Hugo De Bruyn

Immediate single‐tooth implants in the anterior maxilla: 3‐year results of a case series on hard and soft tissue response and aesthetics

PURPOSE The objective of this prospective study was to assess the overall outcome of immediate single implant treatment in the anterior maxilla after a 3-year observation period. MATERIAL AND METHODS Thirty consecutively treated patients with a thick gingival biotype, ideal gingival level/contour and intact socket walls at the time of tooth extraction were treated for single-tooth replacement in the aesthetic zone by two experienced clinicians. Treatment included minimal mucoperiosteal flap elevation, immediate implant placement (NobelReplace TiUnite(®)), insertion of a grafting material between the implant and the socket wall and connection of a screw-retained provisional restoration. The latter was replaced by a cemented crown 6 months thereafter. Patients were clinically and radiographically re-examined after 3 years to assess implant survival, complications and hard and soft tissue conditions. The aesthetic outcome was objectively rated using the Pink Esthetic Score (PES) and White Esthetic Score (WES) by a blinded clinician who had not been involved in the treatment. RESULTS Twenty-five patients could be re-evaluated after 3 years. One early implant failure had occurred resulting in an implant survival rate of 96%. Radiographic examination yielded on average 1.13 mm mesial, respectively 0.86 mm distal bone loss. The clinical conditions showed fairly low peri-implant plaque (18%) and bleeding (24%) and mean probing depth was 3.17 mm. Mean mesial/distal papilla shrinkage and midfacial soft tissue recession in reference to the pre-operative status accounted for 0.05, 0.08 and 0.34 mm, respectively. Between the 1- and 3-year reassessment mesial papillae showed significant re-growth (0.36 mm; p=0.015). Advanced midfacial recession (>1 mm) was found in 2/25 (8%) cases. Five (21%) cases were aesthetic failures (PES<8 and/or WES<6) and 5/24 (21%) showed an (almost) perfect outcome (PES≥12 and WES≥9). The remainder (14/24 or 58%) demonstrated acceptable aesthetics. CONCLUSIONS The proposed strategy seems a valuable and predictable treatment option for well-selected patients in the mid-long term as shown by almost full papillary re-growth and a low risk for advanced midfacial recession.

Immediate functional loading of TiOblast dental implants in full‐arch edentulous mandibles: a 3‐year prospective study

INTRODUCTION Immediate functional loading of dental implants for full-arch restoration is a patient-friendly approach, shown to be feasible with a good long-term prognosis in a completely edentulous mandible. For the complete restoration of the maxilla, acceptable long-term clinical follow-up is lacking or based on case reports rather than on prospective studies. OBJECTIVES This prospective mono-centre study reports the 3-year outcome of immediately functionally loaded Astra Tech Dental implants in completely edentulous maxillae based on clinical survival and success based on radiographical assessment of bone level. MATERIAL AND METHODS One hundred and ninety-five Astra Tech TiOblast surface fixtures were installed in 25 consecutively treated patients (age range: 42-76 years), of whom eight were smokers, 12 had a confirmed history of periodontitis and six had poor bone quality normally deemed for delayed loading. Fixtures and abutments were inserted in a one-stage procedure and functionally loaded within 24 h with a 10-unit provisional glass-fibre or metal-reinforced screw-retained restoration. After 6 months, each implant was checked for stability using a manual torque of 20 N cm and the provisional restoration was replaced by a 10-12-unit screw-retained metal-ceramic or metal-resin cantilever bridge. Bone level was assessed radiographically from the day of surgery up to 3 years and used to calculate mean bone loss at the patient level and individual implant success. RESULTS No failures occurred in implants or prostheses, the total survival rate being 100%. Mean marginal bone loss was 0.58 mm (SD 0.58); 0.6 mm (SD 0.53); 0.63 (SD 0.61); and 0.72 (SD 0.63) after 6 and 12 months, and 2 and 3 years, respectively, yielding a 100% success at the patient level. Wilcoxons signed ranks test showed only statistically significant bone loss between baseline and 6 months and a steady-state condition during all other intervals. At the individual fixture level, 82% lost <1 mm marginal bone between baseline and 1 year. After 3 years, 86% have <1.5 mm total bone loss and can be considered a success. The fixtures expressing more bone loss were all inserted in smokers. CONCLUSION Immediate loading of a full-arch maxillary bridgework on 7-9 Astra Tech TiOblast implants is a predictable treatment option with 100% fixture survival and stable bone-to-implant contact up to 3 years. The steady state in bone remodelling is indicative of a good long-term prognosis in non-smokers but smokers seem to be more prone to bone loss.

Long‐term follow‐up of turned single implants placed in periodontally healthy patients after 16–22 years: radiographic and peri‐implant outcome

OBJECTIVES Retrospectively evaluate the survival, radiographic and peri-implant outcome of single turned Brånemark™ implants after at least 16 years. MATERIALS AND METHODS From 134 patients (C-group), 101 could be contacted concerning implant survival and 50 (59 remaining implants) were clinically examined (I-group). Marginal bone level was radiographically measured from the implant-abutment junction at baseline (=within 6 months after abutment connection) and 1-4, 5-8 and 16-22 years post-operatively. Probing depth, gingival and plaque index were measured. Marginal bone-level changes were analyzed using Friedmans and Wilcoxons signed ranks tests. Spearmans correlations between radiographic and clinical parameters were calculated. RESULTS In the C-group, 13 out of 166 implants in 11 out of 134 patients failed (CSR=91.5%). In the I-group (28 males-22 females; mean age 23.9 years at baseline; range 14-57), the mean follow-up was 18.4 years (range 16-22). The mean bone level was 1.7±0.88 mm (range -0.8 to 5) after 16-22 years. Changes in the mean marginal bone level were statistically significant between baseline and the second measuring interval (1-4 years). Thereafter, no significant differences could be demonstrated. The mean interproximal probing depth, gingival and plaque indices were 3.9±1.27 mm, 1.2±0.81 and 0.2±0.48, respectively. Probing depth was moderately correlated with gingival inflammation (r=0.6; P<0.001) but not with bone level (P>0.05). 81.4% of the implants had a bone level ≤2nd thread and 91.5% had a probing depth ≤5 mm. 76.3% had both bone level ≤2nd thread and probing depth ≤5 mm. CONCLUSIONS AND CLINICAL IMPLICATIONS The single turned Brånemark™ implant is a predictable solution with high clinical survival and success rates. In general, a steady-state bone level can be expected over decades, with minimal signs of peri-implant disease. A minority (5%), however, presents with progressive bone loss.

A Prospective Study on the Accuracy of Mucosally Supported Stereolithographic Surgical Guides in Fully Edentulous Maxillae

BACKGROUND Flapless implant placement using guided surgery is widespread, although clinical publications on the precision are lacking. PURPOSE The purpose of this study was to evaluate the accuracy of mucosal-supported stereolithographic guides in the edentulous maxillae. MATERIALS AND METHODS Seventy-eight OsseoSpeed™ implants (Astra Tech AB, Mölndal, Sweden) of 3.5 to 5 mm width and 8 to 15 mm length were installed consecutively in 13 patients. Implants were functionally loaded on the day of surgery, and implant location was assessed with a computed tomography scan. Mimics 9.0 software (Materialise N.V., Leuven, Belgium) was used to fuse the images of the virtually planned and actually placed implants, and the locations, axes, and interimplant distances were compared. RESULTS One implant was lost shortly after insertion because of abscess formation caused by remnants of impression material. Seventy-seven implant locations were analyzed. The deviation at the entrance point ranged between 0.29 mm and 2.45 mm (SD: 0.44 mm), with a mean of 0.91 mm. Average angle deviation was 2.60° (range 0.16-8.86°; SD: 1.61°). At the apical point, the deviation ranged between 0.32 mm and 3.01 mm, with a mean of 1.13 mm (SD: 0.52 mm). The mean deviation of the coronal and apical interimplant distance was respectively 0.18 mm (range 0.07-0.32 mm; SD: 0.15) and 0.33 mm (range 0.12-0.69 mm; SD: 0.28). These deviations are lower than the global coronal and apical deviations. CONCLUSION The present study is the first to investigate the accuracy of stereolithographic, full, mucosally supported surgical guides in the treatment of fully edentulous maxillae. Clinicians should be warned that angular and linear deviations are to be expected. Short implants show significantly lower apical deviations compared with longer ones. Reasons for implant deviations are multifactorial; however, it is unlikely that the production process of the guide has a major impact on the total accuracy of a mucosal-supported stereolithographic guide.

Single Implant Treatment in Healing Versus Healed Sites of the Anterior Maxilla: An Aesthetic Evaluation

PURPOSE The aim was to compare and document in detail the aesthetic outcome of single implant treatment in healing sites (early implant placement) with fully healed sites (conventional implant placement) of the anterior maxilla. MATERIALS AND METHODS A cross-sectional study in patients who had been treated by two periodontists and two prosthodontists in 2006 and 2007 was conducted. Surgical treatment involved standard flap elevation without releasing incisions and restorative procedures included cemented crowns in all patients. Only straightforward single implant treatments using Nobelreplace tapered TiUnite® implants (Nobel Biocare, Göteborg, Sweden) in healing sites (6-8 weeks following tooth extraction) and fully healed sites (≥6 months following tooth extraction) were considered with both neighboring teeth present and without the need for hard and/or soft tissue grafting. The aesthetic outcome was objectively rated using the pink esthetic score (PES) and white esthetic scrore (WES) by a blinded clinician who had not been involved in the treatment. Patients rated aesthetics by means of visual analogue scales. RESULTS Twenty-one out of 22 early and 25/27 conventional implant treatments were available for aesthetic evaluation after on average two and a half years of function (range 17-41 months). There were no significant differences for any of the criteria between the treatment concepts. Overall, papillae were most easy to satisfy, whereas alveolar process and tooth color most difficult. A thin-scalloped biotype was associated with low distal papillae (p=.041) and alveolar process deficiency (p=.039). Twenty-six percent of the cases were aesthetic failures (PES<8 and/or WES<6) and 13% showed an (almost) perfect outcome (PES≥12 and WES≥9). The remainder (61%) demonstrated acceptable aesthetics. There was no significant correlation between objective and subjective ratings. CONCLUSIONS Early and conventional single implant treatment yielded comparable aesthetic outcome. Albeit all treatments had been performed by experienced clinicians and only straightforward cases had been selected, 1 out of 4 cases were aesthetic failures and only a strict minority showed perfection. Research is required on the aesthetic outcome of alternative surgical procedures especially in high-risk patients with a thin-scalloped biotype.

Clinical, aesthetic and patient-related outcome of immediately loaded single implants in the anterior maxilla: a prospective study in extraction sockets, healed ridges and grafted sites

PURPOSE The objective of this prospective clinical study was to document the overall treatment outcome of immediately loaded single Astra Tech Osseospeed™ (Astra Tech AB, Mölndal, Sweden) implants placed in extraction sockets, healed ridges, and grafted sites. MATERIALS AND METHODS Forty-eight patients in need of a single implant in the anterior maxilla (15-25) were recruited. Patients were allocated to a conventional implant treatment (CIT) or immediate implant treatment (IIT) group on the basis of specific criteria. If the buccal bone plate was damaged or missing upon tooth removal, patients were allocated to a grafted implant treatment (GIT) group. Irrespective of the treatment concept, implants were immediately provisionalized. Hard and soft tissue alterations, aesthetic parameters (pink and white esthetic scores, [PES and WES]) and patients opinion (Oral Health Impact Profile [OHIP-14] questionnaires) were registered at different time points. RESULTS After 1 year of function, the overall implant survival rate was 98% with one failure following IIT. The mean bone level to the implant-abutment interface was 0.65 (SD 0.79), 0.85 (SD 0.64), and 0.56 mm (SD 0.44) for CIT, IIT, and GIT. Complete papilla loss was rare following either strategy. Mean midfacial recession amounted to 1.00 (SD 1.15), 0.12 (SD 0.78), and 0.49 mm (SD 0.82) for CIT, IIT, and GIT, respectively. The aesthetic outcome showed a mean PES of 10.30 (SD 1.89) and mean WES of 7.11 (SD 2.14), all patients considered. Patients satisfaction showed a significant improvement after 1 year of function on all seven domains (p < .001). CONCLUSIONS This prospective study showed that single implants clinically and aesthetically perform well under immediate non-occlusal loading conditions in the premaxilla. In this context, it is of pivotal importance to stress that patients were carefully selected for IIT and GIT.

Patient‐centered outcome of immediately loaded implants in the rehabilitation of fully edentulous jaws

INTRODUCTION Edentulism often involves functional, esthetic, phonetic and psychological problems. OBJECTIVES To evaluate patient-centered outcomes of full-arch screw-retained rehabilitation on immediately loaded implants. MATERIAL AND METHODS Fifty patients treated with Astra Tech(TM) implants answered self-administered questionnaires on a visual analogue scale (VAS) 100 mm scale or with multiple-choice or open questions: at baseline, 1 week, 3 or 6 months and 1 year. Changes of VAS in time were analyzed using mixed models for repeated measures, adjusting for gender, age and jaw; comparison of cross-sectional parameters between jaws was performed with the Mann-Whitney U- or chi(2)-test, all at the 0.05 significance level. RESULTS The median calculated general satisfaction score increased from 40.25 (mean=40.9; SD=23.82; range=0-95) at baseline to 98.25 (mean=95.3; SD=6.68; range=74-100) after 1 year. Overall comfort, eating comfort, speaking comfort and perceived esthetics improved significantly within 1 week after surgery and immediate provisionalization. This did not change significantly until the final bridge was installed after 3 months (mandible) or 6 months (maxilla), when a further significant improvement was demonstrated. The most common postoperative complication was swelling, especially in the maxilla. The importance of one-stage surgery and immediate loading was rated very high by patients before treatment, especially in the mandible. The main reason for choosing fixed prosthetics was eating comfort. Phonetics and esthetics were more important in the maxilla than in the mandible. CONCLUSION Immediate full-arch rehabilitation yeilds an instant significant improvement in general patient satisfaction and self-perceived factors related to comfort, function and esthetics. Eating comfort is the main concern for the patient and shows the highest improvement. Postoperative complications are limited and patients considered immediate loading important.

Soft Tissue Preservation and Pink Aesthetics around Single Immediate Implant Restorations: A 1-Year Prospective Study

PURPOSE (1) To document soft tissue aspects using a specific protocol for immediate implant treatment (IIT) following single-tooth removal; (2) to evaluate whether this protocol allows preservation of pink aesthetics as objectively assessed. MATERIALS AND METHODS Patients with a thick gingival biotype and intact buccal bone wall upon extraction of a single tooth in the aesthetic zone (15-25) were consecutively treated. The protocol included flapless extraction and implant surgery, socket grafting, immediate nonocclusal loading with a screw-retained provisional crown, and replacement by a permanent crown 6 months thereafter. The outcome was assessed after 3, 6, and 12 months. Cases demonstrating major alveolar process remodeling and/or advanced midfacial recession (>1 mm) at 3 months were additionally treated with a connective tissue graft (CTG). The emergence profile of the provisional crown was replicated for all permanent crowns. RESULTS Twenty-two patients (12 men, 10 women; mean age 50) were treated after tooth extraction for nonperiodontal reasons using a novel bone condensing implant with variable-thread design, conical connection, and platform switch (NobelActive®, Nobel Biocare, Göteborg, Sweden). One implant failed and mean marginal bone loss was 0.1 mm (p = .059). Temporary mesial papilla reduction occurred, whereas distal papilla reduction was permanent (mean 0.5 mm; p = .001). At 3 months, five cases demonstrated major alveolar process remodeling and two advanced midfacial recession. Hence, slight initial decline in the pink esthetic score (PES) (p = .053) was observed. CTG resulted in a steady improvement of the PES after 3 months (p ≤ .037). At 12 months, pink aesthetics (mean PES 12.15) was comparable to the preoperative status (mean PES 11.86; p = .293). Distal papillae had significantly deteriorated (p = .020) in this time span, whereas midfacial contour had significantly improved (p = .005). CONCLUSIONS Preservation of pink aesthetics is possible following IIT. However, to achieve that, CTG may be necessary in about one-third of the patients. Major alveolar process remodeling is the main reason for additional treatment.

Immediate Provisionalization of Dental Implants Placed in Healed Alveolar Ridges and Extraction Sockets: : A 5-year Prospective Evaluation

PURPOSE This 5-year prospective multicenter study compared implant survival and success, peri-implant health and soft tissue responses, crestal bone level stability, and complication rates following immediate loading of single OsseoSpeed implants placed in anterior maxillary healed ridges or extraction sockets. MATERIALS AND METHODS Individuals requiring anterior tooth replacement with single implants were treated and immediately provisionalized. Definitive all-ceramic crowns were placed at 12 weeks. Implant survival, bone levels, soft tissue levels, and peri-implant health were monitored for 5 years. RESULTS One hundred thirteen patients received implants in fresh sockets (55) and healed ridges (58). After 5 years, 45 and 49 patients remained for evaluation, respectively. During the first year, three implants failed in the extraction socket group (94.6% survival) and one implant failed in the healed ridge group (98.3% survival); this difference was not significant. No further implant failures were recorded. After 5 years, the interproximal crestal bone levels were located a mean of 0.43 ± 0.63 mm and 0.38 ± 0.62 mm from the reference points of implants in sockets and healed ridges (not a significant difference). In both groups, papillae increased over time and peri-implant mucosal zenith positions were stable from the time of definitive crown placement in sockets and healed ridges. Compared to flap surgery for implants in healed ridges, flapless surgery resulted in increased peri-implant mucosal tissue dimension (average, 0.78 ± 1.34 mm vs 0.19 ± 0.79 mm). CONCLUSION After 5 years, the bone and soft tissue parameters that characterize implant success and contribute to dental implant esthetics were similar following the immediate provisionalization of implants in sockets and healed ridges. The overall tissue responses and reported implant survival support the immediate provisionalization of dental implants in situations involving healed ridges and, under ideal circumstances, extraction sockets.

Clinical Outcome and Bone Preservation of Single TiUnite™ Implants Installed with Flapless or Flap Surgery

BACKGROUND Flapless, free-handed implant surgery offers advantages for patient comfort, but studies on long-term clinical success based on marginal bone loss are scarce. AIM The aim of this study was to compare single implants installed with a flap (F) or flapless (FL) surgery with respect to survival and marginal bone preservation after at least 3 years. MATERIALS AND METHODS Fifty-three TiUnite™ Brånemark implants, installed in 49 patients (27 females; 22 males; mean age 53 years) were examined. Then, 25 F and 28 FL were delayed loaded; bone level from the abutment-implant level was measured on intraoral radiographs. From 44 (21 F, 23 FL), 31 (18F, 13 FL), and 36 (18 F, 18 FL) implants, radiographs were available at baseline and after 1 and 3 years of function. RESULTS The overall survival rate was 100% and the overall mean bone loss after an average of 38 months was 1.35 mm (SD 0.91; range 0-3.7). Both F and FL showed increasing bone loss during the first year with a higher bone loss for FL than for F sites (p < .01). Afterward, no further bone loss occurred and both groups were statistically equal (p > .7). On individual implant level, nearly 80% in both F and FL were considered a success showing bone loss between 1.5 and 1.9 mm. CONCLUSIONS Single implants yield an excellent prognosis with stable bone levels irrespective of the surgical technique, and free-handed flapless surgery is a viable alternative to more extensively planned guided surgery. Proper case selection and clinical experience are considered prerequisites for a predictable treatment outcome.