Primary vs Secondary Endosseous Implantation After Fibular Free Tissue Reconstruction of the Mandible for Osteoradionecrosis.

IMPORTANCE: The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established. OBJECTIVE: To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015. INTERVENTIONS: All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11). MAIN OUTCOMES AND MEASURES: Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis. RESULTS: Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation (P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation. CONCLUSIONS AND RELEVANCE: Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON. LEVEL OF EVIDENCE: 3.

Cost minimization analysis of a long-term randomized clinical trial of patients treated with immediately loaded implant-supported fixed prosthesis.

PURPOSE: To document the long-term costs from a randomized controlled clinical trial (RCT) on edentulous patients treated with mandibular 4-implant-supported fixed prosthesis and two loading protocols. METHODS: Taking the perspective of the individual patient, costs associated with treatment, complications, and patients' time from 18 patients who received an immediate-loading protocol and 21 patients treated with a conventional loading protocol were compared over 10 years of observation. All costs are in Canadian dollars and discounted to the RCT base year of 2006 at a rate of 1.5%. RESULTS: The complication rate in both arms was similar and relatively low. No statistically significant difference was observed in the total cost and discounted total cost, along with its five comprising parameters between the two arms. CONCLUSIONS: Over the 10-year time frame, the immediate loading of dental implants with mandibular fixed prosthesis proved to cost similar to the conventional loading protocol, underscoring the feasibility and reliability of this protocol from the patient's perspective. (REB protocol reference # 33395).

Costs and clinical outcomes of implant placement during ablative surgery and postponed implant placement in curative oral oncology: a five-year retrospective cohort study.

OBJECTIVES: The aim of this study was to compare costs and clinical outcomes of two protocols for implant placement in edentulous oral cancer patients: implant placement during ablative surgery and postponed implant placement. MATERIAL AND METHODS: All edentulous patients who underwent curative tumor surgery between 2007 and 2009 at the Radboud university medical center (Radboudumc) and UMC Utrecht, both in the Netherlands, were included retrospectively. At the Radboudumc, 79 of 98 patients received implants during ablative surgery. At the UMC Utrecht, 18 of 95 patients received implants after a disease-free period of at least 6 months, because satisfying conventional dentures could not be made. Costs, implant details and clinical outcomes were recorded retrospectively up to 5 years after tumor surgery. RESULTS: Individual costs of implant placement were lower in the during-ablative-surgery protocol (€2235 vs. €4152), while implant failure and loading were comparable to the postponed-placement protocol. In the during-ablative-surgery protocol, more patients received implant-retained overdentures (62% vs. 17%) and more patients had functioning dentures (65% vs. 47%), which were placed at an earlier stage (291 vs. 389 days after surgery). Overall costs of the during-ablative-surgery protocol were higher, as more patients received implants and functioning implant-retained dentures, which were more expensive than conventional dentures. CONCLUSIONS: Placing implants during ablative surgery lowered the individual costs of implant placement and led to more patients with functioning dentures, while implant failure and loading were comparable to postponed placement.

Cost and lack of insurance coverage are prohibitive to having dental implants after resections for benign mandibular neoplasms.

OBJECTIVES: To assess how often patients receive dental implants after mandibular resection for benign neoplasms and to determine barriers to completion of functional reconstruction. STUDY DESIGN: This was a retrospective cohort study of patients who underwent resection for benign mandibular neoplasms between 2005 and 2014. Demographic variables included age, sex, and race. Outcome variables include rates of implant placement, implant restoration, and reasons for not having implants. Fisher's exact test and odds ratios were calculated. RESULTS: In all, 52 subjects (age 47.1 ± 19.2 years) were included. Twenty (38.6%) received dental implants. Race was associated with the likelihood of receiving implants (P = .0302). African Americans (1/11, 9.1%) were least likely compared to all other racial groups to have implants (odds ratio = 0.1158; P = .035; 95% confidence interval 0.013-0.989). Caucasians (17/35, 48.6%) were 4.41 times more likely to receive implants compared to all other races (odds ratio = 4.41; 95% confidence interval 1.073-18.093; P = .038). Of the 20 patients who received implants, 10 went on to have dental prostheses. The most common reason for not having implants was cost (37.5% overall), cited by 50% of black and 16.7% of white patients. CONCLUSION: Patients do not typically go on to dental reconstruction after mandibular resection, with cost as a major barrier. African Americans were least likely to complete full reconstruction.

In-office fabrication of dental implant surgical guides using desktop stereolithographic printing and implant treatment planning software: A clinical report.

Guided surgery is accepted as the most accurate way to place an implant and predictably relate the implant to its definitive prosthesis, although few clinicians use it. However, recent developments in high-quality desktop 3-dimensional stereolithographic printers have led to the in-office fabrication of stereolithographic surgical guides at reduced cost. This clinical report demonstrates a protocol for using a cost-effective, in-office rapid prototyping technique to fabricate a surgical guide for dental implant placement.

Implants for the aged patient: biological, clinical and sociological considerations.

Until recently, age, particularly old age, was considered a contraindication to the placement of dental implants. However, this was based largely on anecdotal dogma rather than on empirical information. This review considers the biological, clinical and socio-economic implications of implants placed in the aged population. Aging has been shown to have an influence on the biological aspects of soft- and hard-tissue wound healing and tissue remodeling, which may influence the establishment and maintenance of implant integration. However, information to date indicates that age should not be an a priori contraindication for implant placement and there is good evidence to indicate that dental implants can be placed successfully in the elderly with good clinical and socio-economic outcomes.

A qualitative analysis on participants' perspectives on oral implants.

BACKGROUND: Quantitative research methods provide clinicians with information about the effectiveness of interventions and determined causal-effect relationships, whereas qualitative research investigates other aspects of clinical implant practice, particularly the participants' perspectives and expectations. The aim of the qualitative study was to understand the experience of participants with immediate single molar implants. METHODS: In-depth, audiorecorded, semistructured interviews were conducted with 15 participants who had participated in a controlled clinical trial of immediate molar implants. Participants were aged 36-77 years. Nine participants received single implants in mandibular molar fresh extraction sockets while the remaining participants had their implants in healed sites. The interviews that assessed participants' perspectives of the pre-operative, operative, and postoperative phases of therapy were transcribed verbatim and analysed using inductive and content analysis. RESULTS: Participants took part in the clinical trial mainly because it offered oral implant therapy at a reduced cost. The affordability of implant treatment was the main factor in determining restorative options. Minimal differences were found between male and female participants of different age groups in terms of their perceptions of function and aesthetics. However, single molar implants did not have an impact on aesthetics and self-esteem. Participants' expectations regarding the longevity of oral implants were not realistic and their knowledge about future maintenance needs was not adequate. CONCLUSIONS: Using face-to-face verbal conversation more frequently may improve communication between clinicians and participants and minimize misunderstanding about the procedures of different treatment modalities. Special emphasis should be placed on understanding the importance of maintenance by spending more time with the participants to identify any future barriers to maintaining good outcomes of oral implants.

The patient undergoing implant therapy. Summary and consensus statements. The 4th EAO Consensus Conference 2015.

INTRODUCTION: The assignment for this working group was to update the existing knowledge regarding factors considered being of special relevance for the patient undergoing implant therapy. This included areas where conflicting opinions exists since long or recently has been expressed, like the role of antibiotic prophylaxis in dental implant surgery and peri-implantitis. Also areas with growing interest and concern such as patient-reported outcome measures (PROMs) and health-economy was included in this review. MATERIALS AND METHODS: The literature in the respective areas of interest (antibiotic prophylaxis, peri-implantitis, patient-reported outcome measurements and health-economic aspects) was searched using different strategies for the different papers. Search strategies ranged from a complex systematic review to systematic- and narrative reviews, depending on subject and available literature. All collected material was critically reviewed. Four manuscripts were subsequently presented for group analysis and discussion and plenum discussions and concensus approval. The selected areas were considered to be of key importance and relevance for the patient undergoing implant therapy. RESULTS: The results and conclusions of the review process are presented in the respective papers. The group's conclusions, identified knowledge gaps, directions for future research and concensus statements are presented in this article. The following reviews were available for group discussions and the foundation for subsequent plenary sessions: Lund B, Hultin M, Tranaeus S, Naimi-Akbar A, Klinge B. (2015) Perioperative antibiotics in conjunction with dental implant placement. A complex systematic review. Renvert S & Quirynen M. (2015) Risk indicators for peri-implantitis. A narrative review. De Bruyn H, Raes S, Matthys C, Cosyn J. (2015) The current use of patient centered/reported outcomes in implant dentistry. A systematic review. Beikler T & Flemmig T.F. (2015) Economic evaluation of implant-supported prostheses. A narrative review.

EAO consensus conference: economic evaluation of implant-supported prostheses.

OBJECTIVE: There are various alternatives for the management of oral conditions that may lead to or already have lead to partial or full edentulism. Economic evaluations measure the efficiency of alternative healthcare interventions and provide useful information for decision-making and the allocation of scarce resources. MATERIAL AND METHODS: The current English literature dealing with "cost-effectiveness" of dental implant therapy versus different alternative treatment modalities, that is, complete and fixed partial dentures, root canal, and periodontal treatment, has been included in this narrative review. Due to the high heterogeneity within the literature, a meta-analysis could not be conducted. RESULTS: The available evidence from economic evaluations indicated that for the treatment of central incisors with irreversible pulpitis and coronal lesions, root canal treatments were most cost-effective initial treatment options. When initial root canal treatments failed, orthograde retreatments were most cost-effective. When root canal retreatments failed, extractions and replacement with single implant-supported crowns were more cost-effective compared to fixed or removable partial dentures. In the treatment of periodontitis in molars with Class I furcation invasion, non-surgical periodontal therapy was more effective and costed less than implant-supported single crowns. For the replacement of single missing teeth, two evaluations indicated that implant-supported single crowns provided better outcomes in terms of greater quality-adjusted tooth years or survival rates at lower costs compared to fixed partial prostheses. Another economic evaluation found that implant-supported crowns costed more, but provided greater survival rates compared to fixed partial dentures. For the restoration of edentulous mandibles, two evaluations indicated that overdentures retained by two or four implants improved oral health-related quality of life outcomes, but costed more than complete dentures. CONCLUSIONS: To better assess the efficiency of implant-supported prostheses in various clinical conditions, more economic evaluations are needed that follow well-established methodologies in health economics.

A simple, safe and affordable cast-based guided implant placement system.

A fully restrictive surgical guide allows controlled execution of a preoperatively planned osteotomy and subsequent implant placement. There are two fabrication modes. One is a digital path, where these guides can be fabricated based on data from a cone beam CT source. Alternatively, 3-D data can be derived from a dental cast and periapical radiographs. The 3D Click Guide is a cast-based, fully restrictive surgical guide that can be generated in the dental office.

Randomized controlled multicentre study comparing short dental implants (6 mm) versus longer dental implants (11-15 mm) in combination with sinus floor elevation procedures. Part 1: demographics and patient-reported outcomes at 1 year of loading.

AIM: To test whether or not the use of short dental implants (6 mm) results in an implant survival rate similar to long implants (11-15 mm) in combination with sinus grafting. METHODS: This multicentre study enrolled 101 patients with a posterior maxillary bone height of 5-7 mm. Patients randomly received short implants (6 mm) (group short) or long implants (11-15 mm) with sinus grafting (group graft). Six months later, implants were loaded with single crowns and patients re-examined at 1 year of loading. Outcomes included treatment time, price calculations, safety, patient-reported outcome measures (OHIP-49 = Oral Health Impact Profile) and implant survival. Statistical analysis was performed using a non-parametric approach. RESULTS: In 101 patients, 137 implants were placed. Mean surgical time was 52.6 min. (group short) and 74.6 min. (group graft). Mean costs amounted to 941EUR (group short) and 1946EUR (group graft). Mean severity scores between suture removal and baseline revealed a statistically significant decrease for most OHIP dimensions in group graft only. At 1 year, 97 patients with 132 implants were re-examined. The implant survival rate was 100%. CONCLUSIONS: Both treatment modalities can be considered suitable for implant therapy in the atrophied posterior maxilla. Short implants may be more favourable regarding short-term patient morbidity, treatment time and price.

Why guided when freehand is easier, quicker, and less costly?

Computer-assisted implant planning and subsequent production of a surgical template based on this plan has gained attention because it provides restoratively driven esthetics, patient comfort, satisfaction, and the option of flapless surgery and immediate restoration. However, it adds expense and requires more time. Another significant but not so apparent advantage may be improved survival and success over freehand techniques in types III and IV bone. This retrospective analysis was undertaken to examine that possibility. It reports 1-year outcome for 80 implants in 27 consecutively presenting patients treated over a 7-year period using computer-assisted techniques across all bone qualities in commonly encountered treatment indications in private practice. Implants were placed to support single teeth, small bridges, and complete arch restorations in exposed or immediately restored applications, based on primary stability as determined by insertion torque, resonance frequency analysis, and Periotest. For the 80 implants supporting 35 restorations, the median observation period is 2.66 years; 73 implants supporting prostheses in 22 patients had readable radiographs at 1 year. There was a 1-year overall implant survival and a success rate of 100%. Radiographic analysis demonstrated the change in bone level from the platform at 1-year is less than 2 mm. Intra-operative median measurements of primary stability were insertion torque, 40 Ncm; resonance frequency, 76 ISQ; and Periotest, -3. All intra-operative measurements were consistent for acceptable primary stability regardless of bone density. Restoratively driven diagnosis and precision planning and initial fit were possible with computer-assisted techniques resulting in the achievement of high primary stability, even in areas of less dense bone. The ability to plan implant position, drill sequence, and implant design on the basis of predetermined bone density gives the practitioner enhanced pretreatment information which can lead to improved outcome.

Computer-guided versus free-hand placement of immediately loaded dental implants: 1-year post-loading results of a multicentre randomised controlled trial.

PURPOSE: To compare planning and patient rehabilitation using a 3D dental planning software and dedicated surgical guides with conventional rehabilitation of partially or fully edentulous patients using flapless or mini-flap procedures and immediate loading. MATERIALS AND METHODS: Fifty-one fully or partially edentulous patients requiring at least 2 implants to be restored with a single prosthesis, having at least 7 mm of bone height and 4 mm in bone width, had their implant rehabilitation planned on three-dimensional (3D) cone beam computed tomography (CBCT) scans using a dedicated software. Afterwards they were randomised according to a parallel group study design into two arms: computer-guided implant placement aided with templates (computer-guided group) versus conventional implant placement without templates (conventional group) in three different centres. Implants were to be placed flapless and loaded immediately; if inserted with a torque over 35 Ncm with reinforced provisional prostheses, then replaced, after 4 months, by definitive prostheses. Outcome measures, assessed by masked assessors were: prosthesis and implant failures, complications, peri-implant bone level changes, number of treatment sessions, duration of treatment, post-surgical pain and swelling, consumption of pain killers, treatment time, time required to solve complications, additional treatment cost, patient satisfaction. Patients were followed up to 1 year after loading. RESULTS: Twenty-six patients were randomised to the conventional treatment and 25 to computerguided rehabilitation. No patient dropped out. One provisional prosthesis failed, since one of the two supporting implants failed 11 days after implantation in the conventional group (P = 1.0). Four patients of the conventionally loaded groups experienced one complication each, versus five patients (6 complications) in the computer-guided group (P = 0.726). There were no statistically significant differences between the two groups for any of the tested outcomes with the exception of more postoperative surgical pain (P = 0.002) and swelling (P = 0.024) at conventionally treated patients. CONCLUSIONS: When treatment planning was made on 3D CBTC scan using a dedicated software, no statistically significant differences were observed between computer-guided and a free-hand rehabilitations, with the exception of more postoperative pain and swelling at sites treated freehand because more frequently flaps were elevated.

Patient-related and financial outcomes analysis of conventional full-arch rehabilitation versus the All-on-4 concept: a cohort study.

BACKGROUND: Patient-related variables such as cost of treatment, length of the treatment period, and comfort provided by the interim prosthesis when treatment planning for full-arch rehabilitation are often neglected in dental publications. METHODS: Two patient cohorts were followed up longitudinally in this study: the "All-on-4 treatment concept group" and the "historical group." The number of implants, total treatment time, number of surgical procedures, number of sinus grafts, necessity for immediate provisional implants, adjusted cost associated for treatment in each group, and the quality of interim prosthesis were compared. RESULTS: The total adjusted cost for patients receiving All-on-4 treatment concept averaged at $42,422 ± 3860 (&OV0556;31,392 ± 2856), whereas the mean total adjusted cost for the historical group was $57,944 ± 20,198 (&OV0556;42,879 ± 2113) (P = 0.01). The difference in cost had a mean value of $7307 (&OV0556;5407) per jaw. Factors associated with complexity of treatment and patient comfort, such as the quality of interim prosthesis, number of surgeries, and duration of treatment time, all significantly favored the All-on-4 treatment concept group in comparison with conventional treatment modalities. CONCLUSIONS: When implant rehabilitation of the total jaw is sought, the All-on-4 treatment concept should be considered the least costly and least time consuming treatment option.

[Aftercare for durability and profitability of single-unit and multi-unit fixed dental prostheses]. / Nazorg voor dutrzaamheid en profijtelijkheid van kronen en bruggen.

An important aim ofa treatment with single-unit and multi-unit fixed dental prostheses is a durable and profitable treatment outcome. That requires aftercare, too. First, the frequency of routine oral examinations should be assessed, using an individual risk profile. The objectives of the routine oral examinations are the prevention and, when necessary, the treatment of pathological conditions and complications. With regard to prevention, attention should be paid to information and instruction, oral biofilm and calculus, non-functional activities, hard tooth tissues, periodontal and peri-implant tissues, and saliva. Subsequently, it can be determined whether the intended durability and profitability have been achieved or can still be achieved, whether or not through indicated adjustments. Special attention should be paid to endodontically treated teeth. Restorative, repair or replacement treatments may be indicated in case ofcomplications, such as loose single- or multi-unitfixed dental prosthesis, fracture of a fixed dental prosthesis unit, lost tooth pulp vitality, tooth root fracture, and implant or implant abutment problems.

Economics of periodontal care: market trends, competitive forces and incentives.

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

Assessing image-guided implant surgery in today's clinical practice.

As implant dentistry has progressed, greater emphasis has been placed on natural-looking tooth replacement, minimally invasive techniques, and better cost efficiencies, with implant positioning being guided by the desired prosthetic outcome. Image-guided surgery is a technique that merges preoperative diagnostic imaging with computer-based planning tools to facilitate surgical and restorative plans and procedures. This article discusses the intricacies of guided implant surgery, including 3-dimensional presurgical planning and the challenges of maintaining guide stability during surgical execution.