1. Dental Implant Therapy -
D t l I l t Th
Trends & Literature
Critical Appraisal
University of Florida, Gainesville
Seminar, F b
S i February 19 2008
19,
Asbjørn Jokstad DDS PhD
Jokstad, DDS,
Professor and Head, Prosthodontics
Faculty of Dentistry, University of Toronto

2. University of Florida, Gainesville, 19.2.2008

3. Adolescent patient with a crown–
root fracture of central: options?
p
Fracture line
palatinally
1. Extraction orthodontics veneer or crown
2. Extraction etch-bridge or FPD
3. Extraction implant abutment crown
4. Extraction & replantation 180° endo crown
5.
5 Endo orthodontic extrusion crown
6. Decoronation+etch-bridge/flipper implant
abutment University of Florida,&Gainesville, 19.2.2008Depts. of Pedodontics,
crown of Dentistry, University of Oslo, & Birkeland, 2007.
Faculty
Orthodontics Prosthodontics. Stenvik

4. Adolescent patient with missing
laterals: options?
p
A. Orthodontic Treatment
A O th d ti T t t
B. Etch-bridges
C. (Provisional) Removable Partial
D. Conventional Fixed Partial
E. Implant-supported crowns19.2.2008
University of Florida, Gainesville,

5. Adolescent patient with missing
laterals: options?
Additional
considerations:
A. Orthodontic Treatment
What if buccal bone augmentation is required?
A. Single implants + crowns in the lateral
regions
B. Mesial movement of canines composites
+ single implants in canine region
g p g
C. Mesial movement of canines & bicuspids
composites + single implants in bicuspid
region
University of Florida, Gainesville, 19.2.2008

6. “Medicine is a science
Medicine
of uncertainty and an
y
art of probability”
Sir William O l
Si Willi Osler
Canadian Physician (1849-1919)
University of Florida, Gainesville, 19.2.2008

7. Dental Implants -
How many y
systems do we
y
have and how well
are th
they
documented?
d t d?

8. Number of dental implants 1988
p
English CE. Implants. Part three. An overview.
California Dent Assoc J. 1988;16: 34-8.
50
45
45
40
35
30
25
20
15
10
5
0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
University of Florida, Gainesville, 19.2.2008
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20

9. Review of existing literature
g
Eckert S et al. Validation of dental implant
systems through a review of literature
supplied by system manufacturers. J
Prosthet Dent 1997;77: 271-9
271 9.
Conclusion:
On the basis f the literature supplied b
O th b i of th lit t li d by
the manufacturers, only one implant
system d
t demonstrated scientifically valid
t t d i tifi ll lid
long-term success.
University of Florida, Gainesville, 19.2.2008

10. Situation, 1999
1.
1 The number of implants and implant systems
increase continuously worldwide
2.
2 The FDI World Dental Federation is concerned
about the quality of all the new implants being
marketed
3. The FDI Science Committee is asked to
investigate the issue
4. The work is commissioned to prof. A Jokstad
University of Florida, Gainesville, 19.2.2008

11. Implant brands/ systems available
in N. America i 1999 ( 98)
i N A i in (n=98)
University J Oral Maxillofac Impl 2000 15(1): 76-95
Int of Florida, Gainesville, 19.2.2008

12. Number of implants 2000
Binon PP Implants and components: entering the new
PP.Implants
millennium. Int J Oral Maxillofac Implants. 2000;15:76-94.
English CE. Implants. Part three. An
g
overview.CDA J. 1988;16: 34-8.
120
98
100
80
60
45
40
20
0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
University of Florida, Gainesville, 19.2.2008
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20

13. Jokstad, Brägger, Brunski, Carr,
Naert, Wennerberg. Int Dent J
, g
2003; 53 Sup 2: 409-33
Asbjørn J k t d O l N
A bj Jokstad, Oslo, Norway
Urs Braegger, Bern, Switzerland
John B. Brunski, Troy, USA
, y,
Alan B. Carr, Rochester, USA
Ignace Naert, Leuven, Belgium
Ann Wennerberg Gothenburg Sweden
Wennerberg, Gothenburg,

14. Commercially available implant and implant
y p p
systems in October 2003:
225 implant brands
78 manufacturers – from all continents
~70 implant brands no longer marketed
University of Florida, Gainesville, 19.2.2008

15. Number of implants 2003
Jokstad A, et al. Quality of dental implants. Int Dent J.
2003;53(6 Suppl 2):409-43
Binon PP..Implants and components: entering the new millennium. Int
J Oral Maxillofac Implants. 2000;15:76-94.
English CE. Implants. Part three. An overview. CDA J. 1988;16: 34-8.
250
220
200
150
98
100
45
50
0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
University of Florida, Gainesville, 19.2.2008
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20

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

17. Flange
design
g
Flange vs. no flange
Straight vs. flared
vs. widening
Height
Polished vs threads
vs.
Added features
Surface topography
S f
University of Florida, Gainesville, 19.2.2008

18. Threads vs. non-threads
Shape: V- vs. square- vs. reverse buttress- vs. combinations
Number and size of “lead threads”
Number and location of grooves, groove forms and groove sizes
Surface micro-topography
Thread angle University of Florida, Gainesville, 19.2.2008

19. Apex
Threaded
Th d d vs non-
threaded
V-shape vs fl t vs
V h flat
curved apex
Holes, round,
H l d
oblong
Apical h b
A i l chamber
Grooves and
groove size
i
Flared apex
Surface
topography
University of Florida, Gainesville, 19.2.2008

20. Interface geometry
External vs Internal
Hexagonal vs.
Octagonal vs cone
Morse t
M taper
Rotational vs non-
rotational
Added non-
rotational features
Heights & widths
Butt vs bevel joints
j
Slip-fit vs friction-fit
joints
Resilience vs
nonresilience ….
University of Florida, Gainesville, 19.2.2008

21. High (top) and low (bottom) magnification of cpTi
surfaces as used for surface characterization
characterization.
Plasma– Grit-blasted Grit-blasted Dual acid- Machined
sprayed and dual etched (turned)
(TPS); acid-etched
University of Florida, Gainesville, 19.2.2008 Davies, 2003

22. Surface topography Machining process Example
Anisotropic with Turned Brånemark System® MKIII
oriented cutting marks (Nobel Biocare)
Isotropic Blasted TiO2 particles (Tioblast®,
AstraTech)
A t T h)
Isotropic Blasted + acid etched 1. Large size Al2O3 particles
& HCl & H2SO4 (SLA®,
Straumann) - 2 T i l i
St ) 2. Tricalcium
phosphate & HF & NO3
(MTX®, Centerpulse)
Isotropic with high Acid etched HCl / H2SO4 (Osseotite®, 3i)
frequency irregularities
Isotropic and rough Hydroxyapatite coated Sustain® (Lifecore)
Isotropic and rough
p g Titanium Plasma ITI® TPS (Straumann)
( )
Sprayed
Isotropic with craterous Oxidized TiUnite® (Nobel Biocare)
structure University of Florida, Gainesville, 19.2.2008

23. Clinical
documentation?
University of Florida, Gainesville, 19.2.2008

24. Clinical documentation
A. Implant or implant system with
extensive clinical documentation: >4 10
clinical trials
B. Implant implant
B I l t or i l t system with li it d
t ith limited
clinical documentation, i.e. <4 trials, 11
but f
b t of good methodological quality
d th d l i l lit
C. Implant or implant system with limited 29
published clinical documentation
D. Implant or implant system with no
p p y
published clinical documentation. 28
University of Florida, Gainesville, 19.2.2008

25. The quality of RCTs of oral implants is generally poor and needs
to be improved
University of Florida, Gainesville, 19.2.2008 16: 783-92
Esposito et al., IJOMI 2001;

26. How many new
y
implant systems?
University of Florida, Gainesville, 19.2.2008

27. Number of implants 2006
Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6
Suppl 2):409 43
2):409-43
Binon PP.Implants and components: entering the new
millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. Jan
English CE Implants Part three An
CE. Implants. three. 2007
overview.CDA J. 1988;16: 34-8.
400
357
350
300
250
220
200
150
98
100
45
50
0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
University of Florida, Gainesville, 19.2.2008
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20

28. Number of implants 2008
Jokstad A, et al. Quality of dental implants. Int Dent J. 2003;53(6
Suppl 2):409 43
2):409-43
Binon PP.Implants and components: entering the new Jan
millennium. Int J Oral Maxillofac Implants. 2000;15:76-94. 2008
English CE Implants Part three An
CE. Implants. three. Jan
overview.CDA J. 1988;16: 34-8. 2007
600
535
500
400 357
300
220
200
98
100
45
0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
University of Florida, Gainesville, 19.2.2008
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20

29. Implant Manufacturers
USA: 28
G
Germany:
y 25
Italy: 14
per 2 2007
2.2007
Korea: 8
(n=120)
Spain: 8
Brazil: 5
Switzerland : 5
Canada: 4
France: 4
Sweden: 4
Israel: 3
United Kingdom: 3
Other countries: 9
University of Florida, Gainesville, 19.2.2008

30. Implant Manufacturers
USA: 28 Germany: 32
G
Germany:
y 25 USA: 31
Italy: 14 Italy: 15
Korea: 8 Korea: 10
Feb. 2008?
Spain: 8 Spain: 10
Brazil: 5 Brazil: 9
Switzerland : 5 France: 7 (n=147!)
Canada: 4 Japan 6
France: 4 Switzerland : 6
Sweden: 4 Canada: 4
Israel: 3 Sweden: 4
United Kingdom: 3 Israel: 3
Other countries: 9 United Kingdom: 3
Feb 2007: n=120 Other countries:
University of Florida, Gainesville, 19.2.2008
9

31. Clinical
documentation of
the
th new i l t
implant
systems?
University of Florida, Gainesville, 19.2.2008

32. Implant systems introduced
since October 2003 ?
University of Florida, Gainesville, 19.2.2008

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

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

35. New Implant materials
University of Florida, Gainesville, 19.2.2008

36. New Implant surface treatment
Magnesium ion incorporated, oxidized
implants ? Dr Young-Taeg Sul - Korea
Sul YT, et al.
Biomaterials. 2005
Nov;26(33):6720-30
Sul YT, et al. Int J Prosthodont. 2006;19:319-28
University of Florida, Gainesville, 19.2.2008

37. Implant surface treatment
Magnesium ion incorporated, oxidized
implants ? Dr Young-Taeg Sul - Korea
Sul YT, et al.
Biomaterials. 2005
Nov;26(33):6720-30
Sul YT, et al. Int
J Prosthodont.
2006;19:319-28
University of Florida, Gainesville, 19.2.2008

38. Clinical trials – Dental implants
350
300
250
200
150
1 0 309
263 282
233 242
100
175
142
50 85
57
0 1 2 1 0 0 4 4 4 7 14 16 28
67
9
1
3
4
6
8
0
2
4
6
8
0
2
4
6
8
0
2
4
6
-6
-7
-7
-7
-7
-7
-8
-8
-8
-8
-8
-9
-9
-9
-9
-9
-0
-0
-0
-0
19
68
70
72
73
75
77
79
81
83
85
87
89
91
93
95
97
99
01
03
05
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
University of Florida, Gainesville, 19.2.2008

39. Clinical trials – Dental implants
180 168
160 147
140 138 144
140 131 133
122 123
120 111 109
102
100
76 72
80
66
60
46
37 39
40 34
22
20 15 12 16
0
86
87
88
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
86
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
9
<1
University of Florida, Gainesville, 19.2.2008

40. Clinical trials – Dental implants
Clinical trials since 2003 = 455
Brånemark / Replace x8
ITI /Straumann x6
3i/Osseotite x2
Frialit2/Frialit+/Frialoc/Frios 1
2
Astra 1
~75%
University of Florida, Gainesville, 19.2.2008

41. Clinical l
Cli i l relevance of
f
animal models f
i l d l for
predicting implant
therapy outcomes?
University of Florida, Gainesville, 19.2.2008

42. The relevance of data from
animal models to predict
longitudinal trial results?
is high?
University of Florida, Gainesville, 19.2.2008

43. The relevance of data from
animal models to predict
longitudinal trial results?
is high?
is of little or no value?
London et al. 2002; Novaes et al. 2002;
Carlsson et al 1988; Gotfredsen et al 1992;
al. al.
Vercaigne et al. 1998, 2000.
Offers some indications within a midrange
of roughness?
Wennerberg & Albrektsson 2000
Albrektsson,
University of Florida, Gainesville, 19.2.2008

44. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
University of Florida, Gainesville, 19.2.2008

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

46. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
Model used?
University of Florida, Gainesville, 19.2.2008

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

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

49. University of Florida, Gainesville, 19.2.2008

50. Parameters affecting histologic/biomechanical data
Sykaras et al., 2000
University of Florida, Gainesville, 19.2.2008

51. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
Model used?
Roughness characterization?
University of Florida, Gainesville, 19.2.2008

52. University of Florida, Gainesville, 19.2.2008

53. University of Florida, Gainesville, 19.2.2008

54. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
Model used?
Roughness characterization?
Measuring device?
University of Florida, Gainesville, 19.2.2008

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

56. Grit-blasted and etched Microfabricated and etched
Scanning EM
g
Interference
microscopy
Non-contact
laser
profilometry
University of Florida, Gainesville, 19.2.2008
Wieland et al. 2001

57. Grit-blasted and etched
Laser
profilometry
Interference
microscopy
Scanning EM
University of Florida, Gainesville, 19.2.2008
Wieland et al. 2001

58. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
Model used?
Roughness characterization
Measuring device
Consistency of results?
University of Florida, Gainesville, 19.2.2008

59. University of Florida, Gainesville, 19.2.2008

60. University of Florida, Gainesville, 19.2.2008

61. Relevance animal models vz.
longitudinal t i l results?
l it di l trial lt ?
Surface topography description?
Model used?
Roughness characterization?
Measuring device?
Consistency of results?
Surgical technique for placement?
University of Florida, Gainesville, 19.2.2008

62. Oral implants, the state of the science
and practice
www.torontoimplantconference.ca
University of Florida, Gainesville, 19.2.2008

63. University of Florida, Gainesville, 19.2.2008

64. THE EFFICACY OF DENTAL
IMPLANTS: EVIDENCE-BASED
OVERVIEWS
From 11 Cochrane reviews on
osseointegrated dental implants
Last update, Jan 2007
Esposito, Coulthard, Worthington;
Thomson, (Wennerberg, Jokstad et al.)

65. Cochrane systematic reviews
1. Fresh extraction sockets 2006
2. Perimplantitis 2006 ver.2
3. Bone augmentation techniques 2006 ver.2
4. Zygomatic implants 2005 ver.2
5. Various implant systems 2003 ver.3
6. Immediate/early or delayed loading 2004 ver.2
7. Maintenance 2004 ver.2
8. Hyperbaric oxygen therapy 2003
9.
9 Use of prophylactic antibiotics 2003
10. Surgical techniques 2003
11.
11 Preprosthetic surgery vs implants 2002
University of Florida, Gainesville, 19.2.2008

66. 1. Fresh extraction sockets
Last literature search: Aug 2006
2 RCTs – 96 patients
Conclusion:
May ff
M offer some advantages i t
d t in terms
of patient satisfaction and aesthetics
possibly by preserving alveolar bone
bone.
Properly designed RCTs are still
needed to fully evaluate the potential
advantages and risks of this treatment
modality since more complications
and failures may occur

67. 2. Perimplantitis - ver 2 2006
2.
Last literature search: March 2006
5 RCTs – 134 patients
Conclusion:
There is no reliable evidence
suggesting which could be the most
effective interventions for treating
perimplantitis.
i l titi

68. 3. Bone augmentation
techniques – ver 2 2006
ver.
Last literature search: October 2005
13 RCTs – 330 patients
RCT ti t
Conclusion:
Major b
M j bone grafting procedures of extremely
fti d f t l
resorbed mandibles may not be justified.
Bone substitutes may replace autogenous
bone for sinus lift procedures of extremely
atrophic sinuses.
p
Both guided bone regeneration (GBR)
procedures and distraction osteogenesis can
augment b
t bone vertically, b t it i unclear which
ti ll but is l hi h
is the most efficient technique.

69. 4. Zygomatic implants –
ver 2. 2005
Last literature search: May 2005
0 RCTs
Conclusion:
Cannot answer whether Zygomatic
implants without bone grafting
versus conventional i l
i l implants i
in
grafted or regenerated bone is
superior

70. 5. Various implant
characteristics & systems
ver.3 -2005
Last literature search: June 2004
12 RCTs with 512 participants and 12
different implant systems ( RCTs were
p y (19
excluded). 4 RCTs with a 5-year follow-up
Conclusion:
Minor differences in marginal bone loss and
in th
i the occurrence of perimplantitis. N
f i l titi No
statistically significant difference in failure
rates. W d not k
t We do t know whether any i l t
h th implant
system is superior to the others.

71. 6. Immediate, early or
conventional loading -
ver.2-2004
Last literature search: February 2004
5 RCTs with 124 participants (2 RCTs
excluded)
l d d)
Conclusion:
While it is possible to successfully load
oral implants immediately after their
p y
placement in mandibles of adequate bone
density and height of carefully selected
y g y
patients, it is yet unknown how predictable
this approach is.

72. Thank you for your
kind tt ti
ki d attention
University of Florida, Gainesville, 19.2.2008