissues.[6] The use

of chemical agents (irrigation with local disin-fectants, local or systemic antibiotic therapy) has been recommended to enhance healing after treatment.[7] The elimination of biofilm is essential in the management and control of peri-implant infections.[8,6] The screwshaped designs of dental implants, combined with sur-face modifications that allow for an enhanced osseointegration, may also enhance biofilm formation, and thereby increase the risk for inflammation.[9] Since the surface structure of the implant hinders to remove hard and soft de-posits from the implant surface without surgical intervention, another treatment option may be regenerating bone defects around the implants.[10] The use of laser systems has been pro-posed for the treatment of peri-implant infec-tions since lasers can perform excellent tissue ablation with high bactericidal and detoxifica-tion effects.[11] Another phenomenon called “retrograde periimplantitis” has been recently described in literature.[12,13] It is defined as a periapical radiolucency that develops short-ly after implant insertion while the coronal portion of the implant achieves a healthy bone to implant interface and integrates well. This condi-tion may be accompanied by symptoms of pain, tenderness, swelling and/or the presence of a fistula. Such lesions start at the implant apex but may exhibit the capacity of spreading coro-nally, proximally, and facially. It has been ques-tioned whether or not implant characteristics such as diameter and surface structure may contribute to the development of peri-implant disease. Wider-diameter implants have been suggested in jaw regions with low-dense bone. They are used to avoid damage to the inferior


alveolar canal or maxillary sinus where there is inadequate bone available for implant place-ment.[14] In areas of a reduced buccolingual dimension (less than 4 mm in width), where the placement of a standard-diameter implant is not possible, narrow-diameter implants may be an alternative treatment.[15-17] Surfaces modifications with coating, surface blasting or acid treatments increase the surface area and roughness of the implant, which is proposed to improve osseointegration.[18-20] However, surface roughness may also increase the risk of periimplantitis [21]due to an increased sus-ceptibility to bacterial infection and rapid osse-ous breakdown around the implant site.[22,23] The purpose of this systematic review was to answer three clinical questions:1. What are the outcomes of treatment for

peri-implant disease?2. What is the relationship between implant

diameter and peri-implant disease?3. What is the relationship between surface

structure of dental implants and peri-implant disease?

Material and Methods

Electronic Literature DatabaseIn the first step, a systematic search in

MEDLINE and the Cochrane Collaboration Library for literature published through July 2009 was conducted to identify studies report-ing peri-implant disease with respect to the clini-cal questions identified above. Searches were done using standard MeSH terms (controlled vocabulary) as well as specific free-text terms and combinations of terms related to the clini-cal conditions. A subsequent hand search in the

bibliographies of key articles followed to ensure each topic was comprehensively examined. The retrieved and examined full text articles of those remaining applied the same inclusion criteria once more.Inclusion CriteriaFor questions of efficacy or effectiveness of

an intervention (i.e. treatment for peri-implant disease) or technology (i.e. implant diameter, implant surface structure), randomized con-trolled trials or comparative cohort studies were searched and included. Comparative cohort studies were defined as clinical stud-ies comparing the treatment or technology of interest to another concurrent treatment or technology. Studies of prognosis that identified risks or rates of complications from endosse-ous dental implants were included if both, the numerator (number of cases with the compli-cation or the number of complications) and the denominator (number of patients at risk for the complication) were reported. Results were limited to human cohorts, articles pub-lished in English, and articles that reported on peri-implant disease associated with endosse-ous dental implants. Only studies which report-ed both, clinical and radiographic diagnostic criteria for peri-implant disease, were evaluated. Exclusion CriteriaEditorials, review articles without quantita-

tive data, opinion articles, articles without sci-entific data or a report of their methodology, cadavers, and case reports were excluded (Figure 1). Studies with subjects less than 18 years of age and with less than 10 subjects were also omitted. For the first study ques-tion, studies specifically designed to evaluate

100

the outcomes of treatment for peri-implant dis-ease were desired. To determine the relation-ship between implant diameter and peri-implant disease (study question #2), studies that spe-cifically evaluated peri-implant outcomes asso-ciated with implant diameter were identified. To determine the relationship between surface structure of dental implants and peri-implant disease (study question #3), studies that evalu-ated peri-implant outcomes associated with den-tal implant surface structure were searched for. Data ExtractionEach retrieved citation was reviewed by two

independently working reviewers (D.N., D.J.F.). Most articles (61 %) were excluded on the basis of information provided by the title or abstract. Citations that appeared to be appropriate or those that could not be excluded from title or abstract were identified, and the corresponding full text reports were investigated. Any disagree-ment between the reviewers was resolved by con-sensus. The following data were extracted from the included articles: study design, study popu-lation characteristics, implant characteristics, definition of peri-implant disease, treatment/in-tervention for therapeutic studies, diagnostic tests and reference standards for diagnosis, outcome measures, study complications, and follow-up time. Study QualityArticles, which were selected for inclusion

were classified by level of evidence. The method for assessing the quality of evidence and the overall quality of the body of evidence incor-porates aspects of the rating scheme devel-oped by the Oxford Centre for Evidence-based Medicine.[24] It was used with modification by The Journal of Bone and Joint Surgery Ameri-

can Volume (J Bone Joint Surg Am),[25] pre-cepts outlined by the Grades of Recommenda-tion Assessment, Development and Evaluation (GRADE) Working Group[26] and recommen-dations made by the Agency for Healthcare Research and Quality (AHRQ).[27] Each individ-ual study was rated by two different investiga-tors based on pre-set criteria that resulted in an evidence rating (Level of Evidence I, II, III, or IV). Disagreements were resolved through discussion. AnalysisOutcomes were reported as the proportion

of patients experiencing an outcome or mean values for gingival and radiographic param-eters. Analysis was performed for quality of studies (level of evidence), quantity of stud-ies (the number of published studies similar in patient population, condition treated and outcome assessed) and consistency of results across studies (whether the results of the different studies lead to a similar conclusion).[28,27] Data were summarized in tables. It was judged whether the retrieved literature represented a minimum standard for each of the three domains using the following criteria: for study quality, at least 80 % of the studies reported needed to be rated as a level of evidence I or II; for study quantity, at least three published studies were needed which were adequately powered to answer the study question; for study consistency, at least 70 % of the studies had to have consistent results. The overall strength of the selected literature was expressed in terms of the impact that further research may have on the results. An overall strength of “HIGH” means that further research is very unlikely to change the results or the confidence in the results. The


overall strength of “MODERATE” is interpreted as further research is likely to have an impor-tant impact on the results and may change the results. A grade of “LOW” means that further research is very likely to have an important impact on confidence in the results and likely to change the results, while “VERY LOW” means that any result reported is uncertain. (Figure 2).

Results

103 articles were identified reporting on implant structure and peri-implant disease or outcomes associated with treatment for peri-implant disease. 40 were involved in full text review, whereof 16 were excluded for the following reasons: In thirteen articles, outcome did not include peri-implant disease, and three treatment efficacy studies were poorly designed, Figure 3. Of the remaining 24 articles, 16 provided information on outcomes of treat-ment for peri-implant disease (study question 1), 3 reported on the relationship between im-plant diameter and peri-implant disease (study question 2), and 5 provided information on the relationship between implant surface structure and peri-implant disease (study question 3).

Question 1. What are the outcomes of treatment for peri-implant disease?

Several comparative studies attempted to evaluate treatment outcomes for peri-implant disease are highlighted in Table 1. Fifteen of these studies were randomized controlled trials graded level of evidence II[29-34,9,35-42] and one was a prospective cohort study graded level of evidence III.[43] Treatment

modalities were categorized into chemi-cal, mechanical and surgical interventions. Five studies reported on the outcomes of chemical treatments using antibacterials for peri-implant disease. Two of these studies found a beneficial change in gingival parameters after using local antibiotics (Atridox)[44]or antiseptic (Chlorhexidine) [32] compared to mechanical debridement. Studies evaluating the effects of antibiotic (Tetracycline[37] or Metronidazole gel [42]) to mechanical debridement did not influ-ence gingival parameters. In one study a signifi-cant decrease in bleeding on probing in individu-als who were treated with Arestin was found.[45] Two studies evaluated the effects of me-chanical debridement using a Vector System compared to standard mechanical debride-ment. The autors did not find significant differ-ences in gingival parameters between these two mechanical treatment modalities.[30,9] Surgi-cal treatments for peri-implant disease were assessed in four studies.[31,35,43,41] In one study, periimplant defects were treated with a bone graft with or without a resorbable mem-brane and a significant decrease in periodon-tal probing depth in the group that received the resorbable membrane was found.[31] In an-other study implant surface modification was compared to resective surgery to treat peri-im-plant disease. Gingival parameters significantly improved in the surface modification group, while mucosal recession was significantly greater compared to the resective surgery group.[35] No differences in treatment out-comes were found in studies that investigated peri-implant defects with: a) bone substitute placement with vs. without a resorbable mem-

102

analysis of randomized controlled trials graded level of evidence I [47], one was a prospective cohort graded level of evidence II, [48] one was a prospective and retrospective cohort graded level of evidence II-III,[13] one was a retrospec-tive cohort graded level of evidence III, [49] and one was a case series graded level of evidence IV.[50] Esposito and colleagues [47] performed a meta-analysis to evaluate the frequency of pe-riimplantitis in implants with turned (machined) surfaces compared to those with roughened surfaces at 3 years following placement. Three randomized controlled trials were included [51,52,47,53] Peri-implantitis was significantly less in implants with turned compared o rough-ened surfaces (RR=0.80, 95 % CI: 0.67-0.98).In a prospective cohort study[48], 89 patients

were treated with 112 hollow screw, 49 hol-low cylinder, or 18 angulated hollow cylinder implants and were followed for 8 to 12 years. The incidence of peri-implantitis was 15.4 % (n=27/179). The incidence was greatest for hollow cylinder implants (29 %), followed by an-gulated hollow cylinder implants (12 %), and then hollow screw implants (10 %). The incidence of peri-implantitis was significantly greater for hol-low cylinder compared to hollow screw implants (p<.03). In a retrospective cohort study [54], stan-dard (n=53), self-tapping (n=14), MKII (n=320), MKIII machined (n=72), and roughened TiUnite (n=80) implants were placed and evaluated for he presence of retrograde peri-implantitis. The frequency of retrograde peri-implantitis was 9 %. The prevalence of retrograde peri-implantitis was significantly greater in TiUnite (10.0 %) om-pared to machined (0.4 %) implants (p<.0001). Evidence Summary

brane, [43] or b) natural bone placement with a resorbable membrane compared to bone substitute placement with no membrane.[41]

Question 2. What is the relationship between implant diameter and peri-implant disease?

One prospective cohort graded level of evidence III [46] and 2 case series graded level of evidence IV that evaluated the relationship between implant diameter and peri-implant disease were identified. (Table 2) In the pro-spective cohort study 68 patients were treat-ed with small (3.3 mm) diameter titanium plasma-sprayed (TPS) implants while 120 patients received standarddiameter (4.1 mm) TPS implants. Peri-implantitis was reported in 5.7 % (n=7/122) of narrow diameter implants and 3.4 % (n=7/208) of standard diameter implants.[46] Three narrow diameter and 2 standard diameter implants failed secondary to peri-implantitis. Additionally, 3 narrow diameter and 2 standard diameter implants experienced pathologic peri-implant bone resorption as a result of peri-implantitis. There were no signifi-cant differences in gingival parameters between the two groups.

Question 3. What is the relationship between surface structure of dental implants and periim-plant disease?

Four comparative studies and one noncom-parative study evaluated the relationship be-tween surface structure of dental implants and peri-implant disease.(Table 3) The stud-ies differentiated as follows: One was a meta-


The overall strength of evidence with respect to treatment outcomes for peri-implant disease is “Low”. The outcomes of treatment are unclear and further research could alter the results. Theoverall strength of evidence for the relation-ship between implant diameter and peri-implant disease is “Very Low”, indicating that, any result reported is uncertain. The overall strength of evidence for the relationship between implant surface structure and peri-implant disease is “Moderate” to “Low”, that means that, for surface microstructure, results are likely to have an important impact on the results and may change the results, and for surface mac-rostructure, further research is likely to change the results. The overall strength of evidence for each key question is highlighted in Table 4. The evidence levels stratified for the questions above, the summarized findings in the studies as well as a definition of the different levels of evidence for articles on therapy and prognosis of peri-implant diseases are in Table 5-11.

Discussion

This systematic review showed that there is a wide variety of treatment modalities for periimplant disease but just few significance. 1. Chemical treatments, in addition to me-chanical debridement, may have a beneficial effect upon gingival parameters. There appears to be no difference between types of mechanical treatment for peri-implant disease. There is minimal evidence proving that modification of the implant surface may have a beneficial effect upon peri-implant gingival parameters.2. The rate of peri-implantitis in small diam-

eter implants is reported to be 2.3 to 5.7 %. One comparative study demonstrated that the rate of peri-implantitis was greater in small diameter implants, though the difference was not statistically significant. One case series of large diameter implants reported no cases of peri-implantitis. So no direct influence from diameter to peri-implantitis could be found.3. The risk of peri-implantitis was greater in

roughened surface microstructure compared to machined dental implants. The small num-ber of studies limits conclusions with respect to treatment outcomes for periimplant disease as well as prognostic factors such as implant diameter and surface structure that may contribute to the risk for peri-implant disease. Additional studies may provide a more robust estimation if implant character-istics are associated with peri-implantitis.

104

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moderate and advanced periimplantitis lesions: A controlled clinical study. Clin Oral Investig 10 (4):279-288 40. Schwarz F, Bieling K, Latz T, Nuesry E, Becker J (2006) Healing of intrabony periimplantitis

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108

Figure Legends

Figure 1. Inclusion and Exclusion criteria. Figure 2. Definition of overall strength of evidence. Figure 3. Flow chart showing results of literature search

Table Legends

Table 1. Summary studies comparing treatment outcomes for peri-implant diseaseTable 2. Summary of studies evaluating outcomes associated with diameter of endosseous dental implantsTable 3. Summary of studies evaluating

48. Karoussis IK, Bragger U, Salvi GE, Burgin W, Lang NP (2004) Effect of implant design on survival and success rates of titanium oral implants: A 10-year prospective cohort study of the iti dental implant system. Clin Oral Implants Res 15 (1):8-1749. Teixeira ER, Sato Y, Akagawa Y, Kimoto T (1997) Correlation between mucosal

inflammation and marginal bone loss around hydroxyapatite-coated implants: A 3-year crosssectional study. Int J Oral Maxillofac Implants 12 (1):74-8150. Tang Z, Sha Y, Lin Y, Zhang G, Wang X, Cao C (2000) Peri-implant mucosal inflammation and

bone loss: Clinical and radiographic evaluation of 108 dental implants after 1-year loading. Chin J Dent Res 3 (2):15-2051. Astrand P, Engquist B, Anzen B, Bergendal T, Hallman M, Karlsson U, Kvint S, Lysell L,

Rundcrantz T (2002) Nonsubmerged and submerged implants in the treatment of the partially edentulous maxilla. Clin Implant Dent Relat Res 4 (3):115-12752. Astrand P, Engquist B, Dahlgren S, Engquist E, Feldmann H, Grondahl K (1999) Astra tech and

branemark system implants: A prospective 5-year comparative study. Results after one year. Clin Implant Dent Relat Res 1 (1):17-2653. Moberg LE, Kondell PA, Sagulin GB, Bolin A, Heimdahl A, Gynther GW (2001) Branemark

system and iti dental implant system for treatment of mandibular edentulism. A comparative randomized study: 3-year follow-up. Clin Oral Implants Res 12 (5):450-46154. Quirynen M, Abarca M, Van Assche N, Nevins M, van Steenberghe D (2007) Impact of support-

ive periodontal therapy and implant surface roughness on implant outcome in patients with a history of periodontitis. J Clin Periodontol 34 (9):805-815

outcomes associated with surface structure ofendosseous dental implantsTable 4. Rating of overall strength of evidence for each key question.Table 5. Level of Evidence grade for studies comparing treatments for peri-implant diseaseassociated with endosseous dental implantsTable 6. Level of Evidence grade for studies evaluating the association between implant diameter and peri-implant disease in endosseous dental implantsTable 7. Level of Evidence grade for studies evaluating the association between implant surface structure and peri-implant disease in


Figure 1. Inclusion 1 and Exclusion criteria.

StudyComponent Inclusion Exclusion

Participants • Adults• Patients with peri-impla titis (question #1)• Patients with and without peri-implantitis

(question #2 and #3)

• Animal• ≤ 10 in each

treatment group• <18 years of age

Intervention • Patients treated for peri-implantitis as a result of dental implant surgery (question #1)

• Patients treated with dental implants(questions #2 and #3)

• No surgery or treatment otherthan dental implants

Comparator • No treatment given or other treatments thanprimary intervention for peri-implantitis

• Patients treated with dental implants(questions #2 and #3)

• NA

Outcomes • Outcomes of treatment for peri-implantitis• Correlation between implant diameter and

peri-implantitis• Correlation between implant surface structure

and peri-implantitis

• Outcomes not associated withtreatment for peri-implantitis

endosseous dental implantsTable 8. Detailed information on studies comparing treatments for peri-implant diseaseassociated with endosseous dental implantsTable 9. Detailed information on studies evaluating peri-implantitis associated with

endosseous dental implant diameterTable 10. Detailed information on studies evaluating peri-implantitis associated with endosseous dental implant surface structureTable 11. Definition of the different levels of evidence for articles on therapy and prognosis

110

Overall Strengthof Evidence Further Research Impact

Domain Criterion Met

Quality Quantity Consistency

HIGH Very unlikely to change theresults or the confidence in theresults

+ + +

MODERATE Likely to have an important impact on the results and maychange the results

+ - +

+ + -

LOW Very likely to have an important impact on confidence in theresults and likely to change theresults

+ - -

- + +

VERY LOW Any result reported is uncertain - + -

- - +

- - -

Figure 2. Definition of overall 1 strength of evidence.

1. Total Citations( n = 360)

2. Title/Abstractexclusion (n = 63)

3. Retrieved for ful-l t extevaluation ( n = 19)

4. Excluded at full textreview (n = 16)

5. Publicationsincluded ( n = 24)

Figure 3. Flow chart showing results 1 of literature search.


Table 1. Summary studies comparing treatment outcomes for peri-implant disease

LoE Outcomes No. ofStudies

AntibacterialMean ± SD

MechanicalDebridementMean ± SD

Effect Size Favors*

IIBOP Change 1

(Bucher2004)

0.27±0.06 mm 0.13±0.08 mm p=.01 Atridox

Atridox PPD Change 1.15±0.23 mm 0.56±0.30 mm p<.05 Atridox

PAL Change 1.17±0.27 mm 0.56±0.30 mm p<.03 Atridox

CHX I1PPD

1 320.56 mm 0.93 mm p<.05 CHX

PAL 0.33 mm 1.07 mm p<.05 CHX

Arestin vs.CHX

II

Plaque Score

1(Renvert,2008)

27±24 % 27±45 % p>.05 Neither

BOP 48.1±20.7 % 63.5±19.2 % p<.001 Arestin

PPD 3.55±0.98 mm 3.72±1.02 mm p>.05 Neither

MBL 0.70±0.85 mm 0.46±0.76 mm p>.05 Neither

# Bacteria 1.6±4.5 1.4±4.2 p>.05 Neither

Tetracycline IImPI Change 1

(Schenk1997)

0.11±0.15 0.01±0.53 p>.05 Neither

BOP Change -17±25 % 15±37 % p>.05 Neither

MetronidazoleGel

II BOP Change1 (Tang2002)

0.7±1.0 mm 0.9±1.6 mm p>.05 Neither

LoE Outcomes No. ofStudies

VectorSystem

Mean ± SD

MechanicalDebridementMean ± SD

Effect Size Favors*

II

BOP 1(Karring2005)

36.4 % 81.8 % p>.05 Neither


MBL Change -0.3±1.0 mm -0.3±0.8 mm p>.05 Neither

I1

Plaque Score1

(Renvert2009)

51.3±23.9 % 54.9±29.5 % p>.05 Neither

BOP 28.7±26.4 % 34.3±28.2 % p>.05 Neither


CoE Outcomes StudiesCase

Mean ± SDControl

Mean ± SDEffect Size Favors*

Bone graftwith vs.

without resorbmembrane

II

PPD Change 1(Khoury2001)

2.6±1.6 mm 5.1±2.7 mm p<.05 Membrane

Intrabony DefectChange

1.9±3.2 mm 2.4±2.7 mm Incalculable Neither

Implant surfmodificationvs. resective

surgery

II

Implant Survival

1(Romeo2005)

100 % (19/19) 87.5 % (14/16) Neither

mBI 0.88±0.33 1.00±0.63 p<.05 Surf mod

PPD 3.58±1.06 mm 5.50±1.47 mm p<.05 Surf mod

Mucosal recession 2.30±1.45 mm 1.64±1.29 mm p<.05 Surgery

PAL 5.89±2.02 mm 7.04±1.67 mm p<.05 Surf mod

Bonesubstitutewith vs.

without resorbmembrane

II

Intrabony Defect Change

1 (Roos-J 2007)

1.52±1.16 mm 1.44±1.27 mm NR Neither

PPD Change 2.86±2.00 mm 3.44±1.58 mm p>05 Neither

Mucosal recession -1.28±1.51 mm -1.61±1.61 mm p>05 Neither

PAL Change 1.59±2.00 mm 1.80±1.37 mm p>05 Neither

Bone+resorbmembrane vs.

bonesubstitute II

mPI Change

1(Schwarz2008)

0.7±0.5 0.4±0.5 NR Neither

BOP Change 36 % 44 % NR Neither

PPD Change 1.5±0.6 mm 2.4±0.8 mm NR Neither

Mucosal recession 0.5±0.5 mm 0.4±0.4 mm NR Neither

PAL Change 1.0±0.4 mm 2.0±0.8 mm NR Neither

Che

mic

alM

echa

nica

lS

urgi

cal

112

* p<.05, bold indicates statistical significancemBI = modified bleeding sulcus index (bleeding tendency of marginal peri-implant tissues), PPD = periodontalprobing depth (linear distance from the peri-implant gingival margin to the bottom of the peri-implant pocket), PAL= probing attachment level (distance from the implant shoulder to the bottom of the peri-implant pocket), BOP =bleeding on probing (presence of bleeding within 30 seconds after the pocket had been probed), MBL = marginalbone loss on radiographs, mPI = modified plaque index (plaque accumulation)

Table 2. Summary of studies evaluating outcomes associated with diameter of endosseous dental implants

LoE OutcomeNo. ofStudies

NarrowDiameter

StandardDiameter

LargeDiameter

Effect Size-Narrow/

StandardRR (95 % CI)

Favors*

Peri-Implantitis Romeo 5.7 % (7/122) 3.4 % (7/208) 1.7 (0.6, 4.7) Neither

Implant Failuredue to Peri-Implantitis

2.5 % (3/122) 1.0 % (2/208) 2.6 (0.4, 15.1) Neither

Peri-Implant boneresorption due toPeri-Implantitis

2.5 % (3/122) 1.0 % (2/208) 2.6 (0.4, 15.1) Neither

IIINarrowDiameterMean ± SD

StandardDiameterMean ± SD

Effect Size Favors*

Modified BleedingIndex

0.3 ± 0.5 0.4 ± 0.5 NR Neither

PeriodontalProbing Depth

2.2 ± 1.6 mm 2.1 ± 1.7 mm NR Neither

Marginal BoneLoss

1.5 ± 1.5 mm 1.4 ± 1.1 mm NR Neither

IV Peri-Implantitis Zinsli 2.3 % (7/298)

Peri-Implantitis Prosper 0.0 % (0/111)

* p<.05, bold indicates statistical significance


Table 3. Summary of studies evaluating outcomes associated with surface structure of endosseous dental implants

LoE Outcome Author Machined Roughened

Effect Size-Machined/Roughened

RR (95 % CI)

Favors*

I Peri-Implantitis Esposito 0.80 (0.67, 0.98) Machined

IIIRetrograde Peri-Implantitis

Quirynen 0.4 % (2/459) 10.0 % (8/80) 0.04 (0.01, 0.20) Machined

III Hollow Screw 56 HollowCylinder (HC)

AngulatedHollow

Cylinder(AHC)

Effect Size-HC/HS

RR (95 % CI)

Effect Size-AHC/HS

RR (95 % CI)Favors*

Peri-Implantitis Karoussis 10.0 % (11/112) 29.0 % (14/49) 12.0 % (2/18) 2.9 (1.4, 5.9) 1.13 (0.3, 4.7) Hollow Screw

Mean ± SD

HS

Mean ± ±SD

HS

Mean ±± SD

HS

Effect Size-

HC/HS

Effect Size-

AHC/HSFavors*

Modified PlaqueIndex

1(Karoussis

2004)2.6 ± 0.9 mm 2.2 ± 1.6 mm 2.1 ± 1.7 mm NR NR Neither

PeriodontalProbing Depth

2.6 ± 0.9 mm 3.1 ± 1.4 mm 3.1 ± 1.1 mm HC>HS, p<.05 NR Hollow Screw

Bleeding onProbing

0.4 ± 0.4 mm 0.5 ± 0.3 mm 0.5 ± 0.3 mm HC>HS, p<.05 NR Hollow Screw

* p<.05, bold indicates statistical significance

114

Domain CriterionQuality: > 80 % of studies LoE I or II

Quantity: 3+ studies adequately powered

Consistency: Results lead to similarconclusions

Strength of evidence Conclusions/Comments Quality Quantity Consistency

Question 1: What are the outcomes of treatment for peri-implant disease?

Outcomeschemical

Low evidence

(Further research is likely to change the results or the confidence in the results)

• A beneficial change in gingival parameters was reported with the use of Atridoxwith mechanical debridement in 1 study, and 0.12 % chlorhexidine withmechanical debridement in another study.

+ - -

mechanical Low evidence(Further research is likely to changethe results or the confidence in theresults)

• Two studies reported no differences in gingival parameters when comparing theVector System to mechanical debridement for treatment of peri-implant disease.

+ - -

surgical Low evidence(Further research is likely to changethe results or the confidence in theresults)

• Gingival parameters improved after implant surface modification compared toresective surgery in one study. + - -

Question 2: What is the relationship between implant diameter and peri-implant disease?

Narrow Diameter Very low evidence(any result reported is uncertain)

• The rate of peri-implantitis in narrow diameter implants was 2.3-5.7 %. - - +

Large Diameter Very low evidence(any result reported is uncertain)

• One case series reported a 0 % rate of peri-implantitis associated with largediameter (5.9 mm) implants

- - +

Question 3: What is the relationship between implant surface structure and peri-implant disease?

RoughenedMicrostructure

Moderate evidence(Likely to have an important impacton the results and may change theresults)

• A meta-analysis reported an increased risk of peri-implantitis in roughenedcompared to machined surface implants. A greater rate of retrograde periimplantitiswas reported in implants with rough-ened surfaces (10.0 %) comparedto machined-surface implants (0.4 %).

+ - +

Macrostructure Low evidence(Further research is likely to changethe results or the confidence in theresults)

• One study reported a 29 % rate of peri-implantitis in hollow cylinder implants,12 % in angulated hollow cylinder, and 10 % in hollow screw implants.

+ - -

Table 4. Rating of overall strength of evidence for each key question.


Methodological PrincipleBuchter

2004

Karring2005

Khoury2001

Porras2002

Renvert2006

Renvert2008

Romeo2005

Romeo2007

Roos-Jan-

sakar2007

Schenk1997

Study design

Randomized controlled trial

Prospective cohort study

Retrospective cohort study

Case control

Patients at similar point inthe course of their diseaseor treatment

Patients followed longenough for outcomes tooccur

Complete follow-up of>80 % v

Controlling for extraneousprognostic factors*

Evidence Level II II II II II II II II II II

Methodological PrincipleSchwarz

2005

Schwarz

2006a

Schwarz

2006b

Schwarz

2008

Tang

2002

Study design




Case Control

Patients at similar point inthe course of their diseaseor treatment

Patients followed longenough for outcomes to occur

Complete follow-up of>80 %

Controlling for extraneousprognostic factors*

Evidence Level II II II II II

Table 5. Level of Evidence grade for studies comparing treatments for periimplantdisease associated with endosseous dental implants

116

Table 6. Level of Evidence grade for studies evaluating the association between implant diameter and peri-implant disease in endosseous dental implants

Methodological PrincipleRomeo

2006

Zinsli

2004

Prosper

2003

Study design




Case Control

Case Series

Patients at similar point in the course of theirdisease or treatment

Patients followed long enough for outcomes tooccur

Complete follow-up of >80 %

Controlling for extraneous prognostic factors

Evidence Level III IV IV

Table 7. Level of Evidence grade for studies evaluating the association between implant surface structure and peri-implant disease in endosseous dental implants

Methodological PrincipleEsposito

2005

Karoussis

2004

Quirynen

2005

Tang

2000

Teixeira

1997

Study design


Prospective cohort studyv


Case Control

Case Series

Patients at similar point in the course of theirdisease or treatment

Patients followed long enough for outcomes tooccur

Complete follow-up of >80 %

Controlling for extraneous prognostic factors

Evidence Level I II II-III IV III


Detailed Tables

Table 8. Detailed information on studies comparing treatments for peri-implant disease associated

with endosseous dental implants

AUTHOR

(YEAR)

STUDY

DESIGNLOE

POPULA-

TION

POPULATION/IMPLANT

CHARACTERISTICS

TREATMENT /

INTERVENTION

RESULTS

(OUTCOMES)COMPLICATIONS†

Buchter(2004)

Randomizedcontrolled

trial

II N=28Male: 21.4 %Mean age: 55±16 (25-78) yearsF/U: 18 weeksF/U %: NR

Diagnosis of chronic periimplantitis.Bone defects

≥50 % implant length.Full-mouth debridementand subgingival irrigationof peri-implant defects

with 0.2 % chlorhexidinedigluconate solution 2-18

weeks before baselineexamination

Subgingival localdebridement

(controls,N=14) or localdebridement with topical

application of 8.5 %doxycycline hyclate(Atridox; Block Drug

Corp, Jersey City, NJ)(cases, N=14)

BOP change (18 wk), p=.01

Atridox: 0.27 ± 0.06 mmControl: 0.13 ± 0.08 mm

PPD change (18 wk), p<.05

Atridox: 1.15 ± 0.23 mmControl : 0.56 ± 0.30 mmPAL change (18 wk), p<.03Atridox: 1.17 ± 0.27 mmControl : 0.56 ± 0.30 mm

NR

Karring(2005)


trial

II N=11Male: 45.5 %Age range: 50-78 yearsF/U: 6 monthsF/U %: NR

At least 2 screw-typeimplants of the same

brand with periimplantitis.Diagnosis of

peri-implantitis: BOP,PPD ≥5 mm, ≥1.5 mmradiographic bone loss

One implant treated with

Vector system (case;hydrodynamic flow

system combined withfine polishing

particles),and the other implant

was treated withsubmucosal debridement

with a carbon fibercurette (control)

BOP (6 mo), p>.05Vector: 36.4 % (n=4)Control: 81.8 % (n=9)

PPD (6 mo), p>.05Vector: 5.8 ± 1.2 mmControl : 6.3 ± 2.2 mm

MBL change (6 mo), p>.05Vector: -0.3 ± 1.0 mmControl : -0.3 ± 0.8 mm

NR

Khoury(2001)


trial

II N=25; Ni=41Male: 12 %Mean age 48.2±6.3 (43-53) yearsF/U: 3 yearsF/U %: NR

Peri-implant disease withintrabony defects >50 %implant length; history ofmechanical debridement

+ 0.2 % CHX gel

Peri-implant defectsaugmented with flap

surgery and autogenous

bone grafts along(control; N=7) or, in

addition, non-resorbable

(test 1; N=11) orbioabsorbable barrier

membranes (test 2; N=7).

PPD change (3 yr), p<.05Test 2 vs. Control

Test 1: 5.4 ± 3.0 mmTest 2: 2.6 ± 1.6 mm

Control : 5.1 ± 2.7 mmIntrabony defect height

change (3 yr), p>.05Test 1: 2.8 ± 3.1 mmTest 2: 1.9 ± 3.2 mm

Control : 2.4 ± 2.7 mm

DehiscenceTest 1: 36.3 % (n=4/11)Test 2: 28.6 % (n=2/7)

FistulaTest 1: 18.2 % (n=2/11)

SequestraTest 1: 9.1 % (n=1/11)Test 2: 28.6 % (n=2/7)

Porras(2002)


trial

II N=16Male: NRMean age 58.9±8.4 (34- 76) yearsF/U: 3 moF/U %: NR

One or more plasmasprayedtitanium,

commercially puretitanium, or

hydroxyapatite-coateddental implants and

periimplantmucositis.

Mechanical scaling only

(control, N=8) ormechanical scaling,

supplemented by localirrigation with

chlorhexidine (CHX) 0.12 % and topical

mPI, mBI, BOP (3 mo),p>.05

PPD (3 mo), p<.05CHX: 0.56b mm

Control : 0.93 mmPAL (3 mo), p<.05

CHX: 0.33 mm

NR

118

Diagnosis of mucositis:supra- and sub-gingival

plaque, PPD ≤5 mm, andinflammation measured

with mBI

application of CHX gel2x/day for 10 days (case,

N=8).

Control : 1.07 mm

Renvert(2006)[overlap-

pingpopulation

withRenvert2008]


trial

II N=30Male: 40 %Mean age: 63.6 ± 8.6 (41-75) yearsF/U: 12 monthsF/U %: NR

At least one implantplaced 10-12 years

previously with bone loss≤3 threads on radiograph,

PPD ≥4 mm, bleedingand/or purulence on

probing, microbial sampleof anaerobic bacteria

Mechanical debridementfollowed by: single doseof Arestin (OraPharma,Warminster, PA) (case,N=16), or one-time 1 %

topical CHX gelapplication (control,

N=14)

Plaque score (12 mo), p>.05Case: 27 ± 24 %Control : 21 ± 18 %

BOP (12 mo), p>.05Case: 71 ± 22 %Control : 78 ± 13 %

PPD (12 mo), p<.001Case: 3.6 ± 0.6 mmControl : 3.9 ± 0.4 mm

NR


trial

II N=32; Ni=95Male: 31.3 %Mean age: 61.4 ± 10.2(41-75) yearsF/U: 12 monthsF/U %: NR


previously with bone loss≤3 threads on radiograph,

PPD ≥4 mm, bleedingand/or purulence on

probing, microbial sampleof anaerobic bacteria

Mechanical debridementfollowed by: single doseof Arestin (OraPharma,Warminster, PA) (case,

N=17 ;Ni=58), or onetime1 % topical CHX

gel application (control,N=15 ; Ni=37)

Plaque score (12 mo), p>.05Case: 22 ± 42 %Control : 27 ± 45 %

BOP (12 mo), p<.001Case: 48.1 ± 20.7 %Control : 63.5 ± 19.2 %

PPD (12 mo), p>.05Case: 3.55 ± 0.98 mmControl : 3.72 ± 1.02 mm

MBL (12 mo), p>.05Case : 0.70 ± 0.85 mmControl: 0.46 ± 0.76 mm

# bacteria (12 mo), p>.05Case: 1.6 ± 4.5Control : 1.4 ± 4.2

NR


trial

II N=31Male: 54.8 %Mean age: 61.4 ± 12.5yearsF/U: 6 monthsF/U %: NR

At least one implant withbone loss <2.5 mm on

radiograph, PPD ≥4 mm,bleeding and/or purulence

on probing

Mechanical debridementusing Vector system

(Durr Dental AG,Bietigheim-Bissingen,

germany) (case, N=14)or mechanical

debridement usingcurrettes (control, N=17)

Plaque score (6 mo), p>.05Case: 51.3 ± 23.9 %Control : 54.9 ± 29.5 %

BOP (6 mo), p>.05Case: 28.7 ± 26.4 %Control : 34.3 ± 28.2 %

PPD (6 mo), p>.05Case: 3.9 ± 0.8 mmControl : 4.0 ± 0.8 mm

Overall, mean plaque score(p<.01) and BOP (p<.03)decreased over time

NR


trial

II N=17; Ni=35Male: NR

Diagnosis of periimplantitis:suppuration

Resective surgery andmodification of surface

Cumulative survival (36 mo)Case: 100 % (n=19/19)

NR


trial Mean age: NRF/U: 36 months% F/U: NR

or sulcus bleeding, PPD>4 mm, radiographicevidence of horizontal

peri-implantradiolucency, no mobility

Solid screw (Ni=24) orhollow screw (Ni=11)implants with titaniumplasma-sprayed (TPS)

surface

topography (cases,N=10 ; Ni=19) or

resective surgery only(controls, N=7 ; Ni=16)

Control : 87.5 % (n=14/16)mBI (24 mo), p<.05Case : 0.88 ± 0.33Control: 1.00 ± 0.63

PPD (24 mo), p<.05Case: 3.58 ± 1.0 6mmControl : 5.50 ± 1.47 mm

Mucosal recession (24 mo),p<.05Case: 2.30 ± 1.45 mmControl : 1.64 ± 1.29 mm

PAL (24 mo), p<.05Case: 5.89 ± 2.02 mmControl : 7.04 ± 1.67 mm

Romeo(2007)


trial

II N=19; Ni=38Male: NRMean age: NRF/U: 36 months% F/U: NR

Diagnosis of periimplantitis:suppuration

or sulcus bleeding, PPD>4 mm, radiographicevidence of horizontal

peri-implantradiolucency, no mobilitySolid screw (Ni=27) orhollow screw (Ni=11)implants with titaniumplasma-sprayed (TPS)

surface and periimplantitis

Resective surgery andmodification of surface

topography (cases,N=10 ; Ni=20) or

resective surgery only(controls, N=9 ; Ni=18)

MBL (36 mo), p<.05Case : 0.01 ± 0.41 mmControl: 1.54 ± 0.70 mm

NR

Roos-Jansa-

kar(2007)

ProspectiveCohort

II N=36; Ni=65Male: 38.9 %Mean age: 66.0 ± 7.0F/U: 1 year% F/U: NR


previously with periimplantitis.Diagnosis of

peri-implantitis: ≥3exposed threads, bleedingand/or pus on probing.

Surgical treatment withbone substitute

(Algipore, Friadent,Malmo, Sweden) alone(controls, N=19; Ni=36)or bone substitute withresorbable membrane

(cases, N=17; Ni=29) indefects.

Defect fill (1 yr), p=.04Membrane: 1.52 ± 1.16 mmControl : 1.44 ±1.27 mm

PPD reduction (1 yr), p>.05Membrane: 2.86 ± 2.00 mmControl : 3.44 ± 1.58 mm

Mucosal recession (1 yr),p>.05Membrane: -1.28 ± 1.51 mmControl : -1.61 ± 1.61 mm

PAL gain (1 yr), p>.05Membrane: 1.59 ± 2.00 mmControl : 1.80 ± 1.37 mm

PainMembrane:5.9 % (1/17)Control: 5.3 % (1/19)

SwellingMembrane:5.9 % (1/17)Control: 10.5 %(2/19)

Schenk(1997)


trial

II N=8; Ni=24Male: 37.5 %Mean age: 62 (53-69) yrs

At least 2 implants withclinical signs of periimplant

mucositis (PPD

Supra- and subgingivalmechanical scaling alone(controls; N=8; Ni=12),

mPI change (12 wk), p>.05Case: 0.11 ± 0.15Control : 0.01 ± 0.53

No adverse effectsreported

120

trial F/U: 12 wksF/U %: NR

≥4mm and BOP) and/orperi-implant mucosalhyperplasia, without

detectable peri-implantbone loss on radiographs

or with locally deliveredtetracycline HCl fibers(Actisite, ALZA Corp,Palo Alto, CA) (cases;

N=8; Ni=12)

BOP change (12 wk), p>.05Case: -17 ± 25 %Control : 15 ± 37 %

PPD, PAL (12 mo), p>.05

Schwarz(2005)

[duplicatedata withSchwarz2006]


trial

II N=20; Ni=32Male: 60 %Mean age: 48 yrs (cases),51 yrs (controls)F/U: 6 monthsF/U %: NR

At least one dentalimplant with periimplantitis.

Definition ofperi-implantitis: ≥4 mm

PPD, bleeding and/or puson probing, bone loss, no

implant mobility.

Er:YAG laserinstrumentation (cases,

N=10; Ni=16) ormechanical debridement

plus 0.2 % CHX gel(controls, N=10; Ni=16)

BOP reduction (6 mo):significatnly greater in casesthan controls (p<.001)

PPD, PAL, mucosalrecession (6 mo): nosignificant differences btwngroups (p>.05)

No complica-tions wereobserved

Schwarz(2006)

[duplicatedata withSchwarz2005]


trial

II N=20; Ni=40Male: 45 %Mean age: 56±14 yrs(cases), 52±11 yrs(controls)F/U: 12 monthsF/U %: NR

At least one dentalimplant with periimplantitis.

Definition ofperi-implantitis: ≥4 mm

PPD, bleeding and/or puson probing, bone loss, no

implant mobility.

Er:YAG laserinstrumentation (cases,

N=10; Ni=20) ormechanical debridement

plus 0.2 % CHX gel(controls, N=10; Ni=20)

BOP reduction (12 mo):significatnly greater in casesthan controls (p<.01)

PPD, PAL, mucosalrecession, MBL (12 mo): nosignificant differences btwngroups (p>.05)

No complica-tions wereobserved

Schwarz(2006)—

JCP[duplicatedata withShwarz2008]


trial

II N=22; Ni=22Male: 36.4 %Mean age: 54.4±12.5 yrsF/U: 6 monthsF/U %: NR

At least one dentalimplant with history of

mechanical debridement+ 0.2 % CHX gel and

current intra-bony defect:>6mm PPD, >3 mm

intrabony loss onradiograph, no implant

mobility.

Peri-implant defectswere treated using either

nanocrystallinehydroxyapatite (Ostim,

Heraeus, Hanau,Germany) (cases, N=11)or a natural bone mineralplus collagen membrane

(controls ; N=11)

mPI difference (6 mo), p=NRCase: 0.1 ± 0.5Control : 0.1 ± 0.3

BOP decrease (6 mo), p=NRCase: 52 %Control : 50 %

PPD decrease (6 mo), p=NRCase: 2.1 ± 0.5mmControl : 2.6 ± 0.4mm

Mucosal recession decrease(6 mo), p=NRCase: 0.3 ± 0.2 mmControl : 0.3 ± 0.2 mm

PAL increase (6 mo), p=NRCase: 1.8 ± 0.6 mmControl : 2.3 ± 0.6 mm

NR

Schwarz(2008)[duplicatedata withShwarz2006-JCP]

Randomizedcontrolledtrial

II N=22; Ni=22Male: 36.4 %Mean age: 54.4±12.5 yrsF/U: 2 yearsF/U %: NR

At least one dentalimplant with history ofmechanical debridement+ 0.2 % CHX gel andcurrent intra-bony defect:>6 mm PPD, >3 mmintrabony loss on

Peri-implant defectswere treated using eithernanocrystallinehydroxyapatite (Ostim,Heraeus, Hanau,Germany) (cases, N=11)or a natural bone mineral

mPI difference (2 yr), p=NRCase: 0.7 ± 0.5Control : 0.4 ± 0.5BOP decrease (2 yr), p=NRCase: 36 %Control : 44 %PPD decrease (2 yr), p=NR

NR


trial F/U: 12 wksF/U %: NR

radiograph, no implantmobility.

plus collagen membrane(controls, N=11)

BCase: 1.5 ± 0.6 mmControl : 2.4 ± 0.8 mm

Mucosal recession decrease(2 yr), p=NRCase: 0.5 ± 0.5 mmControl : 0.4 ± 0.4 mm

PAL increase (2 yr), p=NRCase: 1.0 ± 0.4 mmControl : 2.0 ± 0.8 mm

Tang (2002)

[Obtainedfrom

CochraneReview,2009]*


trial

II N=27Male: NRMean age: NRF/U: 3 monthsF/U %: 90 %

1 stable IMZ or Frialit-2implant with periimplantitis:

peri-implantbone loss <4 mm, PPD

≤6 mm with BOP

Metronidazole gel 25 %injected into pocket at adepth of 3 mm (N=14)

vs. subgingivalmechanical debridement(N=13). Both procedures

were performed atbaseline and 1 wk later.

PPD change (3 mo), p>.05Metro: 0.7 ± 1.0 mmControl : 0.9 ± 1.6 mm

NR

N = Number of subjects; Ni = Number of implants; NR = Not reported; F/U = follow-up; PPD = periodontal probing depthmBI = modified bleeding sulcus index (bleeding tendency of marginal peri-implant tissues), PPD = periodontal probing depth (linear distance from the peri-implant gingival margin to the bottom of the peri-implant pocket) PAL = probing attachment level (distance from the implantshoulder to the bottom of the peri-implant pocket), BOP = bleeding on probing (presence of bleeding within 30 seconds after the pocket had been probed), MBL = marginal bone loss on radiographs, mPI = modified plaque index (plaque accumulation)Er:YAG = erbium-doped:yttrium, aluminum and garnet* Article in Chinese; data presented was obtained from Cochrane Review, 2009

122

Table 9. Detailed information on studies evaluating peri-implantitis associated with endosseous dental

implant diameter

AUTHOR

(YEAR)

STUDY

DESIGNLOE POPULATION

POPULATION/IMPLANT

CHARACTERISTICS

TREATMENT /

INTERVENTION

RESULTS


Romeo(2006)

Prospectivecohort

III N=188; Ni=330Male: 44.1%Mean age: 55.8 (21-74)yearsF/U: 1-6 yearsF/U %: NR

Titanium plasma-sprayedITI (Institute Straumann,

Waldenburg/BL,Switzerland) implants

were placed. Patients withnarrow buccolingual ridge

width received smalldiameterimplants, and

other patients receivedstandard-diameter

implants. Peri-implantitiscriteria not stated.

Patients wereconsecutively treatedwith the following: 68patients were treated

with 122 small-diameter(3.3 mm) implants, and120 patients received

208 standard-diameter(4.1 mm) implants.

Peri-Implantitis (PI)Narrow: 5.7 %Standard: 3.4 %

Implant failure due to PINarrow: 2.5 %Standard: 1.0 %

Peri-implant bone resorptiondue to PI (no implant failure)Narrow: 2.5 %Standard: 1.0 %

mBI (last eval), p>.05Narrow: 0.3 ± 0.5Standard: 0.4 ± 0.5

PPD (last eval), p>.05Narrow: 2.2 ± 1.6 mmStandard : 2.1 ± 1.7 mm

MBL (last eval), p>.05Vector: 1.5 ± 1.5 mmControl : 1.4 ± 1.1 mm

NR

Zinsli(2004)

Case series IV N=154; Ni=298Male: 32 %Median age: 62 (19 to 87)yrsF/U: up to 10 yearsF/U %: NR

Narrow diameter implantswere used for the

following indications: a)narrow buccolingual

width of edentulous ridge,and b) small single-tooth

gaps.

2-part ITI implants witha reduced diameter of

3.3- mm and intraosseous

length of 8, 10, or 12mm were placed.

Implant failure due to PI:1.0 % (n=3/298)

Peri-implant inflammation(no failure):1.3 % (n=4/298)

Peri-implant disease:2.3 % (n=7/298)

NR

Prosper(2003)

Case series IV N=83; Ni=111Male: 47.0 %Mean age: 46.2 ± 14.3F/U: 12 monthsF/U %: 100 %

Cylindric, sandblasted,screw-type titaniumimplants with large

diameter (5.9 mm) andlength of 11 or 13 mm

Large diameter (5.9 mm)implants were placed infresh extraction sockets

with synthetichydroxyapatite or a

bioabsorbable membrane

Success rate: 97.3 %(n=108/111)

Peri-Implantitis : 0 %(n=0/111)

Mobility : 0 % (n=0/111)Bone loss : 0 % (n=0/111)

NR

mBI = modified bleeding sulcus index (bleeding tendency of marginal peri-implant tissues), PPD = periodontal probing depth (linear distance from the peri-implant gingival margin to the bottom of the peri-implant pocket), MBL = marginal bone loss on radiographs


Table 10. Detailed information on studies evaluating peri-implantitis associated with endosseous dental

implant surface structure

AUTHOR

(YEAR)

STUDY

DESIGNLOE POPULATION

POPULATION/IMPLANT

CHARACTERISTICS

TREATMENT /

INTERVENTION

RESULTS


Esposito(2005))

Metaanaly-sis of

RCTs (Astrand 1999; Astrand2002; Moberg

2001)

III N=NR; Ni=NRMale: NRMean age: NRF/U: 3 yearsF/U %: NR

Turned (machined) androughened surface

implants were placed.Peri-implantitis: advancedmarginal bone loss with

signs of infection such assuppuration

The frequency of periimplantitis

wascompared between

implant systems

Incidence of PI,rough>machined, p<.05Turned vs. Machined:RR=0.80, 95 % CI 0.67-0.96

NR

Karoussis(2004)

Prospectivecohort

IV N=89; Ni=179Male: 38.2 %Mean age: 49.3 (19-78)yrsF/U: 8-12 yearsF/U %: 70 %

Hollow cylinder (HC;n=49), hollow screw (HS;n=112), and angulatedhollow cylinder (AHC;n=18) ITI implants

(Institute Straumann,Waldenburg, Switzerland)

were placed. Periimplantitis:PPD ≥5 mm,

BOP and radiographicsigns of bone loss

Implants were followed

for peri-implantitis

Incidence of PI,HC>HS, p<.03HC: 29 % (n=14/49)HS: 10 % (n=11/112)AHC: 12 % (n=2/18)All implants: 15.4 %(n=27/179)

mPI, p>.05HC: 2.2 ± 1.6 mmHS: 2.6 ± 0.9 mmAHC: 2.1 ± 1.7 mm

PPD, HC>HS, p<.05HC: 3.1 ± 1.4 mmHS: 2.6 ± 0.9 mmAHC: 3.1 ± 1.1 mm

BOP, HC>HS, p<.05HC: 0.5 ± 0.3 mmHS: 0.4 ± 0.4 mmAHC: 0.5 ± 0.3 mm

NR

Quirynen(2005)

Retrospectiveand

prospectivecohort

IV N=NR; Ni=539Male: NRMean age: NRF/U: 1-6 yearsF/U %: NR

Cylindric, sandblasted,screw-type titaniumimplants with large

diameter (5.9 mm) andlength of 11 or 13 mm

Implants with retrograde

peri-implantitis werefollowed pro-

spectively

Incidence of retrograde PI,TiUnite>Machined, p<.0001Machined: 0.4 % (n=2/459)TiUnite: 10.0 % (n=8/80)All implants: 1.9 %

Fistula associated with retrograde PI: n=10 % (n=1)Implant loss due toretrograde PI: n=10 %(n=1)

implantitis. Retrograde PIcriteria not stated.

Tang (2000)

Case series IV N=70; Ni=108Male: 51.4 %Mean age: 36.2 (17-64)yearsF/U: 1 yearF/U %: NR

Titanium (IMZ andFrialit-2; Friatic,

Germany) dental implantswere placed

Peri-implant conditions

were assessed

MBL: 0.63 ± 0.78 mmPlaque index: 0: 7.6 %≥ 1: 92.4 %Sulcus Bleeding index(indicator of peri-implantmucosal inflammation):0: 67.1 % ≥ 1: 32.9 %

NR

Teixeira(1997)

Retrospectivecohort

III N=22; Ni=32Male: 40.5 %Mean age: 54.2 yearsF/U: mean 3.5 yearsF/U %: NR

Patients received 2-stagehydroxyapatite-coated

dental implants. Patientswere divided into controls

with no inflammatorysigns, borderline group

with moderateinflammation, gingivitisgroup with peri-implant

mucositis

Peri-implant conditions

were assessed

Mean bone loss,gingivitis>borderline;gingivitis>controlGingivitis: 3.22±1.92Borderline: 1.37±0.99Control: 1.15±0.81

mBI = modified bleeding sulcus index (bleeding tendency of marginal peri-implant tissues), PPD = periodontal probing depth (linear distance from the peri-implant gingival margin to the bottom of the peri-implant pocket), MBL = marginal bone loss on radiographs

124

Table 11. Definition of the different levels of evidence for articles on therapy and prognosis

Studies of Therapy Studies of Prognosis Studies of Diagnosis

Level Studydesign

Criteria Studydesign

Criteria Studydesign

Criteria

I Good qualityRCT

• Concealment • Blind or independent assess-

ment for important outcomes • Co-interventions applied equally • F/U rate of 80%+• Adequate sample size

Good qualitycohort

• Prospective design• Patients at similar point in

the course of their disease or treatment

• F/U rate of 80 % +• Patients followed long

enough for outcomes to occur

• Controlling for extraneous

prognostic factors**

Good qualityprospectivecohort

• Prospective validation ofprevious criteria

• Consecutive series of patients• Broad spectrum of persons

with the expected condition• Adequate description of test

and reference for replication• Blinded comparison of tests

with appropriate reference standard

• Reference standard performed independently of diagnostic test

II Moderate orpoor qualityRCT

• Violation of any of the criteriafor good quality RCT

Moderatequalitycohort

• Prospective design, withviolation of one of the othercriteria for good qualitycohort study

• Retrospective design,meeting all the rest of thecriteria in level I

Moderatequalityprospectivecohort study

• Violation of any one of thecriteria for a good qualityprospective study (LoE I)

Good qualitycohort

• Blind or indepedent assessmentin a prospective study, or use ofreliable data* in a retrospectivestudy

• Co-interventions applied equally• F/U rate of 80 % +• Adequate sample size• Controlling for possible

confounding†

Good qualityretrospectivecohort study

• Validation of previous criteria,with violation of one of the othercriteria for a good qualityprospective cohort

III Moderate orpoor qualitycohort

• Violation of any of the criteriafor good quality cohort

Poor qualitycohort

• Prospective design withviolation of 2 or more criteriafor good quality cohort, or

• Retrospective design withviolation of 1 or more criteriafor good quality cohort

Poor qualityprospectivecohort study

• Violation of any two or more ofthe criteria for a good qualityprospective study (LoE I)

Case-control • Any case-control design Case-control • Any case-control design Moderatequalityretrospectivecohort study

• Violation of any criteria for agood quality retrospective study(LoE II)

IV Case series • Any case series design Case series • Any case series design Poor qualityretrospectivecohort study

• Violation of any criteria for agood quality retrospective study(LoE II)

Case-controlstudy

• Violation of two or more of thecriteria for a good qualityretrospective study (LoE II)

*Reliable data are data such as mortality or reoperation.**Authors must provide a description of robust baseline characteristics, and control for those that are unequally distributed between treatment groups for studies assessing prognostic factors. For studies of risk, results must reflect the risk of obtaining the outcome of interest stratified by other prognostic factors.


Sofortbelastung bei Totalrehabilitation

des Ober- und Unterkiefers beim Vor-

liegen einer ausgepräääääaeägten Atrophie

Authors:

Henri Diederich, Dr. med. dent.51, av. Pasteur2311 LuxembourgPhone: +352 225815-31 eE-mail:[email protected]

Abstrakt

In dem vorliegendem Fall wird gezeigt wie ein stark atrophierter Kieferknochen durch So-fortbelastung und vollkeramischen Brücken in kurzer Zeit rehabiliert werden kann und dies mit Hilfe von BOI Implantaten und Tuberschrauben.

Schlagworte:

Basale Implantate, Tubero-pterygoid-Schrauben, Tubero-sphenoid-Schrauben Sofortbelastung

Einleitung

Eine 65-jährige Patientin stellte sich in der Praxis mit einem desolaten Gebisszustand vor. Im Ober- und Unterkiefer trug sie eine schlecht angepasste Teil-Skelettprothese. Es lag keine erkennbare Kaufunktion mehr vor. Sie wünschte sich festsitzenden Zahnersatz.

Material und Methode

In einem ersten Schritt wurden die vorhandenen Zähne entfernt und die Prothesen erweitert. Anschliessend wurden die Prothesen nach dem DIR-System re-okkludiert , wonach eine stabile Unterkieferposition mit einer definierten retralen Position vorlagen.

Daraufhin wurden die Prothesenzähne und die vorhandenen Prothesen in dieser Stellung während vier Monaten so belassen um even-tuelle Gelenkprobleme abzuwarten und eine funktionelle Adaptation zu ermöglichen. Nach dieser Zeitspanne wurde dann die Implantat-versorgung vorgenommen.Zusammen mir der Patientin wurde entschie-

den beide Kiefer separat zu behandeln. Sehr oft behandeln wir beide Kiefer natürlich in einer Sitzung. Die Patientin bekam am Vorabend Atarax 100 mg verschrieben und dieselbe Dosis zwei Stunden vor der Intervention.Die Intervention wurde in Lokalanästhesiel durch-

geführt. Vor dem Eingriff wurde ein Silikonabdruck genommen um damit sofort nach der Implanta-tion ein Provisorium anzufertigen. Die vertikale und die sagittale Relation wurden so eingestellt, wie sie bei der Prothese vorlagen.Für die Unterkieferinmplantation wurde beidseits

je ein Vollappen seitlich von der Mittellinie bis zum aufsteigenden Ast der Mandibula präpariert. So konnte der N. mentalis gut dargestellt werden. Eine zirkuläre Aufklappung nehmen wir nicht vor, um die Frenuli nicht zu versetzen und dem Techniker einen sicheren Anhaltspunkt für die skelettale Mittelline zu geben.In Regio 37 und 35 werden zwei BOI Implantate

BOI BAS 9/16 H6 und in Region 33,32,31,41,42,43 crestale Implantate KOS 3.7.mm 15mm, KOS 3.2 15 mm und eine TPG-Schraube 4.1 17mm.Für die BOI Implantate ein zu setzen wird

zuerst ein vertikaler Schlitz mit einem Vertikalcutter gesetzt und danach mit Lateralcuttern von 9 mm wird aufgefräst von vestibulär nach bukkal.Die Nähte entfernen wir nach maximal 5

Tagen. Je früher die Nähte entfernt werden, umso

126

schneller heilten die Weichteilwunden. Der Silkinoabdruck wird unmittelbar nach der Implantation genommen. Die zum Implantatsys-tem gehörenden Abdruckkappen werden auf den Implantatköpfen installiert. Hier waren es die TSK4 und TSK5. Nach dem Abdruck werden die Laboranaloge IA4 und IA5 in den Abdrucklöffel eingesetzt und das Modell kann erstellt werden.Die Patientin verlässt die Praxis mit einem sofort angefertigten festsitzenden Provisorium. Die Intervention dauerte zwei Stunden. Zur Nach-sorge bekommt die Patientin Antibiotika 2 mg pro Tag während 8 Tagen und Kortison (Celeston chronodose 2 ml) intramuskulär gespritzt.In der zweiten Sitzung 5 Tage später nach

der Nahtentfernung wird in derselben Sitzung das Gerüst aus Nichtedelmetall anprobiert und die Bisshöhe wird noch einmal kontrolliert. Vier Tage später erscheint die Patientin zum Eingliedern der keramisch verblendeten Brücke. Die Brücke wird provisorisch mit Seal temp fixiert. Ein erster Recall findet nacheinem Monat statt.Zwei Monate später wird der Oberkiefer

operiert. Auch hier wurde die Patientin wie-der mit Atarax 100 mg prämedikamentiert. Gesetzt wurden folgende Implantate : in Regio 18 und 28 Tuberschrauben TPG 21mml 4.1mmd, in Regio 17 und 27 Diskos IDO 9/12 G3/H2, Regio 24 TPG 15mml 4.1mmd, Regio 23 TPG 17mml 4.1mmd, Regio 13 TPG 17mml 4.1mmd, Regio 15 TPG 15mml 4.1mmd (Hersteller: Dr. Ihde Dental AG, Schweiz, www.implant.com ) Auch hier bekam die Patientin nach der Intervention sofort wieder ein Provisorium ange-fertigt. Nach Anprobe des Gerüsts, wurde dann die definitive Versorgung aus Metall- Keramik nach 10 Tagen eingegliedert. Die prothetische Versorgung

im Oberkiefer ist teils dauerprovisorisch geklebt, und teils verschraubt und so jederzeit abnehmbar.Recall nach einem Monat, nach 3 Monaten und dann jeweils nach 6 Monaten, zur Hygienkontrolle und Okklusionskontrolle.

Zusammenfassung

Es handelte sich um einen komplexen Fall. Die Patientin wünschte sich festsitzenden Zahnersatz es sollte schnell sein und vor allem aber keine Knochenaufbauten weder Sinuslifts. Dank BOI und Tuberschrauben konnte die Patientin jeweils für Oberkiefer und Unterkiefer in 3 Sitzungen jeweils fertiggestellt werden.


Röntgenbilder

Fig. 1 : Panroama-Uebersichtsaufnahme vor Behandlungsbeginn

Fig. 2: Panorama-Übersichtsaufnahme nach Versorgung des Unterkiefers.

128

Fig. 3: Panorama-Ueberischtsaufnahme nach Versorgung des Oberkierfers, ca. 4 Monate nach Versogung des Unterkliefers. Die vertikalen Schlitz bei den BOI-Implantaten sind schon beinahe verknöchert.

Fig. 4: Kontrollaufnahme nach weiteren 6 Monaten.


Weiterführende Literatur:IHDE S. Priciples of BOI (Springer 2005)IHDE S. No more sinuslifts (CMF Implants Dir.Vol Nr2 160-174 2009SCORTECCI G, Doms P: Biological anchor-age in small bone volumes. Publication scien-tifique dans la Revue de Première Rencontre Internationalede Rouen d’Implantologie et des Biomatériaux, mars 1991Scortecci, Donsimoni JM Mise en fonction immédiate des implants dentaires. La lettre de Stomatologie, juin 2000, n6 :7-8Scortecci G, Misch C.Odin G,Bindermann ISers L.: Implantologie basale: approche chirurgicale conforme aux données actuelles avérées.La tribune Dentaire nr 11, vol1 juin 2006 10-12

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Guide for Authors

ID publishes articles, which contain information, that will impro-ve the quality of life, the treatment outcome, and the affordability of treatments.The following types of papers are published in the journal: Full length articles (maximum length abstract 250 words, to-tal 2000 words, references 25, no limit on tables and figures). Short communications including all case reports (maximum length abstract 150 words, total 600 words, references 10, fi-gures or tables 3) Technical notes (no abstract, no introduction or discussion, 500 words, references 5, figures or tables 3). Interesting cases/lessons learned (2 figures or tables, legend 100 words, maximum 2 references).

Literature Research and Review articles are usually commis-sioned.Critical appraisals on existing literature are welcome.

Direct submissions to:[email protected] text body (headline, abstract, keywords, article, conclusion), tables and figures should be submitted as separate documents. Each submission has to be accompanied by a cover letter. The cover letter must mention the names, addresses, e-mails of all authors and explain, why and how the content of the article will contribute to the improvement of the quality of life of patients.

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