Indications for implant-supported rehabilitation of the posterior atrophic maxilla: A multidisciplinary consensus among experts in the field utilising the modified Delphi method.

PURPOSE: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. MATERIALS AND METHODS: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. RESULTS: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. CONCLUSION: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable.

Radiographic protrusion of dental implants in the maxillary sinus and nasal fossae: A multidisciplinary consensus utilising the modified Delphi method.

The aim of the present study was to generate an international and multidisciplinary consensus on the clinical management of implant protrusion into the maxillary sinuses and nasal fossae. A total of 31 experts participated, 23 of whom were experts in implantology (periodontologists, maxillofacial surgeons and implantologists), 6 were otolaryngologists and 2 were radiologists. All the participants were informed of the current scientific knowledge on the topic based on a systematic search of the literature. A list of statements was created and divided into three surveys: one for all participants, one for implant providers and radiologists and one for otolaryngologists and radiologists. A consensus was reached on 15 out of 17 statements. According to the participants, osseointegrated implants protruding radiographically into the maxillary sinus or nasal fossae require as much monitoring and maintenance as implants fully covered by bone. In the event of symptoms of sinusitis, collaboration between implant providers and otolaryngologists is required. Implant removal should be considered only after pharmacological and surgical management of sinusitis have failed.

Risk of early implant failure in grafted and non-grafted sites: A systematic review and meta-analysis.

PURPOSE: To assess whether bone grafting is associated with early implant failure (defined as a lack of osseointegration detected prior to functional loading) and to evaluate the association between bone grafting procedures and other risk factors for early implant failure. MATERIALS AND METHODS: Two independent reviewers conducted an electronic search of MEDLINE (via PubMed). Meta-analysis was performed for the odds ratio of bone grafting procedures associated with early implant failure. The Newcastle-Ottawa Scale for cohort studies was used to assess the risk of bias. RESULTS: Of the 231 articles selected for full-text review, 10 were included in the qualitative analysis and for quantitative meta-analysis. An odds ratio of 1.50 (95% confidence interval 1.06-2.13) was recorded for bone grafting procedures associated with early implant failure. Data regarding the association of bone grafting and other risk factors in determining early implant failure were insufficient for quantitative analysis. CONCLUSIONS: Within the limitations of this study, a significant positive association was found between bone grafting procedures and early implant failure. The possible negative effect of bone grafting procedures on implant osseointegration should be considered when planning implant therapy.

Long-Term Results of Intraforaminal Immediately Loaded Implants and Posterior Mandibular Regrowth Evaluation in Severely Atrophic Mandibles.

PURPOSE: The aim of this clinical study was to verify the predictability of the rehabilitation of extremely atrophic jaws with immediately loaded short implants and evaluate posterior mandibular regrowth. MATERIALS AND METHODS: A cohort of consecutive fully edentulous patients wearing complete dentures in both arches was enrolled. Periodically, implant survival and prosthetic success were assessed. After informed consent, a subsample of 10 patients who had preoperative CBCT underwent a postoperative CBCT 1 year after immediate implant loading, and 3D superimpositions of pre- and postoperative images were performed. Linear measurements of bone height were performed at two sites in each hemimandible and, on the same sections, bone density according to the qualitative gray values (GVs) was analyzed in an area of 3 mm2 including the cortical mandibular bone. RESULTS: Fifty-nine fully edentulous patients (31 females, 28 males) with Class VI atrophic mandibles according to Cawood and Howell were rehabilitated with the insertion of four to five short implants (4-mm diameter, 7- or 8.5-mm long). Overall, 251 implants were immediately loaded with a fixed hybrid prosthesis. Four patients did not show up for recall visits, bringing the final number down to 55 patients (31 females, 24 males) and 231 implants. In up to 14 years of follow-up, a total of 4 implant failures were recorded (cumulative survival rate, 98.4%). The biologic complications included 9 mucositis (3.9%) and 3 peri-implantitis (1.3%) at implant-level analysis. Mechanical complications involved 9 chippings of the prosthetic restorations (17.0%). In the 10-patient subsample, the analysis showed bone growth (average of 1.2 ± 0.7 mm) in the posterior areas of the mandible. In addition, bone density was found to increase 17% to 27% with reference to the preoperative CBCT. CONCLUSION: The immediate loading of short implants may represent a feasible therapeutic option for the treatment of fully edentulous patients with severely atrophic mandibles. Bone regrowth in the posterior areas and an increase in bone density of the mandible may occur.

A Novel Technique for the Estimation of Gingival Thickness: A Preliminary Study.

This study aimed to evaluate the correlation between soft tissue thickness measured by CBCT and phenotype probing estimation and to assess the thickness cutoffs for each phenotype probing outcome. CBCT was performed with a lip retractor in order to isolate periodontal soft tissues in 10 consecutive patients. Using colored probes, the phenotype was evaluated for all present teeth and recorded as thin, medium, thick, or very thick. The overall correlation between tissue thickness and the phenotype probe score was r = 0.86 (CI: 0.80, 0.90). The correlation was r = 0.90 (CI: 0.81, 0.94) when only maxillary anterior teeth were considered. The obtained cutoffs were 0.83 mm between thin and medium phenotypes, 1.07 mm between medium and thick phenotypes, and 1.24 mm between thick and very thick phenotypes. Thus, a high correlation between tissue thickness and the phenotype probe score was found. Preliminary data on the use of phenotype probes as an evaluation method for gingival thickness were promising.

Total Face Approach (TFA) 3D Cephalometry and Superimposition in Orthognathic Surgery: Evaluation of the Vertical Dimensions in a Consecutive Series.

BACKGROUND: Cephalometry is fundamental in diagnosis, analysis, and planning of orthodontic-surgical treatment as it reveals skeletal relationship between the upper and lower jaw as well as facial aesthetic parameters. Nevertheless, 3D cephalometry has still not become the exam of choice in orthognathic treatment even though today CBCT (Cone Beam Computed Tomography) is routinely used in other branches of dentistry. METHODS: In a sample of 13 patients undergoing bimaxillary orthognathic surgery a chin-vertex CBCT exam was prescribed prior to orthodontic treatment (OT) and 12 months after surgery (T1). The DICOM files uploaded to MaterialiseSimplant Ortho software pro 2.1 (Materialise Co., Leuven, Belgium) were analyzed following the multiplane 3D Total Face cephalometry protocol (TFA). RESULTS: Results comparing pre-op and post-op TFA 3D cephalometry, were then evaluated considering reference values reported in literature. The CBCT, carried out pre- and post-surgery, were subsequently analyzed employing the superimposition method using cranial base as reference. The aim of this study is to evaluate the advantages and disadvantages of the two methods in orthognathic surgery. CONCLUSIONS: Multiplane 3D TFA allows the clinician to locate where major or minor skeletal discrepancies are found with respect to ideal parameters and is also useful in classifying skeletal intermaxillary relation. The superimposition method is highly intuitive but does not provide information on the quantity and location of osteotomic movement.

Total Face Approach (TFA): A Novel 3D Approach to Describe the Main Cephalometric Craniomaxillofacial Parameters.

The aim of this study is to propose a 3D skeletal classification and relative normal values of reference. Method: from a pool of 271 cone-beam computerized tomography images 108 chin-summit examinations of the skull were selected and divided into 3 traditional skeletal classes. The same Cone-beam Computerized Tomography (CBCT) images were then assessed using the cephalometric multiplanar analysis following the total face approach protocol. Results: the results of this study indicate standard 3D cephalometric norms for the vertical and sagittal evaluation of the skull. Conclusion: data obtained from our measurements allowed the creation of intervals supplying nosological classification that could be used in orthodontics, orthognatic surgery and implant surgery in fully edentulous patients.

Management of a neurological lesion involving Canalis Sinuosus: A case report.

This case report describes the management of a lesion involving the Canalis Sinuosus (CS), that is a bone channel originating from the infraorbital canal below the orbital margin and posterior to the infraorbital foramen and coursing in an anterolateral direction to the anterior wall of the nasal cavity. A female patient, 62y, ASA 1, wearing full mobile dentures, came to our clinic asking for upper jaw rehabilitation. Due to a severe bone atrophy, a graft procedure was performed and the placement of eight implants was planned. One week after implants were positioned, the patient referred pain in the upper right central incisor region, that was compatible with a normal post-operative healing. After 15 days, since the symptoms worsened and became localized and persistent, a more detailed CBCT analysis was carried out. The images demonstrated that a CS on the right side was compressed by the apex of the implant in position #11. The implant was replaced with a shorter one and adequate pharmacological therapy was prescribed. All the symptoms completely disappeared after 30 days.

Prevalence of Peri-Implantitis: A Multi-Centered Cross-Sectional Study on 248 Patients.

The aim of this multicenter cross-sectional study was to determine the prevalence of peri-implantitis and to assess its association with several patient- and implant-related factors. Patients with at least one implant, who came for a recall visit to one of the four centers over a period of five months, were enrolled. Presence of peri-implantitis (defined as bleeding on probing, exudate/suppuration, bone loss > 0.2 mm/year and increased pocket depth) and several other variables (e.g., smoking habits, history of periodontitis, diabetes) were recorded. Out of 248 enrolled patients (1162 implants), 10 patients had at least one implant with peri-implantitis (4.03%); a total of 14 implants were affected (1.20%). A statistically significant association between peri-implantitis and diabetes was found (OR 8.65; CI: 1.94-38.57). Smoking more than 10 cigarettes per day (OR: 0.53; CI 0.03-9.45) and history of periodontitis (OR: 2.42; CI: 0.49-11.89) were not found to be statistically associated with peri-implantitis. Even if implant therapy is a consolidated treatment, biological complications do happen. Strict supportive therapy recalls could lead to lower rates of peri-implantitis and earlier diagnosis.

Periodontal implications of surgical-orthodontic treatment of an impacted dilacerated maxillary incisor: A case report with a 2-year follow-up.

The treatment of an 8-year-old girl with a dilacerated maxillary incisor began in the mixed dentition; a modified palatal arch attached to the molars served as anchorage for the forced eruption of the dilacerated tooth to prevent the intrusion of the adjacent teeth and reduce the risk of root resorption. Two surgical sessions were planned: the first to permit the closed eruption; the second was an apically positioned flap to add attached gingiva to the labial side of the erupting tooth. The result was an optimal periodontal outcome; moreover, the roots of the adjacent teeth did not show any sign of resorption at the end of the forced eruption. The tooth was vital at the end of the treatment, and the apex covered by alveolar mucosa. The root developed normally throughout the treatment, and the periodontium was healthy and esthetically acceptable at the 2-year follow-up. Further study is needed to assess the advantages of the combined surgical-orthodontic treatment.