The Impact of Sinus Floor Elevation Techniques on Sinus Membrane Perforation: A Systematic Review and Network Meta-analysis.

Purpose: To compare the risk of sinus membrane perforation (SMP) among lateral window sinus floor elevation (LSFE) and transcrestal sinus floor elevation (TSFE) techniques in prospective and retrospective studies for patients who underwent sinus augmentation for dental implant placement. Materials and Methods: A database search was conducted to screen the literature published from January 1960 to August 2021. The associations between SMP and surgical techniques as well as other clinical factors were evaluated via network meta-analysis. The impact of SMP on vertical ridge gain and implant survival was also evaluated. Results: Eighty-five studies with 5,551 SFE procedures were included. In LSFE techniques, using rotary burs showed the highest risk of SMP (surface under the cumulative ranking area [SUCRA] = 0.0745). In TSFE techniques, using reamers had the lowest risk of SMP (SUCRA = 0.9444). Increased SMP prevalence was significantly associated with reduced implant survival rate (odds ratio [OR] = 0.45 per 10% increase of SMP rate [95% credible interval (CreI): 0.21, 0.71], P < .001). Conclusions: With the inherent limitations, this network meta-analysis suggested that some techniques within either the LSFE or TSFE group may reduce SMP risk. Additional randomized controlled trials and better assessment of SMP are required to directly compare the risk of SMP between LSFE and TSFE.

Subcrestal Implantoplasty for Treating Peri-implantitis With Regenerative Care-How Deep Should Treatment Go?

Used to treat implants failing due to peri-implantitis, implantoplasty has traditionally been performed in conjunction with a resective approach or to smooth the portion of the dental implant above the bone to facilitate oral hygiene efforts. This article demonstrates the use of implantoplasty to decontaminate the implant surface both above and below the crest of bone in an attempt to reosseointegrate the failing implant; to the authors' knowledge this is the first time in the literature that implantoplasty was used in this manner and demonstrated potential regenerative efficacy.

Effect of activation rate on output torque values from a dental implant toggle-style torque wrench.

STATEMENT OF PROBLEM: The output torque delivered by a dental implant toggle-style torque wrench is known to be affected by activation rate. The International Organization for Standardization (ISO) established the ISO 6789-1 standard to provide guidance on activation rates relative to desired output torque in the Nm torque range. Whether the ISO 6789-1 standard applies at the relatively lower dental torque ranges is not known, and little information is available on the activation rates that clinicians use and how this may affect output torque. PURPOSE: The purpose of this in vitro study was to determine how output torque values vary with the activation rates used by clinicians at dental implant-relevant target torque values. MATERIAL AND METHODS: To determine clinically relevant activation rates, a new adjustable dental implant toggle-style torque wrench was activated from 0 to 25 Ncm target torque by 5 prosthodontists by using a custom mandibular and maxillary typodont model containing implants and abutments with screws. This provided a baseline of activation rates (mm/sec). Data were transferred to a computerized numerical control model incorporating a variable speed linear motor, which was used to drive a dental implant toggle-style torque wrench attached to an electronic torque measuring device. Constant speed and a regulated dual-speed-assigned 80/20 rate group, where 80% of target torque value was delivered first, then a pause, and the final 20% at different speeds as suggested by the ISO 6789-1 standard, were evaluated. Fast, medium, and slow rates were categorized and applied with target torque values of 10, 25, and 35 Ncm, respectively, for n=12 activations. The output torque values were recorded for both constant and 80/20 groups and compared with the desired target torque values. Data were statistically analyzed with 1-way ANOVA and the Scheffé post hoc paired t test (α=.05). RESULTS: The clinicians' activation rates from 0 to 25 Ncm on the typodont model converted into linear speeds resulted in fast =24.19 mm/sec, medium =14.5 mm/sec, and slow =7.25 mm/sec. When actioned at a constant rate, the mean output torque values were generally in the order of slow > medium > fast in activation rates. Generally, precision output torque decreased as target torque increased, especially when slow and medium rates, either constant or regulated 80/20 were used. All mean output torque for slow, medium, and their 80/20 variants were greater than target torque. Fast and 80/20 fast produced the lowest mean output torque values for all torque settings, and at the 35 Ncm setting, the dental implant toggle-style torque wrench output torque mean values were lower than target torque. Statistically significant differences (P<.05) were found among groups, most notably in the 80/20 dual-speed groups, especially in comparisons with the 80/20 fast rate group. When the target torque value was 10 Ncm with the 80/20 fast rate, the output torque value deviated from the maximum ISO limit by more than 6%. CONCLUSIONS: The rate of actioning a dental implant toggle-style torque wrench influenced the delivered torque value, with fast rate actioning producing lower and less precise output torque values.

Effect of viewing angles on measurement errors when using an implant cantilever beam torque-limiting device.

STATEMENT OF PROBLEM: Implant cantilever beam torque-limiting devices are affected by parallax, which may result in measurement read error. The overread or underread of the true target torque value could lead to premature failure of the screw joint of a dental implant. PURPOSE: The purpose of this in vitro study was to determine the effect of the operator's viewing angle relative to the cantilever beam and measurement reading scale when the torque-limiting device is actioned toward or away from the operator. MATERIAL AND METHODS: A beam torque wrench (Nobel Biocare USA) was used with the cantilever beam position fixed by using a wedge to read 32 Ncm on the marker arm. It was suspended in a vertical position relative to a digital single-lens reflex camera set at a fixed distance of 48 cm from the marker reading. The camera was rotated in 10-degree increments clockwise and counterclockwise relative to the cantilever beam reading, starting perpendicular to the marker. Photographs were recorded at each angle. Percentage measurement read error was calculated from dimensions of the cantilever beam torque device, including the beam diameter, distance from the marker arm, and the incremental marks on the measurement scale. Data were analyzed descriptively to determine the differences after comparison with the International Organization for Standardization (ISO) 6789-1:2017 recommendations. RESULTS: Photographs compared beam position relative to the 32-Ncm marker. The beam diameter was recorded as 1.5 mm, corresponding to approximately 5 Ncm. The distance between the marker arm and center of the beam was 0.08 mm. Percentage errors were greatest at lower torque values and increased relative to the viewing angle. Photographs showed that instrument overread was most likely to occur as the beam was moved away from the operator, which would result in potential undertightening unless compensated for. Underread was noted when the beam was pulled toward the operator. CONCLUSIONS: To prevent measurement read error when using an implant cantilever beam torque-limiting device, the operator should be positioned as close to a perpendicular viewing angle to the cantilever beam as possible. Viewing from an angle greater than 10 degrees from the perpendicular should be avoided for torque values less than 15 Ncm. For screws tightened between 25 Ncm and 35 Ncm, the viewing angle should be less than 30 degrees so that the applied torque is within the maximum deviation of the target torque value set by the ISO 6789-1:2017 recommendations.

American Academy of Periodontology best evidence consensus statement on the use of biologics in clinical practice.

A biologic is a therapeutic agent with biological activity that is administered to achieve an enhanced regenerative or reparative effect. The use of biologics has progressively become a core component of contemporary periodontal practice. However, some questions remain about their safety, indications, and effectiveness in specific clinical scenarios. Given their availability for routine clinical use and the existing amount of related evidence, the goal of this American Academy of Periodontology (AAP) best evidence consensus (BEC) was to provide a state-of-the-art, evidence-based perspective on the therapeutic application of autologous blood-derived products (ABPs), enamel matrix derivative (EMD), recombinant human platelet-derived growth factor BB (rhPDGF-BB), and recombinant human bone morphogenetic protein 2 (rhBMP-2). A panel of experts with extensive knowledge on the science and clinical application of biologics was convened. Three systematic reviews covering the areas of periodontal plastic surgery, treatment of infrabony defects, and alveolar ridge preservation/reconstruction and implant site development were conducted a priori and provided the foundation for the deliberations. The expert panel debated the merits of published data and exchanged experiential information to formulate evidence-based consensus statements and recommendations for clinical practice and future research. Based on an analysis of the current evidence and expert opinion, the panel concluded that the appropriate use of biologics in periodontal practice is generally safe and provides added benefits to conventional treatment approaches. However, therapeutic benefits and risks range based on the specific biologics used as well as patient-related local and systemic factors. Given the limited evidence available for some indications (e.g., gingival augmentation therapy, alveolar ridge preservation/reconstruction, and implant site development), future clinical studies that can expand the knowledge base on the clinical use of biologics in periodontal practice are warranted.

Complications of sinus floor elevation procedure and management strategies: A systematic review.

AIM: This systematic review aimed to investigates the types and incidences of complications following sinus floor elevations (SFE) along with their prevention and management strategies. MATERIALS AND METHODS: Electronic database and hand search were conducted to screen the literature published from January 1960 to June 2021. The selected studies had to report well-described SFE techniques, complications during, and post-SFE. Data extraction included types of SFE techniques, complications, and their treatment strategies. RESULTS: A total of 74 studies with 4411 SFE procedures met the inclusion criteria. Different SFE techniques demonstrated varying patterns for both complications and complication rates. Postoperative pain, swelling, and edema were widely reported. The most common complications that required intervention following Lateral SFE (LSFE) were sinus membrane perforation (SMP), wound dehiscence, graft exposure and failure, and sinusitis. LSFE had more SMPs and sinusitis cases compared with a transcrestal SFE (TSFE). The presence of benign paroxysmal positional vertigo following TSFE was significant in certain selected studies. CONCLUSION: Given the inherent limitations, this systematic review showed distinct features of complications in SFE using varying techniques. Treatment planning for these procedures should incorporate strategies to avoid complication occurrence.

A Revised Peri-implantitis Classification Scheme: Adding Three-Dimensional Considerations to Facilitate Prognosis and Treatment Planning.

Historically, diagnosing peri-implantitis is done based on whether the disease is present, evaluated using the arbitrary thresholds of probing depths and bone loss. Using this approach as a tool to ascertain meaningful information regarding prevalence and treatment is limited. Efforts have been made to improve upon this, but to date, only one of these classifications has provided a simple method to communicate disease severity based on the amount of bone loss. A modified version of this simplified classification is proposed here, including information regarding the implant position, as emerging information suggests that this is a crucial factor in the etiology and prognosis of peri-implantitis. This enhancement to the classification better serves both researchers and clinicians in their discussion about peri-implantitis and helps to determine and recommend the most effective methods of management.

Survey of Dental Clinicians for Attitude and Use of Torque-Limiting Devices.

PURPOSE: The purpose of this study was to survey practicing clinicians and determine if differences existed concerning their use of torque-limiting devices (TLDs) and screw-tightening protocols, comparing this with existing universal industry standards. MATERIALS AND METHODS: A nine-question survey was administered with 428 dentists providing data for three specific areas: (1) demographic information-TLD ownership, device age, frequency of use, and observations of screw loosening; (2) recognition information-calibration, reading measurements of the TLD, and the meaning of preload; (3) usage information-screw-tightening protocols and effect of speed during actioning of the TLD. Data collection was compared with industry standards for use of hand torque tools including ISO-6789 1,2:2017 and related texts pertaining to screw fastener protocols. RESULTS: The beam-type TLD was the most popular; however, 33% surveyed used it incorrectly. Most TLDs being used were older than 1 year, with only 6% calibrated. Forty-eight percent observed screw loosening less than once per year, while 44% reported three or more occurrences per year. A similar number used the TLD for implant placement and abutment screw tightening. Screw-tightening protocols varied. Preload was not understood by the majority of those surveyed. CONCLUSION: Dentistry does not appear to adhere to the protocols and standards recommended by other industries that also rely on screw-fastening mechanisms and TLDs. Further education and training appears to be warranted in this area of implant dentistry to reduce the risks of screw-associated complications.

Validating implant torque limiting devices with a custom tool: A dental technique.

The dental torque limiting device is a tool used to deliver a measured torque to implants and to their associated components. The torque delivery must be accurate and precise, especially when considering screw joints. Similar torque wrenches are used in various industries, and recommendations on calibration are provided by the International Organization for Standardization 6789-2:2017. It states that hand torque tools should be calibrated annually or more frequently if subjected to extreme temperature conditions such as steam sterilization. The International Organization for Standardization standard recommends that calibration may be performed by direct comparison of 2 torque devices provided that 1 is known to be within calibration. This technique article describes the procedures for fabricating a tool that couples 2 dental torque limiting devices. It may be used for calibrating and validating both electrical and mechanical torque limiting devices.

What Is an Effective Method for Treatment of Peri-implantitis?

Based on a high level of success, dental implant therapy has become a preferred means of treatment for a wide variety of oral problems related to historic or impending tooth loss. Peri-implantitis is a biologic complication that can threaten the survival of dental implants. Many systematic reviews and meta-analyses that have evaluated the varying treatment options available to manage this problem suggest that dental implants have questionable to poor prognoses when the bone loss becomes moderate to advanced. This article presents two case reports that demonstrate successful treatment of peri-implantitis. A commonality in both cases was the implementation of thorough surface decontamination and ablation of soft tissues for residual bacteria or particulate matter.

A Rationale for Postsurgical Laser Use to Effectively Treat Dental Implants Affected by Peri-implantitis: Two Case Reports.

Peri-implantitis is a biologic complication that can affect the survival of a dental implant. Most surgical and nonsurgical treatments have been relatively ineffective even when using targeted antimicrobial approaches. A growing number of reports are documenting the presence of titanium granules and/or cement in the soft tissues surrounding peri-implantitis-affected dental implants. Two case reports are presented demonstrating how the Nd:YAG or a carbon dioxide (CO2) laser used following regenerative surgeries changed failures into successes as measured by radiographic bone fill and improved clinical parameters. These cases suggest that successful peri-implantitis treatment may need to incorporate decontamination of the soft tissues in addition to the implant's surface. Further studies are warranted to determine if each of these lasers would be successful over a larger patient cohort.

The Merit to Phenotypic Modification Treatment for Dental Implants: Two Case Reports.

INTRODUCTION: The American Academy of Periodontology convened a Best Evidence Consensus workgroup in August 2019 in Chicago, IL to address whether the conversion of a thin to a thick tissue phenotype through various phenotype modification therapy (PhMT) can positively influence peri-implant health. CASE SERIES: PhMT was applied to two dental implant cases using subepithelial connective tissue grafting to increase peri-implant keratinized tissue. These cases demonstrated that when PhMT was used in either a reactive or proactive manner, the keratinized tissue improvement can support long-term peri-implant health. CONCLUSION: PhMT can prevent further gingival recession and provide a more stable environment conducive to maintaining peri-implant health.

A technique to validate the accuracy of a beam-type mechanical torque limiting device.

Tightening torques are often specified in implant dentistry, including for surgical procedures, testing implant stability, and attaching prosthetic components when screws are used. The mechanical torque limiting devices (MTLDs) commonly used are typically either a toggle-type or beam-type. The International Organization for Standardization (ISO) 6789 recommends MTLDs should be periodically tested to confirm the validity of their readings, and, where necessary, recalibrated if possible or replaced. The verification of the toggle-type MLTD has been previously published. This article describes a straightforward, in-office technique to verify a beam-type MTLD.

Testing and calibrating the mechanical-type toggle torque wrenches used in implant dentistry: A dental technique.

Abutment screw loosening is still the most common complication reported with implant-supported crowns. One factor that contributes to screw loosening is not achieving the proper torque during the tightening process. Torque application and measurement is usually achieved by using one of the available types of mechanical torque wrench. Of these, the toggle wrench has been shown to produce erroneous readings, and regular testing is recommended. If it is inaccurate, it must be recalibrated or replaced. Calibration typically requires specialized instruments unavailable to most clinicians, so the device must be sent away. This article describes a straightforward, in-office, and inexpensive alternative for testing and recalibrating a toggle torque wrench.

Peri-implant Mucositis.

Peri-implant mucositis has been defined as a reversible inflammatory reaction in the soft tissues around a functioning implant with no bone loss. This paper reviews the prevalence, etiology, risk indicators, prevention, and treatment of mucositis. Relying on the literature concerning mucositis, the bacterial etiology is discussed as well as the varying ranges of prevalence, reported to be from 20% to 80% of subjects (13% to 62% of implants) after a minimum of 5 years of implant function. A discussion of the definition of mucositis questions the assumption of it being completely reversible following treatment and challenges the concept of mucositis "transfer" (conversion) to peri-implantitis.

Measurement of the "Bungee Dip" in Implant Stability Using Resonance Frequency Analysis: Two Case Reports.

Implant stability is a key consideration when determining the point in time a dental implant should be loaded. Often a change in implant stability is observed as healing progresses from initial mechanical stability to biologic stability, ie, osseointegration, during the bone modeling/remodeling process. This change in stability can be objectively measured using resonance frequency analysis (RFA). Because bone healing varies from patient to patient, the timing of this sequence may be unpredictable; in a small subset of patients the drop in implant stability can be quite precipitous and profound. Such a drop is referred to as a "bungee dip." If the implant is loaded too prematurely, it may fail due to inadequate healing. This article presents two case reports that demonstrate the use of RFA and its values, known as implant stability quotients, to monitor implant stability during healing. RFA is a form of personalized care that provides objective evidence that can guide the clinician in establishing safe and successful loading protocols.

A 1-7 year retrospective follow-up on consecutively placed 7-mm-long dental implants with an electrowetted surface.

BACKGROUND: This retrospective consecutive case series study was performed to determinate the survival rate and implant stability of short (7 mm length) dental implants with an electrowetted hydrophilic surface that were in function from 1 to 7 years. METHODS: A retrospective chart review identified and evaluated 86 consecutively placed 7-mm-long dental implants (ProActive, Neoss Ltd., Harrogate, England) in 75 patients. Analysis was performed for implant survival as well as implant stability, as measured by insertion torque (IT) and resonance frequency analysis (RFA). RESULTS: Clinical follow-ups were performed from 1.0 to 7.0 years after implant placement (mean 4.0 ± 2.1 years). Two implants failed prior to loading resulting in a 5-year cumulative survival rate (CSR) of 97.7%. An additional late failure occurred at 60 months post-loading for a 7-year CSR of 94.8%. Mean insertion torque was 30.1 ± 7.4 Ncm and mean RFA at insertion was 73.6 ± 8.1 ISQ. Follow-up RFA measurements suggested that the achieved primary stability was maintained throughout the healing phase. CONCLUSION: The present study demonstrates that treatment with short implants can be a predictable treatment option with high survival rate in sites with limited available bone.