The prognosis of partial implant supported fixed dental prostheses

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The prognosis of partial implant supported fixed dental prostheses

  1. 1. ALMOÇO CIENTÍFICOApresentação e discussão de ArtigoUberlândia, 14 de Maio de 2013.Universidade Federal de UberlândiaFaculdade de OdontologiaNEPRO - Núcleo de Estudo e Pesquisa emReabilitação Oral
  2. 2. OBJETIVOS• Apresentação do trabalho.• Discussão do trabalho.• Questionamentos sobre a qualidade do trabalho.• Benefícios para o paciente que podem advir do trabalho.
  3. 3. Editor in Chief: Dr. Marco EspositoLatest issue: Issue 1/2013Publication frequency: quarterlyLanguage: EnglishImpact Factor (ISI): 1.667 (2011) Qualis Capes: B1 -nterdisciplinarOfficial publication of:The British Society of Oral Implantology (BSOI),The Italian Society of Oral Surgery and Implantology (SICOI),The Danish Society for Oral Implantology (DSOI),The German Association of Oral Implantology (DGI),The Spanish Society of Implantology (SEI), and theThe British Academy of Implant & Restorative Dentistry (BAIRD).
  4. 4. Paulo Maló, DDS, PhDOral Surgery Department, Maló Clinic, Lisbon,PortugalMiguel de Araújo Nobre, RDH, MSc EpiResearch and Development, Maló Clinic, Lisbon,PortugalArmando Lopes, DDSOral Surgery Department, Maló Clinic, Lisbon,PortugalTHE PROGNOSIS OF PARTIAL IMPLANT-SUPPORTED FIXED DENTALPROSTHESES WITH CANTILEVERS. A 5-YEAR RETROSPECTIVE COHORTSTUDY.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  5. 5. INTRODUCTION• Cantilever ?????• Rehabilitation in the posterior zone:• lack of bone quantity, bone quality orpresence of infection• lack of bone height and/or crest widthhttp://www.rockymountainsmilecenter.com/case_of_month.htmMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  6. 6. CANTILEVER AS A TREATMENT ALTERNATIVE• Lack of bone height and crest width• Avoid surgery – bone augmentation• Less of 5mm height crest tomandibular nerver or 5 mm crest tosinus floor• Bone width less tham 3 mmhttp://www.anatomiafacial.com/saiba_mamaxilares_desdentados.htmMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  7. 7. CANTILEVER A PROBLEM SOLVER• Anterior region• Insufficient inter-implant and tooth-implant distances• Preserve inter-dental papilla and soft tissue architecture• Achieve good aesthetic standardshttp://www.oralhealthgroup.com/news/anterior-implant-cantilevered-restorations/1000535210/Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  8. 8. CANTILEVER SOME PROBLEMS• Biomechanical Problem• Stress concentration• Axial forces, bending moments, microstrains – higher• Techinical complications in prostheses• Screw loosening• Minor porcelain fracturesMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  9. 9. PURPOSE• The purpose of this study was to report the 5-yearoutcome of implant-supported fixed dentalprostheses with one to two cantilevers. This articlewas written following the STROBE (Strengthening theReporting of Observational Studies in Epidemiology)guidelinesMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  10. 10. MATERIALS AND METHODS• Maló Dental Clinic – Lisbon• 174 patients :106 female ,68 male (mean age: 49years; age range: 17–84 years of age)• Medical records as rehabilitated with partial implant-supported fixed prostheses.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9http://dental.maloclinics.com/
  11. 11. MATERIALS AND METHODS• Patients included, in need of partial rehabilitation in the maxillaor mandible and had sufficient amount of bone to place an implantof at least 7 mm in length.• Insufficient bone volumes (less than 7 mm bone height to the mandibularnerve or less than 7 mm bone height below the maxillary sinus floor, orpatients with bone crest width inferior to 3 mm) a cantilever was addedto the prosthesis.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  12. 12. MATERIALS AND METHODS• in the anterior regions, only two implants were placed to restore the fourmissing incisors.• Inter-implant and tooth-implant distances were compromised• Inter-dental papilla and soft tissue architecture were needed to bepreserved• Whenever the rehabilitation presented an aesthetic challengeMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  13. 13. MATERIALS AND METHODS• Emotional instability , active radiation or chemotherapy wereexcluded.• A total of 225 implants were inserted (Mk II, Mk III and Mk IVBrånemark system; NobelSpeedy Groovy; and Replace, NobelBiocare, Kloten, Switzerland)• 57 implants with machined surfaces and 168 oxidized surfacesMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9https://store.nobelbiocare.com/
  14. 14. MATERIALS AND METHODS• The implant diameters ranged from 3.3 mm to 4 mm, and lengths from 7 mmto 18 mm.• 9 implants were placed using a 2-stage technique• 90 implants were placed using a 1-stage technique• 126 implants immediately loadedMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  15. 15. MATERIALS AND METHODS• insertion torque of 32 Ncm was obtained or if it was not possible to usenatural teeth as support for the fixed prosthesis during the healing period.• 149 implants were placed in maxillae and 76 implants in mandibles• 191 fixed dental prostheses (125 in the maxilla and 66 in the mandible)Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  16. 16. MATERIALS AND METHODSSURGICAL PROTOCOL• A clinical examination with a preoperative panoramic radiograph and acomputed tomography (CT) scan were used to plan the surgery.• The minimum bone quantity was 7 mm in height and 3 mm in width.• Pre operative photographs and preliminary irreversiblehydrocolloidimpressions (Orthoprint, Orthodontic Alginate Extra Fast Setting,Zhermack, Badia Polesine, Italy) were made.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  17. 17. MATERIALS AND METHODSSURGICAL PROTOCOL• All patients were sedated with 10 mg diazepam (Valium®, Roche, Amadora,Portugal)• Antibiotics (amoxicillin 875 mg plus clavulanic acid 125 mg, Labesfal, Campode Besteiros, Portugal) were given 1 hour prior to surgery and daily for 6 daysthere-after• local anaesthesia with mepivacaine or articaine chlorhydrate withepinephrine 1:100,000 (Scandinibsa®2%, Inibsa Laboratory, Barcelona, spain)Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  18. 18. MATERIALS AND METHODSSURGICAL PROTOCOL• 5 mg of cortisone medication (prednisone,Meticorten®, Schering-PloughFarma, Agualva-Cacém, Portugal) was given daily in a regression modefrom the day of surgery until 4 days postoperatively.• Ibuprofen, 600 mg, (Ratio pharm, Carnaxide, Portugal) was administered for4 days postoperatively starting on day 4.• Analgesic clonixine 300 mg (Clonix®, Janssen-Cilag Farmaceutica,Barcarena, Portugal) was given on the day of surgery and postoperativelyfor the first 3 days if needed.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  19. 19. MATERIALS AND METHODSSURGICAL PROTOCOL• Antiacid medication (omeprazole, 20 mg, Lisbon, Portugal) was given on theday of surgery and daily for 6 days postoperatively.• Implant site preparation followed the standard procedures with the followingmodifications: an incision was performed on the palatal side of the crest formaximum tissue repositioning of the papilla in the maxilla, and the flaps werekept as small as possible to maximize blood supply.• The drilling sequence was modified according to bone density in order toachieve maximum apical anchorage using the implant manufacturer bursMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  20. 20. MATERIALS AND METHODSSURGICAL PROTOCOL• Countersinking was not performed to preserve marginal bone. If an implantinsertion torque of 32 Ncm was achieved, implants were loaded immediatelywith provisional acrylic resin prostheses the same day.• The implant platform was planned to be 0.8 mm above the bone crest forMk II, Mk III and Mk IV implants .• Or flush to the bone crest for Nobelspeedy implants.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  21. 21. MATERIALS AND METHODSSURGICAL PROTOCOL• Bicortical anchorage was established whenever possible.• The soft tissues were readapted and sutured back into position with 4-0 non-resorbable sutures (Broun, Aesculap, Tuttlingen, Germany)Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  22. 22. MATERIALS AND METHODSPROSTHETIC PROTOCOL• The abutment choice at surgery was made according to the surgery stagingtechnique:• Cover screws were used when implants were submerged (9 implants)• Healing abutments, Estheticone abutments, Miruscone abutments or multi-unit abutments (Nobel Biocare AB) were used when a 1-stage techniquewas used (90 implants);• Estheticone abutments, Miruscone abutments or multi-unit abutments wereused when implants were loaded immediately (126 implants).Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  23. 23. MATERIALS AND METHODSMAINTENANCE AND FOLLOW UP• The patients with immediately loaded implants were placed on a soft fooddiet for 2 months.• Ten days after surgery, the sutures were removed, and evaluations wereperformed regarding hygiene and implant stability (for immediately loadedimplants or those placed with a 1-stage technique).• The procedure was repeated 2 months (except for implants inserted with a2-stage technique)• 4 months after surgery until a stable situation was secured• After this period, the patients were recalled every 6 months for maintenance.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  24. 24. MATERIALS AND METHODSFINAL PROSTHETIC PROTOCOL• Final prostheses delivered typically after 6 months• Consisting mainly of screw-retained metal ceramic fixed dental prostheses inthe posterior regions• Cemented or screw retained Procera® ceramic fixed dental prostheses(zirconia, Nobel Bio-care) in the anterior regions.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  25. 25. MATERIALS AND METHODSOUTCOME MEASURES• Prosthesis success was measured by function• Implant success 4 criteria :• I-Support for reconstruction• II-Stable when tested (once a year)• III-no sign of pain or infection• IV-no radiolucent areas around the implant (periapical or orthopantomografy)• Mechanical Complications : fracture or loosening of mechanical andprosthodontics components – follow up after 1 – 3 – 5 yearsMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  26. 26. MATERIALS AND METHODSOUTCOME MEASURES• Biological complications: peri-implant pathology (presence of peri-implantpockets ≥ 5 mm• Bone loss of ≥ 2 mm)• Soft tissue inflammation (present or absent)• Fistula formation (present or absent).Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  27. 27. MATERIALS AND METHODSSEC. OUTCOME MEASURES• Peri-implant marginal bone level evaluation was performed on periapicalradiographs (Kodak, Rochester, NY) obtained at implant insertion, 6 months,and 1 and 5 years.• Marginal bone level was assessed with image analysis software (Image Jversion 1.40g for Windows, National Institutes of Health, Bethesda, MD, USA)• The reference point :implant platform (the horizontal interface between theimplant and the abutment), and marginal bone remodeling was defined asthe difference in marginal bone level relative to the bone level at the time ofsurgery.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  28. 28. MATERIALS AND METHODS• Aesthetic complaints (aesthetic complaints of the patient or dentist)assessed clinically at each follow-up appointment for the patient and atprosthetic evaluation, yearly, for the dentist.• Functional complaints (phonetic complaints, masticatory complaints,comfort complaints or hygienic complaints) assessed clinically at eachfollow-up appointment by collecting the patient’s opinion.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  29. 29. MATERIALS AND METHODSSTATISTICAL EVALUATION• Descriptive statistics were used to classify the variables of interest.• Survival analysis was performed using the Kaplan–Meyer product limitestimationMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  30. 30. RESULTS• 16 patients with 21 implants dropped out of the study (9.2% of patients; 9.4%of implants).Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  31. 31. RESULTSPRIMARY OUTCOME MEASURES• Prosthesis success: a total of 2 prostheses were lost in 2 patients, rendering aprosthetic success rate of 99%.• The 2 prosthetic failures occurred in the anterior segment of the maxilla.• New implants after 6 months in the first patient, and on the same day ofimplant removal for the second patient, with both rehabilitations remainingin function during the follow-up of the studyMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  32. 32. RESULTSPRIMARY OUTCOME MEASURES• Implant success: a total of 3 implants were lost in 3 patients after 1 and 4months of follow-up.• From the 3 implant losses, 2 resulted in the loss of 2 prostheses, rendering asurvival rate estimation of 99.0% at 5 years (Kaplan–Meier).• The mean survival estimate was 59.4 months (95% CI: 58.6–60.2 months; allcases were censored at 60 months of follow-up).Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  33. 33. RESULTSIMPLANT LOSSESMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  34. 34. RESULTSPROSTHESES SURVIVAL RATEMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  35. 35. • The mechanical complications registered were fracture of the prosthesis andloosening of prosthetic or abutment screws, with a global frequency of 27.6%(n = 48 patients) at patient level and 25% (n = 56 implants) at implant level.• The frequency of prosthesis fractures was 20.7% at patient level (n = 36patients) and 18.9% at the prosthesis level (n = 36 prostheses).• The frequency of prosthetic screw loosening was 8.5% at patient level (n = 14patients) and 7.3% at prosthesis level (n = 14 prostheses) and occurred in 9provisional prostheses and 5 definitive prostheses.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  36. 36. RESULTSBIOLOGICAL COMPLICATIONS• Peri-implant pathologies (with presence of peri-implant pockets of at least 5mm together with at least 2 mm of bone loss).• The frequency 2.9% at patient level (n = 5 patients) 2.7% at implant level (n= 6 implants).• In 3 patients, these 4 implants were treated successfully with a non-surgical• The other 2 implants in 2 patients were surgically treated.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  37. 37. RESULTSMARGINAL BONE LEVELMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–99% 50% 81%
  38. 38. DISCUSSION• A 99.0% prosthetic survival rate at 5 years proves that it is viable to performimplant-supported fixed dental prosthesis partial rehabilitations with a canti-lever.• High frequency of mechanical complications (27.6%) in these types ofrehabilitations, corresponding to 1 for every 4 prostheses.• Zurdo et al-Systematic review - mean frequency of 20.3% (frequencyrange13–26%) for technical complications during the follow-up of thesetypes of rehabilitations.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  39. 39. DISCUSSION• Parafunctional habits (13 patients were heavy bruxers)• Design of the prosthesis (presence of leverage),• To a lower extent, by the opposing dentition (metal-ceramic implantsupported fixed prostheses in 12 patients).Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  40. 40. DISCUSSION• Marginal bone level are accepted• Nevertheless, there were 18 implants in 15 patients with a marginal bone lossover 3 mm after 5 years of function.• Systemicall problem , smoker ,periodontal and mechanical complications.• Implant failure – 3 – early stage.Maló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  41. 41. DISCUSSION• Retrospective design (only one clinic involved) and the low number ofavailable radiographs at implant insertion and at the 1-year follow-up.• Number of implants unaccounted for (n = 21) belonging to the group ofdrop-out patients (n = 16; 9% of the sample), which could affect the failurerate as these patients could be expected to have a higher failure ratecompared to the patients complying with the follow-up in the study.• Prospective clinical trials with long-term follow-up should be performedMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  42. 42. CONCLUSIONMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9
  43. 43. OBRIGADOMaló P, Nobre M De, Lopes A. The prognosis of partial implant-supported fixed dental prostheses with cantilevers. A 5-year retrospective cohort study. Europeanjournal of oral implantology. 2013 Jan;6(1):51–9

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