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Periodontology 2000, Vol. 66, 2014, 7–12 Printed in Singapore. All rights reserved © 2014 John
Periodontology 2000, Vol. 66, 2014, 7–12 Printed in Singapore. All rights reserved © 2014 John

Periodontology 2000, Vol. 66, 2014, 7–12 Printed in Singapore. All rights reserved

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Implant therapy: 40 years of experience

M ARC Q UIRYNEN , D AVID H ERRERA , W IM T EUGHELS & M ARIANO S ANZ

Dental implants placed under favorable conditions in healthy patients have success rates of over 95%, even after 15 years of follow up. In spite of this excellent outcome, technical, biologic and esthetic complications do occur (17, 27, 30, 31). Moreover, the outcome can be less desirable if dental implants are placed in patients affected with sys- temic diseases or other compromising conditions (2, 4, 13, 22, 25). Metabolic disorders or immune deciencies can, for example, give rise to surgical complications and may also interfere with bone apposition and/or remodeling at the implant bone interface. Similarly, radiation therapy in the surgical area may signi cantly reduce cellularity and vascu- larity, and hence affect the healing of oral implants. In compromised patients, implant-based treatment may be a questionable choice. Medica- tion, such as biphosphonates and/or anticoagu- lants, may also affect the outcome of implant placement or increase the frequency of postopera- tive complications. The placement of dental implants in such patients must adhere to strict treatment protocols (19, 20). The clinical protocol for the placement of dental implants has changed signicantly over the past 40 years (Table 1). From the initial biocompatibility - oriented protocol, aiming at osseointegration and long-term success, there has been an evolution toward less stringent criteria for implant placement in order to speed the healing process and improve the esthetic results, although it is still questionable whether patients will ultimately bene- t from these changes. The purpose of this volume of Periodontology 2000 is to evaluate the new developments in implantology, review their scien- tic evidence and analyze their indications, advan- tages and disadvantages. It is organized into 16 chapters dealing with diagnostic and therapeutic concepts, from the use of current

three-dimensional radiographic techniques to guided surgical implantation and enhanced surgical protocols. The overall goal is to guide the clinician in decision making around implant therapy and to provide an understanding of the etiology and therapy of peri-implant diseases.

Indication/treatment planning

Whereas initially only fully edentulous patients with optimal jaw bone dimensions (width and height) were the basic indication for implant therapy, now nearly every edentulous space is considered as suit- able for implant placement. In situations where insuf cient bone is available for implant therapy, bone-augmentation techniques are routinely consid- ered. Benic & Hammerle(3) concluded that such techniques are highly predictable if the proper indi- cations are respected and appropriate healing time is allowed for bone regeneration. Another approach is the use of the zygoma when the maxillary bone is severely atrophic. As discussed by Aparicio et al. (1), the zygomatic implant technique offers the possibil- ity to treat highly complex situations with low mor- bidity. The bone height in the posterior maxilla is often limited and a sinus lift procedure is recom- mended. Besides the conventional lateral window technique, a less invasive transalveolar approach is described by Pjetursson & Lang (26). As an alterna- tive to surgical bone regeneration, various studies have reported successful outcome with the use of short implants in the mandible as well as in the maxilla. Nisand & Renouard (24) discuss the indica- tions and evidence-based ef cacy of the use of short and narrow implants. The esthetic outcome of implant therapy is addressed by Merheb et al. (21) and Thoma et al. (34). Merheb et al. (21) review the optimal implant-placement within the bone

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Table 1. Changes to the original standard implant protocol of the 1970s to 1980s

Current changes to implant protocols

Original protocol (strict, biocompatibility = crucial)

Present protocol (less strict, speed and esthetics = crucial)

Indication/planning

Primarily fully edentulous patients

All type of indications

Strict inclusion/exclusion criteria

Rare exclusion criteria

Minimal jaw bone width of 7 8 mm

Guided bone regeneration for horizontal augmentation

Minimal jaw bone height of 10 mm

Guided bone regeneration for vertical augmentation

Planning based on two-dimensional radiographs

Three-dimensional cone beam computed tomography and virtual planning

Six to eight implants in edentulous jaw

Three to six implants in edentulous jaw

Anterior to the maxillary sinus

Sinus augmentation techniques

Timing

Four to 6 months of healing after tooth extraction

Immediate placement

Two-stage surgery

One-stage surgery

Submerged healing (3 6 months)

Nonsubmerged healing

No denture immediately after implant insertion

Immediate loading

Surgical protocol

Only specialists

General dentists

No surgical guides

Guided implant placement

Presurgical antibiotics

No standard antibiotic prophylaxis

Presurgical atropine to reduce saliva ow

No atropine

Low-speed placement + excessive cooling

Higher-speed placement, no cooling

Two surgical aspirators (operation area and mouth)

Single aspiration

Palatally/lingually pediculated ap

Crestal incision

Prosthetic protocol

Abutments not removed after the second surgery

Prosthesis on implant level

Titanium abutments

Different materials in mucosa

Implants interconnected

Free-standing implants

Screw retained

Cemented

Cast chromium cobalt/goldframework

Computer numeric controlled-milled titanium framework

Occlusion in resin

Occlusion in porcelain/metal

Prosthesis design focused on cleansability

Prosthesis design focused on esthetics

Implant material/design

Minimally rough implants

Moderately rough implants

Commercially pure Grade I titanium implants

Grade III V titanium implants

External hex connection implant-abutment

Internal connection

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Table 1. (Continued )

Current changes to implant protocols

Implants diameter: 3.5 mm and length: 10 mm

Short/narrow implants

No platform switch

Platform switch

Overall appreciation

Very strict protocol, biocompatibility = crucial

Less strict protocol, speed and esthetics = crucial

envelope to achieve acceptable long-term results, and Thoma et al. (34) focus on the peri-implant soft tissues and their impact on the esthetic outcome. The treatment of the fully edentulous patient is dis- cussed by Emami et al. (8), from the use of full- mouth xed rehabilitations to overdentures retained by two to four implants. This latter treatment option can offer excellent results with a satisfactory cost bene t ratio.

Implant treatment strategies

The original implant protocol was based on the place- ment of dental implants in healed ridges (at least 6 months after tooth extraction) and respecting an extended healing time (of 3 6 months) in order to obtain optimal osseointegration. The advent of implants with a moderately rough surface has accel- erated osseointegration and decreased the required healing time (40, 41). This healing period may even be reduced to a minimum, and immediate loading pro- tocols have been used with a high degree of predict- ability under speci c clinical conditions. These indications, and the scienti c evidence, are reviewed by De Bruyn et al. (6). Similarly, the placement of dental implants at the time of tooth extraction has signi cantly reduced the treatment time and patient morbidity. This sur- gical protocol, however, can be associated with esthetic complications as a result of remodeling of the hard/soft tissue after tooth extraction (5, 7, 11, 28). Vignoletti & Sanz (38) review the incidence of complications as well as the evidence-based out- comes of immediately placed implants. Implants with rough surfaces have raised concerns about the possible negative impact of enhanced bio lm for- mation (29), even though studies have failed to show signicant differences in bone loss or in the incidence of peri-implant infections for implants with minimally and moderately rough surfaces (16, 23, 35, 41).

Surgical protocol

The classical implant surgical protocol has chan- ged signicantly over the years (Table 1). The focus on maximal attention to sterility has diminished, and even the need for systemic antibiotic cover is questioned (9, 32). The introduction of three- dimensional imaging has led to improvements in preoperative diagnosis and implant surgery (12). The complex anatomy of the jaws and the implica- tions in implant surgery are discussed by Jacobs et al. (14), and the use of cone beam computed tomography for diagnosis/planning of dental implant therapy is reviewed by Jacobs & Quirynen (15). Guided surgery can improve the positioning of implants, shorten the surgical time and reduce postoperative complications. The advantages/disad- vantages of guided implant surgery, either dynamic or static, are reviewed respectively by Vercruyssen et al. (36) and Vercruyssen et al. (37).

Peri-implant diseases

Two major infectious processes, designated apical peri-implantitis and marginal peri-implant diseases, may develop around successfully integrated dental implants. Clinical studies have demonstrated that apical peri-implantitis is strongly linked with periapi- cal pathology around an extracted tooth at the implant site (18). Temmerman et al. (33) discuss the etiology, diagnosis and treatment of apical peri-im- plantitis. Marginal peri-implant diseases are dened as inammatory processes of infectious origin of the marginal peri-implant tissues. Similarly to peri- odontitis, marginal peri-impant diseases have a mul- tifactorial etiology (Fig. 1). Two types of marginal peri-implant diseases have been identi ed. Peri- implant mucositis affects the peri-implant mucosa without evidence of peri-implant crestal bone loss, whereas peri-implantitis denotes in ammation

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Quirynen et al. Genetics/Host (e.g. quality immune response) Environment (e.g. periodontopathogens and beneficial

Genetics/Host (e.g. quality immune response) (e.g. quality immune response)

Environment (e.g. periodontopathogens and beneficial bacteria) (e.g. periodontopathogens and beneficial bacteria)

Lifestyle (smoking, oral hygiene, diet and stress) (smoking, oral hygiene, diet and stress)

Hardware (sand-blasted and acid-etched implant/abutment, connection, platform, etc.) (sand-blasted and acid-etched implant/abutment, connection, platform, etc.)

Procedure (guided bone regeneration, type of restoration, cemented/screw, etc.) (guided bone regeneration, type of restoration, cemented/screw, etc.)

Hard/Soft tissue (density, vascularization, thickness of mucosa, etc.) (density, vascularization, thickness of mucosa, etc.)

Fig. 1. Complexity of peri-implanti- tis, underlining the multicausality model and the interaction among different causal factors.

associated with bone loss. Whilst peri-implant muco- sitis has clinical and histopathological characteristics similar to gingivitis, peri-implantitis exhibits distinct characteristics in terms of rate of progression and histopathology. Concerning treatment response, peri-implant mucositis is reversible with appropriate therapy, but the treatment of peri-implantitis is unpredictable and suffers from the lack of an evidence-based treatment protocol. Figuero et al. (10) discuss the two marginal peri-implant diseases in terms of etiopathogenesis, diagnosis and therapy. The chronic in ammation that denes peri- implant diseases depends not only on the degree of microbial accumulation and the composition of the implant-associated bio lm, but also on factors relat- ing to the implant and the patient. Some of the patient risk factors may be behaviourally based, and therefore modiable, such as lack of oral hygiene and smoking; however, other risk factors are not modi - able, such as genetic susceptibility to infection and systemic health status (e.g. diabetes).

Prosthetic protocol/materials

As shown in Table 1, changes have also occurred in implant composition and macro-design, in implantabutment connection and in restorative materials and protocols. Although the new types of material and therapy can in uence the outcome of implant therapy, they are not dealt with in this volume of Periodontology 2000 .

Conclusions

Implant dentistry has changed signi cantly during the past 40 years. At the introduction of the osseoin- tegration principle, implant placement and restora- tion were mostly carried out by specialists, but such

treatments are now increasingly being performed by general dentists. A clear shift has also been seen in the indications for implants, from xed full prosthe- ses to overdentures, and later to partial bridges and solitary implants. Implants were initially only placed in healed extraction sites with convenient bone parameters (bone height 10 mm and bone width 7 mm), and were loaded after a submerged healing period, but these prerequisites have now been partly abandoned. At the same time, patients have become more demanding, with requests for faster treatment and with clearly higher esthetic expectations. Diagnostic improvements in implantology include the introduction of computed tomography technol- ogy. The clinician suddenly obtained the ability to examine the jaw anatomy in more detail. The identi - cation of lingual foraminae, a double mental fora- men, an undercut in the caninepremolar area of the mandible, an extension of the alveolar canal to the midline, sinus pathology, a widened naso-palatine canal, an artery underneath the maxillary canine or in the lateral wall of the sinus, and so forth, made treat- ment planning more dif cult, but also reduced the risk for neurovascular disturbance and/or serious hemorrhage. A three-dimensional analysis of the jaw bone and surrounding soft tissues has made guided surgery possible. However, a review of the current lit- erature indicates that the accuracy of the available diagnostic techniques is not always perfect, and that clear guidelines, as detailed in several chapters of this volume, have to be carefully followed in order to pre- vent the malpositioning of implants (12). Improvements in implant surface topography and macro- and microdesign have facilitated the osseoin- tegration process and paved the way for new con- cepts in implantology, such as short implants, immediate loading and immediate placement (39). However, immediate placement might not always be as successful, from the esthetic point of view, as the conventional approach to implant therapy, and

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therefore should be carried out with appropriate cau- tion. Guided bone regeneration is becoming an accepted treatment option, either prior to, or simulta- neously with, implant insertion. The use of resorbable barrier membranes can simplify surgical procedures, but requires careful attention to new guidelines, as highlighted in this volume. It is now generally accepted that horizontal bone augmentation is a pre- dictable therapy, but this is not the case for vertical augmentation. Current advances in implantology are adversely affected by an unexpected high prevalence of peri-implantitis. As no well-de ned treatment is currently available to arrest peri-implantitis, or to regenerate bone lost to infection, the prevention of peri-implantitis becomes even more important. Finally, it is, of course, always important to keep the patient at the center of any treatment planning and to consider carefully his/her special wishes and expectations. Not all patients need a xed restoration. A simple overdenture can offer several advantages for many patients, including a less demanding position- ing of the implants, lower costs and simplicity of maintenance.

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