Trends

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Trends

  1. 1. Dental Implant Therapy - D t l I l t Th Trends & Literature Critical Appraisal University of Florida, Gainesville Seminar, F b S i February 19 2008 19, Asbjørn Jokstad DDS PhD Jokstad, DDS, Professor and Head, Prosthodontics Faculty of Dentistry, University of Toronto
  2. 2. University of Florida, Gainesville, 19.2.2008
  3. 3. Adolescent patient with a crown– root fracture of central: options? p Fracture line palatinally 1. Extraction orthodontics veneer or crown 2. Extraction etch-bridge or FPD 3. Extraction implant abutment crown 4. Extraction & replantation 180° endo crown 5. 5 Endo orthodontic extrusion crown 6. Decoronation+etch-bridge/flipper implant abutment University of Florida,&Gainesville, 19.2.2008Depts. of Pedodontics, crown of Dentistry, University of Oslo, & Birkeland, 2007. Faculty Orthodontics Prosthodontics. Stenvik
  4. 4. Adolescent patient with missing laterals: options? p A. Orthodontic Treatment A O th d ti T t t B. Etch-bridges C. (Provisional) Removable Partial D. Conventional Fixed Partial E. Implant-supported crowns19.2.2008 University of Florida, Gainesville,
  5. 5. Adolescent patient with missing laterals: options? Additional considerations: A. Orthodontic Treatment What if buccal bone augmentation is required? A. Single implants + crowns in the lateral regions B. Mesial movement of canines composites + single implants in canine region g p g C. Mesial movement of canines & bicuspids composites + single implants in bicuspid region University of Florida, Gainesville, 19.2.2008
  6. 6. “Medicine is a science Medicine of uncertainty and an y art of probability” Sir William O l Si Willi Osler Canadian Physician (1849-1919) University of Florida, Gainesville, 19.2.2008
  7. 7. Dental Implants - How many y systems do we y have and how well are th they documented? d t d?
  8. 8. Number of dental implants 1988 p English CE. Implants. Part three. An overview. California Dent Assoc J. 1988;16: 34-8. 50 45 45 40 35 30 25 20 15 10 5 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 University of Florida, Gainesville, 19.2.2008 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20
  9. 9. Review of existing literature g Eckert S et al. Validation of dental implant systems through a review of literature supplied by system manufacturers. J Prosthet Dent 1997;77: 271-9 271 9. Conclusion: On the basis f the literature supplied b O th b i of th lit t li d by the manufacturers, only one implant system d t demonstrated scientifically valid t t d i tifi ll lid long-term success. University of Florida, Gainesville, 19.2.2008
  10. 10. Situation, 1999 1. 1 The number of implants and implant systems increase continuously worldwide 2. 2 The FDI World Dental Federation is concerned about the quality of all the new implants being marketed 3. The FDI Science Committee is asked to investigate the issue 4. The work is commissioned to prof. A Jokstad University of Florida, Gainesville, 19.2.2008
  11. 11. Implant brands/ systems available in N. America i 1999 ( 98) i N A i in (n=98) University J Oral Maxillofac Impl 2000 15(1): 76-95 Int of Florida, Gainesville, 19.2.2008
  12. 12. Number of implants 2000 Binon PP Implants and components: entering the new PP.Implants millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. English CE. Implants. Part three. An g overview.CDA J. 1988;16: 34-8. 120 98 100 80 60 45 40 20 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 University of Florida, Gainesville, 19.2.2008 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20
  13. 13. Jokstad, Brägger, Brunski, Carr, Naert, Wennerberg. Int Dent J , g 2003; 53 Sup 2: 409-33 Asbjørn J k t d O l N A bj Jokstad, Oslo, Norway Urs Braegger, Bern, Switzerland John B. Brunski, Troy, USA , y, Alan B. Carr, Rochester, USA Ignace Naert, Leuven, Belgium Ann Wennerberg Gothenburg Sweden Wennerberg, Gothenburg,
  14. 14. Commercially available implant and implant y p p systems in October 2003: 225 implant brands 78 manufacturers – from all continents ~70 implant brands no longer marketed University of Florida, Gainesville, 19.2.2008
  15. 15. Number of implants 2003 Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409-43 Binon PP..Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. English CE. Implants. Part three. An overview. CDA J. 1988;16: 34-8. 250 220 200 150 98 100 45 50 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 University of Florida, Gainesville, 19.2.2008 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20
  16. 16. Straight, Tapered, Conical, Ovoid, Trapezoidal, Stepped & combinations … University of Florida, Gainesville, 19.2.2008
  17. 17. Flange design g Flange vs. no flange Straight vs. flared vs. widening Height Polished vs threads vs. Added features Surface topography S f University of Florida, Gainesville, 19.2.2008
  18. 18. Threads vs. non-threads Shape: V- vs. square- vs. reverse buttress- vs. combinations Number and size of “lead threads” Number and location of grooves, groove forms and groove sizes Surface micro-topography Thread angle University of Florida, Gainesville, 19.2.2008
  19. 19. Apex Threaded Th d d vs non- threaded V-shape vs fl t vs V h flat curved apex Holes, round, H l d oblong Apical h b A i l chamber Grooves and groove size i Flared apex Surface topography University of Florida, Gainesville, 19.2.2008
  20. 20. Interface geometry External vs Internal Hexagonal vs. Octagonal vs cone Morse t M taper Rotational vs non- rotational Added non- rotational features Heights & widths Butt vs bevel joints j Slip-fit vs friction-fit joints Resilience vs nonresilience …. University of Florida, Gainesville, 19.2.2008
  21. 21. High (top) and low (bottom) magnification of cpTi surfaces as used for surface characterization characterization. Plasma– Grit-blasted Grit-blasted Dual acid- Machined sprayed and dual etched (turned) (TPS); acid-etched University of Florida, Gainesville, 19.2.2008 Davies, 2003
  22. 22. Surface topography Machining process Example Anisotropic with Turned Brånemark System® MKIII oriented cutting marks (Nobel Biocare) Isotropic Blasted TiO2 particles (Tioblast®, AstraTech) A t T h) Isotropic Blasted + acid etched 1. Large size Al2O3 particles & HCl & H2SO4 (SLA®, Straumann) - 2 T i l i St ) 2. Tricalcium phosphate & HF & NO3 (MTX®, Centerpulse) Isotropic with high Acid etched HCl / H2SO4 (Osseotite®, 3i) frequency irregularities Isotropic and rough Hydroxyapatite coated Sustain® (Lifecore) Isotropic and rough p g Titanium Plasma ITI® TPS (Straumann) ( ) Sprayed Isotropic with craterous Oxidized TiUnite® (Nobel Biocare) structure University of Florida, Gainesville, 19.2.2008
  23. 23. Clinical documentation? University of Florida, Gainesville, 19.2.2008
  24. 24. Clinical documentation A. Implant or implant system with extensive clinical documentation: >4 10 clinical trials B. Implant implant B I l t or i l t system with li it d t ith limited clinical documentation, i.e. <4 trials, 11 but f b t of good methodological quality d th d l i l lit C. Implant or implant system with limited 29 published clinical documentation D. Implant or implant system with no p p y published clinical documentation. 28 University of Florida, Gainesville, 19.2.2008
  25. 25. The quality of RCTs of oral implants is generally poor and needs to be improved University of Florida, Gainesville, 19.2.2008 16: 783-92 Esposito et al., IJOMI 2001;
  26. 26. How many new y implant systems? University of Florida, Gainesville, 19.2.2008
  27. 27. Number of implants 2006 Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409 43 2):409-43 Binon PP.Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. Jan English CE Implants Part three An CE. Implants. three. 2007 overview.CDA J. 1988;16: 34-8. 400 357 350 300 250 220 200 150 98 100 45 50 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 University of Florida, Gainesville, 19.2.2008 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20
  28. 28. Number of implants 2008 Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409 43 2):409-43 Binon PP.Implants and components: entering the new Jan millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. 2008 English CE Implants Part three An CE. Implants. three. Jan overview.CDA J. 1988;16: 34-8. 2007 600 535 500 400 357 300 220 200 98 100 45 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 University of Florida, Gainesville, 19.2.2008 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20
  29. 29. Implant Manufacturers USA: 28 G Germany: y 25 Italy: 14 per 2 2007 2.2007 Korea: 8 (n=120) Spain: 8 Brazil: 5 Switzerland : 5 Canada: 4 France: 4 Sweden: 4 Israel: 3 United Kingdom: 3 Other countries: 9 University of Florida, Gainesville, 19.2.2008
  30. 30. Implant Manufacturers USA: 28 Germany: 32 G Germany: y 25 USA: 31 Italy: 14 Italy: 15 Korea: 8 Korea: 10 Feb. 2008? Spain: 8 Spain: 10 Brazil: 5 Brazil: 9 Switzerland : 5 France: 7 (n=147!) Canada: 4 Japan 6 France: 4 Switzerland : 6 Sweden: 4 Canada: 4 Israel: 3 Sweden: 4 United Kingdom: 3 Israel: 3 Other countries: 9 United Kingdom: 3 Feb 2007: n=120 Other countries: University of Florida, Gainesville, 19.2.2008 9
  31. 31. Clinical documentation of the th new i l t implant systems? University of Florida, Gainesville, 19.2.2008
  32. 32. Implant systems introduced since October 2003 ? University of Florida, Gainesville, 19.2.2008
  33. 33. University of Florida, Gainesville, 19.2.2008 www.implantdirect.com
  34. 34. University of Florida, Gainesville, 19.2.2008 www.implantdirect.com
  35. 35. New Implant materials University of Florida, Gainesville, 19.2.2008
  36. 36. New Implant surface treatment Magnesium ion incorporated, oxidized implants ? Dr Young-Taeg Sul - Korea Sul YT, et al. Biomaterials. 2005 Nov;26(33):6720-30 Sul YT, et al. Int J Prosthodont. 2006;19:319-28 University of Florida, Gainesville, 19.2.2008
  37. 37. Implant surface treatment Magnesium ion incorporated, oxidized implants ? Dr Young-Taeg Sul - Korea Sul YT, et al. Biomaterials. 2005 Nov;26(33):6720-30 Sul YT, et al. Int J Prosthodont. 2006;19:319-28 University of Florida, Gainesville, 19.2.2008
  38. 38. Clinical trials – Dental implants 350 300 250 200 150 1 0 309 263 282 233 242 100 175 142 50 85 57 0 1 2 1 0 0 4 4 4 7 14 16 28 67 9 1 3 4 6 8 0 2 4 6 8 0 2 4 6 8 0 2 4 6 -6 -7 -7 -7 -7 -7 -8 -8 -8 -8 -8 -9 -9 -9 -9 -9 -0 -0 -0 -0 19 68 70 72 73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 University of Florida, Gainesville, 19.2.2008
  39. 39. Clinical trials – Dental implants 180 168 160 147 140 138 144 140 131 133 122 123 120 111 109 102 100 76 72 80 66 60 46 37 39 40 34 22 20 15 12 16 0 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 86 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 9 <1 University of Florida, Gainesville, 19.2.2008
  40. 40. Clinical trials – Dental implants Clinical trials since 2003 = 455 Brånemark / Replace x8 ITI /Straumann x6 3i/Osseotite x2 Frialit2/Frialit+/Frialoc/Frios 1 2 Astra 1 ~75% University of Florida, Gainesville, 19.2.2008
  41. 41. Clinical l Cli i l relevance of f animal models f i l d l for predicting implant therapy outcomes? University of Florida, Gainesville, 19.2.2008
  42. 42. The relevance of data from animal models to predict longitudinal trial results? is high? University of Florida, Gainesville, 19.2.2008
  43. 43. The relevance of data from animal models to predict longitudinal trial results? is high? is of little or no value? London et al. 2002; Novaes et al. 2002; Carlsson et al 1988; Gotfredsen et al 1992; al. al. Vercaigne et al. 1998, 2000. Offers some indications within a midrange of roughness? Wennerberg & Albrektsson 2000 Albrektsson, University of Florida, Gainesville, 19.2.2008
  44. 44. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? University of Florida, Gainesville, 19.2.2008
  45. 45. Wieland et al. Int J Oral Florida, Gainesville, 19.2.2008 University of Maxillofac Implants 2001;16:163–181)
  46. 46. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? Model used? University of Florida, Gainesville, 19.2.2008
  47. 47. University of Florida, Gainesville, Sykaras et al., 2000 19.2.2008
  48. 48. Astra Branemark ITI University of Florida, Gainesville, Abrahamson et al. 1996 19.2.2008
  49. 49. University of Florida, Gainesville, 19.2.2008
  50. 50. Parameters affecting histologic/biomechanical data Sykaras et al., 2000 University of Florida, Gainesville, 19.2.2008
  51. 51. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? Model used? Roughness characterization? University of Florida, Gainesville, 19.2.2008
  52. 52. University of Florida, Gainesville, 19.2.2008
  53. 53. University of Florida, Gainesville, 19.2.2008
  54. 54. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? Model used? Roughness characterization? Measuring device? University of Florida, Gainesville, 19.2.2008
  55. 55. Wieland et al. Int J Oral Maxillofac Implants 2001;16:163–181) University of Florida, Gainesville, 19.2.2008
  56. 56. Grit-blasted and etched Microfabricated and etched Scanning EM g Interference microscopy Non-contact laser profilometry University of Florida, Gainesville, 19.2.2008 Wieland et al. 2001
  57. 57. Grit-blasted and etched Laser profilometry Interference microscopy Scanning EM University of Florida, Gainesville, 19.2.2008 Wieland et al. 2001
  58. 58. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? Model used? Roughness characterization Measuring device Consistency of results? University of Florida, Gainesville, 19.2.2008
  59. 59. University of Florida, Gainesville, 19.2.2008
  60. 60. University of Florida, Gainesville, 19.2.2008
  61. 61. Relevance animal models vz. longitudinal t i l results? l it di l trial lt ? Surface topography description? Model used? Roughness characterization? Measuring device? Consistency of results? Surgical technique for placement? University of Florida, Gainesville, 19.2.2008
  62. 62. Oral implants, the state of the science and practice www.torontoimplantconference.ca University of Florida, Gainesville, 19.2.2008
  63. 63. University of Florida, Gainesville, 19.2.2008
  64. 64. THE EFFICACY OF DENTAL IMPLANTS: EVIDENCE-BASED OVERVIEWS From 11 Cochrane reviews on osseointegrated dental implants Last update, Jan 2007 Esposito, Coulthard, Worthington; Thomson, (Wennerberg, Jokstad et al.)
  65. 65. Cochrane systematic reviews 1. Fresh extraction sockets 2006 2. Perimplantitis 2006 ver.2 3. Bone augmentation techniques 2006 ver.2 4. Zygomatic implants 2005 ver.2 5. Various implant systems 2003 ver.3 6. Immediate/early or delayed loading 2004 ver.2 7. Maintenance 2004 ver.2 8. Hyperbaric oxygen therapy 2003 9. 9 Use of prophylactic antibiotics 2003 10. Surgical techniques 2003 11. 11 Preprosthetic surgery vs implants 2002 University of Florida, Gainesville, 19.2.2008
  66. 66. 1. Fresh extraction sockets Last literature search: Aug 2006 2 RCTs – 96 patients Conclusion: May ff M offer some advantages i t d t in terms of patient satisfaction and aesthetics possibly by preserving alveolar bone bone. Properly designed RCTs are still needed to fully evaluate the potential advantages and risks of this treatment modality since more complications and failures may occur
  67. 67. 2. Perimplantitis - ver 2 2006 2. Last literature search: March 2006 5 RCTs – 134 patients Conclusion: There is no reliable evidence suggesting which could be the most effective interventions for treating perimplantitis. i l titi
  68. 68. 3. Bone augmentation techniques – ver 2 2006 ver. Last literature search: October 2005 13 RCTs – 330 patients RCT ti t Conclusion: Major b M j bone grafting procedures of extremely fti d f t l resorbed mandibles may not be justified. Bone substitutes may replace autogenous bone for sinus lift procedures of extremely atrophic sinuses. p Both guided bone regeneration (GBR) procedures and distraction osteogenesis can augment b t bone vertically, b t it i unclear which ti ll but is l hi h is the most efficient technique.
  69. 69. 4. Zygomatic implants – ver 2. 2005 Last literature search: May 2005 0 RCTs Conclusion: Cannot answer whether Zygomatic implants without bone grafting versus conventional i l i l implants i in grafted or regenerated bone is superior
  70. 70. 5. Various implant characteristics & systems ver.3 -2005 Last literature search: June 2004 12 RCTs with 512 participants and 12 different implant systems ( RCTs were p y (19 excluded). 4 RCTs with a 5-year follow-up Conclusion: Minor differences in marginal bone loss and in th i the occurrence of perimplantitis. N f i l titi No statistically significant difference in failure rates. W d not k t We do t know whether any i l t h th implant system is superior to the others.
  71. 71. 6. Immediate, early or conventional loading - ver.2-2004 Last literature search: February 2004 5 RCTs with 124 participants (2 RCTs excluded) l d d) Conclusion: While it is possible to successfully load oral implants immediately after their p y placement in mandibles of adequate bone density and height of carefully selected y g y patients, it is yet unknown how predictable this approach is.
  72. 72. Thank you for your kind tt ti ki d attention University of Florida, Gainesville, 19.2.2008

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