Group 3 ITI Consensus Report: Materials and antiresorptive drug-associated outcomes in implant dentistry.

OBJECTIVES: The aim of Working Group 3 was to address the influence of both material- and anti-resorptive drug- related factors on clinical and biological outcomes and complications in implant dentistry. Focused questions were addressed on (a) implant materials other than titanium (alloy)s, (b) transmucosal abutment materials and (c) medications affecting bone metabolism were addressed. MATERIALS AND METHODS: Three systematic reviews formed the basis for discussion in Group 3. Consensus statements and clinical recommendations were formulated by group consensus based on the findings of the systematic reviews. Patient perspectives and recommendations for future research were also conveyed. These were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Zirconia is a valid alternative to titanium as material for implant and transmucosal components, allowing soft and hard tissue integration with clinical outcomes-identified by implant survival, marginal bone loss and peri-implant probing depths-up to 5-years comparable to titatnium. However, most of the evidence for zirconia implants is based on 1-piece implants limiting the indication range. Furthermore, based on expert opinion, zirconia transmucosal components might be preferred in the esthetic zone. In patients receiving low-dose bisphosphonate therapy, the rate of early implant failure is not increased, while the long-term effects remain poorly studied. Although it has not been sufficiently addressed, similar outcomes can be expected with low-dose denosumab. A drug holiday is not recommended when considering implant placement in patients treated with low-dose ARD. However, the specific therapeutic window, the cumulative dose and the administration time should be considered. Access to peri-implant supportive care is mandatory to prevent peri-implantitis-related medication-related osteonecrosis of the jaw (MRONJ) or implant-related sequestra (IRS). In patients receiving low-dose anti-resorptive drugs (ARD) therapy, the risk of complications related to implant placement is high, and implant procedures in this specific population should be strictly treated in a comprehensive multidisciplinary center. Finally, healthy dental implants should not be removed before low or high-dose ARD. CONCLUSIONS: Zirconia implants can be an alternative to titanium implants in selected indications. However, the current state of evidence remains limited, especially for 2-piece implant designs. Administration of low-dose ARD did not show any negative impact on early implant outcomes, but careful follow-up and supportive care is recommended in order to prevent peri-implant MRONJ and IRS. Implant placement in high-dose patients must be strictly considered in a comprehensive multidisciplinary center.

Maxillary overdenture on three implants retained by low-profile stud attachments - A prospective cohort study.

BACKGROUND: Clinical data are needed on long-term outcomes of removable implant-supported prostheses in the fully edentulous maxilla as a function of the number of implants, effects of the attachment system and other clinical variables. OBJECTIVE: To restore individuals with an edentate maxilla with a metal-reinforced removable prosthesis without palatal coverage retained by low-profile stud attachments on three implants. METHODS: The regional ethics committee approved a prospective cohort study that included all consecutive patients treated in a private speciality clinic. Primary outcomes were patients reported, that is denture satisfaction scale and oral health-related quality of life - OHIP-20. Secondary outcomes were implant- (bone loss, implant complications and peri-implant conditions) and prosthesis-related (prosthesis complications, maintenance needs and mucosa condition). RESULTS: Thirty-two study participants were recruited between March 2007 and October 2016 and followed for a minimum of five years. According to Kruskal-Wallis tests, the OHIP-20 and Denture Satisfaction Scale questionnaire pre-treatment scores differed significantly. After an average of 6.7 years, peri-implant bone loss of more than 2 mm was observed on 17% of all implants, while no or minor bone loss was seen on 38%. The estimated success of implants was 0.95 at 168 months. The estimated success of the prosthesis, that is no adverse events or need for any repairs, was 0.55 at 156 months. CONCLUSION: The positive findings in the current clinical study strengthen the notion that for many individuals with an edentulous maxilla, a removable prosthesis retained by three implants fitted with low-profile stud-attachment is a reliable technical solution.

Fabrication, workflow and delivery of reconstruction: Summary and consensus statements of group 4. The 6th EAO Consensus Conference 2021.

OBJECTIVES: To report assessments of four systematic reviews (SRs) on (i) clinical outcomes of all-ceramic implant-supported crowns (iSCs), (ii) production time, effectiveness, and costs of computer-assisted manufacturing (CAM), (iii) computer-assisted implant planning and surgery (CAIPS) time and costs, and (iv) patient-reported outcome measures (PROMS). MATERIAL AND METHODS: An author group consisting of experienced clinicians and content experts discussed and evaluated the SRs and formulated consensus on the main findings, statements, clinical recommendations, and need for future research. RESULTS: All four SRs were conducted and reported according to PRISMA and detailed comprehensive search strategies in at least three bibliometric databases and hand searching. The search strategies were deemed reproducible. Variation was noted regarding language restrictions and inclusion of grey literature, but the search comprehensiveness appeared persuasive. The SRs included bias risk assessments of the primary studies, and their study methodology impacted the interpretations of the extracted data. CONCLUSIONS: (i) There is limited evidence (49 NRCT) showing that veneered and monolithic all-ceramic iSCs have excellent outcomes observed up to 3 years. (ii) There is no evidence evaluating production time and effectiveness comparing subtractive and additive CAM of implant models, abutments and crowns. (iii) There is limited evidence (4 RCT) that CAIPS involves more time and costs when considering the entire workflow and for diagnostics, manufacturing, and insertion of the restoration. Time seems to be the decisive factor for higher costs. (iv) Patients' comfort increases when optical compared to conventional impressions are used for fabricating iSCs and short-span FPDs (2 RCT, 5 NRCT).

Piezoelectric bone surgery compared with conventional rotary instruments in oral surgery and implantology: Summary and consensus statements of the International Piezoelectric Surgery Academy Consensus Conference 2019.

PURPOSE: Piezoelectric bone surgery was introduced into clinical practice almost 20 years ago as an alternative method for cutting bone in dental surgical procedures, in an attempt to reduce the disadvantages of using conventional rotary instruments. The aim of this Consensus Conference was to evaluate the current evidence concerning the use of piezoelectric surgery in oral surgery and implantology. MATERIALS AND METHODS: Three working groups conducted three meta-analyses with trial sequential analysis, focusing on the use of piezoelectric surgery in impacted mandibular third molar extraction, lateral sinus floor elevation and implant site preparation. The method of preparation of the systematic reviews, based on comprehensive search strategies and following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, was discussed and standardised. RESULTS: Moderate/low evidence suggests that piezoelectric surgery is significantly associated with a more favourable postoperative course (less pain, less trismus) after impacted mandibular third molar extraction than conventional rotary instruments. Moderate evidence suggests that implants inserted with piezoelectric surgery showed improved secondary stability during the early phases of healing compared with those inserted using a drilling technique. Strong/moderate evidence suggests that piezoelectric surgery prolongs the duration of surgery in impacted mandibular third molar extraction, sinus floor elevation and implant site preparation, but it is unclear whether the slight differences in duration of surgery, even if statistically significant, represent a real clinical advantage for either operator or patient. Weak evidence or insufficient data are present to draw definitive conclusions on the other investigated outcomes. CONCLUSIONS: Further well-designed trials are needed to fully evaluate the effects of piezoelectric surgery, especially in implant site preparation and sinus floor elevation.

Piezoelectric bone surgery for implant site preparation compared with conventional drilling techniques: A systematic review, meta-analysis and trial sequential analysis.

PURPOSE: To evaluate whether the use of piezoelectric bone surgery (PBS) for implant site preparation reduces surgical time, improves implant stability, preserves marginal bone level and improves the survival rate of oral implants compared with conventional drilling techniques. MATERIALS AND METHODS: This meta-analysis followed the PRISMA (preferred reporting items for systematic review and meta-analysis) guidelines and was registered in the PROSPERO (international prospective register of systematic reviews) database (CRD42019142749). The PubMed, Embase, Scopus and Open Grey databases were screened for articles published from 1 January 1990 to 31 December 2018. The selection criteria included randomised controlled trials (RCTs) and case-control studies (CCTs) comparing the PBS with conventional rotary instruments for implant site preparation, and reporting any of the selected clinical outcomes (surgical time, implant stability, marginal bone variations and implant failure rate) for both groups. The risk of bias assessment was performed using the Cochrane Collaboration tool for RCTs and the Newcastle-Ottawa scale (NOS) for CCTs. A meta-analysis was performed, and the power of the meta-analytic findings was assessed by trial sequential analysis (TSA). RESULTS: Eight RCTs and one CCT met the inclusion criteria and were included in the review. The meta-analysis and the TSA showed moderate evidence suggesting that the PBS prolongs surgery duration and improves secondary stability 12 weeks after implant placement compared with conventional drilling techniques. Insufficient data are available in literature to assess if the PBS reduces marginal bone loss and/or improves the implant survival rate compared with conventional drilling techniques. CONCLUSIONS: Adequately powered randomised clinical trials are needed to confirm the PBS positive effect on the secondary stability and to draw conclusions about the influence of PBS on marginal bone stability and implant survival.

Quantification of porosity in composite resins delivered by injectable syringes using X-ray microtomography.

OBJECTIVE: To assess whether composite polymer resin delivered in compules include pores and the possible effect on the amount of porosity in dental restorations. METHOD AND MATERIALS: Original compules containing unpolymerised composite polymer resin (CPR) were scanned in a micro-CT. Four products were examined, which comprised universal composites (Herculite XRV Ultra, Ceram.X Universal, Tetric Evo Ceram) and a flowable bulk-fill composite (SDR) (n = 10 per group). The pore size distribution and amount of porosity (vol.%) were estimated for the unpolymerized and polymerized material used to restore a standardised cavity in a typodont tooth. Manufacturers' instructions were followed regarding material handling, and polymerisation by use of a calibrated light-curing unit. The pore characteristics and their size distribution, and the amount of porosity in the dental restoration were contrasted with the values measured in the compule. Non-parametric tests were used to analyse differences between the four products. RESULTS: All the composite polymer resin compules contained unpolymerised material that included pores. The universal composite compules included pores predominantly in the sub-100 µm sizes. In contrast, the flowable bulk-fill compules included a few pores with a diameter >100 µm, which were assumed to be air-bubbles. The unpolymerised material within the compule included consistently more pores compared to the extruded portion from the compule tip, and in the final restoration (p < .001). The amount of porosity in the restorations differed amongst the tested materials, with the flowable bulk-fill composite showing the lowest amount of porosity (p < .01).

Dog-assisted therapy in the dental clinic. Part B. Hazards and assessment of potential risks to the health and safety of the dental therapy dog.

Background: A dental therapy dog may help anxious patients in the dental clinic overcome their fear and facilitate the completion of necessary dental care. Dental clinic activities are associated with hazards that may pose potential risks to the health and safety of the dental therapy dog. Objectives: To describe potential hazards associated with risks to health and safety to therapy dogs in dental clinics and to present suggestions for risk minimisation by adopting best practices in dental clinic settings. Materials and method: Literature searches in Medline, http://Clinicaltrials.gov, and Google Scholar for qualitative and quantitative assessments of occupational hazards and risks in dental clinics, in combination with a review of the reference list of the included studies. Identified hazards and risks were analysed relative to their relevance for the health and welfare of a therapy dog present in a dental clinic setting. Results: Workplace hazards in the dental clinic that apply to both humans and therapy dogs are allergies, sharps injury, eye injury, stress, rhinitis, hearing impairment, and other hazards. Additional concerns associated with risks for the dental therapy dog are situations involving erratic patient behaviour and threats if the patient is an undisclosed disease carrier. Risks to the health and safety of the dental therapy dog in the clinics are present but are low if the dental clinical staff and dog handlers comply with best practices. Conclusions: Best practice includes awareness amongst the clinic staff and the dog handler of all potential hazards in the dental clinic and on how to reduce these hazards as well as adverse events that may scare the dental therapy dog. The dental therapy dog team must be specially trained to work in a dental clinic. Each treatment session has to be exclusively tailored to that specific appointment and the individual patient.

Dog-assisted therapy in the dental clinic: Part A-Hazards and assessment of potential risks to the health and safety of humans.

Background: Dog-assisted therapy in the dental clinic may be an attractive alternative to sedation for anxious patients. Including a dental therapy dog in a clinical setting introduces new hazards and potential risks to health and safety for both humans and animal. Objectives: The study aims to describe potential hazards associated with risks to humans by having a therapy dog present in the dental clinic and to provide guidance on best practices to minimise and control risks for the patients, the dentist, and the dental clinic staff. Materials and Methods: Literature searches in Medline, http://Clinicaltrials.gov, and Google Scholar for qualitative and quantitative assessments of hazards and risks associated with the use of therapy dogs in health care settings, in combination with a review of the reference list of the included studies. Identified hazards and risks were analysed with respect for the health and welfare of humans in a dental clinic setting that involves the presence of a therapy dog. Results: Potential risks to health and safety for humans in dental clinics that offer dog-assisted therapy can be categorised within four general categories of hazards: the dog as a source of zoonotic pathogens and human diseases, exposure to canine allergens, adverse animal behaviour, and dangers associated with high activity in a congested dental clinic operatory. Risks to humans are reduced by maintaining awareness amongst the dental clinic staff and the dog handler of all potential hazards in the dental clinic, and on how to reduce these hazards as well as adverse events that may scare the dental therapy dog. Conclusions: Risks to the health and safety of humans in the presence of therapy dog in the clinics are present but are low if the dental clinical staff and dog handlers comply with best practices.

Group 1 ITI Consensus Report: The influence of implant length and design and medications on clinical and patient-reported outcomes.

OBJECTIVES: The aim of Working Group 1 was to address the influence of different local (implant length, diameter, and design) and systemic (medications) factors on clinical, radiographic, and patient-reported outcomes in implant dentistry. Focused questions on (a) short posterior dental implants (≤6 mm), (b) narrow diameter implants, (c) implant design (tapered compared to a non-tapered implant design), and (d) medication-related dental implant failures were addressed. MATERIALS AND METHODS: Four systematic reviews were prepared in advance of the Consensus Conference and were discussed among the participants of Group 1. Consensus statements, clinical recommendations, and recommendations for future research were based on structured group discussions until consensus was reached among the entire expert Group 1. The statements were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Short implants (≤6 mm) revealed a survival rate ranging from 86.7% to 100%, whereas standard implant survival rate ranged from 95% to 100% with a follow-up from 1 to 5 years. Short implants demonstrated a higher variability and a higher Risk Ratio [RR: 1.24 (95% CI: 0.63, 2.44, p = 0.54)] for failure compared to standard implants. Narrow diameter implants (NDI) have been classified into three categories: Category 1: Implants with a diameter of <2.5 mm ("Mini-implants"); Category 2: Implants with a diameter of 2.5 mm to <3.3 mm; Category 3: Implants with a diameter of 3.3 mm to 3.5 mm. Mean survival rates were 94.7 ± 5%, 97.3 ± 5% and 97.7 ± 2.3% for category 1, 2 and 3. Tapered versus non-tapered implants demonstrated only insignificant differences regarding clinical, radiographic, and patient-reported outcomes. The intake of certain selective serotonin reuptake inhibitors and proton pump inhibitors is associated with a statistically significant increased implant failure rate. The intake of bisphosphonates related to the treatment of osteoporosis was not associated with an increased implant failure rate. CONCLUSIONS: It is concluded that short implants (≤6 mm) are a valid option in situations of reduced bone height to avoid possible morbidity associated with augmentation procedures; however, they reveal a higher variability and lower predictability in survival rates. Narrow diameter implants with diameters of 2.5 mm and more demonstrated no difference in implant survival rates compared to standard diameter implants. In contrast, it is concluded that narrow diameter implants with diameters of less than 2.5 mm exhibited lower survival rates compared to standard diameter implants. It is further concluded that there are no differences between tapered versus non-tapered dental implants. Certain medications such as selective serotonin reuptake inhibitors and proton pump inhibitors showed an association with a higher implant failure rate.

Systematic review of clinical and patient-reported outcomes following oral rehabilitation on dental implants with a tapered compared to a non-tapered implant design.

BACKGROUND: Dental implants are available in different shapes. AIMS: This systematic review aims to address whether tapered compared to non-tapered implants demonstrate similar clinical and patient-reported outcomes. The review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. MATERIALS & METHODS: We searched electronic databases including MEDLINE through PubMed and the Cochrane Central Register of Controlled Trials for randomized clinical trials (RCT) that compare tapered versus non-tapered implants with at least 10 treated participants and a minimum mean follow-up time of 3 years. There were no restrictions to a particular treatment indication or outcome measures. Two authors independently conducted screening, risk of bias assessment, and data extraction of eligible trials in duplicate. We applied the Cochrane risk of bias assessment tool to consider risk of bias. RESULTS: We identified 18 different RCTs, of which three reported outcomes at 3 years or greater. The three trials described the results of 245 participants with 388 implants at 3 years, from the initially 306 participants with 494 implants at baseline. The three trials compared, respectively, two, two, and three different commercially available implant brands and reported only clinically insignificant differences. We judged all three trials to be at moderate risk of bias. The low number and heterogeneity of RCTs did not allow for meta-analyses. DISCUSSION AND CONCLUSION: Appropriate professional judgment in clinical decision making must include a comprehensive diagnosis of the patient's jawbone quality and quantity and consideration of osteotomy protocol in accordance with the patient's treatment preferences, where the shape of the dental implant is only one contributory factor.

Investigational Clinical Trial of a Prototype Optoelectronic Computer-Aided Navigation Device for Dental Implant Surgery.

PURPOSE: New digital technologies enable real-time computer-aided (CA) three-dimensional (3D) guidance during dental implant surgery. The aim of this investigational clinical trial was to demonstrate the safety and effectiveness of a prototype optoelectronic CA-navigation device in comparison with the conventional approach for planning and effecting dental implant surgery. MATERIALS AND METHODS: Study participants with up to four missing teeth were recruited from the pool of patients referred to the University of Toronto Graduate Prosthodontics clinic. The first 10 participants were allocated to either a conventional or a prototype device study arm in a randomized trial. The next 10 participants received implants using the prototype device. All study participants were restored with fixed dental prostheses after 3 (mandible) or 6 (maxilla) months healing, and monitored over 12 months. The primary outcome was the incidence of any surgical, biologic, or prosthetic adverse events or device-related complications. Secondary outcomes were the incidence of positioning of implants not considered suitable for straightforward prosthetic restoration (yes/no); the perception of the ease of use of the prototype device by the two oral surgeons, recorded by use of a Likert-type questionnaire; and the clinical performance of the implant and superstructure after 1 year in function. Positioning of the implants was appraised on periapical radiographs and clinical photographs by four independent blinded examiners. Peri-implant bone loss was measured on periapical radiographs by a blinded examiner. RESULTS: No adverse events occurred related to placing any implants. Four device-related complications led to a switch from using the prototype device to the conventional method. All implants placed by use of the prototype device were in a position considered suitable for straightforward prosthetic restoration (n = 21). The qualitative evaluation by the surgeons was generally positive, although ergonomic challenges were identified. All study participants were present for the 1-year examination (n = 20 patients, 41 implants, 32 superstructures), and no complications or failures with any implants or superstructures were revealed. The peri-implant bone loss was less than 1 mm for all implants. CONCLUSION: Within the limitations of this trial, the prototype device provided placement of dental implants without adverse events.