13-year follow-up of a randomized controlled study on zirconia and titanium abutments.

OBJECTIVES: To assess survival rates and compare technical, biological, and esthetic outcomes of customized zirconia and titanium abutments at 13 years post loading. MATERIALS AND METHODS: Initially, 22 patients with 40 implants in posterior regions were included. The sites were randomly assigned to 20 customized zirconia abutments with cemented all ceramic crowns (ACC) and 20 customized titanium abutments with cemented metal ceramic crowns (MCC). At a mean follow-up of 13.4 years, patients were examined and implants/restorations assessed for survival and technical complications, as well as biological and esthetic outcomes (pocket probing depth [PPD], bleeding on probing [BOP], plaque control record [PCR], bone level [BL], papilla index [PAP], mucosal thickness, and recession (distance of the margo mucosae [MM]/margo gingivae MG)). Descriptive analyses were performed for all outcome measures. RESULTS: Fifteen patients with 21 abutments (13 zirconia, 8 titanium) were examined at 13 years. The drop-out rate was 25% (patient level). The technical survival rate of the abutments was 100%. The survival rate on the restorative level (crowns) was 100%. The assessed biological outcomes (PPD, PCR, BOP, BL) and esthetic outcomes (MG, PAP) were similar. CONCLUSIONS: Zirconia and titanium abutments supporting single implant-borne restorations rendered a high survival rate and minimal differences in terms of technical, biological, and esthetic outcomes at 13 years of follow-up.

The L-shape technique in guided bone regeneration with simultaneous implant placement in the esthetic zone: A step-by-step protocol and a 2-14 year retrospective study.

OBJECTIVES: To describe the methodology of the "L-shape" technique in guided bone regeneration (GBR) with simultaneous implant placement and report on the clinical, esthetic, and patient satisfaction outcomes up to 14 years of follow-up. MATERIAL AND METHODS: Fourteen patients treated with the "L-shape" technique were included in this retrospective study. The L-shape technique was performed by trimming and placing a soft-type bone block made of deproteinized bovine bone mineral with 10% collagen at the buccal-occlusal aspect of the dental implant. The remaining gaps were filled with deproteinized bovine bone mineral granules and the augmented area was covered with a collagen membrane. The following parameters were recorded:  probing depth (PD), bleeding on probing (BOP), plaque index (PI), keratinized tissue width (KT) and marginal bone level (MBL). Esthetic outcomes were assessed according to the pink esthetic score (PES) and the white esthetic score (WES). Patient satisfaction was evaluated by means of a numerical rating scale (0-10). The stability of each augmented site was assessed by measuring the volumetric changes between baseline (crown delivery) and the respective follow-up. RESULTS: A total of 13 maxillary incisors and one maxillary canine in 14 patients were included. The mean follow-up period was 7.7 ± 3.8 years. PES values amounted to 10.7 ± 3.3 and WES to 8.8 ± 1.4. Patient satisfaction reached 9.4 ± 0.8. Mean PD at implant sites were 2.7 ± 0.7 mm while BOP amounted to 15.0 ± 0.2% and Pl to 5.0 ± 0.0%. Volumetric analyses revealed minimal changes at the augmented sites irrespective of the region of interest. Radiographic MBL remained relatively stable. CONCLUSIONS: Within the limitation of the present study the L-shape augmentation procedure seems to be a reliable technique when performing GBR with simultaneous implant placement in the esthetic zone. Outcomes encompassed stable clinical and esthetic results accompanied by high levels of patient satisfaction. Future randomized controlled trials are warranted to confirm possible benefits of the L-shape technique over traditional approaches. CLINICAL SIGNIFICANCE: The L-shape appears to be a simple yet promising technique in GBR with simultaneous implant placement that can easily be translated into clinical practice.

Effect of collagen membrane fixation on ridge volume stability and new bone formation following guided bone regeneration.

AIM: To test the effect of membrane fixation on ridge volume stability and new bone formation using guided bone regeneration. MATERIALS AND METHODS: In eight beagle dogs, after bilateral extraction of the maxillary pre-molars, a box-shaped defect was created on each side. All defect sites were augmented with a particulate bone substitute material, covered with either one of two non-cross-linked collagen membranes (CM1 or CM2) with or without fixation (-F or -UF). Samples were collected after 8 weeks. Histomorphometric and micro-computed tomography analyses were performed. RESULTS: Membrane fixation made no significant difference to the total augmented volume for both membranes (p > .05). Histological data indicated that at the ridge crest the augmented tissue width amounted to 2.4 ± 0.4 mm in the group CM1-F and 2.4 ± 0.5 mm in the group CM1-UF, with no significant difference between the groups. Conversely, in CM2-F the augmented tissue width was significantly larger than in CM2-UF (2.3 ± 0.1 vs. 1.57 ± 0.27, p < .05). CONCLUSIONS: Membrane fixation in contained defects failed to improve ridge volume stability regardless of the membrane type. However, it may enhance the width of the augmented ridge at the coronal portion depending on the type of membrane.

Membrane fixation enhances guided bone regeneration in standardized calvarial defects: A pre-clinical study.

AIM: To determine whether collagen membrane (CM) fixation enhances guided bone regeneration in standardized defects. MATERIALS AND METHODS: Four 8-mm-diameter defects were surgically made in eight rabbit calvaria, and randomly allocated into four groups: control (empty), unfixed-CM, fixed-CM, and unfixed-CM with bone graft (BG + CM) (positive control). After 1- and 4-week healing periods, the animals were sacrificed and quantitative reverse transcription polymerase chain reaction, micro-computed tomography, and histological outcomes were assessed. RESULTS: At week 1, the expression levels of BMP-2, FGF-2, VEGF, and osteocalcin were significantly higher in the fixed-CM group than in the unfixed-CM and control groups (p < .05). Conversely, cathepsin-K was significantly expressed in the unfixed-CM group. No significant differences in expression markers were observed between the fixed-CM and BG + CM groups (p > .05). At week 4, new bone formation was significantly higher in the fixed-CM group than the unfixed-CM and control groups (p < .05), but similar to the BG + CM group (p > .05). CONCLUSIONS: CM fixation enhances the expression of osteogenic factors similar to BG + CM, leading to significantly more new bone formation. This suggests that the osteogenic potential is greater when membranes are fixed, thereby limiting the necessity of membrane-supporting materials to enhance bone formation.

Influence of wound closure on volume stability with the application of different GBR materials: an in vitro cone-beam computed tomographic study.

PURPOSE: To assess the influence of using different combinations of guided bone regeneration (GBR) materials on volume changes after wound closure at peri-implant dehiscence defects. METHODS: In 5 pig mandibles, standardized bone defects were created and implants were centrally placed. The defects were augmented using different combinations of GBR materials: xenogeneic granulate and collagen membrane (group 1, n=10), xenogeneic granulate and alloplastic membrane (group 2, n=10), alloplastic granulates and alloplastic membrane (group 3, n=10). The horizontal thickness was assessed using cone-beam computed tomography before and after suturing. Measurements were performed at the implant shoulder (HT0) and at 1 mm (HT1) and 2 mm (HT2) below. The data were statistically analysed using the Wilcoxon signed-rank test to evaluate within-group differences. Bonferroni correction was applied when calculating statistical significance between the groups. RESULTS: The mean horizontal thickness before suturing was 2.55±0.53 mm (group 1), 1.94±0.56 mm (group 2), and 2.49±0.73 mm (group 3). Post-suturing, the values were 1.47±0.31 mm (group 1), 1.77±0.27 mm (group 2), and 2.00±0.48 mm (group 3). All groups demonstrated a loss of horizontal dimension. Intragroup changes exhibited significant differences in group 1 (P<0.001) and group 3 (P<0.01). Intergroup comparisons revealed statistically significant differences of the relative changes between groups 1 and 2 (P=0.033) and groups 1 and 3 (P=0.015). CONCLUSIONS: Volume change after wound closure was minimized by using an alloplastic membrane. The stability of the augmented horizontal thickness was most ensured by using this type of membrane irrespective of the bone substitute material used for membrane support.

Increasing the tissue thickness at implant sites using guided bone regeneration and an additional collagen matrix: Histologic observations in beagle dogs.

OBJECTIVES: To histologically determine the alteration in horizontal mucosal thickness at sites that received guided bone regeneration (GBR) with additional use of collagen matrix and to assess whether bone formation is affected by adding collagen matrix at GBR sites at 8 weeks of healing. MATERIALS AND METHODS: Eight weeks after bilateral extraction of maxillary premolars, standardized defects were created on buccal side of edentulous ridges in four beagle dogs. One side was randomly allocated as control (biphasic calcium phosphate plus collagen membrane; GBR only), while contralateral side was allocated as test (biphasic calcium phosphate plus collagen membrane plus an additional layer of collagen matrix). Histologic observations, histomorphometric and micro-computed tomography analyses were performed after 8 weeks. RESULTS: Membrane complex comprising residual collagen membrane and adjacent dense connective tissue was observed at both control and test sites. The thickness in the histologic analysis were 1.69 ± 0.23 mm (control) and 1.76 ± 0.07 mm (test) in histologic analysis and were 2.03 ± 0.26 mm (control) and 2.14 ± 0.24 mm (test) in radiographic analysis. The thickness of the membrane complex in soft-tissue layer were 723.0 ± 241.6 µm (control) and 984.6 ± 334.4 µm (test). The percentage of new bone formation were 22.30 ± 5.92% (control) and 25.50 ± 8.08% (test). All measured outcome did not show significant differences between control and test groups. CONCLUSION: The addition of collagen matrix on top of standard GBR procedure did not increase the soft tissue thickness and dense connective tissue formation at 8 weeks of healing. Bone regeneration was not affected by the addition of collagen matrix. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 741-749, 2019.

Tissue integration of zirconia and titanium implants with and without buccal dehiscence defects.

PURPOSE: The purpose of the present study was to validate an experimental model for assessing tissue integration of titanium and zirconia implants with and without buccal dehiscence defects. METHODS: In 3 dogs, 5 implants were randomly placed on both sides of the mandibles: 1) Z1: a zirconia implant (modified surface) within the bony housing, 2) Z2: a zirconia implant (standard surface) within the bony housing, 3) T: a titanium implant within the bony housing, 4) Z1_D: a Z1 implant placed with a buccal bone dehiscence defect (3 mm), and 5) T_D: a titanium implant placed with a buccal bone dehiscence defect (3 mm). The healing times were 2 weeks (one side of the mandible) and 6 weeks (the opposite side). RESULTS: The dimensions of the peri-implant soft tissue varied depending on the implant and the healing time. The level of the mucosal margin was located more apically at 6 weeks than at 2 weeks in all groups, except group T. The presence of a buccal dehiscence defect did not result in a decrease in the overall soft tissue dimensions between 2 and 6 weeks (4.80±1.31 and 4.3 mm in group Z1_D, and 4.47±1.06 and 4.5±1.37 mm in group T_D, respectively). The bone-to-implant contact (BIC) values were highest in group Z1 at both time points (34.15%±21.23% at 2 weeks, 84.08%±1.33% at 6 weeks). The buccal dehiscence defects in groups Z1_D and T_D showed no further bone loss at 6 weeks compared to 2 weeks. CONCLUSIONS: The modified surface of Z1 demonstrated higher BIC values than the surface of Z2. There were minimal differences in the mucosal margin between 2 and 6 weeks in the presence of a dehiscence defect. The present model can serve as a useful tool for studying peri-implant dehiscence defects at the hard and soft tissue levels.

Bone Regeneration of Peri-Implant Defects Using a Collagen Membrane as a Carrier for Recombinant Human Bone Morphogenetic Protein-2.

This study is designed to determine the effect of collagen membrane (CM) soaked with bone morphogenetic protein-2 (rhBMP-2) for the treatment of peri-implant dehiscence defects. Material and Methods. Three treatment groups were allocated at each defect in 5 dogs: (i) collagenated synthetic bone (OC) and CM soaked with rhBMP-2 (BMP group), (ii) OC and CM soaked with saline (nonBMP group), and (iii) no further treatment (control group). Titanium pins were used to stabilize the membranes in two dogs. Radiographic and histomorphometric analyses were performed 4 weeks later. Results. The median augmented volumes were 4.27 mm3, 6.24 mm3, and 2.75 mm3 in the BMP, nonBMP, and control groups, respectively; the corresponding median first bone-to-implant contact (fBIC) distances were 3.25 mm, 3.08 mm, and 2.56 mm (P > 0.05). The placement of pins (with the BMP and nonBMP groups pooled) significantly improved bone regeneration: the augmented volumes were 17.60 mm3 with pins and 3.68 mm3 without pins (P = 0.024), with corresponding fBIC distances of 2.25 mm and 3.31 mm, respectively (P < 0.001). Conclusions. The addition of rhBMP-2 to CM failed to improve bone regeneration of peri-implant dehiscence defects compared to using an unsoaked CM after 4 weeks. However, the stabilization of CMs using pins positively influenced the outcomes.

Color Differences Between Pink Veneering Ceramics and the Human Gingiva.

The aim of this study was to examine 10 different shades of pink ceramic to determine which one best matches the mean color of human gingiva. Bar-shaped zirconia samples were fabricated and veneered with 1 of 10 pink zirconia veneering ceramics. The color of the gingiva at the central maxillary incisors of 20 healthy volunteers was compared to the pink veneering ceramics using a spectrophotometer (Spectroshade, MHT). The obtained color parameters L*, a*, and b* (CIELAB) of the gingiva and the ceramics were used to calculate the color difference (ΔE). Mean ΔE values were descriptively analyzed and compared to the threshold value for visibility of color differences of gingiva (ΔE = 3.1). The lowest pink ceramic ΔE value obtained (closest to the mean ΔE of all the volunteers' gingiva) was 6.2. All the tested ceramics exhibited a color difference above the threshold value for visibility.

10-year randomized trial (RCT) of zirconia-ceramic and metal-ceramic fixed dental prostheses.

OBJECTIVES: To monitor zirconia-ceramic and metal-ceramic posterior FDPs with respect to survival and technical/biological complication rates. MATERIALS AND METHODS: Fifty-eight patients received 76 3- to 5-unit posterior FDPs. The sites were randomly assigned to 40 zirconia-based (ZC) and 36 metal-based (MC) FDPs. FDPs were examined at baseline (cementation), at 6 months, at 1 year and then yearly up to 10 years. Technical outcomes were assessed using modified United States Public Health Service (USPHS) criteria. Biologic outcomes included probing depth, plaque, bleeding on probing and tooth vitality. Statistical analysis was performed applying Kaplan-Meier (KM) estimation, log-rank, Mann-Whitney and Fisher exact test. RESULTS: During the 10-year follow-up thirteen patients (17 FDPs) dropped out and 6 FDPs in 6 patients (5 ZC,1 MC) were considered catastrophic failures for technical and/or biological reasons. Forty-four patients with 53 FDPs (29 ZC, 24 MC) were available for examination. The median observation period was 10.3 years (ZC) and 10.0 years (MC). The 10-year KM survival estimate of ZC FDPs was 91.3% (95%CI:69.5;97.8) and 100% of MC FDPs. Minor chipping of the veneering ceramic and occlusal wear were found to a similar extent at ZC and MC FDPs. ZC FDPs demonstrated a significantly higher rate of framework fracture, de-bonding, major fractures of the veneering ceramic and poor marginal adaption. Biological outcomes were similar in both groups and between abutment and control teeth. CONCLUSION: At 10 years, ZC and MC posterior FDPs resulted in similar outcomes for the majority of the outcome measures (p > 0.05).

Single-Tooth Replacement Using Dental Implants Supporting All-Ceramic and Metal-Based Reconstructions: Results at 18 Months of Loading.

The aim of this study was to compare customized zirconia and titanium abutments with respect to survival rates and technical, biologic, and esthetic outcomes. A total of 28 patients with single implants were randomly assigned to 12 customized zirconia (test, AC) and 16 customized titanium (control, MC) abutments. Technical, biologic, and esthetic outcomes were assessed after a mean follow-up time of 18 months. No biologic complications were observed, and no statistical difference for the bone-to-implant distance was found at 18 months (AC -0.05 ± 0.51 mm vs MC -0.28 ± 0.77 mm; P = .40). A similar discoloration of the peri-implant mucosa was observed (ΔEAC 9.6 ± 5.4, ΔEMC 7.6 ± 5.3; P = .46). The mean papilla score values evaluation presented no statistically significant differences between the test and control groups (AC 2.07 ± 0.94, MC 1.96 ± 0.84). At 18 months, reconstructions based on zirconia and titanium abutments exhibited similar survival rates and similar clinical outcomes.

Comparison of Fixed Dental Prostheses with Zirconia and Metal Frameworks: Five-Year Results of a Randomized Controlled Clinical Trial.

PURPOSE: The aim of this study was to test whether posterior zirconia-ceramic (ZC) and metal-ceramic (MC) fixed dental prostheses (FDPs) exhibit similar survival and technical/biologic complication rates. MATERIALS AND METHODS: A total of 58 patients in need of 76 posterior FDPs were randomly assigned to receive 40 ZC and 36 MC FDPs. The restorations were examined at baseline (cementation) and yearly for 5 years. Technical and biologic outcomes were compared. The independent treatment groups were compared with nonparametric Mann-Whitney test for metric variables and with Fisher exact test for categoric data. RESULTS: A total of 52 patients with 40 ZC and 29 MC FDPs were examined at 5 years. No FDP failed during the 5 years; 2 ZC FDPs failed at 65.4 and 73.3 months. Debonding occurred at 3 ZC FDPs. Technical outcomes (modified US Public Health Service criteria) and general periodontal parameters did not show significant differences between ZC and MC FDPs. CONCLUSION: ZC FDPs exhibited similar outcomes to MC FDPs based on 5-year survival estimates. The majority of technical and biologic outcome measures were not significantly different.

Treatment concepts for the posterior maxilla and mandible: short implants versus long implants in augmented bone.

The aim of this narrative review is to describe treatment options for the posterior regions of the mandible and the maxilla, comparing short implants vs. longer implants in an augmented bone. The dental literature was screened for treatment options enabling the placement of dental implants in posterior sites with a reduced vertical bone height in the maxilla and the mandible. Short dental implants have been increasingly used recently, providing a number of advantages including reduced patient morbidity, shorter treatment time, and lower costs. In the posterior maxilla, sinus elevation procedures were for long considered to be the gold standard using various bone substitute materials and rendering high implant survival rates. More recently, implants were even placed without any further use of bone substitute materials, but the long-term outcomes have yet to be documented. Vertical bone augmentation procedures in the mandible require a relatively high level of surgical skill and allow the placement of standard-length dental implants by the use of autogenous bone blocks. Both treatment options, short dental implants, and standard-length implants in combination with vertical bone augmentation procedures, appear to result in predictable outcomes in terms of implant survival rates. According to recent clinical studies comparing the therapeutic options of short implants vs. long implants in augmented bone, the use of short dental implants leads to a number of advantages for the patients and the clinician.

All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs.

OBJECTIVE: To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported fixed dental prostheses (FDPs) and to describe the incidence of biological, technical and esthetic complications. METHODS: Medline (PubMed), Embase and Cochrane Central Register of Controlled Trials (CENTRAL) searches (2006-2013) were performed for clinical studies focusing on tooth-supported FDPs with a mean follow-up of at least 3 years. This was complemented by an additional hand search and the inclusion of 10 studies from a previous systematic review [1]. Survival and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS: Forty studies reporting on 1796 metal-ceramic and 1110 all-ceramic FDPs fulfilled the inclusion criteria. Meta-analysis of the included studies indicated an estimated 5-year survival rate of metal-ceramic FDPs of 94.4% (95% CI: 91.2-96.5%). The estimated survival rate of reinforced glass ceramic FDPs was 89.1% (95% CI: 80.4-94.0%), the survival rate of glass-infiltrated alumina FDPs was 86.2% (95% CI: 69.3-94.2%) and the survival rate of densely sintered zirconia FDPs was 90.4% (95% CI: 84.8-94.0%) in 5 years of function. Even though the survival rate of all-ceramic FDPs was lower than for metal-ceramic FDPs, the differences did not reach statistical significance except for the glass-infiltrated alumina FDPs (p=0.05). A significantly higher incidence of caries in abutment teeth was observed for densely sintered zirconia FDPs compared to metal-ceramic FDPs. Significantly more framework fractures were reported for reinforced glass ceramic FDPs (8.0%) and glass-infiltrated alumina FDPs (12.9%) compared to metal-ceramic FDPs (0.6%) and densely sintered zirconia FDPs (1.9%) in 5 years in function. However, the incidence of ceramic fractures and loss of retention was significantly (p=0.018 and 0.028 respectively) higher for densely sintered zirconia FDPs compared to all other types of FDPs. CONCLUSIONS: Survival rates of all types of all-ceramic FDPs were lower than those reported for metal-ceramic FDPs. The incidence of framework fractures was significantly higher for reinforced glass ceramic FDPs and infiltrated glass ceramic FDPs, and the incidence for ceramic fractures and loss of retention was significantly higher for densely sintered zirconia FDPs compared to metal-ceramic FDPs.

All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs).

OBJECTIVE: To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported single crowns (SCs) and to describe the incidence of biological, technical and esthetic complications. METHODS: Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials (CENTRAL) searches (2006-2013) were performed for clinical studies focusing on tooth-supported fixed dental prostheses (FDPs) with a mean follow-up of at least 3 years. This was complimented by an additional hand search and the inclusion of 34 studies from a previous systematic review [1,2]. Survival and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS: Sixty-seven studies reporting on 4663 metal-ceramic and 9434 all-ceramic SCs fulfilled the inclusion criteria. Seventeen studies reported on metal-ceramic crowns, and 54 studies reported on all-ceramic crowns. Meta-analysis of the included studies indicated an estimated survival rate of metal-ceramic SCs of 94.7% (95% CI: 94.1-96.9%) after 5 years. This was similar to the estimated 5-year survival rate of leucit or lithium-disilicate reinforced glass ceramic SCs (96.6%; 95% CI: 94.9-96.7%), of glass infiltrated alumina SCs (94.6%; 95% CI: 92.7-96%) and densely sintered alumina and zirconia SCs (96%; 95% CI: 93.8-97.5%; 92.1%; 95% CI: 82.8-95.6%). In contrast, the 5-year survival rates of feldspathic/silica-based ceramic crowns were lower (p<0.001). When the outcomes in anterior and posterior regions were compared feldspathic/silica-based ceramic and zirconia crowns exhibited significantly lower survival rates in the posterior region (p<0.0001), the other crown types performed similarly. Densely sintered zirconia SCs were more frequently lost due to veneering ceramic fractures than metal-ceramic SCs (p<0.001), and had significantly more loss of retention (p<0.001). In total higher 5 year rates of framework fracture were reported for the all-ceramic SCs than for metal-ceramic SCs. CONCLUSIONS: Survival rates of most types of all-ceramic SCs were similar to those reported for metal-ceramic SCs, both in anterior and posterior regions. Weaker feldspathic/silica-based ceramics should be limited to applications in the anterior region. Zirconia-based SCs should not be considered as primary option due to their high incidence of technical problems.