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EDI 2Product Studies

A twelve-month preliminary study

Immediate Functional Loading of Implants in Controlled Diabetics Luca Di Alberti, DDS, PhD1, Federica Donnini, RDH1, Claudio Di Alberti, DDS, MSc1, Raffaella Amoruso, DDS3, Rossi Germano4 and Michele Camerino, DDS2 The increased prevalence of diabetes mellitus has become a public-health problem in several countries. Although a direct relationship with periodontal disease has been shown, little is known about the impact of dental implants on diabetics. This article presents preliminary positive and encouraging results, demonstrating that the osseointegration of Seven and Mistral implants (MIS, Israel) and subsequent soft-tissue healing in the context of immediately loaded full-arch restorations have no adverse effect on an existing diabetes condition.

Diabetes mellitus is a metabolic disorder characterized by an increase in plasma glucose levels. This hyperglycaemia is the result of deficient insulin secretion, insulin action, or both. Chronic hyperglycaemia affects several tissues and organs, produces an inflammatory effect and has been shown to be a stimulus for bone resorption in vitro. Bone loss in diabetes does not seem to depend as much on an increase in osteoclastogenesis as on a reduction in bone formation [1]. It is known that hyperglycaemia inhibits osteoblastic differentiation and alters the response of the parathyroid hormone that regulates the metabolism of phosphorus and calcium [2], has a negative effect on the bone matrix and its components and also affects the adherence, growth and accumulation of extracellular matrix [3]. Periodontal disease is frequently present in patients with diabetes; it is considered one of the complications of this disease. Analysis of the effect of diabetes on implants has revealed an alteration in bone remodelling processes and mineralization deficiencies, leading to less osseointegration. Some studies have shown that, although the amount of bone formed is similar when comparing animals induced with diabetes with controls, there is a reduction in the bone-implant contact in diabetics [4, 5]. This article covers twelve months of follow-up of the clinical and radiological implications of diabetes for the prognosis of immediately loaded dental implants for full-arch restorations.

Fig. 1 Mistral and Seven Implants inserted in the edentulous maxilla and loaded.

Fig. 2 Prosthetic components during try-in.

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Materials and methods 2

The study was performed in two clinical centres by two investigators who followed the same clinical protocol for immediate occlusal loading of implants. All patients received sandblasted/acid-etched Seven and Mistral screw implants (MIS, Schlomi, Israel). The surgical protocol provided for crestal implant placement was followed as described in the literature (Figs. 1 and 2) [6, 7].

3

4

Private practice, Chieti, Italy Private practice, Pescara, Italy Private practice, Campobasso, Italy Dental technician, Alba Adriatica, Italy


EDI

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Product Studies

Fig. 3 Prosthetic components for immediate loading. Fig. 4 Final provisional prosthesis with titanium abutments.

All clinicians followed the implant manufacturer’s instructions for implant site preparation and implant insertion procedure. The initial primary stability was assessed by setting the insertion torque of the surgical unit and recorded according to the following classification: “tight” when torque was >32 Ncm, “firm” between 25 and 32 Ncm or “loose” when <25 Ncm [8].

Prosthetic procedures The design of the prosthesis was determined by a collaborative effort between the dental surgeon, the restorative dentist, the dental technician and the patient within the framework of with the study objectives. A metal-reinforced acrylic provisional bridge was relined over provisional cylinders and immediately screwed onto the abutments (Figs. 3 and 4). The occlusion was carefully checked. No specific diet was recommended to the patients. Periapical radiographs were taken after three, six and twelve months of occlusal loading.

was 45.5 years (range: 33 to 69 years). All patients were rehabilitated with a fixed prosthesis supported by Seven and Mistral implants. Six patients were smokers and reported consuming up to ten cigarettes per day. A total of 74 implants were inserted. The lengths and diameters of all the implants are summarized in Table 1. Fifty-six implants (75-68%) were inserted into maxillary anterior and posterior areas in normal or soft bone at a torque of between 35 and 50 Ncm (“firm”). Eighteen implants (24.32%) were placed in the interforaminal and posterior area of the mandible in dense or normal bone, utilizing an insertion torque of > 32 Ncm (“tight”). No deviations from the protocol were reported. Radiographic evaluation All the periapical radiographs of the inserted implants were evaluated for marginal bone changes and bone densitometry. Assessment of radiographic change in bone level over time showed no statistically significant differences in marginal bone loss between the mesial and distal sides at each time frame.

Results Between January and October 2006, ten patients (seven men and three women) were enrolled in the study. The average age at the time of implant surgery

Tab. 1 Lengths and diameters of the implants inserted.

Success rate None of the patients dropped out from the study. All implants were clinically stable and met the success criteria. The overall implant success rate was 100 percent.

Mistral 3.75

Mistral 4.10

Mistral 3.30

Mistral 3.75

Mistral 4.20

Total

10 mm

3

4

3

3

5

18

11,5 mm

6

7

4

9

10

36

13 mm

0

0

5

10

5

20

Total

9

11

12

22

20

74


EDI 4Product Studies Discussion Diabetes is currently classified as a relative contraindication for implant treatment. Compared with the general population, a higher failure rate has been seen in diabetic patients with adequate metabolic control [9].

The fact that most failures occur after the secondphase surgery and during the first year of functional loading may indicate that microvascular complications are one of the factors implicated in implant failures in diabetic patients [11].

Reviewing the literature, the survival rate for implants in diabetic patients ranges between 88.8% and 97.3% one year after placement, and 85.6 to 94.6% one year after insertion of the prosthesis. Another study carried out with 227 implants placed in 34 patients shows a success rate of 94.3% at the time of the second surgery, prior to the insertion of the prosthesis [10]. In a retrospective study with 215 implants placed in 40 diabetic patients, 31 failed implants were recorded, 24 of which (11.2%) occurred in the first year of functional loading. This analysis shows a survival rate of 85.6% after 6.5 years of functional use.

In view of the literature, the use of one-stage implants with cervical microthreads that were immediately loaded and did not require a second surgical step could be the principal reason for the clinical and radiological success seen in this study.

Contact Address Dr Luca Di Alberti Via Colonnetta, 22 66013 Chieti ITALY dialbertiluca@yahoo.it

References [1] Diabetes Control and Complications Trial Research Group. The effect of intensive treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993;329: 977-86.

[7] Horwitz J, Zuabi O, Machtei E. Radiographic changes around immediately restored dental implants in periodontally susceptible patients: 1-year results. Int J Oral Maxillofac Implants. 2008 May - Jun; 23(3): 531-8.

[2] Santana RB, Xu L, Babakhanlou C, Amar S, Graves DT, Trackman PC. A role for advanced glycation end products in diminished bone healing in type 1 Diabetes. Diabetes 2003;52: 1502-10.

[8] Testori T, Del Fabbro M, Feldman S, Vincenzi G, Sullivan D, Rossi R Jr, Anitua E, Bianchi F, Francetti L, Weinstein RL. A multicenter prospective evaluation of 2-months Osseotites implants placed in the posterior jaws: 3-year follow-up results. Clinical Oral Implants Research 2002; 13: 154-161.

[3] Weiss RE, Gora A, Nimni ME. Abnormalities in the biosynthesis of cartilage and bone proteoglycans in experimental diabetes. Diabetes 1981;30: 670-77. [4] McCracken M, Lemons JE, Rahemtulla F, Prince CW, Feldman D. Bone response to titanium alloy implants placed in diabetic rats. Int J Oral Maxillofac Implants 2000;15: 345-54. [5] Nevins ML, Karimbux NY, Weber HP, Giannobile WV, Fiorellini JP. Wound healing around endosseous implants in experimental diabetes. Int J Oral Maxillofac Implants 1998;13: 620-29. [6] Darvanapah M, Martinez H, Tecucianu J-F. Apical-coronal position: recent surgical proposals. Technical note. International Journal of Oral & Maxillofacial Implants 2000;15: 865-872.

[9] Morris HF, Ochi S, Winkler S. Implant survival in patients with type 2 diabetes: placement to 36 months. Ann Periodontol 2000; 5: 157-65. [10] Balshi TJ, Wolfinger GJ. Dental implants in the diabetic patient: a retrospective study. Implant Dent 1999;8: 355-59. [11] Farzad P, Andersson L, Nyberg J. Dental implant treatment in diabetic patients. Implant Dent 2002;11: 262-67.

Alberti 2009 EDI  

Immediate Functional Loading of Implants in Controlled Diabetics

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