Osseointegration and Dental Implants

Asbjorn Jokstad and Dental Implants

Osseointegration and Dental Implants

Edited by Asbjorn Jokstad, DDS, PhD

A John Wiley & Sons, Inc., Publication Asbjorn Jokstad, DDS, PhD, is Professor and Head of the Discipline of , Faculty of at the University of Toronto in Toronto, Ontario, Canada. He is also the Director of the prosthodontic speciality training and holds the Nobel Biocare Chair in Prosthodontics at the University of Toronto.

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Library of Congress Cataloguing-in-Publication Data

Toronto Osseointegration Conference Revisited (2008 : Toronto, Canada) Osseointegration and dental implants / [edited by] Asbjorn Jokstad. p. ; cm. Based on the proceedings of the Toronto Osseointegration Conference Revisited, which took place on May 8–10, 2008. Includes bibliographical references and index. ISBN-13: 978-0-8138-1341-7 (alk. paper) ISBN-10: 0-8138-1341-7 (alk. paper) 1. Dental implants–Congresses. 2. Osseointegration–Congresses. I. Jokstad, Asbjorn. II. Title. [DNLM: 1. Dental Implantation–methods–Congresses. 2. Osseointegration–Congresses. 3. Dental Implants–Congresses. WU 640 T686o 2008] RK667.I45T67 2008 617.6′92–dc22 2008033209

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1 2008 Contents

Foreword ix 2 Comprehensive Treatment Preface xi Planning for Complete Arch Contributing Authors xiii Restorations 27 Treatment of the Edentulous Introduction xix Maxilla and Mandible with Asbjorn Jokstad Implant-Retained Overdentures 27 David A. Felton Key Implant Positions and Implant 1 Implant Dentistry: Number: A Biomechanical A Technology Assessment 3 Rationale 32 Carl E. Misch How Many Implant Systems Treatment Alternatives for the Do We Have and Are They Terminal Dentition Patient 35 Documented? 3 Luca Cordaro Asbjorn Jokstad What Have We Learned from Randomized Controlled Clinical 3 Comprehensive Treatment Trials on Oral Implants? 9 Planning for the Patient Marco Esposito, Maria Gabriella with Complex Treatment Grusovin, Paul Coulthard, and Needs 43 Helen Worthington The Challenging Patient with Systematic Reviews of Survival and Facial Deformities, Rare Complication Rates of Implant- Disorders, or Old Age 43 Supported Fixed Dental Prostheses Birgitta Bergendal, and Single Crowns 14 James D. Anderson, and Bjarni Elvar Pætursson Frauke Müller

v vi Contents

4 Comprehensive Treatment Pre-implant Surgical Planning for the Patient Interventions Tissue-Engineering with Oral or Systemic Solutions 125 Infl ammation 63 E. Todd Scheyer The Effi cacy of Osseointegrated Guided Bone Regeneration with Dental Implants for or without Bone Grafts: From Periodontally Compromised Experimental Studies to Clinical 63 Application 129 Myron Nevins and Nikolaos Donos David M. Kim Profi les and Treatment Options 7 Pre-implant Surgical for Refractory Patients in a Augmentation Periodontal Practice 70 Interventions 141 Øystein Fardal and Gerard J. Linden Hard-Tissue Augmentation to Osseointegrate Implants 141 Systemic Implications of Peri- Friedrich W. Neukam, implant Infl ammation: Mimicry Emeka Nkenke, and Rainer Lutz of the Periodontitis-Systemic Disease Model? 74 Onlay and Inlay Grafting in Howard C. Tenenbaum, Michael Implant Rehabilitation: Clinical Glogauer, Michael Landzberg, and Aspects 148 Michael Goldberg Karl-Erik Kahnberg Is Autogenous Bone Still the 5 Surgery Phase Planning 85 “Gold Standard” for Grafting? Advances in Diagnosis and Current Opinion on the Use of Treatment Planning Utilizing CT Autograft in Implant Dentistry 152 Scan Technology for Improving Craig M. Misch Surgical and Restorative Implant Reconstruction: Tools of 8 Pre-implant Surgical Empowerment 85 Interventions with Focus Scott D. Ganz on the Maxilla 167 Immediate Implants in Infected Evolution of the Sinus Sites: Contraindications Augmentation Procedure: 1982, Reconsidered 95 2008, and Beyond 167 Jay R. Beagle Stephen S. Wallace and Stuart J. Froum Image-Based Implant Therapy: Current Status and Future Bone Augmentation in the Perspectives 101 Severely Resorbed Maxilla 175 Homah Zadeh Lars Rasmusson

6 Pre-implant Surgical 9 Biomaterials and Substances Interventions 117 for Site Optimizing 183 Horizontal and Vertical Bone Alveolar Augmentation: Past, Regeneration in the Maxilla and Present, and Future 183 Mandible 117 Ulf M.E. Wikesjö, Massimo Simion, Burton Langer and Michael S. Reddy Contents vii

10 Implant Surgery Changing Rationales: Connecting Interventions 197 Teeth with Implants by a Suprastructure 260 Three-Dimensional Reverse Tissue Paul Weigl Engineering for Optimal Reconstruction 197 16 Restorative Phase Treatment Michael A. Pikos and Planning Using Shortened Albert H. Mattia Clinical Protocols 269 11 The Implant and Biological Stability of Implant-Abutment Response 205 Connections 269 Thomas D. Taylor The Healing Bone-Implant Interface: Role of Micromotion and Shortened Clinical Protocols: The Related Strain Levels in Tissue 205 (R)evolution Is Still Ongoing 273 John B. Brunski, Jennifer A. Currey, Roland Glauser Jill A. Helms, Philipp Leucht, Antonio Nanci, and Rima Wazen 17 The Transmucosal Component and the Supra- 12 The Implant Surface and construction Revolution 279 Biological Response 213 Abutment Design and Materials The Changing Interface 213 Using CAD/CAM Technology 279 John E. Davies, Peter Schüpbach, Steven E. Eckert and Lyndon Cooper CAD/CAM in Implant Dentistry 285 13 The Implant Design and Jörg-R. Strub and Biological Response 225 Siegbert Witkowski Infl uences of Implant Design 18 The Implant Design and and Surface Properties on Clinical Outcomes 295 Osseointegration and Implant Stability 225 Contemporary Dental Implants Jan Gottlow and Clinical Performance 295 John K. Schulte and Shadi Daher Implant Surface Design and Local Stress Fields—Effects on The Internal Connection: A Peri-implant Bone Formation Contributing Factor to Achieving and Retention with “Short” an Aesthetic Result 302 Porous-Surfaced Implants 230 Antonio Sanz Ruiz Robert M. Pilliar 19 Loading Protocols and 14 Loading Protocols and Clinical Outcomes 311 Biological Response 239 Peter K. Moy, Georgios E. What Have We Learned about Romanos, and Mario Roccuzzo the Infl uence of Loading on the Quality and Maintenance of 15 Restorative Phase Osseointegration? 311 Treatment Planning 255 Ignace Naert, Katleen Vandamme, and Joke Duyck Integration of Biological Principles to Achieve Stable Aesthetics 255 The Concept of Early Loading 315 Clark M. Stanford Hans-Peter Weber viii Contents

What Have We Learned from 22 Patient Focus on Function Clinical Trials about Early Loading and Quality of Life and of Implants? 319 Future Implementation 361 Asbjorn Jokstad J. Mark Thomason, Jocelyne S. Feine, and Daniel Wismeijer 20 Patient Focus on Neurophysiology 333 23 Dental Implants in the A Neurophysiologic Perspective Habilitation of Young on Rehabilitation with Oral Patients 373 Implants and Their Potential George K.B. Sándor Side Effects 333 Barry J. Sessle, Iven Klineberg, 24 Minimum Competency for and Peter Svensson Providing Implant Prosthodontics—What 21 Patient Focus on Expected Should Be the Educational and Unexpected Requirements? 381 Outcomes 345 Guaranteeing Treatment for Dental Implant Innovations— Everyone: Changing Educational Growing Evidence for Best Criteria for “Garden Variety” Decisions 345 Cases to Major Bone Grafts 381 Kent Knoernschild Kenneth W.M. Judy

Subjective and Objective Appendix: The Toronto Osseointegration Evaluation of Implant-Supported Conference Revisited, May 9–10, 2008: Reconstructions for Partially Program and Biographies of Speakers 385 Edentulous Patients 354 Klaus Gotfredsen Index 405 Foreword

The 2008 Toronto Osseointegration Confer- with a main purpose to critically appraise ence Revisited and this book would not have where we have come from and where we are been possible without the enthusiastic support heading within the fi eld of implant dentistry. of everyone involved. Enormous thanks is extended to my We are grateful to our conference speakers husband and editor of this book, Asbjorn and especially the individuals who spent time Jokstad. This book would never have been putting on paper what they consider are the written without his indefatigable energy and important messages to be conveyed. desire to share scientifi c knowledge with den- We thank our industry sponsors for sup- tists and researchers throughout the world. porting the conference, and our participating associations and journals for their coopera- Dr. Anne M. Gussgard, DDS tion in selecting speakers and program themes. Steering Committee Chair We also express gratitude to everybody who Toronto Osseointegration Conference shared our ambition to organize a conference Revisited, May 9–10, 2008

ix

Preface

Osseointegration and implant dentistry from, where we are, and where we seem to research are at an unprecedented peak. More be heading. By learning from our past mis- than one million worldwide are ready takes, we may better be able to meet the to learn more about implant practices and future. What have we achieved over the last eager to offer implant solutions to their 25 years and what are emerging as new and patients. The consequence is that the market innovative developments in the fi eld of today is saturated with new implant manu- osseointegration? This textbook attempts to facturers, new implant brands, new surfaces, answer these questions by refl ecting on the and new marketing strategies. Some say this many signifi cant developments of the current is history repeating itself, that the fi eld has and future application of implants to support regressed to the implant dentistry practices intra and extraoral prostheses. A sincere and research preceding the fi rst Toronto thank you to all colleagues who have shared Osseointegration Conference, which was this vision and contributed to the Toronto organized by Professor Emeritus George A. Osseointegration Conference Revisited and Zarb in 1982. to this textbook. A 25-year mark is a good point to call a time-out, to take stock of our accomplish- Asbjorn Jokstad, DDS, Dr. Odont. ments, and to question where we have come Toronto, May 10, 2008

xi

Contributing Authors

James D. Anderson, DDS, MSD Paul Coulthard, BDS, MDS, PhD Professor, Discipline of Prosthodontics, Professor, Oral and Maxillofacial Surgery University of Toronto, Toronto, Ontario, School of Dentistry, University of Manches- Canada ter, Manchester,

Jay R. Beagle, DDS, MSD Jennifer A. Currey, PhD Certifi ed Periodontist, specialty private prac- Visiting Assistant Professor, Department of tice, Indianapolis, Indiana, United States Mechanical Engineering Union College, Schenectady, New York, United States Birgitta Bergendal, DDS, Odont. Dr. Head and Senior Consultant, National Oral Shadi Daher, DMD Disability Centre, the Institute for Postgradu- Assistant Clinical Professor, Boston Univer- ate Dental Education, Jönköping, Sweden sity Goldman School of Dental Medicine, Boston, Massachusetts, United States John B. Brunski, PhD Professor, Department of Biomedical Engi- John E. Davies, BDS, PhD, DSc neering, Rensselaer Polytechnic Institute, Professor, Institute of Biomaterials and Bio- Troy, New York, United States medical Engineering, University of Toronto, Toronto, Ontario, Canada Lyndon Cooper, DDS, PhD Professor, Department of Prosthodontics, Nikolaos Donos, DDS, MS, PhD University of North Carolina, Chapel Hill, Professor and Head, , UCL North Carolina, United States Eastman Dental Institute, London, United Kingdom Luca Cordaro, MD, DDS, PhD Professor and Head, Department of Period- Joke Duyck, DDS, PhD ontology and Implant Dentistry, Eastman Post doc. Fellow, Department of Prosthetic Dental Hospital, Rome, Italy Dentistry / BIOMAT Research Group, School

xiii xiv Contributing Authors of Dentistry, Faculty of Medicine, KU. Leuven, Klaus Gotfredsen, DDS, Odont. Dr. Leuven, Belgium Professor, Department of Oral Rehabilitation, University of Copenhagen, Copenhagen, Steven E. Eckert, DDS, MS Denmark Professor, Division of Prosthodontics, College of Medicine, Mayo Clinic, Rochester, Min- Jan Gottlow, DDS, Odont. Dr. nesota, United States Department of Biomaterials, University of Göteborg, Göteborg, Sweden Marco Esposito, DDS, PhD Senior Lecturer in Oral and Maxillofacial Maria Gabriella Grusovin, DDS Surgery, School of Dentistry, University of Cochrane Oral Health Group, the University Manchester, Manchester, United Kingdom of Manchester, Manchester, United Kingdom

Øystein Fardal, BDS, MDS, PhD Jill A. Helms, DDS, PhD Certifi ed Periodontist, specialty private prac- Associate Professor, Department of Surgery, tice, Egersund, Norway Stanford University, Stanford, California, United States Jocelyne S. Feine, DDS, MS, HDR Professor and Director of Graduate Studies, Asbjorn Jokstad, DDS, Dr. Odont. McGill University, Montreal, Quebec, Professor and Head, Division of Prosthodon- Canada tics, University of Toronto, Toronto, Ontario, Canada David A. Felton, DDS, MS Professor, Department of Prosthodontics, Kenneth W.M. Judy, DDS University of North Carolina, Chapel Hill, Director, International Congress of Oral North Carolina, United States Implantologists and private practice, New Stuart J. Froum, DDS York, New York, United States Clinical Professor, Department of Periodon- tology and Implant Dentistry, New York Uni- Karl-Erik Kahnberg, DDS, Odont. Dr. versity Dental Center, New York, New York, Professor and Chair, Department of Oral and United States Maxillofacial Surgery, Institute of Odontol- ogy, the Sahlgrenska Academy and Hospital, Scott D. Ganz, DMD University of Göteborg, Göteborg, Sweden Maxillofacial Prosthodontist, specialty private practice, Fort Lee, New Jersey, United States David M. Kim, DDS, DMSc Assistant Professor, Department of Oral Med- Roland Glauser, DMD icine, Infection and Immunity, Division of Certifi ed Prosthodontist, specialty private Periodontics, Harvard School of Dental Med- practice, Zurich, Switzerland icine, Boston, Massachusetts, United States

Michael Glogauer, DDS, PhD Iven Klineberg, BDS, BSc, PhD Associate Professor, Discipline of Periodon- Professor and Head, Jaw Function and Oro- tology, Faculty of Dentistry, University of facial Pain Research Unit, University of Toronto, Toronto, Ontario, Canada Sydney, Sydney, Australia

Michael Goldberg, DDS, MSc Kent Knoernschild, DDS, MS Assistant Professor, Discipline of Periodon- Co-director, Comprehensive Dental Implant tology, Faculty of Dentistry, University of Center, University of Illinois, Chicago, Illi- Toronto, Toronto, Ontario, Canada nois, United States Contributing Authors xv

Burton Langer, DMD Frauke Müller, Dr. med. dent. Certifi ed Periodontist, specialty private Professor, Division of Gerodontology and practice, New York, New York, United Removable Prosthodontics, University of States Geneva, Switzerland

Michael Landzberg, DDS Ignace Naert, DDS, PhD Graduate Student, Discipline of Periodon- Chairman, Department of Prosthetic Den- tology, Faculty of Dentistry, University of tistry/BIOMAT Research Group, School of Toronto, Toronto, Canada Dentistry, Faculty of Medicine, KU. Leuven, Leuven, Belgium

Philipp Leucht, MD Antonio Nanci, PhD Department of Orthopaedic Surgery, Stanford Professor and Director of the Stomatology University School of Medicine, Stanford, Department, Faculty of Dentistry, University United States of Montreal, Quebec, Canada

Gerard James Linden, BDS, BSc, PhD Friedrich W. Neukam, Dr. med., Dr. med. Professor of Periodontology, Head of Depart- dent., PhD ment of , School of Chairman and Head, Department of and Dentistry, Queen’s University, and Cranio-Maxillofacial Surgery, Erlangen- Belfast, United Kingdom Nuremberg University Dental School, Erlan- gen, Germany Rainer Lutz, Dr. med. dent. Assistant , Department of Oral Myron Nevins, DDS and Cranio-Maxillofacial Surgery, Erlangen- Associate Clinical Professor, Department of Nuremberg University Dental School, Erlan- Oral Medicine, Infection and Immunity, Divi- gen, Germany sion of Periodontics, Harvard School of Dental Medicine, Boston, Massachusetts, United States Albert H. Mattia, DMD Associate Professor, Department of Periodon- Emeka Nkenke, Dr. med., Dr. med. dent., tics, University of Alabama at Birmingham, PhD School of Dentistry Chief Physician, Department of Oral and Cranio-Maxillofacial Surgery, Erlangen- Carl E. Misch, DDS, MDS Nuremberg University Dental School, Erlan- Clinical Professor, Oral Implantology, Temple gen, Germany University School of Dentistry, Philadelphia, Pennsylvania, United States Bjarni Elvar Pætursson, DDS, Dr. med. dent. Craig M. Misch, DDS, MDS Professor, Department of Prosthodontics, Certifi ed Oral and Maxillofacial Surgeon and University of Iceland, Reykjavik, Iceland Prosthodontist, Sarasota, Florida, United Michael A. Pikos, DDS States Certifi ed Oral and Maxillofacial Surgeon, Pikos Implant Institute, Palm Harbor, Florida, Peter K. Moy, DMD United States Associate Clinical Professor, Department of Oral and Maxillofacial Surgery, University of Robert M. Pilliar, PhD California, Los Angeles, California, United Professor Emeritus, Faculty of Dentistry and States Institute of Biomaterials and Biomedical xvi Contributing Authors

Engineering, University of Toronto, Toronto, Barry J. Sessle, MDS, PhD Ontario, Canada Professor and Canada Research Chair, Facul- ties of Dentistry and Medicine, University of Lars Rasmusson, DMD, Med. Dr. Toronto, Toronto, Ontario, Canada Professor, Department of Oral and Maxillo- facial Surgery, Institute of Odontology, the Massimo Simion, MD, DDS Sahlgrenska Academy and Hospital, Univer- Professor, Department of Periodontology and sity of Göteborg, Göteborg, Sweden Implant Restoration, University of Milan, Milan, Italy Michael S. Reddy, DMD, DMSc Clark M. Stanford, DDS, PhD Professor and Chairman, Department of Peri- Professor, Dows Institute for Dental Research, odontology, University of Alabama School University of Iowa, Iowa City, Iowa, United of Dentistry, Birmingham, Alabama, United States States Jörg-R. Strub, DDS, Dr. med. dent. habil. Mario Roccuzzo, DDS Professor and Chair, Department of Prostho- Lecturer in Periodontology, University of dontics, Albert-Ludwig University, Freiburg, Torino, Torino, Italy Germany

Georgios E. Romanos, DDS, Dr. med. dent., Peter Svensson, DDS, Dr. Odont. PhD Professor and Chair, Department of Clinical Professor of Clinical Dentistry, Divisions Oral Physiology, University of Aarhus, of Periodontology and General Dentistry, Aarhus, Denmark Eastman Department of Dentistry, Rochester, New York, United States Thomas D. Taylor, DDS, MSD Professor and Head, Department of Recon- George K.B. Sándor, MD, DDS, PhD, Dr. structive Sciences, Skeletal Development and habil. Biomaterials, University of Connecticut, Professor and Head, Oral Maxillofacial Farmington, Connecticut, United States Surgery, University of Toronto, Canada Howard Tenenbaum, DDS, PhD Antonio Sanz Ruiz, DDS Professor, Discipline of Periodontology, Professor, Periodontal and Implant Depart- Faculty of Dentistry, University of Toronto, ment, University de los Andes, Santiago, Toronto, Canada Chile J. Mark Thomason, BDS, PhD Chair of Prosthodontics and Oral Rehabilita- E. Todd Scheyer, DDS, MS tion, Newcastle University, Newcastle, United Certifi ed Peridontist, specialty private prac- Kingdom tice, Houston, Texas, United States Katleen Vandamme, DDS, PhD John K. Schulte, DDS, MSD Post doc. Fellow, Department of Prosthetic Associate Professor, Department of Restora- Dentistry/BIOMAT Research Group, School tive Sciences, University of Minnesota School of Dentistry, Faculty of Medicine, KU. Leuven, of Dentistry, Minneapolis, Minnesota, United Leuven, Belgium States Stephen S. Wallace, DDS Peter Schüpbach, PhD Associate Professor, Department of Implant Research Laboratory for Microscopy and Dentistry, New York University, New York, Histology, Horgen, Switzerland New York, United States Contributing Authors xvii

Rima Wazen, BSc Daniel Wismeijer, DDS, PhD Post Doctoral Associate, Department of Sto- Professor, Oral Implantology and Implant matology, Faculty of Dentistry, University of Prosthodontics, ACTA, Amsterdam, the Montreal, Quebec, Canada Netherlands

Hans-Peter Weber, Dr. med. dent. Siegbert Witkowski, MDT, CDT Raymond J. and Elva Pomfret Nagle Profes- Chief of Dental Technology, University sor of Restorative Dentistry and Biomaterials Hospital Freiburg, School of Dentistry, Sciences, Harvard School of Dental Medicine, Department of Prosthodontics, Albert-Ludwig Boston, Massachusetts, United States University, Freiburg, Germany

Paul Weigl, DDS Helen Worthington, C. Stat., PhD Assistant Professor, Department of Prosthetic Professor, Cochrane Oral Health Group, the Dentistry, J.W. Goethe-University, Frankfurt University of Manchester, Manchester, United am Main, Germany Kingdom

Ulf M.E. Wikesjö, DDS, DMD, PhD Homah Zadeh, DDS, PhD Professor of Periodontics, Oral Biology, and Associate Professor, University of Southern Graduate Studies, Medical College of Georgia, California, Los Angeles, California, United Augusta, Georgia, United States States

Introduction Asbjorn Jokstad

The improvements in implant technology into four categories, that is, the diagnostic and its practical application in the clinic are and pre-surgical (chapters 6, 7, and 8), the not a function primarily of one specifi c surgical (chapter 10), and the restorative implant surface, a treatment procedure, or (chapter 14), although at times some of these some particular loading protocol. Rather it converge. Each intervention involves the use can be understood by conceptualizing the of different biomaterials for possible site individual elements involved in placing one optimizing (chapter 9) and ultimately for the or more endosseous implants to support an different components of the supra-construc- intraoral prosthesis. It is the refi nement of tion (chapter 17). The observant reader may each of these individual elements that has recognize that the chapter theme order contributed to the understanding of osseointe- follows the natural progression in the every- gration itself, and improved the technology day clinical treatment situation. Comple- to solve our patients’ problems even further. menting these practical elements of implant The chapters that have been included in this therapy are the three remaining chapters on collection refl ect these elements. Three inter- the assessment of technology in implant twined treatment planning phases can be therapy (chapter 1), educational require- identifi ed in the practical application process: ments for practice (chapter 24), and use of a total treatment planning strategy (chapters craniofacial and dental implants in adoles- 2, 3, and 4); a surgery planning strategy cent children (chapter 23). (chapter 5); and a restorative planning strat- Chapter 1: Any 4-year-old child is able to egy (chapters 15 and 16). These planning ask the three essential questions in life—what phases take into account patient-centered do we know?, how can you say?, and why considerations, for example, risk factors should I? More learned scholars would cate- (chapters 3 and 4), healing predictability gorize these questions using the more philo- (chapters 11, 12, and 13), and consideration sophical terms ontology, epistemology, and of the probabilities of possible outcomes of ethics. The chapter describes what we know implant interventions (chapters 18, 19, 20, about implant therapy outcomes, how we 21, and 22). The actual interventions fall should interpret the claims in the literature,

xix xx Introduction and on which theoretical basis the practicing bone quality or proximity to vital anatomical community should be guided. structures? Chapter 2: The comprehensive treatment Chapter 6: In most cases optimal aesthetics planning phase is the most crucial element and function with implant-supported pros- determining a successful or unsuccessful treat- thetics can be achieved after a vertical and/or ment outcome. Experience has shown us that horizontal regeneration of damaged hard and it is diffi cult, or at worst impossible, to achieve soft tissues. We have moved from using solely an optimal result if this essential factor is autologous bone and soft-tissue transplants neglected. This chapter describes how multi- from remote sites to adopting new alloplastic faceted treatment planning needs to be in materials, either used alone or in combination order to attain a high probability of treatment with autologous bone and various cell con- success. stituents, with the ultimate aim of improving Chapter 3: Patients with complex rehabili- biomimetics. This chapter describes the tation problems remain a challenge for the current state of the science and suggestions clinician, whether their condition is due to for clinical practice. medical factors, multimorbidity, or old age. Chapter 7: For the patient with the atrophic This chapter describes how acceptable treat- jaw more invasive surgical grafting proce- ment results from a functional, psychological, dures are needed to reconstruct the resorbed and psychosocial aspect can be achieved in bone. Both inlay and onlay grafts as well as sometimes very diffi cult situations. interpositional bone grafts are common tech- Chapter 4: Do periodontal infl ammation niques that are used in individual situations and/or infection increase the risks for sys- where the benefi t is weighed against possible temic medical conditions? If drawing a paral- added treatment length and morbidity. Hard lel with patients with multiple implants, can tissue augmentation needs in implant den- it be inferred that infl ammatory disease in tistry are also infl uenced by upcoming new gingival tissues surrounding endosseous products and applications. This chapter implants might also affect the patient’s sys- describes how advances in bioengineering temic health? This chapter presents new now enable new treatment concepts for the knowledge that needs to be considered when reconstruction of atrophic jaws in combina- planning treatment in patients with current or tion with implants. past history of refractory periodontitis and/or Chapter 8: It has always been a challenge peri-implantitis. to restore the edentulous posterior maxilla Chapter 5: Placing an endosseous dental with implant-supported prostheses. The implant always involves some element of risk advent of implants with new surfaces has only of adverse events. One important role of the partially improved the situation. Various surgeon is to be cognizant of the factors asso- innovative approaches for grafting into and ciated with risks, to assess to which extent onto the sinus have been developed and this they apply to the particular patient at hand, chapter describes the current surgical tech- and to convey the estimated risk to the patient niques, new bioengineering materials, and before commencing treatment. This chapter new research avenues. presents recent fi ndings that challenge our Chapter 9: The enormous advances made perceptions of risk associated with implant in developing innovative recombinant-DNA surgery. Do we still have to avoid placing techniques enable us today to use extracellu- implants in infected sites at all costs? Moreo- lar matrix proteins. Although their exact role ver, are the margins of operator error reduced in the healing process cascade is currently not in special circumstances, for example, by fully understood, it appears that they have an using computer-assisted implant surgery important therapeutic utility. This chapter when there is questionable bone volume or describes the state of the science on regenera- Introduction xxi tion techniques related to dental implant tions. This chapter describes the current technologies. understanding of how the geometries and Chapter 10: Computer-assisted tools for surface topographies of dental implants can diagnosis and surgical placement were rela- be related to bone responses. tively rapidly adopted by implant surgeons. Chapter 14: Have we arrived at the stage These digital technologies have now evolved where improved grafting materials, implant even further and can be applied in treatment design and surfaces, and innovative surgical planning both to the implant placement and approaches can accelerate the biological the complete temporary or permanent resto- responses or is this just wishful thinking? ration. This chapter describes how these new Does it carry any signifi cance that such results digital technologies can be applied, and their can be demonstrated in, for example, rabbits potential to improve surgical and restorative or rats, and should we take it for granted that treatment outcomes. we can generalize what will happen clinically Chapter 11: Implant micromotion has an from laboratory and animal experiments? effect on bone healing, but the relationship This chapter examines what is imagination between the two is complex. For example, and what is the clinical reality. do variations in the macro- and micro- Chapter 15: Planning the right technical morphology of the implant infl uence this rela- solution for the right patient, one that will tionship? This chapter presents new not fail in the foreseeable future, requires experimental data that underpin what the more than a clinician’s delicate touch. This leading authorities today believe is the current chapter presents two different, but comple- understanding of the association between mentary, principles for restorative treatment implant morphology, micromotion, and planning that have been shown to minimize healing responses of the bone. the risk of adverse biological and mechanical Chapter 12: We are bombarded with events. “improved” implants with “improved” sur- Chapter 16: The fi ner details of the plan- faces. How much of the endless focus on mor- ning and execution of interventions may phological differences is hype and how much result in treatment success or failure. Particu- is substantiated by sound research? The asso- larly when shortened clinical loading proto- ciation between implant surfaces and osteo- cols are used, seemingly minor clinical factors genesis remains elusive. Surface modifi cations need to be taken into consideration, while are motivated by fi ndings from advanced making us reconsider some tenets of implant- molecular and cellular biology research, com- abutment connection and immediate and bined with advanced bioengineering experi- early loading in osseointegration that have ments. This chapter provides perspectives on remained unchallenged. which implant surfaces will most likely con- Chapter 17: New prosthetic components to tinue to evolve over the next few years and attach between the endosseous implant and which will falter. the supra-construction, as well as the supra- Chapter 13: Many clinicians today believe construction itself, are developed using a that the fi rst generation of titanium implants wide range of biomaterials, and by using with a turned surface demonstrate less computer-assisted design and/or manufacture. favorable and predictive clinical outcomes The benefi ts for the patient are more individu- compared to implants with other surface alized technical solutions with optimal geometries, especially in specifi c intraoral aesthetic results, and custom-designed three- locations. It is intriguing that we are not dimensional form with improved fi t between really sure why, whether it is due to biological the components, adapted to functional width, osteoinduction or -conduction, stress requirements. The chapter details the merits transfer to cortical bone, or other explana- and disadvantages of current technologies xxii Introduction as well as the history and future of this clinical researchers have slowly moved from development. recording and reporting surrogate outcomes Chapter 18: When the bone mass is limited of implant therapies, modern clinical research or of a quality that does not allow the place- focuses more on patient-centered outcomes ment of routine dental implants, the clinician that matter both to the individual patients is faced with the option to create bone by and those responsible for public health plan- grafting. Cost-benefi t considerations and per- ning. This chapter reviews how treatment ceived risks of associated morbidity caused outcomes were evaluated earlier, and how by invasive surgery may exclude this treat- these are being gradually replaced by novel ment option. Fortunately, specially designed ways of appraising outcomes that are more implants can be used in clinical situations meaningful for our patients. where the placement of standard implants Chapter 22: The term “implant therapy” is will be contraindicated. This chapter presents regarded by many as a misnomer since one data that underpins an association between does not cure nor manage diseases or disor- implant design and clinical outcomes. ders with an implanted object. Implants are Chapter 19: Before Brånemark, oral only adjuncts, albeit very effective, to securely implants were commonly loaded at placement retain dental (i.e., intraoral) or maxillofacial because it was believed that an immediate (i.e., extraoral) prostheses. These prostheses loading stimulation resulted in less crestal in turn are made to enable patients with bone loss. The idea never disappeared com- various amounts of tissue loss to regain a pletely and in fact has gained acceptance in certain degree of oral function, acceptable the last few years. This chapter presents and appearance, and for some socially dysfunc- debates the scientifi c foundation and clinical tional patients, even their confi dence to the risks and benefi ts as refl ected from basic, extent that they are able to return to a normal translational animal, and clinical studies. social life. A common denominator for many Chapter 20: We are aware of the impor- patients receiving implant-supported prosthe- tance of somatosensory nerve fi bers for ses is improved quality of life, which does not recognizing potentially damaging thermal, necessarily depend on the sophistication of mechanical, and painful stimuli. In addition, the technical solution that the offers. periodontal mechanoreceptors respond to This chapter elaborates on how these factors occlusal loads and enable a fi ne motor control are interdependent and are of importance for of tooth contacts through complex central both provider and patients. and peripheral neural interactions. Implants Chapter 23: Maxillofacial deformities, supporting various forms of suprastructures whether due to ablative surgery, congenital induce different regulation mechanisms. defects, or trauma, can be masked or restored Moreover, the neurophysiological conse- by artful design and skillful manufacturing of quences of the actual implant placement in highly individualized prostheses and by using terms of postoperative sensitivity and pain a wide range of biomaterials. Nevertheless, remain an active focus of research. This the advent of oral and craniomandibular chapter presents the relationships between implants has dramatically increased even elements of the implant suprastructure occlu- further the possibilities of achieving optimal sion, function and dysfunction, pain, and results from functional and aesthetic perspec- basic CNS mechanisms. tives. The outcomes are especially critical Chapter 21: There are no medical interven- when treating children and adolescents, and tions that can be called truly predictive, nor this chapter presents an outstanding pano- is it obvious which outcomes best describe the rama of challenges, solutions, and experiences effi cacy of interventions. Some outcomes are with these patients. of great signifi cance for many patients but do Chapter 24: Implant therapy is usually not not necessarily concern others. While the a component in the undergraduate curricu- Introduction xxiii lum in most dental faculties worldwide. The for the clinician to provide safe and effi ca- new graduate as well as the experienced prac- cious implant therapy. The question is, where titioner has to identify and deduce which can you learn enough to place implants? And implant course provider can supply the essen- what is “enough”? tial information and basic knowledge required

Osseointegration and Dental Implants

Implant Dentistry: A Technology Assessment1

HOW MANY IMPLANT SYSTEMS perhaps have succeeded in slowing down the DO WE HAVE AND ARE THEY output of new products, at least for a few DOCUMENTED? years, since by the year 2000 the number of implant systems had increased “only” to 98 Asbjorn Jokstad (Binon 2000). Not only did the quantitative issue cause concern, but also the qualitative Introduction aspects. Were these new implants really clini- cally documented? No, according to Albrekts- son and Sennerby (1991); no, according We have today close to 600 different implant to the American Dental Association (ADA systems produced by at least 146 different 1996); no, according to Eckert and colleagues manufacturers located in all corners of the (1997); and no, according to several other globe. Last year alone, at least 27 new dental investigators publishing at the time. Around implant companies surfaced in the market the turn of the millennium the FDI World (Table 1.1). Dental Federation was alarmed by the appar- Is anybody troubled? At least some repre- ent rapid increase in the number of implants sentatives of the profession have expressed and implant systems worldwide, and ques- their concern about the seemingly unstoppa- tions were raised about the quality of all the ble avalanche of new implants. Alarm was new implants that were being marketed. The raised in the United States in 1988 about the FDI Science Committee was asked to investi- heterogeneity of implant designs and the gate the issue and the fi ndings were rather effectiveness of the then 45 different implant alarming (Jokstad et al. 2003). The investiga- systems (English 1988). One of the world’s tors identifi ed 225 implant brands from 78 foremost experts in the fi eld, Dr. Patrick manufacturers, but also discovered that about Henry, in 1995 challenged the profession and 70 implant brands were no longer being man- the industry and asked whether implant hard- ufactured. Of the 78 manufacturers, 10 could ware changes should be regarded as science support their implant system with more than or just commodity development. He may four clinical trials, 11 could support their

3 Table 1.1. Implant producers of the world.

1. ACE Surgical Supply Company USA 2. Adaptare Sistema de Implantate Brazil 3. Advance Company Japan 4. Allmed S.r.l. Italy 5. Almitech Incorporated USA 6. Alpha Bio GmbH Germany 7. Alpha Bio Implant Limited Israel 8. Altiva Corporation USA 9. Anthogyr France 10. AQB Implant System Japan 11. AS Technology Brazil 12. Astra Tech Sweden 13. Basic Dental Implants LLC USA 14. BEGO Implant Systems GmbH & Co. KG Germany 15. Bicon Dental Implants USA 16. BioHex Corporation (previous name: Biomedical Implant Technology) Canada 17. BioHorizons Implant Systems Incorporated USA 18. Bio-Lok International Incorporated (subsidiary of Orthogen Corporation) USA 19. Biomaterials Korea South Korea 20. Biomedicare Company USA 21. Biomet 3i Implant Innovations Incorporated USA 22. Bionnovation Brazil 23. Biost S.n.c. Italy 24. Biotech International France 25. Blue Sky Bio LLC USA 26. Bone System Italy 27. BPI Biologisch Physikalische Implantate GmbH Germany 28. BrainBase Corporation Japan 29. Brasseler Group (Gebr. Brasseler GmbH & Co. KG) Germany 30. Bredent Medical Germany 31. BTI Biotechnology Institute S.L. Spain 32. Btlock S.r.l. Italy 33. Buck Medical Research USA 34. Camlog Group (previous name: Altatec) Switzerland 35. Ceradyne Incorporated USA 36. CeraRoot Spain 37. Clinical House Europe GmbH Switzerland 38. Conexão Implant System Brazil 39. Cowell Medi Company Limited South Korea 40. CSM Implant South Korea 41. Curasan AG Germany 42. De Bortoli ACE Brazil 43. Dental Ratio Systems GmbH Germany 44. Dental Tech Italy 45. Dentatus Sweden 46. Dentaurum J.P. Winkelstroeter KG Germany 47. Dentium South Korea 48. Dentofl ex Comércio e Indústria de Materiais Odontológicos Brazil 49. Dentos Incorporated South Korea 50. Dentsply Friadent Ceramed Incorporated (Friadent GmbH Germany) USA 51. DIO Implant South Korea 52. Dr Ihde Dental GmbH Germany 53. Dyna Dental Engineering b.v. Netherlands 54. Eckermann Laboratorium Spain 55. Elite Medica Italy 56. Europäische Akademie für Sofort-Implantologie Germany 57. Euroteknika France

4 Table 1.1. Continued

58. GC Implant System Japan 59. General Implant Research System Spain 60. Global Dental Corporation USA 61. Hi-Tec Implants Limited Israel 62. Impladent Limited USA 63. Implamed S.r.l. Italy 64. Implant Direct LLC USA 65. Implant Logic Systems USA 66. Implant Media S.A. (outsourcing manufacturing plant) Spain 67. Implant Microdent System S.L. Spain 68. Implantkopp Brazil 69. IMTEC Corporation USA 70. Institut Straumann AG Switzerland 71. Interdental S.r.l. Italy 72. International Defcon Group Spain 73. Intra-Lock System International USA 74. Ishifu Metal Industry Incorporated Japan 75. Japan Medical Materials Corporation Japan 76. Jeil Medical Corporation South Korea 77. jmp dental GmbH Germany 78. JOTA AG Switzerland 79. Klockner Implants Spain 80. LASAK Limited Czech Republic 81. Leader Italy S.r.l. Italy 82. Leone S.p.A. Italy 83. Lifecore Biomedical Incorporated USA 84. Maxon ceramic Germany 85. Medentis Medical Germany 86. Megagen South Korea 87. MIS Implant Technologies Limited Company (MIS) Israel 88. Mozo-Grau Spain 89. Neobiotech Company Limited South Korea 90. Neodent Brazil 91. Neoss Dental Implant System UK 92. Nobel Biocare Sweden 93. OCO Biomedical (previous name: O Company Incorporated) USA 94. Odontit S.A. Argentina 95. OGA implant Japan 96. o.m.t (previous name: Biocer) Germany 97. Oral implant S.r.l. Italy 98. Osfi x Limited Finland 99. Ospol AB Sweden 100. Osstem Company Limited South Korea 101. Osteocare Implant System Limited UK 102. Osteo-Implant Corporation USA 103. Osteoplant Poland 104. Osteo-Ti UK 105. PACETM Dental Technologies Incorporated (Renick Enterprises Incorporated) USA 106. Paraplant 2000 Germany 107. Paris implants France 108. Park Dental Research Corporation USA 109. Pedrazzini Dental Technologie Germany 110. PHI S.r.l. Italy 111. Poligono Industrail MasD’En Cisa Spain 112. Qualibond Implantat GmbH Germany 113. Quantum Implants USA 114. Renew Biocare USA

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