The effect of implant placement torque on crestal bone remodeling after 1 year of loading.

PURPOSE: The aim of this study was to evaluate and compare crestal bone levels (CBLs) after 1 year of loading of self-tapping bone condensing implants placed with high insertion torque (IT) compared to those placed with lower IT. MATERIALS AND METHODS: A retrospective chart review of 66 consecutive patients who received at least one self-tapping bone condensing implant and were in function for at least 1 year was conducted. On the basis of intrasurgical notes documenting the implant IT, the patient population was divided into group A (implant IT, >55 Ncm) and group B (IT, <55 Ncm). Radiographs taken immediately after insertion and during annual follow-up appointments were evaluated for detecting crestal bone loss. The relationship between IT and crestal bone loss, bone density, and jaw location were analyzed, and a P-value of 0.05 was considered to be statistically significant. RESULTS: A total of 113 self-tapping bone condensing NobelActive™ implants were placed. The average follow-up period from the placement of the implant restoration was 12.87 (±4.83) months. Six implants were classified as failures resulting in overall survival rate of 94.6%. Implants in group A had a mean IT of 67.35 ± 4.0 Ncm, whereas implants in the group B had a mean IT of 37.9 ± 12.62 Ncm. Implants in group A had statistically significant crestal bone loss compared to implants in group B (0.95 ± 1.60 and 0.18 ± 0.68 mm, respectively). Group A implants placed in the mandible showed significantly more pronounced crestal bone loss (2.12 ± 1.99 mm) compared to those placed in the maxilla (0.25 ± 0.65 mm; P<0.05); however, this was not the case in group B implants. CONCLUSION: Implants inserted with high IT (>55 Ncm) showed more peri-implant bone remodeling than implants inserted with a less assertive IT (<55 Ncm). Bone density and jaw location affect IT and CBLs.

The dome technique: a new surgical technique to enhance soft-tissue margins and emergence profiles around implants placed in the esthetic zone.

Achieving symmetry of the soft-tissue margins between anterior maxillary dental-implant restorations and adjacent teeth is a therapeutic challenge for both the implant surgeon and the restorative dentist. This article describes a modified procedure utilizing autogenous connective-tissue grafts to improve primarily buccal soft-tissue margins and secondarily inter-proximal tissues around tooth-bound single dental implants. This technique has the advantage of allowing for coronal augmentation of the peri-implant soft tissue while maximizing the blood supply to the area by using tunneling-technique principles. A detailed description of the technique and a case with a stable result over 24 months after crown placement is presented.

Complications During Maxillary Sinus Augmentation Associated with Interfering Septa: A New Classification of Septa.

PURPOSE: A new classification of maxillary sinus interfering septa based on its orientation is presented along with its relationship to the prevalence and severity of sinus membrane perforations. Additionally, the impact of membrane perforation on post-operative complications and marginal bone loss during the first year of loading is evaluated. MATERIALS & METHODS: Retrospective chart review of 79 consecutive sinus lift procedures with lateral window technique and 107 implants. Preoperative Cone Beam Computed Tomography (CBCT) images were evaluated for the incidence and the direction of maxillary septa. Chart notes were examined for the incidence of membrane perforation and postoperative complications. Measurements of mesial and distal marginal bone levels and average bone resorption adjacent to each implant were calculated in intraoral radiographs taken at implant placement and during follow up appointments. RESULTS: Interfering septa were identified in 48.1 percent of sinuses. 71.1 percent of them had the septum oriented in a buccal-lingual direction (Class I). The overall incidence of membrane perforation was 22.8 percent, and the presence of an interfering septum on CBCT scan was found to be significantly associated with the occurrence of a sinus membrane perforation (P<0.001). The mean implant marginal bone loss for sinuses, which did not experience a membrane perforation, was 0.6±0.8mm, compared with 0.9 ± 0.9 mm for the sinuses that did experience a perforation (P = 0.325). CONCLUSION: Septa should be identified, classified and managed with a meticulous attention to technical details. A classification based on the septal orientation is proposed since the orientation of the septa can complicate the surgical procedure and requires modification of the surgical technique.

Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: a review.

The reliability of immediately loaded dental implants in the mandible has prompted many to investigate their application in the maxilla. Although the body of literature is growing, the long-term survivability of immediate loading in the maxilla is still pending. This review of literature investigates the status of immediate loading of dental implants in the maxilla to determine its predictability as a treatment option for partial and complete maxillary edentulism. Current terminology in the field is summarized first. Subsequently, the rationale and advantages of immediate loading in the maxilla are reviewed, and the relationships between immediate loading and osseointegration, primary stability, implant design, micromotion, immediate implant placement, and bone character are explored. The importance of a prosthodontically driven implant treatment plan emphasizing the role of splinting a high-precision and passively fitting implant restoration with reduced micromotion under function is summarized. The reliability and predictability of immediately loaded implants as a treatment option are proposed, and recommended guidelines for the successful delivery of immediately loaded implants in the maxilla are presented.

Efficacy of injectable demineralized bone matrix as graft material during sinus elevation surgery with simultaneous implant placement in the posterior maxilla: clinical evaluation of 49 sinuses.

PURPOSE: The purpose of the present retrospective investigation was to evaluate the survivability and success of single implants placed simultaneously during direct sinus lifts with allograft forms of bone and to investigate the effect demineralized bone matrix paste has on time management and membrane integrity during these procedures. MATERIALS AND METHODS: The charts of 49 consecutively treated nonsmoking patients who had met the inclusion criteria were examined. All the patients had undergone unilateral direct sinus augmentation using the lateral window technique, during which only 1 implant (minimum 10 mm in length) was placed in the premolar or molar maxillary region. All implants were submerged using a 2-stage technique and with at least 3 mm of residual sinus floor bone height. The control group of 27 patients had received particulate allograft bone as the graft material, and the 22 test patients had received allograft bone in a paste form (DynaBlast). No implants were loaded before a minimum of 6 months from the date of fixture placement. All implant-supported single crowns in the present study had been functioning for at least 12 months. All patients were seen immediately after placement of the final crown and were requested to return to the surgeon's practice for 1 annual radiographic follow-up examination. The range of follow-up for these patients was 12 to 24 months based entirely on patient compliance. This interval constituted the loading time. The patients were not seen by the specialist in between the "final crown" appointment (original radiograph) and the "annual" follow-up evaluation (final radiograph). No patients experienced complications that required surgical re-entry. The average loading time for the control group was 13.62 months and was 18.77 months for the test group. The survivability and success of the implants were studied, along with the operative time, between the 2 groups. Statistical analysis was performed for various comparisons in the present study. RESULTS: None of the fixtures placed in these patients failed. The success and survivability criteria as stated were met for all 49 implants, regardless of the allograft formulation used. The average operative time in the control group was 70.11 minutes and was 62.36 minutes in the test group. This difference was statistically significant (P < .05). CONCLUSIONS: Using an injectable formulation of allograft material during simultaneous direct sinus lift and implant placement seems to be an acceptable alternative to particulate forms of allograft bone. In addition, when using the injectable graft evaluated in our study, a statistically significant 11% decrease in the operative time resulted.

Initial torque stability of a new bone condensing dental implant. A cohort study of 140 consecutively placed implants.

The aim of this paper was to determine the torque resistance of this new implant during placement in different types of bone, immediate placement into sockets, and in grafted bone. The torque at time of placement serves as an indication of initial stability, which is accepted as an important factor for implant osseointegration and immediate loading. Within a 13-month period, 140 NobelActive implants in 84 consecutive patients were placed into types I-IV bone in fresh sockets, and into grafted bone (both in maxillary sinuses and on the facial alveolar surfaces where bone had been lost). The final torque was measured with a manual torque control wrench as manufactured by Nobel Biocare for clinical use with this type of implant. One hundred forty implants with 3.5 to 5 mm diameters and 10 to 15 mm lengths were placed in different types of bone, either as delayed or immediate implants into fresh extraction sockets. These implants demonstrated a mean torque stability value of 50.8 Ncm. The average insertion torque for delayed implants was 49.7 Ncm. For immediate implants the average torque was 52.6 Ncm. Placement into soft bone was also favorable at an average of 47.9 Ncm. Typical straight walled and tapered implants generally exhibit 10 to 35 Ncm insertion torques. The NobelActive implant consistently reaches higher torque levels. This may indicate they are more favorably suited to early provisionalization and loading. Soft bone (type IV) did not seem to decrease significantly the torque of insertion of these implants. Further longer term studies are needed to investigate whether this indeed makes these implants more suited for early provisionalization and loading than traditional root form. Long term studies are also needed to investigate maintenance of bone levels surrounding these implants.

Clinical evaluation of the NobelActive implant system: a case series of 107 consecutively placed implants and a review of the implant features.

The purpose of this paper is to (1) introduce the features of this new implant, (2) investigate the clinical benefits as advertised by the manufacturer in comparison with traditional root form implants, and (3) provide guidelines for its use. One hundred seven NobelActive implants were placed in 67 consecutive patients with type I-IV bone within 8 months. Cases also include implants placed in sinus grafts, ridges with insufficient thickness and facial bone loss and were placed with delayed and immediate loading. Parameters were assessed to determine whether we could confirm the manufacturer's statements on this implant system. Results obtained with 107 implants of 3.5, 4.3, and 5 mm diameters with 10- to 15-mm lengths placed in different types of bone with delayed and immediate loading demonstrated a final insertion torque from 15 to 70 Ncm. All types of bone allowed "redirection" of the implant but were limited in the bone with higher density. According to the manufacturer, this new design of the NobelActive implant has high initial stability, bone condensing properties, redirecting capability, built-in platform shifting, and dual-function prosthetic connections. After investigating these 5 statements within the limits of our study, we were able to confirm these claims, but with some recommendations for the clinical use and placement of these implants.

The challenge of implant therapy in the posterior maxilla: providing a rationale for the use of short implants.

Rehabilitating patients with a resorbed maxilla presents several challenges when the desired treatment plan involves the placement of endosseous implants. Correct diagnosis requires knowledge on jaw healing patterns, systemic effects, and the impact of bone quality changes on implant success rates. Appropriate treatment planning requires an in-depth understanding of the materials and methods available to the contemporary implant surgeon. The clinician must be able to persist on evidence-based techniques and adhere to those proven methods. Successful surgical placement requires correct use of the available armamentarium and acceptance of the limitations that implant dentistry still presents. Especially challenging is the implant treatment of maxillary molars due to the plethora of complicating factors such as limited bone availability, interarch space challenges, sinus problems, etc. These are just a few of the factors that may lead us to placement of short implants in these sites. An extensive review of the literature that is available for short implants (implants < 10 mm in length) indicates that although they are commonly used in areas of the mouth under increased stress (posterior region), their success rates mimic those of longer implants when careful case selection criteria have been used. The available studies and case-series offer a valid rationale for placement of short implants so long as one understands the limitations, indications, risk factors, and limited studies that actually follow-up success rates of short implants for over 5 years. This review of the literature will provide the reader an in-depth view of the evidence in using short implants as an alternative treatment modality for the maxillary molar region.

Preserving the socket dimensions with bone grafting in single sites: an esthetic surgical approach when planning delayed implant placement.

Recent advancements in barrier membranes, bone grafting substitutes, and surgical techniques have led to a predictable arsenal of treatment methods for clinicians who practice implant dentistry. The contemporary clinician is supplied with proven knowledge, substantiated materials, and instrument inventory that allows implant placement in cases that used to be reserved for the specialist in the past because of their complexity. Nowadays, postextraction alveolar ridge maintenance can be a predictable procedure and can certainly aid the clinician in preventing ridge collapse, thereby allowing for implant placement in a position that satisfies esthetics and function. Extraction socket maintenance for future implant therapy does not rule out immediate implant placement but rather provides an additional option when treatment planning implant patients. This article will focus on the concept of extraction socket preservation using regenerative materials. It will describe a technique suggested by the authors to resist bone resorption and soft tissue shrinkage following tooth extraction.

Rationale for socket preservation after extraction of a single-rooted tooth when planning for future implant placement.

After tooth extraction, the alveolar ridge will commonly decrease in volume and change morphologically. These changes are usually clinically significant and can make placement of a conventional bridge or an implant-supported crown difficult. If bone resorption is significant enough, then placement of an implant may become extremely challenging. Postextraction maintenance of the alveolar ridge minimizes residual ridge resorption and, thus, allows placement of an implant that satisfies esthetic and functional criteria. Recent advances in bone grafting materials and techniques allow the dentist to place implants in sites that were considered compromised in the past. This article focuses on the healing pattern of sockets, with and without the use of regenerative materials, and the rationale for preserving the dimensions of the extraction socket. Histologic and clinical evidence is reviewed to provide an in-depth understanding of the logic behind and value of socket preservation.

The use of lasers for periodontal debridement: marketing tool or proven therapy?

The use of lasers in dentistry has recently received much attention, in both clinical practice and research; their unique properties produce favourable clinical results in some cases and encourage patient acceptance. Various types of lasers have been investigated as an adjunct to periodontal therapy; these include carbon dioxide (CO2), diode, neodymium:yttrium-aluminium-garnet (Nd:YAG) and erbium:yttrium-aluminium-garnet (Er:YAG) lasers.However, adverse results have been associated with each type, including thermal damage to root surfaces, increases in pulpal temperature and the production of toxic by-products. The Er:YAG laser has produced the most promising results, as it can ablate effectively with minimal adverse effects. More research is needed to determine the ideal settings and methods for using the laser safely and effectively in clinical practice.

Intentional angulation of an implant to avoid a pneumatized maxillary sinus: a case report.

This case report describes placement of an implant in the posterior maxilla so as to avoid a pneumatized sinus and also to avoid the need for a sinus lift procedure. An 81-year-old woman presented with an edentulous span in the upper right posterior maxilla. She had been missing teeth in this area for many years, and there was a combination of resorption of the alveolar ridge and pneumatization of the maxillary sinus. Eleven years previously, implants had been placed anterior to this region, but the patient was told that implants could not be placed posteriorly unless a sinus lift was done. At the time of the current presentation she was still unwilling to undergo a sinus lift procedure but wanted to know if implants could be placed in the posterior right maxilla. A tomogram obtained with a radiographic stent in place indicated that there was insufficient bone height to allow placement of implants at the usual angulation without a sinus lift. Therefore, to avoid the need for a sinus lift, 2 implants were placed with palatal angulation as guided by a tomographically determined surgical stent. The treatment planning and surgical and restorative techniques are reviewed here. A postoperative tomogram was obtained to determine the final position of the implants. The outcome has been favourable for the patient and the clinicians. In situations where there is sufficient palatal bone medial to the maxillary sinus, placing implants at an angle may prevent the need for a sinus lift procedure, assuming that proper development of an occlusal restorative scheme is possible.