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Survival and Complications of Zygomatic Implants: an Updated Systematic Review

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Survival and Complications of Zygomatic Implants: an Updated Systematic Review Accepted Manuscript Survival and complications of zygomatic implants: an updated systematic review Bruno Ramos Chrcanovic, DDS, MSc, PhD student, Tomas Albrektsson, MD, PhD, Ann Wennerberg, DDS, PhD PII: S0278-2391(16)30446-3 DOI: 10.1016/j.joms.2016.06.166 Reference: YJOMS 57322 To appear in: Journal of Oral and Maxillofacial Surgery Received Date: 21 January 2016 Revised Date: 1 June 2016 Accepted Date: 8 June 2016 Please cite this article as: Chrcanovic BR, Albrektsson T, Wennerberg A, Survival and complications of zygomatic implants: an updated systematic review, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.06.166. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT Survival and complications of zygomatic implants: an updated systematic review Bruno Ramos Chrcanovic 1* Tomas Albrektsson 2 Ann Wennerberg 3 1 DDS, MSc, PhD student, Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden 2 MD, PhD, Retired Professor and former Head of the Department of Biomaterials, Göteborg University, Göteborg, Sweden; Guest Professor of the Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden 3 DDS, PhD, Professor and Head of the Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden MANUSCRIPT * Corresponding author: Bruno Ramos Chrcanovic, Department of Prosthodontics, Faculty of Odontology, Malmö University, Carl Gustafs väg 34, SE-205 06, Malmö, Sweden. [email protected]; [email protected] Mobile: +46 725 541 545 Fax: +46 40 6658503 ACCEPTED 1 ACCEPTED MANUSCRIPT Survival and complications of zygomatic implants: an updated systematic review ABSTRACT Purpose : To assess the survival rate of zygomatic implants (ZIs) and the prevalence of complications based on previously published studies. Methods : An electronic search was performed in December/2015 in three databases and was supplemented by hand-searching. Clinical series of ZIs were included. Interval survival rate (ISR) and cumulative survival rate (CSR) were calculated. The untransformed proportion of complications (sinusitis, soft tissue infection, paresthesia, oroantral fistulas) was calculated, considering the prevalence reported in the studies. Results : Sixty-eight studies were included, comprising 4556 ZIs in 2161 patients, with 103 failures. The 12-year CSR was 95.21%. Most failures were detected within the six-month postsurgical period. Studies (n=26) that exclusively evaluated immediate loading showed a statistically lower ZI failure rate than studies (n=34) evaluating delayedMANUSCRIPT loading protocols (P=0.003). Studies (n=5) evaluating ZIs for the rehabilitation of patients after maxillary resections presented lower survival rates. The probability of presenting postoperative complications with ZIs was as follows: sinusitis 2.4% (95%CI 1.8-3.0), soft tissue infection 2.0% (95%CI 1.2-2.8), paresthesia 1.0% (95%CI 0.5- 1.4), oroantral fistulas 0.4% (95%CI 0.1-0.6). However, these numbers may be underestimated, as many studies failed to mention the prevalence of these complications. Conclusion : ZIs present a high 12-year CSR, with most failures occurring at the early stages postoperatively. The main observed complication related to ZIs was sinusitis, which may appear several years after ZIACCEPTED installation surgery. 2 ACCEPTED MANUSCRIPT INTRODUCTION The combination of an increased maxillary sinus pneumatization with the advanced posterior alveolar resorption often results in insufficient bone for implant anchorage,1 constituting a therapeutic challenge. Bone augmentation is usually required in these conditions, in order to enable the placement of sufficient numbers and lengths of implants. 2 Maxillectomy defects, maxillary sinus aplasia, and cleft deformities are even more challenging conditions. 3,4 The installation of zygomatic implants (ZIs) is one of the various techniques described in the literature to treat the atrophic maxilla,5 and several prospective studies 6-11 have showed successful outcomes. A previous review on the survival of ZIs 12 observed that most failures were detected until 6 months after surgery, with a high 12-year cumulative survival rate (CSR). The use of ZIs has several advantages, such as a considerable shortening of the treatment time, a reduced morbidity, as the technique eliminates the necessity of a graft (and consequently of a graft donor site), a reduced number of implants necessary to support fixed prostheses, and a reduction of the patients’ costs. ZIs have enabled the surgeon to overcome the local osseMANUSCRIPTous deficiency by engaging hard tissue at the distant zygomatic bone, allowing an increased reten tion and stability of a obturator or prosthesis. 13 The technique does have, however, some disadvantages. First, the installation of ZIs is a major surgical procedure and should be performed only by properly trained clinicians. There is a considerable risk of soft tissue complications around the abutments and of sinusitis. A more complex prosthetic design may be necessary when ZIs need to placed in a more palatal location. Furthermore, an eventual failure of a ZI may require a more complex and invasive treatment in comparison to failures of conventional implants. The aims ofACCEPTED the present systematic review was to report an updated survival rate of ZIs and the prevalence of complications based on previously published clinical studies. The present review is an update of a previously published article. 12 3 ACCEPTED MANUSCRIPT MATERIALS AND METHODS The present study followed the PRISMA Statement guidelines. 14 Objective The purpose of the present systematic review was to assess the survival rate of ZIs and the prevalence of complications based on previously published clinical studies. The focused question was elaborated by using the PICO format (participants, interventions, comparisons and outcomes): What are the clinical outcomes (survival rate and complications) of partially and totally edentulous patients undergoing prosthetic rehabilitation supported by at least one ZI? Search strategies An electronic search without time or language restrictions was undertaken in December 2015 in the following databases: PubMed/Medline, WeMANUSCRIPTb of Science, and the Cochrane Oral Health Group Trials Register. The following terms were use d in the search strategies, refined by selecting the term: {Subject AND Adjective} {Subject : (zygomatic OR zygoma OR zygomaticus) AND Adjective : (implant OR implants OR fixture OR fixtures)} ACCEPTED An additional manual search of related journals was conducted. The reference list of the identified studies and the relevant reviews on the subject were scanned for possible additional studies. 4 ACCEPTED MANUSCRIPT Inclusion and exclusion criteria The inclusion criteria comprised clinical human studies reporting clinical series of patients receiving ZIs. The patients could either have an atrophic maxilla bone, be partially or totally edentulous, or had undergone surgery for cancer ablation or radiotherapy. Randomized and controlled clinical trials, cross-sectional studies, cohort studies, case-control studies, and case series were considered. For this review, implant failure represents the complete loss of the implant. Exclusion criteria were case reports, technical reports, biomechanical studies, finite element analysis (FEA) studies, animal studies, in vitro studies, and review papers. Study selection The titles and abstracts of all reports identified through the electronic searches were read independently by the authors. For studies appearing to meet the inclusion criteria, or for which there were insufficient data in the title and abstract to make a clear decision, the full report was obtained. Disagreements were resolved by discussion between MANUSCRIPTthe authors. Data extraction Data were extracted from each of the identified eligible studies, including year of publication, number of patients, patients’ age range and average, number of ZIs and additional conventional implants placed and failed, follow-up time, and the following four postoperative complications: sinusitis, soft tissue infection around the ZIs, paresthesia, and oroantral fistula formation. ACCEPTED Analyses Implant survival was reported for each publication. The interval survival rate (ISR) of ZIs was calculated using the information for the period of failure extracted from the included studies, and the CSR was calculated over the maximal period of follow-up reported. Moreover, the 5 ACCEPTED MANUSCRIPT untransformed proportion of complications (sinusitis, soft tissue infection, paresthesia of infraorbital and/or zygomaticofacial nerves, oroantral fistulas) was calculated, considering the prevalence reported in the studies. The data were analyzed using the software OpenMeta[Analyst]. 15 RESULTS Literature search The study selection process is summarized in Figure 1. The search strategy resulted in 1414 papers. A number of 712 articles were cited in more than one research of terms (duplicates). The three reviewers independently screened the abstracts for those articles
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