Initial exploration of the relationship between homeostatic occlusion and long-term dental implant stability

Despite accumulating evidence for the longitudinal stability of the marginal bone level around an implant, there is limited evidence of predisposing risk factors for marginal bone loss based on some implants in a relatively large patient population. The aim of this study was to retrospectively determine the marginal bone loss around Straumann tissue-level dental implants during follow-up periods among which the maximum lasts up to 10 years, as well as the predisposing risk factors for peri-implant marginal bone loss. This study analyzed 1692 Straumann tissue-level dental implants in 881 patients, and relevant data were collected. The peri-implant marginal bone level was measured on periodic radiographs, and the changes in bone level were analyzed cumulatively from surgery until up to 10 years later. The log-rank test was used to select candidate critical risk factors for marginal bone loss, and multivariate analysis using Cox regression with the shared frailty model was performed. The overall peri-implant bone loss was 0.07 ± 0.21mm, 0.09 ± 0.26mm, 0.14 ± 0.41mm, and 0.17 ± 0.45mm at 3, 5, 7, and 9 years, respectively. Only 14 implants showed pathologic marginal bone loss exceeding 2mm during the follow-up period. While 2 implants were removed with continuous progressive marginal bone loss, 5 of the 14 implants showed early bone loss exceeding 1mm within the first year but then subsequently tended to show a stable marginal bone level. In the other seven implants, bone loss started after the first year and progressed continuously. Multivariate analysis revealed that diameter of the implant affected the peri-implant marginal bone loss. Straumann tissue-level dental implants showed only slight peri-implant marginal bone loss, with a very low incidence of pathologic marginal bone loss exceeding 2mm.

Aim: The aim of this retrospective study was to evaluate the effects of Diabetes Mellitus on peri-implant marginal alveolar bone loss in sinus lifted well-controlled diabetic patients at long term.Materials and Methods: Thirty eight patients with 77 dental implants were included the study. The study consists of 2 groups; control group (C) and diabetes mellitus group (DM). The dental implants were placed after open window maxillary sinus lifting surgery at maxillary posterior region. After conventional loading process patients were followed periodically for bone loss and clinical parameters. The peri-implant marginal bone loss was assessed at minimum 3 years after functional loading. Standardized panoramic radiographs were obtained at the baseline and maintenance which were used for evaluating the marginal bone loss and clinical and anatomical crown to implant ratio. The Student-t test and Mann Whitney-U test were used to analyse any significant differences between two groups (p0.05). The Kruskal Wallis test was used for inter-group comparisons of parameters and Chi-square test, Fisher’s Exact Chi-square test and Continuity (Yates) correction were used to compare qualitative data. Spearman’s rho correlation analysis was used to examine the relationships between parameters with non-normal distribution.Results: A total of 77 dental implants were followed up for at least 36 months. The mean follow-up was 43.47±10.30 months. 2 implants were failed in DM group. The mean marginal bone loss in DM and C group were 1.35±1.22 mm and 0.91±1 mm respectively. There was no statistically significance in terms of marginal bone loss between the two groups (p>0.05).Conclusion: Within the limitations of this study, it was shown that long-term follow-up results of dental implants in well-controlled diabetic patients were similar to those of healthy individuals and DM did not increase the peri-implant marginal bone loss.

Patients have in many studies been identified with progressive bone loss and peri-implantitis problems, but few studies are available where these groups of patients have been followed up. The purpose of this paper is to study further progression of bone loss in a cohort of 182 patients that have been reported to suffer from "progressive" bone loss and peri-implantitis. Altogether, 182 patients that have earlier been identified to suffer from "progressive" bone loss formed the present study group. Data from patients' files have been retrieved, and intraoral radiographs have been analyzed for further bone level changes. Bone loss has been measured from time of inclusion into the present group to last available radiographs. Within each patient, one or several implants were diagnosed to suffer from "progressive" bone loss (affected), whereas others are not (unaffected). Altogether, 145 patients (80%) were radiographically followed up on an average of 9.1 years (SD 3.77) after inclusion. Twenty-four implants (3.1%) were lost in 16 patients (11%). Marginal bone loss was on an average 0.3 mm (SD 0.75) at stable implants with only small differences between "affected" and "unaffected" implants. In total, 67 implants (8.6%) presented an annual bone loss of >0.2 mm. Oral hygienist treatment and/or peri-implantitis surgery did not neither reduce implant failure rate nor marginal bone loss in 88 treated patients as compared with untreated patients. Less than one-third of the patients identified with "progressive bone loss" showed one or more implants as failures or with high annual bone loss (>0.2 mm) during follow-up (11.6% of implants). Treated patients (oral hygienist and/or surgery) did not perform better than untreated patients with regard to bone loss or implant failure.

The aim of this systematic review is to provide an overview of finite element analyses comparing standard and short dental implants concerning biomechanical properties and to detect the most relevant parameters affecting periimplant stress concentrations. After screening the literature and assessment of studies, 36 studies were included in this review. Eighty-three percent of the studies state that short dental implants have to bear higher stress concentrations compared with standard length implants. At the same time, 44% of articles note that implant diameter can be considered a more effective design parameter than implant length to reduce stress concentrations and to avoid an overload of periimplant bone. Regardless of implant dimension, in all studies, the highest stress concentrations are found in the cortical section around the upper part of the implant. Unaffected of bone quality, implant diameter is found to play a key role to minimize periimplant stress concentrations. Concerning stress reduction implant length gains increasing relevance with decreasing bone density. Furthermore, splinting of short implants constitute an appropriate tool to avoid crestal overloading.

Peri-implant bone level values have been used as the clinical standard of reference to describe the status of a dental implant, despite the fact that their significance for the long-term survival of the implant has never been properly assessed. To challenge the assumption that the natural course of peri-implant bone loss is the loss of the implant. This article is a narrative review on reasons and interpretations of marginal bone level changes around dental implants. Different views regarding the pattern and progression of marginal bone loss depending on dental specialties have been identified. However, the present finding of a negative correlation between an increasing cumulative marginal bone loss and a decreasing risk of implant failures over time indicates that peri-implant marginal bone loss does not necessarily represent a condition of disease. Reduction of marginal bone levels may be observed in a majority of patients during follow-up time, with only a minority of those patients losing implants and implant-supported prostheses in the long term. Bone level changes seem often to occur as a consequence of physiological processes and/or as an adaptation to altered external as well as host response factors. Periodical radiological assessments of implant-restorations remain a valid diagnostic tool for the detection of potential implant fractures, loss of osseointegration, screws working loose and for the detection of the few cases with advanced, continuously progressing marginal bone loss during time. The detection of peri-implant marginal bone loss at one time point should not be immediately considered as a sign of ongoing pathology and of an increased risk of future loss of the implant in question.

The aim of the present study was to review the available evidence on the response of the peri-implant bone when subjected to excessive occlusal forces. The search strategy included papers published in English in the Medline database and the Wiley Online Library from January 1991 to December 2011. Experimental or review papers reporting the conditions of the peri-implant bone of dental implants submitted to excessive occlusal loading in the presence of a controlled oral hygiene regime were eligible for inclusion. The knowledge regarding the response of the peri-implant bone when the dental implant is excessively loaded is limited, and the level of evidence is poor. With animal experimental studies showing conflicting results, it is unclear whether occlusal overload might cause marginal bone loss or total loss of osseointegration to already osseointegrated dental implants when the applied load exceeds the biologically-acceptable limit. This biological limit is also unknown. Furthermore, higher remodeling activity of the peri-implant bone is found around implants subjected to high loading forces.

The marginal bone loss around dental implants is an important indicator that helps to evaluate the course and the final outcome of implant-prosthetic treatment. It is, therefore, important to understand the factors that may affect this. The aim of the study was to assess the impact of the specific characteristics of implant-prosthetic treatment on the marginal bone loss around implants. The study included 28 patients, aged 37-66 years, treated with dental implants. Every patient received at least one of the two types of implants: with Morse taper connection and with internal hexagonal connection. The average marginal bone loss around the implants was evaluated on the basis of the panoramic radiographs. The maximum follow-up period after implantation was 46 months. The peri-implant marginal bone loss was evaluated taking into consideration the implant localisation, the procedure of sinus lift with bone augmentation, implant type, implant diameter, vertical implant position relative to the compact bone level and the type of prosthetic restoration, the time between implantation and loading with prosthetic restoration, as well as the time between loading and the measurement of marginal bone loss. The correlation between bone loss and the selected characteristics of the treatment was assessed using generalised estimating equations (GEE). An objective analysis was enabled via the applied research model: evaluation of an impact of the specific implant-prosthetic treatment characteristics on peri-implant marginal bone loss in patients treated with implants with different implant-abutment interface systems. The results of the study showed that peri-implant marginal bone loss increased significantly with implant localisation in canine sites (compared to the localization in premolar sites), as well as with prosthetic restorations in the form of dentures (compared to bridges), and decreased when implants were placed below the compact bone level (compared to those placed at the bone level). At the same time, marginal bone loss was not significantly related to implant diameter or to the sinus lift procedure. The results obtained seem extremely useful in everyday clinical practice

Aim This study was conducted to evaluate the marginal crestal bone loss around immediately loaded one-piece vs. two-piece dental implants associated with two different loading protocols during the first year after implant insertion. Materials and methods Eighty-six patients participated in the study; 90 dental implants (Zimmer Dental) were used. Of those, 30 were Tapered Screw Vent (TSV) implants with an immediate loading protocol (TSVi), 30 TSV with delayed loading (TSVd), and 30 were one-piece implants with an immediate loading protocol (OP). Crestal marginal bone loss in the coronal area of dental implants was evaluated radiographically at three months and one year post-implant insertion. Results Marginal bone loss was significantly higher after one year post-surgery compared to three months post-surgery in all the study groups. The mean values of marginal bone loss obtained by TSV implants were higher than those obtained with OP implants at both follow-up points. TSVd implants experienced the higher crestal marginal bone loss among all the study groups at both three months and one year. Conclusions Crestal marginal bone loss in the most coronal part of one-piece implants is significantly less than the marginal bone loss observed in tapered screw vent implants with either immediate or delayed prosthetic loading protocols with single implant crown rehabilitations. However, further studies with a longer observational time and larger sample are necessary.

Background: Smoking tobacco significantly affects the biology of periodontal tissues and contributes to the increased risk of peri-implant diseases. The aim of the study was to investigate whether smoking cigarettes affects the primary and secondary stability of maxillary dental implants, inserted into fresh sockets immediately after extraction. Methods: The study was conducted on 164 patients between the ages of 27–71 years old. 67 individuals smoked more than 20 cigarettes daily and 97 were non-smokers. 190 immediate implants were inserted in the maxilla. Immediate implantations were performed with simultaneous augmentation of the socket with xenogenic bone grafting material. In the posterior region, implants were inserted into the palatal alveolus. The stability of the implants was measured using Insertion Torque Value (ITV) and two types of devices: Periotest (PT) and Osstell (ISQ). Marginal bone loss was evaluated on cone beam computed tomography scans. Results: In an aesthetic area, the PT values at 6 months post-implantation were higher for smokers than non-smokers (p < 0.05), respectively. The ISQ values were significantly lower in smokers compared to non-smokers at 6 months post-implantation (p = 0.0226), respectively. In the posterior region PT values were higher in smokers both on the day of implantation (p = 0.0179), 6 months after surgery (p = 0.0003) as well as 24 months after surgery (p < 0.0001), as compared to non-smokers, respectively. Smokers revealed lower ISQ values than non-smokers (p = 0.0047) on the day of implantation, as well as 6 months after implantation (p = 0.0002), respectively. There were no significant differences in marginal bone loss after 18 months of loading between smokers and non-smokers in the aesthetic, as well as posterior regions (p > 0.05). ITV measurements were lower in smokers than non-smokers in the aesthetic (16.3 vs. 17.5 Ncm) and posterior area (16.8 vs. 17.9 Ncm). Conclusions: This study indicate that smoking cigarettes has a negative effect on the stability of immediate implants in the maxilla. Primary stability of immediate implants may be lower in the posterior area of the maxilla in smokers when compared to non-smokers, which may eliminate smokers from immediate implants in this region. Secondary stability of immediate implants may be lower in both the aesthetic and posterior areas in smokers compared to non-smokers, which may encourage the postponement of final crowns delivery at 6 months post op and the extension of the occlusaly temporary crowns use in some smoker cases.

The relationship between periodontitis and peri-implantitis remains a matter of debate. The present study compared, "within" randomly chosen partially edentulous patients (n=84 subjects, 97 jaws), the marginal bone loss around teeth and implants during 5 years (range 3 to 11 years) following the first year of bone remodelling. The patients had all been rehabilitated by means of screw-shape c.p. titanium implants with a machined surface (Brånemark system). During the 5 years observation interval, periodontal parameters (marginal bone and attachment loss, the latter for teeth only) were collected together with data on confounding factors (smoking, oral hygiene, tooth loss). Marginal bone loss was measured through long-cone intra-oral radiographs. The mean "interval" bone loss was significantly (P=0.0001) higher around teeth (0.48+/-0.95 mm) than around implants (0.09+/-0.28 mm). The corresponding data for the "worst" performing tooth (0.99+/-1.25 mm) and implant (0.19+/-0.32 mm) per subject showed the same tendency. Neither attachment nor bone loss around teeth correlated with marginal bone loss around implants. This study indicated that the rate of bone loss around screw-shape c.p. titanium implants with a machined surface (Brånemark system implants) was not influenced by the progression rate of periodontal destruction around the remaining teeth within the same jaw.

The integration and long-term success of dental implants exploit the unique biology of the oral cavity, which allows for osseous incorporation of a biomaterial and its long-term health within a bacteria-laden oral milieu.1 The delicate balance of defense and repair mechanisms underlying this unique environment may be challenged by various factors that can act both locally and/or systemically, thereby increasing the risk of implant loss and jeopardizing the long-term success of inserted implants. Local risk factors that are present in the oral cavity and systemic risk factors that have the potential to affect oral health on a systemic level can compromise implant treatment at all stages of treatment delivery by: (a) complicating surgical procedures and other invasive measures required during treatment; (b) compromising the process of tissue healing following implant insertion/increasing the risk of wound infection; and (c) contributing to the deterioration of long-term peri-implant health and tissue stability (Table 1). Reduced bone healing Reduced implant stability Reduced bone remodeling Reduced angiogenesis Reduced bone regeneration Acquired immunosuppression Hypovascularity Iatrogenic immunosuppression Reduced tissue regeneration Hypovascularity hypoxia Leukocyte dysfunction Conditions that interfere with invasive procedures, which include poor general health status (https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system) as a result of severe systemic disease, may impact upon implant surgery, healing, and maintenance. These are mostly cardiovascular conditions that can place the patient at high risk during surgery, irrespective of the nature of the intervention. Bleeding disorders, which may be innate or acquired, as well as attributable to the use of anticoagulants, may also complicate invasive measures. While the former are considered to be relatively rare, the latter may have a significant impact on daily implant treatment in an aging population. All these conditions can also have a negative impact on long-term peri-implant health and maintenance of peri-implant tissues as a result of compromised vascularity, as well as alterations in the immune defense or repair capacity of peri-implant tissues. The increasing patient demand for implant-based treatments in conjunction with a demographic shift of the patient population has resulted in a growing body of literature dealing with an increasing number of patients presenting with medical conditions. A recent cross-sectional analysis indicated that almost 90% of patients aged > 65 years were taking medication for underlying systemic diseases, which could jeopardize implant success.2 The advent of new treatment modalities, such as antiresorptive drugs or monoclonal antibody therapies, adds to the number of potential risk factors,3 leading to an increasing challenge for the provision of implant-based treatments in the future. The aim of this narrative review was therefore to analyze the importance of systemic and local conditions as risk factors for implant loss by critically evaluating the available evidence. During evaluation of the available literature, it was obvious that the term "implant loss" was used to a much lesser degree than "implant failure." Very few reports clearly defined implant failure as implant loss, but the context in which this term has historically been used indicates that implant failure was synonymous for implant loss. It is only in the last decade or so that definitions of implant failure have been published, and not until the 2017 World Workshop on Periodontal and Peri-Implant Disease Classification was an international definition agreed upon.4 One of the major reasons for implant loss is the progressive loss of peri-implant bone support. Therefore, marginal bone loss was also included in the analysis. As progressive crestal bone loss around implants in the absence of clinical signs of soft tissue inflammation is rare,5 reported radiographic bone loss was considered in conjunction with clinical peri-implant parameters (where provided) in the individual reports in order to assess the prognostic relevance of the findings. The effect of cardiovascular conditions on implant treatment has been mostly analyzed in cross-sectional cohort studies. In these reports, 15.6%-37%6-8 of patients were affected by cardiovascular diseases. Two recent multivariate analyses of large cohorts consisting of > 6300 and > 22 000 patients did not identify cardiovascular conditions as significant risk factors for implant loss6 or peri-implant pathology.9 This is in line with other cross-sectional studies of smaller cohorts.10-13 Cardiovascular conditions may, however, be associated with the maintenance of long-term peri-implant tissue health. Patients with diseased implants have shown a higher likelihood of cardiovascular comorbidity,8 and a recent prospective study of 44 patients with fixed mandibular prostheses demonstrated an association between cardiovascular disease and increased radiographic peri-implant bone loss.14 The available evidence currently suggests that cardiovascular conditions are not a major risk factor for implant loss. Although the radiographic bone loss reported had not been classified as progressive, cardiovascular disease should be taken into account in maintenance protocols as a potential comorbidity15 that may affect long-term peri-implant tissue health. Bleeding disorders can be innate, such as hemophilia A/B and von Willebrand–Jürgens Syndrome, or acquired during end stage liver disease, with subsequent deterioration of coagulation factors and platelet counts. The placement of implants in patients with hemophilia is rarely documented in case reports.16, 17 In contrast to this, patients with iatrogenic bleeding disorders as a result of anticoagulation therapy have been studied more frequently. Depending on the underlying disease, anticoagulation therapy may encompass antiplatelet drugs, vitamin K antagonists, or direct oral anticoagulants. There is widespread agreement that anticoagulation therapy with antiplatelet drugs or vitamin K antagonists should not be discontinued for dental surgical procedures, as long as a single drug is used and the level of activity is within the therapeutic range (international normalized ratio 2.5-3.0).18, 19 Some uncertainty exists about the management of patients using direct oral anticoagulants, but it is assumed that no interruption of therapy is required; consulting with the hematologist responsible for the patient's care is always advisable.20 Implant surgery in patients undergoing anticoagulation therapy has been reported in a number of controlled clinical studies, albeit consisting of rather small cohorts.21-24 Follow-up included an immediate postoperative period of 8-10 days. All the authors agreed that implants could be safely placed in patients with anticoagulation therapy without interruption of medication of vitamin K antagonists or direct oral anticoagulants. An exception to this may be dual anticoagulation therapy using two antiplatelet drugs (acetylsalicylic acid and clopidogrel), as is commonly employed following stenting of the coronary arteries. In these cases, postoperative morbidity may occur as a result of the increased risk of postoperative bleeding (Figure 1). Implant surgery should therefore be postponed until dual antiplatelet therapy has returned to single antiplatelet drug use. Depending on the type of stent used, this period may vary from 6 weeks to 6 months. To date, no information is available on implant complications arising in anticoagulated patients beyond the immediate period of surgical wound healing. The management of secondary interventions for soft tissue management or peri-implant diseases has not yet been reported on, but may have an impact on the long-term prognosis of implants, and should be taken into consideration when implants are planned for patients with anticoagulation management. Moreover, it should be noted that the necessity for anticoagulation therapy is commonly an underlying cardiovascular condition that needs to be explored and may require additional action. If anticoagulation therapy is used because of a cardiac condition associated with an increased risk for infective endocarditis, antibiotic prophylaxis is required.25 The necessity for antibiotic prophylaxis has been questioned based on a low risk of bacteremia during implant insertion,26 but adherence to current updates of national guidelines is strongly recommended.27, 28 Osteoporosis is characterized by a loss of structural quality of cancellous bone and a reduction in cortical bone thickness resulting in an overall deterioration of bone density. Approximately 48% of women and 15% of men aged ≥ 75 years are known to be affected.29 Primary osteoporosis can arise because of the loss of osteoanabolic effects of sex hormones (type I) in postmenopausal women (and some 10 years later in men), or because of age-related changes in general metabolism (type II). Osteoporosis may also arise secondary to endocrine diseases (eg, Cushing Syndrome, parathyroid hormone excess) or as a result of medication (eg, corticosteroids). Commonly, the diagnosis is derived from dual energy X-ray absorptiometry of the spine and/or the proximal femur. Dual energy X-ray absorptiometry scans provide a T-score that expresses the deviation of bone mineral density of the patient in standard deviations from the average value of healthy young adults. A T-score of < –2.5 is considered to be indicative of osteoporosis. Osteoporosis has been a concern in implant dentistry from an early stage in the development of the field.30-32 A number of papers have addressed the question of whether reduced skeletal bone density is associated with inferior bone quality in the maxilla or mandible. Subjectively, perceived jaw bone quality did not correlate with documented dual energy X-ray absorptiometry scores.33 Moreover, bone next to implants retrieved from osteoporotic patients did not exhibit a reduced number of bone cells or bone-to-implant contact.34 To identify individuals with reduced skeletal bone density, panoramic indices such as the mandibular cortex width,35 panoramic mandibular index,36 and the Klemetti index37 have been developed. A recent review reported these indices as useful in intercepting patients with reduced bone mineral density (T-score < 1), but did not recommend them to intercept patients with osteopenia/osteoporosis.38 Moreover, a systematic review examining the association between objective measures of jaw bone quality and skeletal bone mineral density was unable to clarify whether skeletal osteoporosis is associated with osteoporosis in the jaw bones.39 The role of osteoporosis in the success of implant treatment and the stability of marginal bone has been evaluated in a number of studies. Recent systematic reviews have found no difference in implant survival rates between patients with and without osteoporosis (risk ratio 1.9, 95% confidence interval 0.93-2.08, P = .11),40 or identified a direct but insignificant effect of osteoporosis on dental implant loss (risk ratio 1.09, 95% confidence interval 0.79-1.52).41 Similarly, earlier reviews and case control studies42-45 did not find evidence for an association between skeletal bone mineral density/osteoporosis and increased implant loss. With regard to peri-implant bone loss, the majority of recent studies (two cross-sectional,46, 47 one prospective,48 and one case control study49) reported no difference in radiographic peri-implant bone loss between patients with and without osteoporosis. Only one cross-sectional study reported significantly increased radiographic loss of marginal bone in osteoporotic patients after 1 year.50 All the patients in this study were part of a maintenance program with low periodontal indices and healthy periodontal conditions. Differences in radiographic bone level changes have been attributed to differences in bone remodeling in osteoporotic patients. The relevance of these findings with regard to long-term implant prognosis remains to be determined. While osteoporosis as such may not play a role in implant failure or loss of peri-implant bone, medications used for osteoporosis therapy may interfere with osseointegration and long-term maintenance of peri-implant health. The drugs prescribed are mostly either bisphosphonates51 or denosumab, a monoclonal antibody against the signaling molecule RANKL that is involved in the recruitment of osteoclasts. Bisphosphonates reduce both the resorptive activity of osteoclasts, as well as the activity of osteoblasts in a dose-dependent manner,52, 53 while denosumab directly reduces osteoclast activity.54 The net effect of the antiresorptive therapy is a decrease in bone turnover and remodeling activity of bone tissues. As remodeling is an essential part of bone regeneration and osseointegration, there has been some concern expressed regarding the capacity of peri-implant bone to incorporate implants inserted under bisphosphonate therapy. Controlled clinical trials have reported implant survival rates of 85.7%-100% in patients taking oral bisphosphonates55, 56 and of 100% for those receiving intravenous bisphosphonates.57 Recent meta-analyses of studies assessing the impact of bisphosphonates on implant treatment concluded that there is insufficient evidence for a negative effect of bisphosphonates on implant survival.58, 59 Besides the effect on implant survival, another aspect of the long-term use of antiresorptive agents is the risk of developing a medication-related necrosis of the jaw.60, 61 Medication-related necrosis of the jaw can be triggered by intra-oral surgical interventions and by bacterial invasion from odontogenic infectious lesions,62 as well as through pressure ulcers resulting from poorly fitting removable dentures.63 Triggering of the onset of medication-related necrosis of the jaw during the insertion of dental implants or through the occurrence of peri-implant infections during follow-up under antiresorptive medication is therefore a significant concern,64-66 and most often requires rather invasive measures for management (Figure 2A-G). The prevalence of medication-related necrosis of the jaw has been considered to depend in part on the route and frequency of bisphosphonate administration, with oral bisphosphonates presenting a lower risk for medication-related necrosis of the jaw than intravenous bisphosphonates. More recent reviews suggest that it is not the route of administration but the dosage of antiresorptive medication that affects the prevalence of medication-related necrosis of the jaw.59 The evidence reported for the occurrence of implant-related medication-related necrosis of the jaw under therapy with either bisphosphonates or denosumab is largely based on case reports64, 67-75 or retrospective case series.63, 76-84 In these reports, the number of cases reported for implant-related medication-related necrosis of the jaw in patients taking oral bisphosphonates is almost as high (n = 74) as in patients receiving intravenous bisphosphonates or denosumab (n = 84), suggesting that it is not the route of administration that is critical for the occurrence of implant-related medication-related necrosis of the jaw. Conversely, a number of case reports and case series reporting on implant treatment with concurrent oral bisphosphonate therapy did not find any cases of medication-related necrosis of the jaw in the patients studied.55, 65, 85-95 The existing level of evidence for an association between implant treatment and the occurrence of medication-related necrosis of the jaw under antiresorptive therapy remains low and needs to be substantiated by appropriately designed randomized controlled trials. Nevertheless, the overall number of reported cases of implant-associated medication-related necrosis of the jaw suggests that antiresorptive drugs need to be considered as a risk factor96 and explained to patients97 prior to the start of the treatment, as part of collecting informed consent. Despite the potential hazards of implant-associated medication-related necrosis of the jaw, implants can help to reduce the occurrence of medication-related necrosis of the jaw, for example, in edentulous patients under antiresorptive drugs by avoiding pressure ulcers resulting from poorly fitting dentures. Therefore, multiple factors need to be considered to inform a balanced decision on whether a patient with antiresorptive drugs is eligible for implant therapy (Table 2). If the majority of these factors indicate a low to moderate risk, implant therapy may also be a valid option in patients with antiresorptive medication. When oral surgical procedures are planned in patients with antiresorptive medication, antibiotic prophylaxis is recommended.98, 99 The ideal protocol for administration of antibiotics has not yet been defined. A clear recommendation is given for preoperative antibiotic coverage,100 however, the dosage and duration of postoperative continuation of antibiotic therapy remain to be determined. Adherence to national guidelines (if available) for the perioperative management of patients with antiresorptive medication is strongly advised. Diabetes mellitus is characterized by a lack of insulin secretion as a result of the loss of insulin-producing beta cells in the Langerhans islands of the pancreas (type 1) or by impaired insulin function because of the failure of insulin receptors to appropriately respond to the stimulation by insulin in the periphery (type 2). This results in constantly elevated blood glucose levels in people with diabetes, which leads to nonenzymatic glycation of numerous proteins to produce advanced glycation end products. An elevated level of advanced glycation end products leads to increased expression and activation of receptors for advanced glycation end products. These receptors are present on many cells (eg, endothelial cells, smooth muscle cells, fibroblasts, and mesanglial cells). Their activation mediates inflammatory reactions, which are considered to be responsible for alterations in the microvasculature and thereby can account for diabetic angiopathy.101 Interaction of advanced glycation end products with receptors for advanced glycation end products on macrophages is considered to be associated with macrophage dysfunction, leading to impaired wound healing in patients with diabetes.102 Moreover, bone regeneration is directly impaired on a molecular level in people with diabetes.103 Clinically, poor glycemic control has been shown to negatively affect the balance of bone growth factors in the peri-implant fluid during implant healing.104 Deterioration of vascularity in conjunction with a less efficient immunologic defense and a decreased regenerative capacity of peri-implant bone may compromise the success of implant treatment in patients with diabetes considerably. The effect of diabetes on implant success and the maintenance of peri-implant tissues has therefore been subject to research for more than 20 years. Numerous reviews have analyzed this relationship.105-115 A recent meta-analysis of 14 controlled clinical trials demonstrated that the risk ratio for implant loss between patients with and without diabetes was 1.07 (95% confidence interval 0.08-1.44), without a significant difference between the groups (P = .65).109 Failure to show an association between the existence of diabetes and an increased loss of dental implants is in line with previous reviews.20, 108, 113, 114, 116 The level of glycemic control as assessed by HbA1c appears to have no effect on implant survival rates, although patients with diabetes have demonstrated a compromised process of implant integration.104, 113, 117-119 Moreover, a recent consensus paper reported only inconclusive evidence for diabetes as a risk factor for peri-implantitis.5 While implant loss and peri-implant tissue health are obviously not affected by the presence of diabetes as such, management of the disease may play a role in the maintenance of peri-implant tissue health. A number of reports and systematic reviews have shown that patients with diabetes and poor glycemic control have an increased risk of peri-implantitis and associated peri-implant bone loss.76, 112, 120 This has been reported to become obvious at 2 years of follow-up compared with healthy individuals.107 However, when HbA1c is within the physiological range and oral hygiene is appropriate, the levels of inflammation have been shown to be reduced to those of healthy patients.121 The prophylactic use of antibiotics in oral surgical procedures in patients with diabetes is still controversial. Data from the scarcely available clinical studies favor the use of antibiotics but the evidence for their benefit is still low.122 The immune system is an indispensable part of tissue healing and repair. This holds true also for bone tissue, where pro-inflammatory cytokines are critical, not only for triggering regeneration but also for orchestrating subsequent bone remodeling.123 Moreover, both nonspecific and specific immune responses are crucial for the defense against bacterial invasion following surgery, as well as during the period of restoration and long-term usage. Immune deficiency can thus be critical for integration of dental implants and for the maintenance of peri-implant tissue health. Immune deficiency can result from a large number of conditions. With the exception of very rare innate immune defects, immune deficiencies are mostly acquired in nature. The nonspecific immune response can be affected by medications (immunosuppression/chemotherapy) and metabolic diseases (eg, diabetes mellitus), or because of chronic malnutrition. Specific immunity can also be reduced by immunosuppressive medication, as well as by hematological diseases and lymphotropic viruses (eg, HIV). Iatrogenic immunosuppression as a result of medications is probably the most frequent cause of immune deficiency in dental implant patients. A major indication for deliberate suppression of the immune response is organ transplantation. Organ transplant patients are treated with a combination of drugs that aim to reduce the proliferation of T-cells and to decrease the number of antigen-presenting cells to avoid rejection of the transplanted organ. Commonly, a combination of monoclonal antibody therapy, inhibitors of that and drugs with of is During the drug are high to immune after which are reduced for maintenance of interventions should not be planned during the of immune The effect of immunosuppression on the success of implant treatment in organ transplant patients has rarely been indicate that the peri-implant bone in a clinical information from a case series on patients with liver reported 100% success after Moreover, two prospective controlled studies found no significant difference in implant survival rates between organ transplant patients and after 1 and years of results without significant differences between groups have also been reported for clinical peri-implant soft tissue and for the of peri-implant The available evidence remains but suggests that the clinical results of implant treatment are and not significantly affected by immunosuppressive drugs used by organ transplant patients. of diseases in which immunosuppressive medication is used is the of diseases. The most for daily clinical are diseases, Syndrome, and disease, as well as conditions of oral and such as oral and systemic with oral or conditions that may largely cause local while such as or disease, may be of concern because of the systemic immunosuppressive medications immunosuppression in and in disease is by a combination of drugs, such as monoclonal against necrosis and drugs are a of agents that include and which are also used for immunosuppression in organ transplant diseases are characterized by and of clinical leading to a level of treatment during their This should be in when treatment for these patients. many patients have medication, the negative of this with regard to bone such as osteoporosis and decreased bone also be taken into osteoporosis is considered to be present at of ≥ These patients should be explored for receiving antiresorptive medication to avoid the There is very information available regarding patients with receiving dental implants. A retrospective evaluation of patients with an implant success of after The success rates but between patients with only and those with tissue diseases The stability of marginal bone by the medication drugs drugs and corticosteroids). The existence of tissue diseases was associated with a significant in peri-implant bone loss and higher bleeding indices compared with patients with an increased of peri-implant tissues to The of authors when examining a smaller cohort of patients with Moreover, a retrospective analysis of a cohort of patients did not identify as a significant risk factor for implant However, an of and systemic may these patients more to marginal peri-implant thus a maintenance The results available for patients with disease are Two cross-sectional analyses and one evaluation of cohorts of were by the examining early and implant loss and the role of implant the study one of the cross-sectional analyses identified a significant association between disease and implant the other cross-sectional study However, the of this is to as the number of patients in this cohort with disease was not diseases with oral Syndrome, systemic and oral in conjunction with dental implants, have largely been reported at an level for almost In and systemic were subject to early case reports years is considered to be critical for implant survival and not only as a result of medication, but more so because of leading to increased and bleeding as well as a higher frequency of As a result of the oral and patients with are often unable to removable and can benefit significantly from implant The level of evidence for the effect of on the success of implant treatment is Two case series and case reports provide into 17 patients with a of 99 implants, with 10 implants after years of Two recent retrospective cohort studies reported success rates of and soft tissues a higher but insignificant in the of patients with compared with healthy The existing thus suggests that implants in patients with are not significantly compromised by either the underlying disease or medication. The for peri-implant in these patients the elevated around in patients with Syndrome, and needs during is a disease associated with general of tissues resulting in reduced with subsequent with and dental has been reported in conjunction with dental implants on an level in individual and for two cases as

Current evidence indicates a possible link between the design of the implant-abutment-prosthesis complex and the development of peri-implant diseases. This cross-sectional study aimed to investigate the association between implant and prosthetic factors and the prevalence of peri-implant diseases and peri-implant marginal bone loss in patients treated with static computer-assisted implant surgery (sCAIS). This cross-sectional study included 115 patients with 417 dental implants, all placed using a standardized sCAIS protocol and with more than 1 year of loading. Each implant was clinically and radiographically assessed, with diagnoses made based on established criteria. Bivariate and multivariable analyses were performed to identify implant and prosthetic parameters, such as implant connection, loading protocol, crown-to-implant ratio (CIR), implant surface, prosthesis type, prosthetic emergence angle (EA), prosthetic emergence profile (EP), cantilever length, mucosal height of the abutment (HA), interproximal contact level, inter-implant distance, implant and abutment angulation, and presence of open contacts, as risk indicators associated with peri-implant diseases, bleeding on probing (BOP) scores, and changes in the peri-implant marginal bone level (MBL). Of the total implants, 156 were diagnosed as healthy, 241 exhibited mucositis, and 20 showed peri-implantitis, corresponding to 37.4%, 57.8%, and 4.8% of the implants, respectively. An odds ratio (OR) of 2.16 (95% confidence interval [CI]: 1.003-4.63) for peri-implantitis was observed in implants supporting removable prostheses, with the fixed prosthesis group serving as the reference category. Marginal bone loss was significantly associated with higher interproximal contact levels, greater prosthetic EA, shorter abutment mucosal height, longer cantilever length, and anodized implant surface treatment, as determined by bivariate and multivariable analyses. In the present cross-sectional study, implants supporting overdentures were associated with a higher prevalence of peri-implantitis. Furthermore, several implant-abutment-prosthesis complex factors were significantly linked to marginal bone loss around dental implants, including interproximal contact level, prosthetic EA, abutment mucosal height, cantilever length, and implant surface treatment. Clinicians are recommended to meticulously select prosthesis types/designs tailored to each peri-implant site, apply digital technology for precise implant planning, and regularly monitor patients to detect and manage peri-implant diseases in early stages. This clinical study looked at how the design of dental implants and their related components (like crowns and abutments) might influence the development of gum problems around implants and bone loss. It involved 115 patients with a total of 417 dental implants that had been placed using a precise, digitally guided technique and had been in place for over a year. The study found that many implants had issues like mucositis (gum inflammation) or peri-implantitis (a more serious gum infection involving bone loss). Implants supporting removable prostheses (like overdentures) had a higher chance of developing peri-implantitis compared to those with fixed prostheses (like crowns or bridges). Certain implant features, like how the prosthesis connects to the implant, the shape and height of the abutment, and the length of the cantilever (part of the prosthesis extending beyond the implant) were linked to bone loss around the implant. The conclusion of the study is that the design of the implant and its components plays an important role in preventing or contributing to peri-implant diseases and bone issues. This study suggests that dentists should carefully choose the right implant and prosthesis design for each patient, use digital tools for precise planning, and monitor patients regularly to resolve peri-implant problems early.

To investigate the effect of a 1-week postoperative course of 600 mg of ibuprofen taken four times a day on marginal bone level around oral implants. Twenty-eight patients were allocated to the ibuprofen group (14 patients) or no-ibuprofen group (14 patients). Overall, 57 implants were inserted, 31 implants in the ibuprofen group and 26 in the no-ibuprofen group. The primary outcome measure was the change in marginal bone level around oral implants from baseline (2 weeks postplacement) to the 3- and 6-month radiographic examinations. The paralleling technique and a film holder coupled to a beam-aiming device were used to take the periapical radiographs. Measurement of changes in bone level was made using a viewing box and ×8 magnifier. Three subjects were withdrawn from the therapy early as they did not complete the dose of ibuprofen (e.g. because of self-reported stomach upset). The mean marginal mesial bone loss from the baseline was 0.37 mm at the 3-month and 0.27 mm at the 6-month follow up for the ibuprofen group, while the corresponding values for the no-ibuprofen group were 0.15 mm and 0.08 mm. The mean marginal distal bone loss from the baseline was 0.42 mm at the 3-month and 0.2 mm at the 6-month follow up for the ibuprofen group, while the corresponding values for the no-ibuprofen group were 0.08 mm and 0.15 mm. There were no significant differences between the ibuprofen and no-ibuprofen groups when comparing the bone changes. Administration of a short course of systemic ibuprofen for postoperative pain management following implant insertion may not have a significant effect on the marginal bone loss around oral implants in the early healing phase.

Still, a major focus of research in implantology is how crown height and width affect marginal bone loss (MBL) and the long-term durability of dental implants. Maximizing the success of implants and lowering problems depends on an awareness of these elements. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review searched pertinent studies across several databases using keywords unique to databases. Studies on MBL and long-term implant stability evaluated in the review included those on crown height and width, horizontal and vertical cantilevers, and prosthesis dimensions. In the chosen studies, we found that both implant success and crestal bone loss were greatly influenced by crown height and width. Particularly in the posterior sections, horizontal cantilevers were connected to both increasing MBL and mechanical problems. Vertical cantilevers also affected MBL; however, their impacts were more obvious in circumstances with greater crown heights. Greater prosthesis widths, especially in the mandibular molar area, were linked to higher MBL. Bone density and insertion torque (IT) were the main determinants of MBL, more than the primary implant stability quotient. Early MBL was influenced by abutment height, mucosal thickness, and implant insertion depth; bone levels stabilized six months later. Short implants allow single crowns to be supported, but in some cases, a higher failure rate was seen. The success and stability of dental implants were found to be mostly dependent on crown height, width, and cantilever design. MBL and long-term stability are greatly influenced by horizontal and vertical cantilevers, which calls for careful design and planning. With specific care for bone density, IT, and early MBL stabilization, both short and standard implants can produce equivalent results. These results highlight the need for customized treatment plans to maximize implant success and lifetime.

ObjectiveThis retrospective radiography study’s main objective was to compare round and milled bars for mandibular overdentures assisted by 4 mini-dental implants (MDI) on peri-implant marginal bone loss (MBL)and posterior mandibular ridge resorption(PRR) after 8 years.Materials and methodsThirty male Participants in a retrospective analysis were treated between 2016 and 2024 who had four interforaminal mini implants supporting an overdenture on a milled bar. Two equal groups of 15 patients each were randomly assigned to receive mandibular overdentures: Group I received overdentures retained by milled bars, while Group II received overdentures retained by round joint bars. After an 8-year follow-up period, a comparison between the two bar designs attachment used for IODs retention. The evaluation of the posterior ridge resorption (PRR) and peri-implant marginal bone loss(MBL) was done after three years (T3), five years(T5), and eight years later (T8)after insertion. The data was analyzed using the Statistical Package of Social Science (SPSS) program for Windows (Standard version 24).ResultsCompared to Group II, Group I’s MBL was noticeably higher. As time went on, MBL rose noticeably for both groups. At certain intervals, Group II’s PRR was significantly higher than its Group I.ConclusionsThe design of the anchorage system has a major impact on posterior ridge resorption and peri-implant bone loss when four mini-implants are utilized to anchor mandibular overdentures.Clinical relevanceAs mini implants are often seen as a cost-effective solution for patients with limited bone, it is important to understand their long-term performance to make more informed decisions in clinical practice.Clinical trial registry number(NCT06185283). Retrospectively registered on (29-12-2023).