Role of the implant design on immediate loading Critical appraisal of the evidence from clinical trials

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dental implants (n=439) 4 45 35 RCTs 4 3 18 % 35 5 15 8 % 3 5 15 1 1 5 5 # Publications on clinical studies on dental

1 Role of the implant design on immediate loading Critical appraisal of the evidence from clinical trials Asbjørn Jokstad, DDS, PhD UiT The Arctic University of Norway University of Toronto # Publications reporting data from clinical studies on dental implants (n=439) RCTs % % # Publications on clinical studies on dental implants, with focus on effects of implant design factors (n=566) RCTs 5 3 % % Market: 39 manufact. > brands 1

2 «Immediate function» terms Patient A patient with an edentulous space or jaw desiring immediate restoration of form and function i.e., «immediate loading*» A patient with a terminal tooth or dentition desiring immediate restoration of form and function i.e., «immediate implant» / «immediate placement» pluss «immediate loading»* *«Functional loading» AKA occlusal loading or «Nonfunctional loading» = («Immediate restoration») «Immediate function» modalities In one treatment session: Type 1 Type Type 3 Type 4 + Placement of implant + Restoration (Temporary or permanent) Soft tissue coverage (Healing ~4 to 8 weeks) + Partial socket bone fill (Healing ~8 to 16 weeks) + Fully healed socket (Healing ~>16 weeks) + (direct) Restoration Immediate loading Restoration Restoration (late) Soft tissue coverage Partial socket bone fill Fully healed socket (Healing ~4 to 8 weeks) (Healing ~8 to 16 weeks) (Healing ~>16 weeks) (Healing 1 week) (Healing 1 week) (Healing 1 week) + Placement of implant (Healing 1 week). Restoration (Temporary or permanent) + Placement of implant (Healing 1 to 8 weeks). Restoration (Temporary or permanent) Early loading + Placement of implant (Healing > 8 weeks). Restoration (Temporary or permanent) Conventional loading Soft tissue coverage (Healing ~4 to 8 weeks) (Healing 1 to 8 weeks) Soft tissue coverage (Healing ~4 to 8 weeks) (Healing > 8 weeks) Partial socket bone fill (Healing ~8 to 16 weeks) (Healing 1 to 8 weeks) Partial socket bone fill (Healing ~8 to 16 weeks) (Healing > 8 weeks) Fully healed socket (Healing ~>16 weeks) (Healing 1 to 8 weeks) Fully healed socket (Healing ~>16 weeks) (Healing > 8 weeks) # Publications reporting data from clinical studies on dental implants, with focus on immediate loading (n=693 / 439 reports) RCTs 18 % %

3 General findings on immediate loading # Systematic reviews: 53 (11 in last years) First clinical research study: (Brånemark et al. 1977: Experience over a 1 year period & 4 tps implants anterior mandible (Ledermann 1978) Longest clinical research study: 44p/176i over 1 years (range 8 18), retrospective study, ITI tps anterior mandible (Lambrecht & Hodel 7) 693 reports #RCT trials: 11 reports (18 in last y.), 76 focus on loading comp., 51 unique RCTs First: 1 p. with 4 Nobelbiocare Mk i. edent.mand. OD (Chiapasco et al. 1) Largest: 66 p. with 35 Straumann SLA i. for crown/3 4i FDP(Zöllner et al. 8) Longest: 1 y. 16p/1i/i OD (Ma et al. 1) & 9 y. 44p/11i (Rocci et al. 13) 11 RCT papers 76 comparing healing protocols, 51 unique RCTs Edentate removable fixed Partial Single Maxilla Posterior Anterior Mandible 4 Anterior 4 All indications: 3 Posterior 3 Clinical trials with focus on shortened loading protocols according to implant brand Prior to 6 (n=186 ) Period 1-15 (n=34) Other 1% Biomet 3i Nobel Biocare 7% 4% Dentsply 1% Straumann (ITI) 18% Other manuf. % Astra (Dentsply) 9% Biomet 3i 7% Dentsply 7% Straumann 1% Nobel Biocare 45% 3

4 Immediate loading vs. healing (SR s - 6) Glauser et al. (17 reports) * Nkenke & Fenner (38) Del Fabbro et al. (71) Ioannidou & Doufexi (Early loading, 13) Cooper et al. (Edent. Maxilla (9)) Attard & Zarb (93) * Esposito et al. (RCTs (7)) Misch et al. (4) * Morton et al. / Chiapasco (Edent.(45) Ganeles&Wismeijer (Single/Part.Edent.(5)) Romanos (Implant brand A (1)) * Misch et al. (7) * Castellon et al. (Mandible anterior (14)) Esposito et al. (RCTs (3)) Lekholm (15) * Aparicio et al. (45) Gapski et al. (6) * Szmukler-Moncler et al. (Vitro & vivo ()) *discuss possible effects of implant design factors = = Immediate loading vs. healing (7-1) Ma & Payne (Mand. i-od (5)) Alsabeeha et al. (Mand. OD (1)) Atieh et al. (Postextraction single molars ( 9)) * Atieh et al. (Single (5)) Atieh et al. (Postextraction single (1)) * Esposito et al. (RCTs()) Gallucci et al. (Edentulous (61)) Roccuzzo et al. (PartialEdent.Post.Max. (8)) Cordaro et al. (Earlyload. PartialEd.Post.Mand. (19)) Grutter & Belser (PartialEdent. Anterior (1)) DeRouck ea (Postextraction single anter. (11)) Henry & Liddelow ( best papers ) Sennerby & Gottlow (Publications>5 (6)) Den Hartog et al. (PartialEdent. Anterior (19)) Esposito et al. (RCTs(11)) Kawai & Taylor (Mand. OD (9)) Avila et al. (8) Jokstad & Carr (RCT+CCTs ()) *discuss possible effects of implant design factors Immediate loading vs. healing (11-15) = = = = Del Fabbro et al. (Postextraction, (5)) * Sanz-Sanchez et al. (RCTs (9)) Chrcanovic et al. (Occl vs Non-occl. (11)) Benic et al. (Single, RCTs, (11)) Chen & Buser (Postextraction ant. Maxilla (5)) Papaspyridakos et al. (Edent. Fixed. (6)) Schimmel et al. (Edent. Remove., (58)) Schrott et al. (Part. Edent. (4)) Su et al. (RCTs, 6) Esposito et al. (RCTs (6)) Suarez et al. (6) Lang et al. (Postextraction, (46)) Menini et al. (All-on-4, (11)) * Strub et al. (9) * Enríquez-Sacristán et al. (Postextraction (13)) *discuss possible effects of implant design factors 4

5 General findings on immediate loading # Systematic reviews: 53 (11 in last years) First clinical research study: (Brånemark et al. 1977: Experience over a 1 year period & 4 tps implants anterior mandible (Ledermann 1978) Longest clinical research study: 44p/176i over 1 years (range 8 18), retrospective study, ITI tps anterior mandible (Lambrecht & Hodel 7) 693 reports #RCT trials: 11 reports (18 in last y.), 76 focus on loading comp., 51 unique RCTs First: 1 p. with 4 Nobelbiocare Mk i. edent.mand. OD (Chiapasco et al. 1) Largest: 66 p. with 35 Straumann SLA i. for crown/3 4i FDP(Zöllner et al. 8) Longest: 1 y. 16p/1i/i OD (Ma et al. 1) & 9 y. 44p/11i (Rocci et al. 13) Pre-surgery modifiers General & local risk factors Bone quantity and quality (jaw) Vertical dimension of occlusion Parafunctional habits Surgery modifiers Flap / Site preparation Primary stability Additional modifiers Single implant vs. Splinted implants Occluding vs. Non-occluding Implant design, including length # Publications reporting data from clinical studies on dental implants, with focus on immediate implants (n= 46 / 439 reports) RCTs 9 % % General findings on immediate implants # Systematic reviews: (11 in last years) First clinical research study: Single Tübinger implants Al O 3 (Schulte 1978) Longest clinical research study: Retrospective data of 168 i./981p. over 5y. Nobel Biocare implants (Balshi et al. 13) #RCT trials: 51 (9 in last years) First: 36p./43i, Ti tps vs Ti_HA +/ DFDB (Gher et al. 1994) Largest: 8 p./ i. Straumann SLA, after 3 weeks healing (Lang et al. (7) Longest follow up: 3 y. 93p/99i Osseospeed (Sanz et al. 1) & (1 y. 7p/i. Osseotite, placement 1days after extraction (Schropp et al. 1) Pre-surgery modifiers General & local risk factors Bone quantity and quality (jaw) Vertical dimension of occlusion Parafunctional habits 46 reports Surgery modifiers Flap / Site preparation Skill of Clinician(s) Primary stability Residual infection Socket defect shape & facial plate integrity/thickness Facial position of the implant Soft tissue biotype 5

# Publications reporting data from clinical studies on dental implants, with focus on immediate implants with immediate loading (n= 161 / 693 reports) 5 18 RCTs 1 % 16 14 1 15 88 % 1 1 8 6 5 4

(Balshi & Wolfinger 1997) Longest clinical research study: 7 y., retrosp., 8p/519i., edentulous jaws, 3i. Implants, (Testori et al. 13) #RCT trials: 18 (4 in last years) First: vs.:(ii+dl) 4p.

11) Longest follow up: 5 years 71p/1i, single posterior, (Prosper et al.

6 # Publications reporting data from clinical studies on dental implants, with focus on immediate implants with immediate loading (n= 161 / 693 reports) 5 18 RCTs 1 % % General findings, immediate implants with immediate loading # Systematic reviews: 9 ( in last years) First clinical research study: 1p./13i, retrosp., edent.mand., Brånemark turned i. (Balshi & Wolfinger 1997) Longest clinical research study: 7 y., retrosp., 8p/519i., edentulous jaws, 3i. Implants, (Testori et al. 13) #RCT trials: 18 (4 in last years) First: vs.:(ii+dl) 4p.(Crespi ea. 8) (i. autograft,heal 4 m., il),76p. (Block ea. 9) Largest: vs. Xenograft+membrane, heal 4m.,+il, 16p., single max. (Felice et al. 11) Longest follow up: 5 years 71p/1i, single posterior, (Prosper et al. 1) 161 reports Pre-surgery modifiers General & local risk factors Bone quantity/quality (jaw) Vertical dimension of occlusion Parafunctional habits Surgery Modifiers Flap / Site preparation Primary stability Residual infection Socket defect shape & facial plate integrity/thickness Facial position of the implant Soft tissue biotype Skill of Clinician(s) Additional modifiers Single implant vs. Splinted implants Occluding vs. Non-occluding Implant design, including length Immediate loading (n=693 reports) 158 Immediate implant (n=46 reports) Effects of implant design factors on outcome (n=566 reports) 6

7 Immediate loading (n=693 reports) Immediate implant (n=46 reports) Artzi et al. (1): Short (8-mm) and narrow (3.3-mm) implant configurations were significantly (P <.5) associated with failure 158 (RCS) Zafiropoulos et al. (9):The type of implant, position, and timing of placement 3 and loading did not influence the survival 35 rate of this treatment method (RCS) 86 Li et al. (9: The implant survival rate was found to be not related to implant diameter, system, configuration, type of Effects of implant design abutment connections, and position of factors on outcome implants (P >.5). (RCS) (n=566 reports) Immediate loading (n=693 reports) Immediate implant (n=46 reports) RCTs (7 reports) At.5 y: cylindrical equivalent to tapered for Straumann-SLA (Lang ea 7) At 3 y: cylindrical equivalent to tapered for 3 35 Osseospeed (Sanz ea 14) At 4 months: ITI-tps & Calcitec(HA) equivalent 86 (Gher ea 1997) Effects of implant design factors on outcome (n=566 reports) Immediate loading (n=693 reports) 9 RCTs (13 reports) At y: ANKYLOS better than (3i)Certain (Romanos ea 13) At 1 y: Osstem TSIII HA & Zimmer TSV equivalent (Kim ea 13) At 9 y: Brånemark TiUnite better than turned (Rocci ea 13) 3y: idem. (Fung ea 11) 3y: idem. (Liddelow&Henry 1) 86 At 1 y: Brånemark TiUnite & turned equivalent (Fröberg ea 6) At 3 y: NobelActive & -Replace equivalent (Arnhart ea 1) At 1y: Brånemark, Southern, ITI Steri-Oss equivalent (Ma ea 1) At 3y: Brånemark Mk & conical equivalent (Gatti&Chiapasco ) Immediate implant (n=46 reports) 35 Effects of implant design factors on outcome (n=566 reports) 7

Summit 14 Edentulous maxilla, effects of implant design in rehabilitation, studies on

5 Testori ea 13 Li ea 9 Length Kinsel & Liss 7 Artzi ea 1 Surface vanassche ea 1 Testori ea

Cavalli ea 1 Malo ea 11b Agliardi ea 9 Surface Pera ea 14 Material Material 187 titles on

8 Summit 14 Edentulous maxilla, effects of implant design in rehabilitation, studies on immediate loading YES NO Design Degidi & Piatelli 3 Testori ea 13 Li ea 9 Diameter Degidi ea 5 Testori ea 13 Li ea 9 Length Kinsel & Liss 7 Artzi ea 1 Surface vanassche ea 1 Testori ea 13 Li ea 9 Ibanez ea 5 YES Design Agnini ea 14 Malo ea 11a Diameter Length NO Malo ea 1 Cavalli ea 1 Malo ea 11b Agliardi ea 9 Surface Pera ea 14 Material Material 187 titles on immediate loading papers reporting on 19 RCT/CCT trials Relative Differences in Survival Estimates % difference 8

microrough, rough) % difference in favor of control Implant morphology

9 Relative Differences in Survival Estimates ~% lower survival & consistently wider confidence intervals Implant morphology (smooth, microrough, rough) % difference in favor of control Implant morphology (smooth, microrough, rough) % difference in favor of control Turned surface implants 9

10 Implant morphology (smooth, microrough, rough) Micro rough surface implants Thank you for your attention Asbjørn Jokstad 1

WORKSHOP ON THE STATE OF THE SCIENCE OF IMPLANT DENTISTRY. Chicago August 2006

WORKSHOP ON THE STATE OF THE SCIENCE OF IMPLANT DENTISTRY. Chicago August 2006 Group 1. What Is the Effect on Outcomes of Time to Loading of a Fixed or Removable Prosthesis Placed on Implant(s)? How does