Marco Esposito

The efficacy of horizontal and vertical bone augmentation procedures for dental implants - a Cochrane systematic review.

BACKGROUND dental implants require sufficient bone to be adequately stabilised. For some patients implant treatment would not be an option without horizontal or vertical bone augmentation. A variety of materials and surgical techniques are available for bone augmentation. OBJECTIVES to test whether and when augmentation procedures are necessary and which is the most effective technique for horizontal and vertical bone augmentation. SEARCH METHODS the Cochrane Oral Health Groups Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were hand searched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. The last electronic search was conducted on 11 June 2009. SELECTION CRITERIA randomised controlled trials (RCTs) of different techniques and materials for augmenting bone horizontally and/or vertically for implant treatment that reported the outcome of implant therapy at least to abutment connection. Trials were divided into two broad categories: horizontal augmentation and vertical augmentation techniques. DATA COLLECTION AND ANALYSIS screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit of the analysis was the patient. RESULTS 13 RCTs out of 18 potentially eligible trials were suitable for inclusion. Three RCTs (106 patients) dealt with horizontal and 10 trials (218 patients) with vertical augmentation. Since different techniques were evaluated in different trials, only one meta-analysis could be performed. When comparing whether vertical augmentation procedures were more advantageous than short implants, a meta-analysis of two trials resulted in more implant failures OR = 5.74 (95% CI 0.92 to 35.82; borderline significance, P = 0.06) and statistically significantly more complications OR = 4.97 (95% CI 1.10 to 22.40) in the vertically augmented group. When comparing various horizontal augmentation techniques (three trials) no statistically significant differences were observed. When comparing various vertical bone augmentation techniques (eight trials) no statistically significant differences were observed except for three trials which showed that more vertical bone gain could be obtained with osteodistraction than with inlay autogenous grafts (mean difference 3.25 mm; 95% CI 1.66 to 4.84), and with bone substitutes rather than autogenous bone in guided bone regeneration (mean difference 0.60 mm; 95% CI 0.21 to 0.99) in posterior atrophic mandibles, and that patients preferred a bone substitute block over a block of autogenous bone taken from the iliac crest (OR = 0.03; 95% CI 0.00 to 0.64; P = 0.02). CONCLUSIONS conclusions are based on few trials including few patients, sometimes having a short follow-up, and often being judged to be at high risk of bias. Various techniques can augment bone horizontally and vertically, but it is unclear which are the most efficient. Short implants appear to be a better alternative to vertical bone grafting of resorbed mandibles. Complications, especially for vertical augmentation, are common. Some bone substitutes could be a preferable alternative to autogenous bone. Osteodistraction osteogenesis allows for more vertical bone augmentation than other techniques, which, on the other hand, can allow for horizontal augmentation at the same time. Titanium screws may be preferable to resorbable screws to fixate onlay bone grafts.

Vertical ridge augmentation of the atrophic posterior mandible with interpositional bloc grafts: bone from the iliac crest vs bovine anorganic bone. Clinical and histological results up to one year after loading from a randomized-controlled clinical trial.

OBJECTIVES To compare two different techniques for vertical bone augmentation of the posterior mandible: bone blocs from the iliac crest vs. anorganic bovine bone blocs used as inlays. MATERIALS AND METHODS Ten partially edentulous patients having 5-7 mm of residual crestal height above the mandibular canal had their posterior mandibles randomly allocated to both interventions. After 4 months implants were inserted, and after 4 months, provisional prostheses were placed. Definitive prostheses were delivered after 4 months. Histomorphometry of samples trephined at implant placement, prosthesis and implant failures, any complication after loading and peri-implant marginal bone-level changes were assessed by masked assessors. All patients were followed up to 1 year after loading. RESULTS Four months after bone augmentation, there was statistically significant more residual graft (between 10% and 13%) in the Bio-Oss group. There were no statistically significant differences in failures and complications. Two implants could not be placed in one patient augmented with autogenous bone because the graft failed whereas one implant and its prosthesis of the Bio-Oss group failed after loading. After implant loading only one complication (peri-implantitis) occurred at one implant of the autogenous bone group. In 16 months (from implant placement to 1 year after loading), both groups lost statistically significant amounts of peri-implant marginal bone: 0.82 mm in the autogenous bone group and 0.59 mm in the Bio-Oss group; however, there were no statistically significant differences between the groups. CONCLUSIONS Both procedures achieved good results, but the use of bovine blocs was less invasive and may be preferable than harvesting bone from the iliac crest.

Vertical augmentation with interpositional blocks of anorganic bovine bone vs. 7-mm-long implants in posterior mandibles: 1-year results of a randomized clinical trial

OBJECTIVES To evaluate whether 7-mm-long implants could be an alternative to longer implants placed in vertically augmented posterior mandibles. MATERIALS AND METHODS Sixty patients with posterior mandibular edentulism with 7-8 mm bone height above the mandibular canal were randomized to either vertical augmentation with anorganic bovine bone blocks and delayed 5-month placement of ≥10 mm implants or to receive 7-mm-long implants. Four months after implant placement, provisional prostheses were delivered, replaced after 4 months, by definitive prostheses. The outcome measures were prosthesis and implant failures, any complications and peri-implant marginal bone levels. All patients were followed to 1 year after loading. RESULTS One patient dropped out from the short implant group. In two augmented mandibles, there was not sufficient bone to place 10-mm-long implants possibly because the blocks had broken apart during insertion. One prosthesis could not be placed when planned in the 7 mm group vs. three prostheses in the augmented group, because of early failure of one implant in each patient. Four complications (wound dehiscence) occurred during graft healing in the augmented group vs. none in the 7 mm group. No complications occurred after implant placement. These differences were not statistically significant. One year after loading, patients of both groups lost an average of 1 mm of peri-implant bone. There no statistically significant differences in bone loss between groups. CONCLUSIONS When residual bone height over the mandibular canal is between 7 and 8 mm, 7 mm short implants might be a preferable choice than vertical augmentation, reducing the chair time, expenses and morbidity. These 1-year preliminary results need to be confirmed by follow-up of at least 5 years.

Immediate non-occlusal vs. early loading of dental implants in partially edentulous patients: a multicentre randomized clinical trial. Peri-implant bone and soft-tissue levels.

OBJECTIVES To compare peri-implant bone and soft-tissue levels of immediately non-occlusally loaded vs. non-submerged early loaded implants in partially edentulous patients up to 14 months after placement. MATERIAL AND METHODS Fifty-two patients were randomized in five Italian private practices: 25 in the immediately loaded group and 27 in the early loaded group. To be immediately loaded, single implants had to be inserted with a torque of > or = 30 N cm, and splinted implants with a torque of > or = 20 N cm. Immediately loaded implants were provided with non-occluding temporary restorations within 48 h. After 2 months, the provisional restorations were placed in full occlusion. Implants were early loaded after 2 months. Final restorations were provided 8 months after placement. Blinded assessors evaluated peri-implant bone and soft-tissue levels. RESULTS Fifty-two implants were immediately loaded and 52 were early loaded. No drop-out occurred. One single immediately loaded implant failed 2 months after placement. Both groups gradually lost peri-implant bone in a highly statistically significant manner at 2, 8, and 14 months. After 14 months, patients of both groups lost an average of 1.1 mm of peri-implant bone. There were no statistically significant differences between the two loading strategies for peri-implant bone and soft-tissue level changes (P > 0.05). After 14 months, the position of the soft tissues did not change significantly from baseline (delivery of the final restorations 8 months after placement). CONCLUSIONS There were no statistically or clinically significant differences between immediate and early loading of dental implants with regard to peri-implant bone and soft-tissue levels as evaluated in the present study.

Lack of adjunctive benefit of Er:YAG laser in non-surgical periodontal treatment: a randomized split-mouth clinical trial

AIM This split-mouth, randomized, clinical trial aimed to evaluate the efficacy of erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser application in non-surgical periodontal treatment. MATERIALS AND METHODS A total of 27 patients underwent four modalities of non-surgical therapy: supragingival debridement; scaling and root planing (SRP)+Er:YAG laser; Er:YAG laser; and SRP. Each strategy was randomly assigned and performed in one of the four quadrants. Clinical outcomes were evaluated at 3 and 6 months. Subjective benefits of patients have been evaluated by means of questionnaires. RESULTS Six months after therapy, Er:YAG laser showed no statistical difference in clinical attachment gain with respect to supragingival scaling [0.15 mm (95% CI -0.16; 0.46)], while SRP showed a greater attachment gain than the supragingival scaling [0.37 mm (95% CI 0.05; 0.68)]. No difference resulted between Er:YAG laser+SRP and SRP alone [0.05 mm (95% CI -0.25; 0.36)]. CONCLUSIONS The adjunctive use of Er:YAG laser to conventional SRP did not reveal a more effective result than SRP alone. Furthermore, the sites treated with Er:YAG laser showed similar results of the sites treated with supragingival scaling.

Vertical Osseodistraction with a New Intraosseous Alveolar Distractor Prototype for Dental Implant Rehabilitation: A Pilot Study in Dogs

PURPOSE To evaluate in dogs a newly developed intraosseous alveolar distractor (Mozo-Grau Alveolar Distractor) for vertical bone augmentation to allow placement of dental implants. MATERIALS AND METHODS Four dogs had their posterior teeth removed, and sockets were left to heal for 20 weeks. The right and left sides of the posterior mandibles were randomly allocated, according to a split-mouth design, to receive either two distractors, distracting a 32-mm-long bone segment, or two distractors supporting one bony segment 20 mm long and one 8 mm long. Each side of the jaw was treated by a different operator. Eight days after placement, distractors were activated with one complete turn (corresponding to 0.75 mm of vertical distraction) per day for 8 days, followed by a latency period of 10 weeks. Distractors were removed, and seven dental implants of two randomly allocated designs were placed in each dog. Implants were submerged for 2 months, and the dogs were sacrificed. Outcome measures were: success of the augmentation procedure (defined as a vertical gain of at least 5 mm of bone), any complications, implant failure, bone-to-implant contact (BIC), and peri-implant marginal bone level changes. RESULTS One dog was withdrawn because of a mandible fracture. Eight complications occurred, and six osseodistractors were lost, but no implant failed. Only two segments in one dog achieved a vertical bone gain of at least 5 mm. The mean radiographic vertical bone gain was 2.28 mm, whereas the mean histologic vertical bone gain was 3.16 mm. Histologically, all the implants were osseointegrated. The mean BIC for implants placed in new distracted bone was 34.78% ± 11.60% and 35.66% ± 8.84% for those placed in native bone. The mean peri-implant marginal bone level loss was 0.56 ± 0.54 mm. CONCLUSION It is possible to achieve vertical augmentation using intraosseous alveolar distractors to allow successful implantation of dental implants; however, the technique still requires surgical refinements and a dedicated training of the surgeons before being applied to humans.

Surgical techniques for the removal of mandibular wisdom teeth. Cochrane Database of Systematic Reviews.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effectiveness of anti-adhesion therapy versus placebo, no therapy or an alternative anti-adhesion therapy following operative hysteroscopy for the treatment of female subfertility.To determine the efficacy and safety of metformin in treating women with endometrial hyperplasia

Authors' Response: Re: Finkelman RD. Letter to the Editor: Re: “Clinical Guidelines of the Italian Society of Periodontology for the Reconstructive Surgical Treatment of Angular Bony Defects in Periodontal Patients”

We appreciate the interest and the comments by Dr. Richard D. Finkelman1 about our article titled ‘‘Clinical guidelines of the Italian Society of Periodontology for the reconstructive surgical treatment of angular bony defects in periodontal patients.’’2 He suggested that the randomized clinical trial by Reddy et al.3 on standard regenerative surgery in infrabony defects using a combined treatment (placement of a freeze-dried demineralized bone allograft, coverage with a bioabsorbable guided tissue regeneration membrane, and adjunctive use of systemic antibiotics) should be included in the guidelines. Even if this study is interesting, the guidelines considered only single treatments of angular bony defects as reported in the Materials and Methods, ‘‘Results concerning combinations of . . . treatments (e.g., bone graft beneath a membrane) were not taken into consideration because . . . it would be difficult to determine the contributions of the single techniques to the overall results.’’2 Therefore, the quoted article3 (as well as other papers) was excluded from the clinical guidelines.