trends

D t l I l t ThDental Implant Therapy -Trends & LiteratureTrends & Literature Critical AppraisalCritical Appraisal

University of Florida, GainesvilleS i F b 19 2008

Asbjørn Jokstad DDS PhD

Seminar, February 19, 2008

Asbjørn Jokstad, DDS, PhDProfessor and Head, Prosthodontics

Faculty of Dentistry, University of Toronto

University of Florida, Gainesville, 19.2.2008

Adolescent patient with a crown–root fracture of central: options? p

Fracture line palatinallypalatinally

1. Extraction orthodontics veneer or crown2. Extraction etch-bridge or FPD3. Extraction implant abutment crown4. Extraction & replantation 180° endo crown5 Endo orthodontic extrusion crown

University of Florida, Gainesville, 19.2.2008Faculty of Dentistry, University of Oslo, Depts. of Pedodontics, Orthodontics & Prosthodontics. Stenvik & Birkeland, 2007.

5. Endo orthodontic extrusion crown6. Decoronation+etch-bridge/flipper implant

abutment crown

Adolescent patient with missing laterals: options? p

A O th d ti T t tA. Orthodontic TreatmentB. Etch-bridgesC. (Provisional) Removable Partial


C. (Provisional) Removable PartialD. Conventional Fixed PartialE. Implant-supported crowns

Additional considerations:

Adolescent patient with missing laterals: options?

considerations:A. Orthodontic Treatment

What if buccal bone augmentation is required?A. Single implants + crowns in the lateral

regionsB. Mesial movement of canines composites

+ single implants in canine region g p gC. Mesial movement of canines & bicuspids

composites + single implants in bicuspid


composites + single implants in bicuspid region

“Medicine is a scienceMedicine is a science of uncertainty and an yart of probability”

Si Willi O lSir William Osler Canadian Physician (1849-1919)


Dental Implants -Dental Implants How many y

systems do we yhave and how well

thare they d t d?documented?

Number of dental implants 1988English CE. Implants. Part three. An overview.

California Dent Assoc J. 1988;16: 34-8.

p

4545

50

30

35

40

20

25

30

5

10

15


0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Review of existing literatureEckert S et al. Validation of dental implant

systems through a review of literature

g

systems through a review of literature supplied by system manufacturers. J Prosthet Dent 1997;77: 271-9Prosthet Dent 1997;77: 271 9.

Conclusion:O th b i f th lit t li d bOn the basis of the literature supplied by the manufacturers, only one implant

t d t t d i tifi ll lidsystem demonstrated scientifically valid long-term success.


Situation, 19991 The number of implants and implant systems1. The number of implants and implant systems

increase continuously worldwide2 The FDI World Dental Federation is concerned2. The FDI World Dental Federation is concerned

about the quality of all the new implants being marketedmarketed

3. The FDI Science Committee is asked to investigate the issueinvestigate the issue

4. The work is commissioned to prof. A Jokstad


Implant brands/ systems available i N A i i 1999 ( 98)in N. America in 1999 (n=98)

University of Florida, Gainesville, 19.2.2008Int J Oral Maxillofac Impl 2000 15(1): 76-95

Number of implants 2000Binon PP Implants and components: entering the new

English CE. Implants. Part three. An

Binon PP.Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94.

98100

120

goverview.CDA J. 1988;16: 34-8.

80

100

45

40

60

20

40


0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Jokstad, Brägger, Brunski, Carr, Naert, Wennerberg. Int Dent J , g2003; 53 Sup 2: 409-33

A bj J k t d O l NAsbjørn Jokstad, Oslo, NorwayUrs Braegger, Bern, SwitzerlandJohn B. Brunski, Troy, USA, y,Alan B. Carr, Rochester, USAIgnace Naert, Leuven, BelgiumAnn Wennerberg Gothenburg SwedenAnn Wennerberg, Gothenburg, Sweden

Commercially available implant and implant y p psystems in October 2003:

225 implant brands78 manufacturers from all continents78 manufacturers – from all continents~70 implant brands no longer marketed


Jokstad A, et al. Quality of dental implants. Int Dent J. Number of implants 2003

Binon PP..Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94.

2003;53(6 Suppl 2):409-43

220250

English CE. Implants. Part three. An overview. CDA J. 1988;16: 34-8.

150

200

98100

150

4550


0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

University of Florida, Gainesville, 19.2.2008Straight, Tapered, Conical, Ovoid, Trapezoidal, Stepped & combinations …

Flange designg

Flange vs. no flangeStraight vs. flared vs. wideningHeightPolished vs threadsPolished vs. threadsAdded featuresS fSurface topography


Threads vs. non-threadsShape: V- vs. square- vs. reverse buttress- vs. combinationsNumber and size of “lead threads”


Number and location of grooves, groove forms and groove sizesSurface micro-topography Thread angle

ApexTh d dThreaded vs non-threadedV h fl tV-shape vs flat vscurved apexH l dHoles, round, oblongA i l h bApical chamberGrooves and

igroove sizeFlared apex


Surface topography

Interface geometryExternal vs InternalHexagonal vs. Octagonal vs coneM tMorse taper Rotational vs non-rotationalrotationalAdded non-rotational featuresHeights & widthsButt vs bevel jointsjSlip-fit vs friction-fit joints


Resilience vs nonresilience ….

High (top) and low (bottom) magnification of cpTi surfaces as used for surface characterizationsurfaces as used for surface characterization.

Plasma– Grit-blasted Grit-blasted Dual acid- Machined


sprayed (TPS);

and dual acid-etched

etched (turned)

Davies, 2003

Surface topography Machining process Example

Anisotropic with Turned Brånemark System® MKIII oriented cutting marks (Nobel Biocare)

Isotropic Blasted TiO2 particles (Tioblast®, A t T h)AstraTech)

Isotropic Blasted + acid etched 1. Large size Al2O3 particles & HCl & H2SO4 (SLA®, St ) 2 T i l iStraumann) - 2. Tricalcium phosphate & HF & NO3 (MTX®, Centerpulse)

Isotropic with high frequency irregularities

Acid etched HCl / H2SO4 (Osseotite®, 3i)

Isotropic and rough Hydroxyapatite coated Sustain® (Lifecore)

Isotropic and rough Titanium Plasma ITI® TPS (Straumann)


p gSprayed

( )

Isotropic with craterous structure

Oxidized TiUnite® (Nobel Biocare)

Clinical documentation?


Clinical documentationA. Implant or implant system with

extensive clinical documentation: >4 10extensive clinical documentation: >4clinical trials

B I l t i l t t ith li it d

10B. Implant or implant system with limited

clinical documentation, i.e. <4 trials, b t f d th d l i l lit

11but of good methodological quality

C. Implant or implant system with limited 29published clinical documentation

D. Implant or implant system with no

29

28University of Florida, Gainesville, 19.2.2008

p p ypublished clinical documentation. 28

The quality of RCTs of oral implants is generally poor and needs to be improved

University of Florida, Gainesville, 19.2.2008Esposito et al., IJOMI 2001; 16: 783-92

How many new yimplant systems?


Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409 43

Number of implants 2006

Binon PP.Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94.English CE Implants Part three An

Suppl 2):409-43

Jan 2007

357350

400

English CE. Implants. Part three. An overview.CDA J. 1988;16: 34-8.

2007

220250

300

220

150

200

45

98

50

100


0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6 Suppl 2):409 43

Number of implants 2008

Binon PP.Implants and components: entering the new millennium. Int J Oral Maxillofac Implants. 2000;15:76-94.English CE Implants Part three An

Suppl 2):409-43

Jan

Jan 2008

535

500

600

English CE. Implants. Part three. An overview.CDA J. 1988;16: 34-8.

Jan 2007

357400

500

220200

300

45

98100

200


0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

Implant Manufacturers

USA: 28Germany: 25G yItaly: 14Korea: 8 per 2 2007Spain: 8Brazil: 5Switzerland : 5

per 2.2007 (n=120)

Switzerland : 5Canada: 4France: 4Sweden: 4Israel: 3United Kingdom: 3


United Kingdom: 3Other countries: 9

Implant Manufacturers

USA: 28Germany: 25

Germany: 32USA: 31G y

Italy: 14Korea: 8

USA: 31Italy: 15Korea: 10

Spain: 8Brazil: 5Switzerland : 5

Feb. 2008?Spain: 10Brazil: 9France: 7 (n=147!)Switzerland : 5

Canada: 4France: 4

France: 7Japan 6Switzerland : 6

(n=147!)

Sweden: 4Israel: 3United Kingdom: 3

Canada: 4Sweden: 4Israel: 3


United Kingdom: 3Other countries: 9

Israel: 3United Kingdom: 3Other countries: 9Feb 2007: n=120

Clinical documentation of th i l tthe new implant

systems?systems?University of Florida, Gainesville, 19.2.2008

Implant systems introducedImplant systems introduced since October 2003 ?


University of Florida, Gainesville, 19.2.2008www.implantdirect.com

New Implant materials


New Implant surface treatmentMagnesium ion incorporated, oxidized implants ? Dr Young-Taeg Sul - Korea

Sul YT, et al. Biomaterials. 2005Biomaterials. 2005 Nov;26(33):6720-30

Sul YT, et al. Int J Prosthodont. 2006;19:319-28


Implant surface treatmentMagnesium ion incorporated, oxidized implants ? Dr Young-Taeg Sul - Korea

Sul YT, et al. Biomaterials. 2005

Sul YT, et al. Int J Prosthodont.

Biomaterials. 2005 Nov;26(33):6720-30

2006;19:319-28


Clinical trials – Dental implantsClinical trials Dental implants

350

250

300

350

3091 0

200

250

142175

233263 282

309

242100

150

1 2 1 0 0 4 4 4 7 14 16 2857

85

0

50

967 69 71 73 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06


196

1968

-619

70-7

1972

-719

73-7

1975

-719

77-7

1979

-819

81-8

1983

-819

85-8

1987

-819

89-9

1991

-919

93-9

1995

-919

97-9

1999

-020

01-0

2003

-020

05-0

Clinical trials – Dental implants

168180

122 123

140 138 144

168

147

131 133140

160

180

76 72

102

122111

123109

100

120

37 34 3946

6676 72

40

60

80

15 12 16 22

0

20

6 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7


<198

619

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

07

Clinical trials – Dental implants

Clinical trials since 2003 = 455

Clinical trials Dental implants

Clinical trials since 2003 = 455Brånemark / Replace x8ITI /Straumann x6ITI /Straumann x63i/Osseotite x2

2 1Frialit2/Frialit+/Frialoc/Frios 1Astra 1

~75%


Cli i l l fClinical relevance of i l d l fanimal models for

predicting implantpredicting implant therapy outcomes?therapy outcomes?


The relevance of data from animal models to predictanimal models to predict longitudinal trial results?

is high?


The relevance of data from animal models to predictanimal models to predict longitudinal trial results?

is high?is of little or no value?is of little or no value?

London et al. 2002; Novaes et al. 2002; Carlsson et al 1988; Gotfredsen et al 1992;Carlsson et al. 1988; Gotfredsen et al. 1992; Vercaigne et al. 1998, 2000.

Offers some indications within a midrangeOffers some indications within a midrange of roughness?

Wennerberg & Albrektsson 2000


Wennerberg & Albrektsson, 2000

Relevance animal models vz.l it di l t i l lt ?longitudinal trial results?

Surface topography description?


University of Florida, Gainesville, 19.2.2008Wieland et al. Int J Oral Maxillofac Implants 2001;16:163–181)


Surface topography description?Model used?Model used?


University of Florida, Gainesville, 19.2.2008Sykaras et al., 2000

University of Florida, Gainesville, 19.2.2008Abrahamson et al. 1996Astra Branemark ITI

Parameters affecting histologic/biomechanical data

University of Florida, Gainesville, 19.2.2008Sykaras et al., 2000


Surface topography description?Model used?Model used?Roughness characterization?



Surface topography description?Model used?Model used?Roughness characterization?Measuring device?


University of Florida, Gainesville, 19.2.2008Wieland et al. Int J Oral Maxillofac Implants 2001;16:163–181)

Grit-blasted and etched Microfabricated and etched

Scanning EMg

Interference microscopy

Non-contact laser profilometry

University of Florida, Gainesville, 19.2.2008Wieland et al. 2001

Grit-blasted and etched

Laser profilometry

Interference microscopy

Scanning EM

University of Florida, Gainesville, 19.2.2008Wieland et al. 2001


Surface topography description?Model used?Model used?Roughness characterizationMeasuring deviceConsistency of results?Consistency of results?



Surface topography description?Model used?Model used?Roughness characterization?Measuring device?Consistency of results?Consistency of results?Surgical technique for placement?


Oral implants, the state of the science and practiceand practice

University of Florida, Gainesville, 19.2.2008www.torontoimplantconference.ca

THE EFFICACY OF DENTAL IMPLANTS: EVIDENCE-BASED OVERVIEWS

From 11 Cochrane reviews onFrom 11 Cochrane reviews on osseointegrated dental implants

Last update, Jan 2007Esposito, Coulthard, Worthington;

Thomson, (Wennerberg, Jokstad et al.)

Cochrane systematic reviews1. Fresh extraction sockets 20062. Perimplantitis 2006 ver.22. Perimplantitis 2006 ver.23. Bone augmentation techniques 2006 ver.24. Zygomatic implants 2005 ver.25. Various implant systems 2003 ver.36. Immediate/early or delayed loading 2004 ver.27. Maintenance 2004 ver.28. Hyperbaric oxygen therapy 20039 Use of prophylactic antibiotics 20039. Use of prophylactic antibiotics 2003 10. Surgical techniques 2003 11 Preprosthetic surgery vs implants 2002


11. Preprosthetic surgery vs implants 2002

1. Fresh extraction sockets1. Fresh extraction socketsLast literature search: Aug 20062 RCTs 96 patients2 RCTs – 96 patientsConclusion:M ff d t i tMay offer some advantages in terms of patient satisfaction and aesthetics possibly by preserving alveolar bonepossibly by preserving alveolar bone. Properly designed RCTs are still needed to fully evaluate the potentialneeded to fully evaluate the potential advantages and risks of this treatment modality since more complicationsmodality since more complications and failures may occur

2. Perimplantitis - ver 2 20062. Perimplantitis ver 2. 2006

Last literature search: March 20065 RCTs – 134 patients

Conclusion:There is no reliable evidence suggesting which could be the mostsuggesting which could be the most effective interventions for treating

i l titiperimplantitis.

3. Bone augmentation techniques – ver 2 2006techniques ver. 2 2006Last literature search: October 200513 RCT 330 ti t13 RCTs – 330 patientsConclusion:M j b fti d f t lMajor bone grafting procedures of extremely resorbed mandibles may not be justified. Bone substitutes may replace autogenousBone substitutes may replace autogenous bone for sinus lift procedures of extremely atrophic sinuses. pBoth guided bone regeneration (GBR) procedures and distraction osteogenesis can

t b ti ll b t it i l hi haugment bone vertically, but it is unclear which is the most efficient technique.

4. Zygomatic implants –ver 2. 2005

Last literature search: May 2005Last literature search: May 2005 0 RCTs

Conclusion:Cannot answer whether Zygomatic implants without bone grafting

i l i l iversus conventional implants in grafted or regenerated bone is superiorsuperior

5. Various implant characteristics & systemscharacteristics & systems ver.3 -2005

Last literature search: June 200412 RCTs with 512 participants and 12 different implant systems (19 RCTs were p y (excluded). 4 RCTs with a 5-year follow-upConclusion:Conclusion:Minor differences in marginal bone loss and i th f i l titi Nin the occurrence of perimplantitis. No statistically significant difference in failure

t W d t k h th i l trates. We do not know whether any implant system is superior to the others.

6. Immediate, early or conventional loading -conventional loading ver.2-2004Last literature search: February 2004Last literature search: February 20045 RCTs with 124 participants (2 RCTs

l d d)excluded)Conclusion:While it is possible to successfully load oral implants immediately after their p yplacement in mandibles of adequate bone density and height of carefully selected y g ypatients, it is yet unknown how predictable this approach is.

Thank you for your ki d tt ti

University of Florida, Gainesville, 19.2.2008kind attention

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