Clinical Classification of Bone Augmentation Procedure Failures in the Atrophic Anterior Maxillae: Esthetic Consequences and Treatment Options

Although the number of complications and failures in bone augmentation procedures is still relatively high, these problems remain poorly documented. Moreover, the literature concerning reconstructive techniques and the treatment of their complications in the anterior areas rarely considers the final esthetic result. The aim of this paper is to propose a new classification of bone augmentation complications in the esthetic area, providing treatment guidelines useful for the management of these cases. Failures of bony regeneration procedures can be mainly divided into partial failures and complete failures. A partial failure can be solved with a corrective surgical intervention: this second surgery can have success or may not be able to provide the desired esthetic result. When the bone reconstructive procedure fails totally, a complete failure occurs and the whole procedure has to be repeated. This new intervention can have success but also this new reconstructive surgery can fail in the same way as the first, causing important damage and a compromise solution that will hardly be acceptable from an esthetic point of view. Bone augmentation techniques are not completely predictable and are not always able to guarantee the expected result, especially in the atrophic anterior maxilla. Complications and failures can often occur and this possibility must always be clearly explained to those patients with high esthetic demands and expectations

Immediate Loading of 3 Mm-diameter Implants as an Alternative to Horizontal Bone Augmentation for Placing Normal Diameter Implants: Four-month Post- Loading Results from a Multicentre Randomised Controlled Trial

PURPOSE. To evaluate the effectiveness of immediately loaded 3 mm-diameter implants in alternative to horizontal bone augmentation procedures to allow placement of implants with a conventional diameter of 4 mm. MATERIALS AND METHODS. Forty-five partially edentulous patients with a bone width of between 4 and 5 mm 3 mm below the crest in areas requiring one to three adjacent implants were randomised, according to a parallel-group design, to receive one to three 3.0 mm-wide implants to be loaded immediately (23 patients) or horizontal crest augmentation with a granular bone substitute covered with a bone lamina for placing, after 6 months of healing, one to three implants at least 4 mm wide (22 patients) at two centres. Implants at augmented sites were left to heal unloaded for 4 months. Four mm-diameter implants were restored using provisional screw-retained reinforced acrylic prostheses, replaced after 4 months by definitive prostheses. Three mm-diameter implants were loaded immediately (if the insertion torque was ≥ 35 Ncm) or after 4 months with definitive metal-composite prostheses. Patients were followed-up to 4-month post-loading. Outcome measures were: prosthesis and implant failures, any complication, peri-implant marginal bone level changes, and patient satisfaction. RESULTS. No patient dropped out. In three patients, five 3 mm-diameter implants could not be inserted with a torque of 35 Ncm, so were submerged unloaded for 4 months. Two implants failed in two patients from the augmented group (P [Fisher’s exact probability test] = 0.2333; difference in proportion =-0.09; CI 95%-0.24 to 0.07) and neither patient was fitted with a definitive prosthesis. Three patients with small diameter implants were affected by three complications versus nine augmented patients with 10 complications, the difference being statistically significant (P [chi-square test] = 0.0346; difference in proportion =-0.28; CI 95%-0.50 to-0.01). Patients with 3 mm-diameter implants lost on average 0.09 mm of peri-implant bone at 4 months, while augmented patients lost 0.26 mm, a statistically significant difference (mean difference = 0.17 mm, 95% CI 0.02 to 0.31, P = 0.0235). All patients were fully satisfied with both function and aesthetics, with two exceptions: one patient from the 3-mm group was only partially satisfied with both aesthetics and function, and one patient from the augmentation group was only partially satisfied with the aesthetics. However, all patients would undergo the same procedure again. CONCLUSIONS. Four months after loading, patients treated using 3 mm-wide implants displayed better results than those horizontally augmented to receive 4 mm-wide im-plants. Three mm-wide implants might therefore be a preferable choice with respect to bone horizontal bone augmentation, the treatment being less invasive, faster, cheaper, and associated with less morbidity; however, 5-to 10-year post-loading data will be necessary before reliable recommendations can be made. CONFLICT OF INTEREST STATEMENT. Global D (Brignais, France) partially supported this trial and donated the implants and prosthetic components. OsteoBiol (Tecnoss, Giaveno, Italy) donated the biomaterials used for bone augmentation. However, the data property belonged to the authors and neither Global D nor OsteoBiol interfered in any way with the conduct of the trial or the publication of the results

Regionalization of ports as a strategic leverage to improve competitiveness. A study on central italy ports and related hinterland

Nowadays, the success of a maritime port does not depend anymore on its traditional intrinsic points of strength, such as the internal capacity, but also on its ability to effectively integrate the development of its hinterland into business relations and supply chains. Mediterranean ports can get competitive, if specific "regionalization" processes are launched and supported. Key point for this strategy is the hinterland involvement: logistics and transports integration, railways, realization and development of dryports, terminals, distribution centres. All these are core elements for this purpose. The overall focus has changed from port performances to performance of the entire supply chain in the port-hinterland relationship. This is what it is going to do the Port of Civitavecchia, the most important port in Lazio Region, would like to become the central point into commercial, industrial and infrastructural development of central Italy. The development of railway terminal and of regional road network for the developing of intermodal logistics chain, of the industrial port activities (shipbuilding sector and oil bunkering), of trade relations with Fiumicino Airport and with the roman agroindustrial sector, of logistics relations with the dryport of Orte and with the intermodal terminal (road-railway) of Pomezia Santa Palomba, are some of the activities planned and undertaken by the port for improving the regionalization of Civitavecchia. Aim of this paper is to show and underline how these regionalization processes can increase the development, and so benefit the entire regional hinterland and the competitiveness and attraction of the entire port system. A model to estimate the regionalization effect has been designed by the authors and implemented to make a comparison analysis between Civitavecchia and competing ports. © 2021 Georg Thieme Verlag. All rights reserved

Posterior Jaw Rehabilitation Using Partial Prostheses Supported by Implants 4.0 X 4.0 Mm or Longer: Three-year Post- Loading Results of a Multicentre Randomised Controlled Trial

PURPOSE. To evaluate whether 4.0 x 4.0-mm dental implants could be viable alternatives to implants of length at least 8.5 mm when placed in posterior jaws with adequate bone volumes. MATERIALS AND METHODS. One hundred and fifty patients with posterior (premolar and molar areas) jaws having at least 12.5 mm bone height above the mandibular canal or 11.5 mm below the maxillary sinus, as applicable, were randomised according to a paral-lel-group design and received one to three 4.0 mm-long implants or one to three implants which were at least 8.5 mm-long at three treatment centres. All implants had a diameter of 4.0 mm. Implants were loaded with permanent screw-retained prostheses after 4 months. Patients were followed-up until 3-year post-loading, and outcome measures considered were prosthesis and implant failure, any complications, and changes in pe-ri-implant marginal bone levels. RESULTS. Seventy-five patients were randomly allocated to each group. Drop-outs at 3-year post-loading assessment were five patients from the long implant group and three from the short implant group. Up to 3 years post-loadings, three patients lost one 4.0 mm-long implant each, in comparison to two patients who lost one long implant each (difference in proportion =-0.013; 95% CI:-0.079 to 0.054; P = 1). All failures occurred before loading; failed implants were replaced, delaying delivery of two prostheses in each group by several months (difference in proportion = 0; 95% CI:-0.061 to 0.062; P = 1). Five short-implant patients experienced six complications versus the three complications seen in three long implant patients (difference in proportion =-0.026; 95% CI:-0.103 to 0.053; P = 0.719). There were no statistically significant differences between groups in prosthesis failures, implant failures or complications. Patients with short implants lost on average 0.55 mm of peri-implant bone, and patients with longer implants lost 0.61 mm. There were no statistically significant differences between short and long implants in bone level changes up to 3 years (mean difference = 0.05 mm; 95% CI:-0.05 to 0.16; P = 0.221). CONCLUSIONS. Outcomes 3 years after loading were similar with 4.0 x 4.0 mm-long implants and 8.5 x 4.0 mm or longer implants in posterior jaws, in the presence of adequate bone volumes. However, 5 to 10-year post-loading data will be necessary before reliable recommendations can be made. CONFLICT OF INTEREST STATEMENT. Global D (Brignais, France) partially supported this trial and donated the implants and prosthetic components. OsteoBiol (Tecnoss, Giaveno, Italy) donated the biomaterials used for bone augmentation. However, the data property belonged to the authors and neither Global D nor OsteoBiol interfered in any way with the conduct of the trial or the publication of the results

Minimally invasive rehabilitation of a severely atrophic and fully edentulous maxilla using 4-mm-ultrashort implants: A case report with 1-year follow-up

This case report describes an alternative minimally invasive treatment option using 4-mm-long ultrashort implants placed to rehabilitate a severely atrophic edentulous maxilla. The patient, coming from a full removable denture, asked for an implant prosthesis avoiding reconstructive surgeries and expensive procedures. Considering that the mean available bone was about 4.8 mm in height on Cone Beam Computed Tomography (CBCT) scans, 6 implants were placed where bone volumes were sufficient to receive 4-mm-ultrashort implants. Six months after implant placement an implant-supported bar-retained overdenture prosthesis was delivered. The healing process was uneventful and 1 year after loading the result appears clinically and radiographically stable and the patient is fully satisfied. The described approach, despite some prosthetic compromises, within all the limitations of this case report, might be applied in selected cases, reducing rehabilitative times, possible complications and costs. However, longer follow-ups on large number of patients coming from Randomised Controlled clinical Trials (RCTs) are necessary before making more reliable recommendations

Short Implants Versus Bone Augmentation and Longer Implants in Atrophic Maxillae. Five Year Post Loading Results of a Randomised Controlled Trial

PURPOSE. To evaluate whether short (5 to 8.5 mm) dental implants could be a suitable alternative to longer (at least 11.5 mm long) implants for supporting dental prostheses placed in atrophic fully edentulous maxillae augmented with autogenous bone. MATERIALS AND METHODS. Twenty-eight patients with fully edentulous atrophic maxillae having 5 to 9 mm of residual crestal bone height at least 5 mm thick, as measured on CT scans, were randomised into two groups, either to receive four to eight short (5 to 8.5 mm) implants (15 patients) or autogenous bone from the iliac crest to allow the place-ment of at least 11.5 mm-long implants (13 patients). Both bone blocks and windows at lifted maxillary sinuses were covered with rigid resorbable barriers. Grafts were left to heal for 4 months before placing implants, which were submerged. After 4 months, pro-visional reinforced acrylic prostheses or bar-retained overdentures were delivered. Pro-visional prostheses were replaced after 4 months by definitive screw-retained metal-re- sin cross-arch restorations. Outcome measures were: Augmentation, prosthesis or implant failures, any complications, peri-implant marginal bone level changes, and pa-tient satisfaction. Patients were followed-up until 5 years after loading. RESULTS. All patients could be rehabilitated with implant-supported prostheses, but four patients dropped-out from the augmentation group and three from the short implant group. One bilateral sinus lift procedure failed due to infection, though short implants could be placed. Four implants failed in four patients from the augmentation group ver-sus three short implants in three patients (Fisher's exact test P = 0.6500; difference in proportions = -0.17; 95% CI -0.51 to 0.21). No prosthesis failed. Significantly more complica-tions occurred in augmented patients: 12 complications occurred in nine augmented pa-tients versus one complication in the short implant group (Fisher's exact test P = 0.0003; difference in proportions = -0.82; 95%o CI -0.97 to -0.41). Periapical radiographs of only four patients were readable, so no bone level could be measured at 5 years after loading. With the exception of three patients from the augmentation group, who were only partially satisfied with function, all remaining patients were fully satisfied with the treatment (P = 0.0957); all would have the treatment again. CONCLUSIONS. This study showed that in patients with fully edentulous atrophic maxillae, short implants can be a preferable alternative to longer implants placed in bone aug-mented with autogenous bone, the treatment being less invasive, cheaper, faster and associated with fewer complications

Conventional Drills Versus Piezoelectric Surgery Preparation for Placement of Four Immediately Loaded Zygomatic Oncology Implants in Edentulous Maxillae: 3 Year Results of a Within Person Randomised Controlled Trial

PURPOSE. A within-person randomised controlled trial to compare the outcome of site preparation for two zygomatic oncology implants per zygoma using conventional preparation with rotary drills or piezoelectric surgery with dedicated inserts. MATERIALS AND METHODS. Twenty edentulous patients with severely atrophic maxillae and insufficient bone volumes for placing dental implants with less than 4 mm of bone height subantrally had their hemi-maxillae randomised according to a within-patient study design into implant site preparation with either conventional rotational drills or piezoelectric surgery. Two zygomatic oncology implants (unthreaded coronal portion) were placed in each hemi-maxilla. Implants that achieved an insertion torque of greater than 40 Ncm were immediately loaded with provisional screw-retained metal-reinforced acrylic prostheses. Outcome measures were: prosthesis and implant failures, any com-plications, time to place the implants, presence of post-operative haematoma, and patient preference, as assessed by blinded assessors when possible. All patients were followed up for 3 years after loading. RESULTS. In two patients, drills had to be used in the piezoelectric surgery arm in order to prepare implant sites properly. One implant from the conventional drill group did not achieve an insertion torque of greater than 40 Ncm since the zygoma fractured. Three patients dropped out. Two distal oncology implants failed in the same patient (one per group), who was not prosthetically rehabilitated. Six patients experienced at least one complication at drilled sites and five at piezoelectric surgery sites (three patients had bilateral complications), the difference not being statistically significant (odds ratio = 1.5; P [McNemar’s test] = 1.0; 95% CI of odds ratio: 0.25 to 8.98). Implant placement with con-vention drills took on average 14.35±1.76 minutes vs. 23.50±2.26 minutes with piezoelectric surgery, the implant placement time being significantly shorter with conventional drilling (difference = 9.15±1.69 minutes; 95%CI: 8.36 to 9.94 minutes; P = 0.000). Post-operative haematomas were larger at drilled sites in 11 patients and similar at both sides in nine patients (chi-square = 20.4; df = 3; P = 0.0001), and 16 patients found both techniques equally acceptable while four preferred piezoelectric surgery (chi-square = 34.4; df = 3; P<0.0001). CONCLUSIONS. Although these results may be system-dependent, and therefore cannot be generalised to other zygomatic systems with confidence, both drilling techniques achieved similar clinical outcomes. However, conventional drilling required 9 minutes less and could be used in all instances, though it was more aggressive

Immediate, Early (6 Weeks) and Delayed Loading (3 Months) of Single, Partial and Full Fixed Implant- Supported Prostheses: Three-year Post- Loading Data From a Multicentre Randomised Controlled Trial

PURPOSE. To compare the clinical outcomes of single, partial and complete fixed im-plant-supported prostheses immediately loaded (within 48 hours), early loaded at 6 we-eks, and conventionally loaded at 3 months (delayed loading). MATERIALS AND METHODS. Fifty-four patients (18 requiring single implants, 18 partial fixed prostheses, and 18 total fixed cross-arch prostheses) were randomised in equal numbers in two private practices to immediate loading (18 patients), early loading (18 patients), and conventional loading (18 patients) according to a parallel group design with three arms. To be immediately or early loaded, implants had to be inserted with a torque superior to 40 Ncm. Implants were initially loaded with provisional prostheses, replaced after 4 months by definitive ones. Outcome measures were prosthesis and implant failu-res, complications and peri-implant marginal bone levels. RESULTS. Two conventionally loaded patients rehabilitated with cross-arch fixed total prostheses dropped-out before 3-year post-loading follow-up. No implant failed. One early-loaded partial prosthesis had to be remade (P = 1.0). Three complications occurred in the immediately loaded group, two in the early-loaded and one in the conventionally loaded group with no statistically significant differences across groups (P = 0.861). Pe-ri-implant marginal bone loss was-0.04 ± 0.85 mm at immediately loaded implants,-0.01 ± 0.55 mm at early-loaded implants and 0.33 ± 0.36 mm at conventional loaded implants with no statistically significant differences between the three loading strategies (P=0.191). CONCLUSIONS. All loading strategies were highly successful, and no differences were observed in terms of implant survival and complications when implants were loaded immediately, early or conventionally

Dental Implants with Internal versus External Connections: 10-year Post-Loading Results of a Pragmatic Multicentre Randomised Controlled Trial

PURPOSE. To compare the effectiveness of identical implants with internal or external connections. MATERIALS AND METHODS. One hundred and twenty patients with any type of edentulism (single tooth, partial or total edentulism) requiring one implant-supported prosthesis were randomly allocated at four centres to two equal groups to receive either implants with external connection (EC) or implants of the same type but with internal connection (IC) (EZ Plus, MegaGen Implant, Gyeongbuk, South Korea). Due to slight differences in implant design/components, IC implants were platform-switched while ECs were not. Patients were followed up for 10 years after initial loading. Outcome measures were: Any prosthesis/implant failures, complications, and marginal bone level changes, as assessed by blinded outcome assessors whenever possible. RESULTS. Sixty patients received 96 EC implants and 60 patients 107 IC implants. Eight patients from the EC group and nine from the IC group dropped out, but all remaining patients were followed up to 10 years post-loading. Two EC patients experienced implant and prosthesis failures versus three IC patients (P = 0.631, diff = 0.02, 95% CI: -0.07 to 0.11). Fifteen complications occurred in 13 EC patients versus 13 complications in 11 IC patients (P = 0.720, diff. = -0.03, 95%o CI: -0.19 to 0.13). There were no statistically significant differences for prosthesis and implant failures and complications between the different con-nection types. Ten years after loading, both groups had lost a significant amount of bone (1.01 mm at EC implants and 1.27 mm at IC implants), but there was no statistically signi-ficant difference in estimated marginal bone levels between the two groups (diff. = 0.07 mm, 95% CI: -0.41 to 0.54 mm, P (ANCOVA) = 0.782). CONCLUSIONS. Acknowledging the difference between EC and IC implants in terms of neck design and platform-switching, 10-year post-loading data revealed no statistically significant differences between the two connection types, and clinicians can therefore choose which they prefer. CONFLICT OF INTEREST STATEMENT. This trial was partially funded by MegaGen Implant, Gyeongbuk, South Korea, the manufacturer of the implants evaluated in this investigation. However, the resulting data belonged to the authors and by no means did the manufacturer interfere with the conduct of the trial or the publication of the results

A proposed protocol for ordinary and extraordinary hygienic maintenance in different implant prosthetic scenarios

Prevention of peri-implantitis involves the early diagnosis of peri-implant mucositis. This article presents a protocol of hygienic maintenance in different implant prosthetic scenarios: single crown, fixed partial prosthesis, fixed full-arch, and overdentures. Others clinical conditions have to be taken into consideration: patient compliance; history of periodontitis; implants placed in augmented bone; short, zygomatic, pterygoid, and tilted implants; and complex prosthesis with false gingiva. Two levels of implant maintenance are described: ordinary, performed by dental hygienist, and extraordinary, carried out by both dentist and hygienist. Extraordinary maintenance also involves the removal and decontamination of the prosthetic structure. To obtain an effective prevention of peri-implantitis, one must plan ordinary and extraordinary hygiene in relation to the type of rehabilitation and clinical parameters