Influence of Splint Support on the Precision of Static Totally Guided Dental Implant Surgery: A Systematic Review and Network Meta-analysis.

Purpose: To assess the accuracy of totally guided implant placement with static surgical splints in relation to the different types of supporting tissues (tooth, mucosa, or bone). Materials and Methods: This review was carried out following the PRISMA guidelines. An electronic search was done of the MEDLINE (PubMed), Embase, and Cochrane Library databases, without publication year or language restrictions. Results: The literature search yielded a total of 877 articles; 18 were included in the qualitative synthesis, and 16 of these articles were included in the quantitative analysis. The included studies presented a high risk of bias, except for one randomized clinical trial. The strength of the recommendations is therefore weak. In the angular deviation treatment, statistically significant differences were observed in the accuracy of the implants with tooth vs bone support: Bone support yielded 1.31 degrees greater deviation vs tooth support (SD = 0.43; 95% CI: 0.47, 2.15, P = .002). No significant differences were observed in the linear deviations. Conclusion: Tooth support proved to be significantly more precise than bone support splints. There were no differences referring to horizontal coronal deviation, horizontal apical deviation, or vertical deviation according to the type of splint support used.

Influence of occlusal loading on peri-implant inflammatory cytokines in crevicular fluid: a prospective longitudinal study.

OBJECTIVE: The objective of the study was to evaluate the relation between occlusal loading and peri-implant crevicular fluid cytokine expression in patients with implant-supported complete fixed prostheses in both arches. MATERIAL AND METHODS: A prospective longitudinal clinical study was performed at a university clinic. Fifteen patients were selected and 11 were included. All patients had bimaxillary implant-supported complete fixed ceramo-metallic prostheses loaded at least 12 months before the beginning of the study. Allocation was established for each patient using a computerized occlusal analysis system. The test implant was the maxillary implant closest to the point of highest occlusal loading. The maxillary implant with least loading was the control implant. Occlusal adjustment was performed using a round diamond burr. This occlusal distribution was verified with the occlusal analysis system. Expression of cytokines from peri-implant crevicular fluid (TNF-α, IL-10, IL-6, IL-1ß, IL-8) were recorded and analyzed in both test and control implants before (baseline: T0) and 2 (T1) and 12 months (T2) after occlusal adjustment. The Brunner-Langer non-parametric test was performed. RESULTS: At T0, the expression of IL-10 was significantly higher in the test group implants (p = 0.018). Between T0 and T1, the expression of all the cytokines decreased in the implants of both groups with statistically significant differences, except for TNF (p = 0.271). When comparing both groups at T1, there was no statistically significant difference in any of the analyzed cytokines. At T2, TNF-α suffered when compared with baseline, a statistical decrease in both study and control implants (p < 0,001). At T2, there were no statistically significant differences between groups in any of the cytokines analyzed. CONCLUSIONS: Implants with higher occlusal load presented higher expression of IL-10 in peri-implant crevicular fluid. Occlusal adjustment produced a decrease in the expression of all the analyzed cytokines, both in test and control implants.

Influence of the use of autogenous bone particles to close the access window after maxillary sinus floor augmentation: an experimental study in rabbits.

AIM: To study the influence on the healing of the placement of particulate autogenous bone in the antrostomy and in the subjacent region after maxillary sinus elevation. MATERIAL AND METHODS: Sixteen New Zealand rabbits were undergone to bilateral maxillary sinus floor augmentation with 4 × 4 mm antrostomy dimension. The sinus mucosa was elevated, and the space obtained was filled with xenograft. In the test site (treated sites), autogenous bone was harvested from the tibia and was placed either in the antrostomy and the subjacent region while the control site was left untreated. Antrostomy was covered bilaterally with collagen membranes. Animals were euthanized after 1 and 8 weeks of healing, with 8 rabbits in each group. Histomorphometric evaluations were done. The Wilcoxon test is used for statistical analysis, for a 5% statistical significance. RESULTS: After 1 week of healing, the new bone proportion in the antrostomy was 7.7 ± 11.2% and 6.1 ± 6.4% in the treated and untreated sites, respectively. In the subjacent region (close-to-window region), hardly any new bone was assessed. In the elevated region, 2.7-2.8% of total new bone was found in both sites. In the antrostomy region, after 8 weeks of healing, 35.5 ± 20.9% of new bone in the treated sites, and 28.6 ± 24.1% in the untreated sites was observed (p = 0.499). In the close-to-window region, the respective proportions were 25.8 ± 16.1% and 17.6 ± 16.3% (p = 0.018). In the elevated region, the total new bone reached fractions of 27.9 ± 12.9% and 23.6 ± 15.2% in the treated and untreated sites, respectively (p = 0.128). CONCLUSIONS: The placement of autogenous bone in the antrostomy and the subjacent region after maxillary sinus elevation, slightly enhanced bone formation compared with sites only grafted with xenograft. Though, only the subjacent close-to-window region showed a statistical significance at 8 weeks of healing. Despite the limitations of the present study, due to its preclinical nature, findings should be extrapolated to humans with caution.

Accuracy of Implant Placement with Computer-Guided Surgery: A Systematic Review and Meta-Analysis Comparing Cadaver, Clinical, and In Vitro Studies.

PURPOSE: The aim of this systematic review was to analyze the accuracy of implant placement using computer-guided surgery and to compare virtual treatment planning and outcome in relation to study type (in vitro, clinical, or cadaver). A further objective was to compare the accuracy of half-guided implant surgery with that of full-guided implant surgery. MATERIALS AND METHODS: A PubMed search was performed to identify studies published between January 2005 and February 2015, searching the keywords "reliability AND dental implant planning" and "accuracy dental implant planning." Inclusion criteria were established a priori. Horizontal coronal deviation, horizontal apical deviation, angular deviation, and vertical deviation were analyzed. RESULTS: A total of 186 articles were reviewed, and 34 fulfilled the inclusion criteria. Information about 3,033 implants was analyzed in 8 in vitro studies (543 implants), 4 cadaver studies (246 implants), and 22 clinical studies (2,244 implants). Significantly less horizontal apical deviation and angular deviation were observed in in vitro studies compared to clinical and cadaver studies, but there were no statistically significant differences in apical coronal deviation or vertical deviation between the groups. Compared to half-guided surgery, full-guided implant surgery showed significantly less horizontal coronal deviation for cadaver studies, significantly less horizontal apical deviation for clinical studies, and significantly less angular deviation for both clinical and cadaver studies. CONCLUSION: Implant placement accuracy was lower in clinical and cadaver studies compared with in vitro studies, especially in terms of horizontal apical deviation and angular deviation. Full-guided implant surgery achieved greater accuracy than half-guided surgery.

Indirect sinus lift without bone graft material: Systematic review and meta-analysis.

A systematic literature review and a meta-analysis of indirect sinus lift without the use of bone graft material was performed. A PubMed search was made from January 2005 to January 2012 with keywords: "sinus lift", "osteotome", "graft" and "maxillary sinus elevation". The inclusion criteria were: maxillary sinus lift technique with osteotomes with a minimum follow-up period of 5 months after surgery without bone graft material. 11 articles were included. The mean gain in residual crestal bone height after maxillary sinus lift without bone graft material was 3,43 mm ± 0,09 (2,5 mm - 4,4 mm). The survival rate ranged from 94% to 100%. Placement of implants with sinus lift without bone graft material, is a valid surgical technique to gain residual crestal height and placed implants in an atrophic posterior maxillary with a crestal height from 5 to 9 mm. Key words:Sinus lift, osteotome, graft, maxillary sinus elevation.

Influence of occlusal loading on peri-implant clinical parameters. A pilot study.

OBJECTIVES: To investigate the relation between occlusal loading and peri-implant clinical parameters (probing depth, bleeding on probing, gingival retraction, width of keratinized mucosa, and crevicular fluid volume) in patients with implant-supported complete fixed prostheses in both arches. MATERIAL AND METHODS: This clinical study took place at the University of Valencia (Spain) dental clinic. It included patients attending the clinic for regular check-ups during at least 12 months after rehabilitation of both arches with implant-supported complete fixed ceramo-metallic prostheses. One study implant and one control implant were established for each patient using the T-Scan®III computerized system (Tesco, South Boston, USA). The maxillary implant closest to the point of maximum occlusal loading was taken as the study implant and the farthest (with least loading) as the control. Occlusal forces were registered with the T-Scan® III and then occlusal adjustment was performed to distribute occlusal forces correctly. Peri-implant clinical parameters were analyzed in both implants before and two and twelve months after occlusal adjustment. RESULTS: Before occlusal adjustment, study group implants presented a higher mean volume of crevicular fluid (51.3 ± 7.4 UP) than the control group (25.8 ± 5.5 UP), with statistically significant difference. Two months after occlusal adjustment, there were no significant differences between groups (24.6 ± 3.8 UP and 26 ± 4.5 UP respectively) (p=0.977). After twelve months, no significant differences were found between groups (24.4 ± 11.1 UP and 22.5 ± 8.9 UP respectively) (p=0.323). For the other clinical parameters, no significant differences were identified between study and control implants at any of the study times (p>0.05). CONCLUSIONS: Study group implants receiving higher occlusal loading presented significantly higher volumes of crevicular fluid than control implants. Crevicular fluid volumes were similar in both groups two and twelve months after occlusal adjustment.

Buccal bone crest dynamics after immediate implant placement and ridge preservation techniques: review of morphometric studies in animals.

PURPOSE: To review morphometric studies performed in animals assessing the dynamics of the buccal bone crest after immediate implant placement and ridge preservation techniques. MATERIAL AND METHOD: A bibliographic search in PubMed was performed. Studies that analyzed morphometrically in animals the buccal bone crest dynamics after immediate implant placement or ridge preservation techniques were included. Twenty-five studies met the inclusion criteria. RESULTS: Immediate implant placement does not prevent the resorption of the buccal bone crest. To minimize this resorption, 2 mm width of the buccal bone crest, palatal/lingual implant placement, and an adequate implant diameter for the width of the ridge are required. The regeneration of the gap after immediate implant placement limits the resorption of the buccal bone crest. Flap elevation and implant surface showed no relation with this resorption. Ridge preservation techniques associated with mucogingival surgery minimize buccal bone crest resorption. Biomaterials are more effective than autograft. CONCLUSIONS: Immediate implant placement does not prevent the resorption of the buccal bone crest after dental extraction. Ridge preservation techniques minimize this resorption.

Comparative split-mouth study of the anesthetic efficacy of 4% articaine versus 0.5% bupivacaine in impacted mandibular third molar extraction.

OBJECTIVE: The purpose of this study was to compare the clinical efficacy of articaine at 4% (epinephrine 1:100,000) with bupivacaine at 0.5% (epinephrine 1:200,000) for surgical extraction of impacted mandibular third molars. STUDY DESIGN: This was a randomized, double blind, split-mouth, clinical trial. Thirty-six patients took part and underwent extraction of 72 lower third molars. The variables studied were: anesthetic latency time, intra-operative bleeding, anesthetic quality, hemodynamic changes during the surgical intervention, anesthetic duration in the soft tissues, post-operative analgesia and post-operative pain at 2, 6, 12 and 24 hours using a visual analogue scale, as well as any need for additional rescue medication. RESULTS: Latency time was 2.0 minutes for articaine and 3.1 minutes for bupivacaine, with statistically significant difference (p<0.05). Bleeding was greater when bupivacaine was used (p<0.05) and anesthetic quality was greater with articaine (p<0.05). The duration of soft tissue anesthesia was longer with bupivacaine (p<0.05). Differences in post-operative analgesia, haemodynamic changes, post-operative pain and the quantity of rescue medication consumed were not statistically significant (p>0.05). CONCLUSIONS: Articaine showed greater clinical efficacy than bupivacaine, reducing latency time, bleeding, anesthetic duration in the soft tissues and achieving higher anesthetic quality, requiring less reinforcement during surgery than bupivacaine. Key words:Articaine, bupivacaine, anesthetic efficacy, impacted mandibular third molar.

Indirect osteotome maxillary sinus floor elevation: an update.

The objective was to review publications on indirect osteotome maxillary sinus floor elevation (OMSFE) procedures. Studies published between 1999 and 2010 on patients with a minimum of 1 year of follow-up were analyzed. Fourteen studies were included. Indirect OMSFE is indicated for a bone height of 6-8 mm. More bone height was gained when graft material was used. Schneiderian membrane perforation was the most frequent complication. Survival rates varied between 93.5% and 100%. Osteotome sinus membrane elevation is a predictable and effective procedure for placing implants in areas of the posterior maxilla with low bone height.

Radiographic signs associated with inferior alveolar nerve damage following lower third molar extraction.

The aim was to carry out a literature review of preoperative radiographic signs in orthopantomography (OPG) and computed tomography (CT) related with the risk of inferior alveolar nerve damage during the surgical extraction of lower third molar (LTM). A search was made on PubMed for literature published between the years 2000 and 2009. In the reviewed literature, radiographic signs in the OPG that indicate a relationship between the LTM and the inferior alveolar canal are considered a risk factor for nerve damage. These signs are darkening and deflection of the root, and diversion and interruption in the white line of the canal. In the majority of these studies, the routine use of CT is not justified, and is only recommended when radiographic signs appear in the OPG that demonstrate a direct anatomical relationship between the LTM and the canal. In the CT, the absence of cortical bone in the canal implies a contact between the root of the LTM and the canal, and is related with the presence of some radiographic signs in the OPG. Some studies demonstrate that despite the absence of cortical bone, the risk of lesion or exposure of the nerve during the extraction of LTM was low.

Distal probing depth and attachment level of lower second molars following surgical extraction of lower third molars: a literature review.

A review of the literature is made to evaluate factors that influence probing depth and attachment level on the distal aspect of the lower second molar (L2M) following extraction of a lower third molar (L3M). The PubMed database was searched for studies published between 1997 and March 2009 using the following keywords: mandibular third molar, distal periodontal defect, distal probing depth, distal attachment level, flap design. Randomized prospective studies, with a minimum follow-up of three months for which the full text could be obtained, and that indicated the attachment level and/or probing depth on the distal surface of the L2M in both the preoperative and postoperative periods were included. In the studies obtained, flap design had no influence on distal probing depth or distal attachment level of the L2M following extraction of an L3M. Curettage of the distal radicular surface of the L2M, together with oral hygiene control by the dentist, reduced probing depth values. Various authors recommend bone regeneration techniques in patients with a distal periodontal defect prior to extraction. The placing of membranes (resorbable or nonresorbable) is not justified; however, the use of demineralized bone powder or platelet-rich plasma gel reduces the distal probing depth and attachment level of the L2M.

Ostectomy versus osteotomy with repositioning of the vestibular cortical in periapical surgery of mandibular molars: a preliminary study.

INTRODUCTION: Accessing the tooth roots in periapical surgery (PS) requires the elimination of periapical bone. OBJECTIVE: To compare the postoperative morbidity and prognosis following PS on mandibular molars by ostectomy, or by osteotomy with repositioning of the vestibular cortical. MATERIAL AND METHODS: A retrospective clinical study of mandibular molars subjected to PS with ultrasound. Two groups were considered according to the surgical procedure used to access the roots: Group 1 (G1) with ostectomy and Group 2 (G2) with osteotomy and repositioning of the vestibular cortical. Only patients who had properly followed the post-operative instructions, adequately completed the post-operative questionnaires, and with a minimum of 12 months follow-up were included in the study. Post-operative morbidity was evaluated, and a clinical and radiographic follow-up was carried out using the criteria established by von Arx and Kurt in 1999. The SPSS program version 15 for Windows was used, considering values of p < or =0.05 as statistically significant. RESULTS: Seventy-five patients, including 18 men and 57 women, with 87 mandibular molars and 107 periapical lesions were subjected to PS. The mean age of the patients was 38.5 years old (range 15-74 years old). The patients were monitored for an average of 27.2 months (range 12-120 months). Sixty-six patients (78 teeth) were treated in G1, and 9 patients (9 teeth) in G2. There was no relationship between the size of the ostectomy and pain, swelling or prognosis (p>0.05). Patients who underwent ostectomy presented more swelling than those subjected to osteotomy (p<0.05). There was no relationship between prognosis and the variables studied (p>0.05). CONCLUSIONS: There was no statistically significant relationship between the surgical procedure used and post-operative pain or prognosis. Patients who underwent an ostectomy presented more swelling than those who were treated with an osteotomy and repositioning of the vestibular cortical.

Inflammatory implant periapical lesion: etiology, diagnosis, and treatment--presentation of 7 cases.

PURPOSE: To investigate implant periapical lesions, and to describe their treatment. The hypothesis of this evaluation is that implant periapical lesions are disorders of the area surrounding the apex of a dental implant, and that their etiology can be multifactorial (ie, vascular impairment, vascular ischemia, overheating of bone during drilling, and implant surface contamination). The diagnosis is based on the clinical manifestations and x-ray findings. The x-ray findings usually involve a periapical radiotransparency. MATERIALS AND METHODS: Seven patients with implant periapical lesions (3 in the upper jaw, and 4 in the mandible) after implant placement are described. All patients reported pain, and 3 suffered from inflammation. Upon percussion, the 3 nonsubmerged implants produced a dull sound, with no mobility. A panoramic x-ray study showed periapical transparencies around 5 implants, whereas in 1 case, computed tomography showed a maxillary sinus reaction. The diagnosis was acute apical peri-implantitis (nonsuppurative in 2 cases, and suppurative in 5 cases). RESULTS: The clinical manifestations did not subside with antibiotics. In all cases, treatment consisted of implant periapical surgery, after which the symptoms disappeared. The radiotransparencies showed progressive resolution. CONCLUSION: The possibility of implant periapical lesions must be taken into account. A rapid diagnosis should be established to treat the lesions at an early stage, hence preventing the need for implant extraction.

Comparative study of wide-diameter implants placed after dental extraction and implants positioned in mature bone for molar replacement.

OBJECTIVE: The aim of this study was to compare wide-diameter implants placed in mature bone versus implants inserted in postextraction bone. MATERIAL AND METHODS: A retrospective case study was made; the sample was composed of subjects who had had wide implants placed in the molar area between 2003 and 2005. Two groups were formed: implants placed in mature bone and implants in postextraction bone. A protocol was prepared in which patient age, sex, oral hygiene, implant length, type of prosthesis, and antagonist dentition were collected. After 12 months, data relating to the clinical and radiologic conditions of the implants and the success rate (criteria of Buser et al) were recorded. A statistical analysis of the variables was made (t test, Pearson correlation coefficient, analysis of variance, chi-square). RESULTS: The study examined 162 implants placed in 100 patients. Of the 162 implants, 130 were placed in mature bone and 32 in postextraction bone. Four implants placed in mature bone failed in 4 patients (success rate of 96.9%). None of the implants placed in postextraction bone failed. CONCLUSIONS: The placement of wide-diameter implants in recent molar extraction sites has been shown to achieve similar results to implants placed in healed mature bone after 12 months of follow-up, within the limitations of this study.

Evaluation of healing criteria for success after periapical surgery.

INTRODUCTION: In periapical surgery, the absence of standardization between different studies makes it difficult to compare the outcomes. OBJECTIVE: To compare the healing classification of different authors and evaluate the prognostic criteria of periapical surgery at 12 months. MATERIAL AND METHODS: 278 patients (101 men and 177 women) with a mean age of 38.1 years (range 11 to 77) treated with periapical surgery using the ultrasound technique and a 2.6x magnifying glass, and silver amalgam as root-end filling material were included in the study. Evolution was analyzed using the clinical criteria of Mikkonen et al., 1983; radiographic criteria of Rud et al., 1972; the overall combined clinical and radiographic criteria of von Arx and Kurt, 1999; and the Friedman (2005) concept of functional tooth at 12 months of surgery. RESULTS: After 12 months, 87.2% clinical success was obtained according to the Mikkonen et al., 1983 criteria; 73.9% complete radiographic healing using Rud et al. criteria; 62.1% overall success, following the clinical and radiographic parameters of von Arx and Kurt, and 91.9% of teeth were functional. The von Arx and Kurt criteria was found to be the most reliable. CONCLUSION: Overall evolution according to von Arx and Kurt agreed most closely with the other scales.

Mandibular connective tissue pedicle flaps in implant dentistry: report of three cases.

An increase in soft tissues and alveolar bone in the anterior mandibular area between the canines is necessary to achieve a good esthetic result. The present article describes a technique for gaining bone volume and soft tissue to cover bone defects that would otherwise compromise the final result of prosthetic implant restoration in the anterior mandible. Three patients with anterior mandibular atrophy caused by loss of the mandibular incisors are presented. Particulate autologous bone grafting, the raising of a pediculate connective tissue flap to increase soft tissue, and implant placement were carried out simultaneously. After 2 years of follow-up, the implants were in good clinical and radiologic condition. The problem of atrophy and the lack of soft tissue were thus solved, and an acceptable esthetic outcome was achieved in a single surgical intervention.

Bone grafting simultaneous to implant placement. Presentation of a case.

Bone defects at mandibular alveolar crest level complicate the placement of dental implants in the ideal location. Surgical reconstruction using autologous bone grafts allows implant fixation in an esthetic and functional manner. We describe a patient with large mandibular bone loss secondary to periodontal inflammatory processes. Reconstruction of the mandibular alveolar process was carried out using onlay block bone grafts harvested from the mandible. The grafts were stabilized by positioning the dental implants through them--a procedure that moreover afforded good primary implant fixation. After two years of follow-up the clinical and radiological outcome is good. In the lower jaw, where bone regeneration is complicated, we were able to achieve good results in this patient--minimizing the corresponding waiting time by grafting and placing the implants in the same surgical step.

Periapical surgery using the ultrasound technique and silver amalgam retrograde filling. A study of 71 teeth with 100 canals.

INTRODUCTION: Periapical surgery using ultrasound allows the treatment of root canals of difficult access, with the sacrifice of little root tissue. As a result, periapical disorders which were condemned to treatment failure in the past can now be dealt with successfully. MATERIAL AND METHODS: In 71 teeth presenting 100 root canals treated with ultrasound and subjected to retrograde filling with silver amalgam, the course and short-term success of management was evaluated in relation to lesion size, the magnitude of apical resection, and the size of the retrograde filling cavity. The duration of follow-up was one year, with post-treatment controls after 6 and 12 months. RESULTS: After 6 months, the percentage clinical and radiological success was 92% and 58%, respectively. One year after periapical surgery the corresponding percentages were 95% and 80%. Global success after 6 months was 63%, versus 84.2% after 12 months. No statistically significant relation was observed between treatment success and the size of the periapical lesion, the amount of apex resected, or the size of retrograde filling. CONCLUSION: Periapical surgery using ultrasound and retrograde filling with silver amalgam affords a high success rate after 12 months.

Localized vertical maxillary ridge preservation using bone cores and a rotated palatal flap.

The aim of vertical augmentation of the alveolar ridge is to restore resorbed alveolar ridges. This technique is critical to the placement of dental implants in a favorable position and the enhancement of restoration esthetics. The present report describes a technique for surgical preservation of the anterior maxillary process using maxillary bone from the surgical site and raising a soft tissue rotated palatal flap. Maxillary lateral incisor extraction and periapical surgery of the central incisors were first carried out. Two bone cores were harvested from the neighboring buccal vestibular region and placed in the sockets of the lateral maxillary incisors. After 3 months, implants were placed; 12 weeks later, the prosthetic restorations were cemented. There were no complications after 2 years of follow-up. This technique constitutes a viable approach for preserving the anterior sector alveolar ridge with the posterior placement of dental implants.