Evaluation of implant esthetics using eight objective indices-Comparative analysis of reliability and validity.

OBJECTIVES: The aim of the present study was to give a detailed analysis on eight proposed implant esthetic indices including a total of 48 parameters with respect to validity and reproducibility as well as its correlation to patients' perception of esthetics. MATERIAL AND METHODS: Standardized intraoral photographs of 189 patients with 189 implant-supported crowns and adjacent peri-implant soft tissue in the esthetic zone (central and lateral incisors, canine, first premolar) served as basis for this evaluation. Eight indices (Papilla Index [PI], Pink Esthetic Score [PES], Implant Crown Aesthetic Index [ICAI], Pink and White Esthetic Score [PES/WES], Complex Esthetic Index [CEI], Implant Aesthetic Score [IAS], Subjective Esthetic Score [SES], and Rompen Index) with a total of 48 parameters were selected. Esthetic evaluation was performed twice by five examiners with an interval of 4 weeks between the evaluations. RESULTS: A total of 1,890 evaluations including eight esthetic indices served as basis for the statistical analysis. Among the overall main scores tested for inter-rater reliability, the highest ρ^inter values were computed for CEI, PES, PI, and IAS scores. By contrast, SES and Rompen showed the worst inter-rater reliability, respectively. The highest level of intra-rater reproducibility was noted for PI, PES, and CEI. The lowest level of intra-rater reproducibility showed Rompen, SES, and ICA. The Papilla Index demonstrated the highest level of inter-rater reliability. The remainder of the single variables (n = 46) did not reach the ρ^inter level of 0.6. The single variables PI mesial, PI distal as well as CEI P4 showed the highest ρ^intra with statistical significance higher than 0.8. The lowest agreement was observed among the variables ICA3, WES5, and IASm2. In general, VAS did not show any good correlation to the esthetic indices proposed so far. The influence of esthetic parameters on subjective patient satisfaction was generally low. CONCLUSION: In conclusion, significant differences regarding reliability and validity could be observed in the present comparison of eight esthetic indices. Objective evaluation of the esthetic outcome of implant therapy inherently fails to reflect subjective patient opinion, however, requires consistency of results to enable between-study comparison and meta-analysis.

A multicenter randomized controlled clinical trial using a new resorbable non-cross-linked collagen membrane for guided bone regeneration at dehisced single implant sites: interim results of a bone augmentation procedure.

OBJECTIVE: To compare clinical performance of a new resorbable non-cross-linked collagen membrane, creos xenoprotect (CXP), with a reference membrane (BG) for guided bone regeneration at dehisced implant sites. MATERIALS AND METHODS: This randomized controlled clinical trial enrolled patients with expected dehiscence defects following implant placement to restore single teeth in the maxillary and mandibular esthetic zone and premolar area. Implants were placed using a two-stage surgical protocol with delayed loading. Bone augmentation material placed at the implant surface was immobilized with CXP or BG membrane. Soft tissue health was followed during the healing period, and the defect size was measured at reentry and 6 months after implant placement. RESULTS: Of the 49 included patients, 24 were treated with CXP and 25 with BG. Patient characteristics did not differ between the two arms. In the CXP arm, the defect height at implant insertion was (mean ± SD) 5.1 ± 2.1 mm (n = 24) and reduced at reentry by 81% to 1.0 ± 1.3 mm (n = 23). In the BG arm, the defect height at implant insertion was 4.9 ± 1.9 mm (n = 25) and reduced at reentry by 62% to 1.7 ± 2.1 mm (n = 24). Assuming a margin of non-inferiority of 1 mm, CXP was non-inferior to BG. Membrane exposure rate was highest at week 3 in both arms, reaching 16.7% for BG and 8.7% for CXP. CONCLUSIONS: The new resorbable non-cross-linked collagen membrane facilitates bone gain to support implant placement in expected dehiscence defects. The observed trend toward higher mean bone gain and lower exposure rate with CXP compared to BG should be further investigated.

Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures.

PURPOSE: To test patient- and sinus-related risk factors for an association with intraoperative membrane perforation and postoperative complications after sinus floor augmentation surgery. MATERIALS AND METHODS: Sinus floor elevation procedures using a lateral approach were retrospectively analyzed for patients' medical history and sinus anatomy on computed tomographic scans. Complications per sinus after membrane elevation and augmentation using a mixture of autologous bone and deproteinized bovine bone substitute (Bio-Oss) were recorded. Logic regression (adjusted using the generalized estimation equation approach) was performed to analyze the influence of patient age, gender, smoking habits, sinus septa, residual bone height, and mesiodistal elevation width. RESULTS: Of 407 sinus grafts in 300 patients (mean age, 56 yr), perforation of the Schneiderian membrane occurred in 35 sinuses (8.6%) and was significantly associated to the presence of sinus septa (odds ratio [OR] = 4.8; P = .002) and decreased residual bone height (OR = 0.01; P < .001). Smoking increased the risk of membrane perforation (OR = 4.8; P = .002), sinusitis (OR = 12.3; P < .001), and wound dehiscence (OR = 16.1; P = .005). Cases of sinus membrane perforation had higher odds for postoperative sinusitis (OR = 10.5; P < .001). The probability of wound dehiscence increased with the size of the elevated area (OR = 3; P < .001). CONCLUSION: The results of the study suggest that the presence of sinus septa and residual bone height less than 3.5 mm are the main risk factors increasing sinus membrane perforation rates. There was a higher prevalence for sinusitis in cases of membrane perforation (31.4%) despite intraoperative closure with resorbable membranes (Bio-Guide). Smokers generally exhibited greater chances for complications.

Effect of personality traits on the oral health-related quality of life in patients with oral mucosal disease.

OBJECTIVES: The aim of this study was to assess the relationship between oral health-related quality of life, the nature of mucosal disease, and personality traits. METHODS: One hundred forty-nine patients seeking care for oral mucosal disease were recruited in this cross-sectional study conducted at the University Clinic of Dentistry in Vienna from June to December 2013. All participants agreed in answering two questionnaires: the Oral Health Impact Profile German version (OHIP-G), which assessed the perceived limitations of oral health-related quality of life and the Neuroticism Extraversion Openness Five-Factor Inventory (NEO-FFI), which evaluated five personality domains. A multiple linear regression was applied to examine the potential influence on OHIP scores. RESULTS: Bullous/erosive mucosal diseases and oral lichen planus patients (n = 73, 49% of total) reported the highest impact on oral health-related quality of life (OHIP total score 49.3 ± 35.7, p = 0.02). A highly significant influence of neuroticism, as a personality trait, was observed on oral health-related quality of life (p = 0.001). Women had significantly more restrictions (OHIP score 45.3 ± 32.2) compared to men (32.6 ± 30.1, p = 0.009). CONCLUSIONS: Psychosocial factors such as personality traits, especially neuroticism, are significantly associated with quality of life ratings in patients with mucosal disease. CLINICAL RELEVANCE: Since mucosal diseases impact patient's daily living and quality of life while affected by their psychological profiles, this should be considered when formulating a therapeutic approach.

Primary implant stability in the atrophic sinus floor of human cadaver maxillae: impact of residual ridge height, bone density, and implant diameter.

OBJECTIVES: Simultaneous implant placement in conjunction with lateral or transcrestal maxillary sinus floor augmentation gives the benefit of reduction in healing times and surgical interventions. Primary implant stability, however, may be significantly reduced in resorbed residual ridges. Aim of the present study was to investigate the impact of residual bone height, bone density, and implant diameter on primary stability of implants in the atrophic sinus floor. MATERIAL AND METHODS: A total of 66 NobelActive implants were inserted in the sinus floor of fresh human cadaver maxillae: 22 narrow (3.5 mm), 22 regular (4.3 mm), and 22 wide (5.0 mm) diameter implants in residual ridges of 2-6 mm height. Presurgical computed tomographic scans were acquired to assess bone height and density. Primary implant stability was evaluated by insertion torque values (ITV), Periotest values (PTV), and Osstell implant stability quotients (ISQ). RESULTS: Correlations within outcomes (ITV, PTV, ISQ) were highly significant (P < 0.001). Radiographic bone density was found to significantly impact all three outcome measures (P < 0.001), while no influence of residual bone height and implant diameter could be revealed by multifactorial analysis. Consistent results were seen in all subgroups (including residual ridges of 5-6 mm height). CONCLUSIONS: Bone density seems to represent the major determinant of primary stability in maxillary sinus augmentation with simultaneous implant placement (as well as 5-6 mm short implants in the maxillary sinus floor). Preoperative bone density assessment may help to avoid stability-related complications in one-stage implant treatment of the atrophic posterior maxilla.

Patients' perspectives on dental implant and bone graft surgery: questionnaire-based interview survey.

PURPOSE: To assess up-to-date expectations and preferences of patients seeking dental implants. MATERIAL AND METHODS: One hundred and fifty consecutive patients (66 male and 84 female interviewees) were asked to rank their concerns regarding implant therapy and answer a questionnaire on implant and bone graft surgery, cost and time considerations and second-opinion behaviour. RESULTS: Treatment predictability and avoidance of removable dentures were ranked high priority (compared with time and cost efficiency or avoidance of bone grafts). Patients' estimation of the 10-year implant success rate was 84%, and 59% of patients expected implants to last for a lifetime. Total treatment time was estimated to be 4 months on average, and only 12% would tolerate increased risk of implant failure for the sake of shortening treatment duration. 61% of interviewees accepted autologous bone grafts (the majority favouring the retromolar area), while only 23% were willing to undergo bone harvesting from the hip. 43% opted for bone substitute material to avoid donor site morbidity. 67% would accept the additional costs associated with computed tomography, software-based treatment planning and guided implant placement to avoid bone graft surgery. Motivation for second-opinion seeking was high (46-62%), especially in young and male patients. CONCLUSION: Patient expectations on implant success and predictability are high compared with their reluctance towards treatment costs and duration. Acceptance of treatment morbidity is high among patients reporting low denture satisfaction; however, minimally invasive treatment alternatives are generally preferred.

Esthetic evaluation of single-tooth implants in the anterior mandible.

OBJECTIVES: Single-tooth replacement of anterior mandibular teeth is frequently complicated by insufficient bucco-lingual bone width and limited mesio-distal space available for implant placement. The aim of the present study was to assess implant esthetics in the partially edentulous anterior mandible. MATERIAL AND METHODS: Esthetic evaluation of 43 anterior mandibular single-tooth implants in 15 women and 28 men was performed using esthetic indices (PES = Pink Esthetic Score, PI = Papilla Index, SES = Subjective Esthetic Score) as well as subjective patients' Visual Analogue Scale (VAS) ratings. Clinical and radiological parameters (implant and crown dimensions, pocket depth, bleeding on probing, plaque, keratinized mucosa, marginal bone level, and distance to adjacent teeth) were tested for influence. RESULTS: Implant esthetics were judged satisfactory (PES ≤10) in 42% of implants compared with a patient satisfaction rate of 87%. Correlation between objective indices (PES/PI: rs  = 0.62, PES/SES: rs  = -0.73, PI/SES: rs  = -0.48) was highly significant (P ≤ 0.001); however, no association to subjective patients' ratings could be observed. Type of prosthetic restoration (single crown vs. tulip-shaped double crowns), mesio-distal crown width as well as anatomic crown length significantly affected esthetic scores. Patients' judgment, by contrast, could not be associated to any prognostic factor. CONCLUSION: Subjective patient satisfaction with implant esthetics in the partially edentulous anterior mandible is high, however, remains hard to predict or objectively quantify.

Immediate occlusal vs nonocclusal loading of implants: A randomized prospective clinical pilot study and patient centered outcome after 36 months.

BACKGROUND: Immediate provisionalization reduces chair time and improves patient comfort. PURPOSE: To analyze immediate functional loading vs nonfunctional loading with restorations in the posterior mandible for marginal bone defects, implant success/survival, and patient satisfaction. MATERIALS AND METHODS: A randomized controlled clinical trial was designed to assess these parameters based on 20 adult patients who underwent implant surgery, followed by immediate delivery of screw-retained or cemented single or splinted restorations in full occlusal contact or in infraocclusion (test and control group). A questionnaire with visual analog scales was used to assess patient satisfaction. RESULTS: Following 36-month data were evaluable for 9 patients (21 implants) in the study group (immediate functional loading) and for 10 patients (31 implants) in the control group (immediate nonfunctional loading). One implant in the control group was lost, hence the overall implant survival and success rate was 98.2%. Marginal bone defects were consistent with previous studies and comparable in both groups. Periotest values did not significantly change from baseline and the 12-month follow-up (Friedmann test). Patient satisfaction was high and did not involve any significant intergroup differences (Mann-Whitney U-test). CONCLUSIONS: Both types of immediate provisional restorations are viable in selected patients. Larger randomized controlled trials are needed to establish immediate functional loading as a standard treatment for partially edentulous jaws.

Does osteoporosis influence the marginal peri-implant bone level in female patients? A cross-sectional study in a matched collective.

BACKGROUND/PURPOSE: Osteoporosis, being a homeostatic imbalance, affects the remodeling of bone. Whether this catabolic bone disease influences peri-implant marginal bone remodeling remains unknown so far. The purpose of this study was to evaluate the influence of osteoporosis on peri-implant marginal bone loss (MBL) in postmenopausal women. MATERIALS AND METHODS: In a matched collective, radiographic peri-implant bone level (at baseline and at follow-up examinations) was compared in healthy and osteoporotic women. General health and behavioral history of the patients were recorded using a printed questionnaire. RESULTS: A best fit matching procedure generated a sample of 48 women with a total of 204 implants matched at patient and implant level that was further statistically analyzed. The mean mesial MBL-statistically corrected to report the first year-was -0.6 ± 1.2 mm (range: -5.1 to 2.2) in the healthy control group and -1.1 ± 1.3 mm (range: -5.3 to 2.2) in the osteoporotic group. Similarly, the mean distal MBL was -0.5 ± 1.3 mm (range: -5.1 to 4.8) in the healthy control group and -1.2 ± 1.3 mm (range: -4.7 to 1.6) in the osteoporotic group, respectively. The base linear regression models including solely osteoporosis and time without any other confounders revealed a significant influence of osteoporosis and time since implant placement on the MBL at the mesial and the distal implant aspect. The significance of osteoporosis on bone loss did not change incorporating the confounders: bone level at implantation, smoking, jaw, location, surface, concrement, plaque, augmentation, edentulism in opposing and implant jaw, bisphosphonates, vitamin D, fixed versus removable prosthetics, connection type. CONCLUSIONS: There is no contraindication to place dental implants in osteoporotic patients. This study implicates to respect the bone level at implant placement and not to place the implant below bone level if possible.

Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized Clinical Pilot Study.

BACKGROUND: Immediate occlusal and non-occlusal loading protocols have been discussed and, despite varying success rates, are considered viable in selected cases. Preoperative implant planning and intraoperative transfer are essential to the success of implant-supported reconstructions in partially or completely edentulous jaws. PURPOSE: This study was performed to compare clinical outcomes of immediate occlusal versus non-occlusal loading of posterior implants. MATERIALS AND METHODS: Of 19 patients with 52 screw-type implants replacing mandibular molars or premolars, nine patients with 21 implants were randomized to a study group that received immediate restorations with occlusal loading, whereas 10 patients with 31 implants were randomized to a control group that received provisional restorations without occlusal loading. Occlusal loading was defined as full loading in maximum intercuspidation. Single-tooth or splinted multiunit restorations were incorporated by screw retention or cementation. Marginal bone defects (MBD), implant survival, and implant success were evaluated 12 months after insertion. RESULTS: Both groups revealed similar MBD levels consistent with previous reports. No implants were lost (overall survival: 100%) or found to fail (overall success: 100%). No significant intergroup differences were noted for any of the evaluated parameters. CONCLUSIONS: Immediate restorations in partially edentulous mandibles demonstrated successful clinical and radiographic 12-month results. Larger long-term prospective studies are needed to confirm the final evidence and predictability of immediate functional loading as a standard treatment concept for partially edentulous jaws.

Does Timing of Implant Placement Affect Implant Therapy Outcome in the Aesthetic Zone? A Clinical, Radiological, Aesthetic, and Patient-Based Evaluation.

PURPOSE: To compare five different implant treatment protocols in the anterior maxilla, including immediate, early, and delayed implant placement, as well as implant placement in conjunction with simultaneous guided bone regeneration and implant placement 3 months following horizontal autologous bone block grafting. MATERIAL AND METHODS: Aesthetic indices used included the Pink Esthetic Score (PES), Papilla Index (PI), Subjective Esthetic Score (SES), and White Esthetic Score (WES). Subjective evaluation of implant aesthetics was performed using a visual analogue scale (VAS). The VAS consisted of a 10 cm-long line representing the degree of discontent (0%) or satisfaction (100%). RESULTS: A total of 153 implants in 153 patients (80 women, 73 men) were evaluated after a mean follow-up of 4.5 ± 2.9 years. Mean peri-implant bone loss was 1.6 ± 0.9 mm and not affected by treatment protocol, time after implant placement, or crown length. Papilla presence, by contrast, differed significantly between the protocols: Papilla formation was more pronounced following delayed and immediate implant placement. No statistical significance was found among treatment modalities with regard to PES, SES, or WES. Longer crowns were associated with lower PES and PI ratings and correlated with greater midfacial recession. SES was also influenced by time after implant placement and keratinized mucosa. Patient satisfaction differed significantly among treatment protocols, favoring immediate implant placement. Agreement between objective and subjective aesthetic ratings was low. CONCLUSION: The present study suggests that comparable clinical, radiological, and aesthetic results can be achieved with all treatment protocols. Gingival recession, however, seems to occur in the long term irrespective of the technique used.

Influence of prosthetic parameters on peri-implant bone resorption in the first year of loading: a multi-factorial analysis.

BACKGROUND: The first year of prosthetic loading is crucial to peri-implant bone levels; however, contributing factors are yet barely understood. PURPOSE: The purpose of the study is to investigate the influence of patient-, implant-, and prosthetic-related parameters on marginal bone resorption in partially edentulous patients within the first year of prosthetic loading. MATERIALS AND METHODS: This retrospective multifactorial analysis involved the following influencing factors: patient gender and age, implant diameter, implant location and neck design, insertion torque, insertion depth, splinted versus single-tooth restorations, crown height space, and crown-to-implant ratio. RESULTS: Mean peri-implant bone resorption around 200 dental implants was 0.98 ± 0.76 mm and significantly correlated to higher implant insertion depth (p < .001), whereas no association to prosthetic parameters could be observed. CONCLUSIONS: Within the limits of the present analysis, it can be concluded that apical implant positioning may constitute a relevant determinant of early peri-implant bone resorption.

Impact of insertion torque and implant neck design on peri-implant bone level: a randomized split-mouth trial.

PURPOSE: The aim of this study is to assess the impact of insertion torque and implant neck design on peri-implant bone levels and gain insights into dynamic crestal tissue alterations by radiological, clinical, and biochemical examinations. MATERIAL AND METHODS: In this prospective trial, a total of 84 implants (four implants in each patient) in the interforaminal region of 21 edentulous mandibles were randomly alternated according to a split-mouth design. Implant placement was performed using different insertion torques (≤20 Ncm vs >50 Ncm). In each group, one machined and one anodized implant neck design (1.5 mm length) was used in the same jaw side. Evaluation of peri-implant tissues involved radiological, clinical examination and immunoassays for interleukin-1ß. RESULTS: No significant influence of insertion torque or implant neck design on peri-implant bone level was found. Protein levels of interleukin-1ß in the peri-implant crevicular fluid revealed no difference between both insertion torque groups and different neck designs. CONCLUSION: Interactive effects of insertion torque and neck surface modification may exist; however, no clinically significant differences in marginal bone resorption after 1 year could be observed in the edentulous anterior mandible.