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Limited Evidence Suggests that the Immediate Placement of Dental Implants Into Infected Sites Versus Noninfected Sites in the Esthetic Zone Show Comparable Clinical Results
The Journal of EVIDENCE-BASED DENTAL PRACTICE
REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
LIMITED EVIDENCE SUGGESTS THAT THE IMMEDIATE PLACEMENT OF DENTAL IMPLANTS INTO INFECTED SITES VERSUS NONINFECTED SITES IN THE ESTHETIC ZONE SHOW COMPARABLE CLINICAL RESULTS For patients who need immediate implant treatment in the esthetic zone, does the insertion of a dental implant into an infected site hold more risk than insertion into a healthy site and what can be done during treatment to improve the prognosis? REVIEWER
AHMED YASEEN ALQUTAIBI
A
SORT SCORE B C
N/A
SORT, Strength of Recommendation Taxonomy.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Immediate placement of dental implants into infected versus noninfected sites in the esthetic zone: A systematic review and meta-analysis. Chen H, Zhang G, Weigl P, Gu X. J Prosthet Dent 2018; 120(5):658-71.
LEVEL OF EVIDENCE 1 2 3 See page 8A for complete details regarding SORT and LEVEL OF EVIDENCE grading system.
SUMMARY Selection Criteria
SOURCE OF FUNDING This study was funded by the authors.
A thorough search was conducted between January 2009 and October 2017 in the PubMed, ISI Web of Knowledge, and Cochrane Library databases along with cross-checking of the identified article references. Clinical trials that were published in English and included a follow-up period of at least 1 year were selected.
TYPE OF STUDY/DESIGN Systematic review and analysis.
The titles and abstracts of eligible articles were screened by 2 reviewers. Full text was assessed when the studies met the eligibility criteria. Studies were included after agreement, and in cases of disagreement, consensus was reached through discussion among the authors.
meta-
KEYWORDS Immediate implant placement, Esthetic zone, Periapical lesion, Periodontal lesion, Failure rate J Evid Base Dent Pract 2019: [180-182] 1532-3382/$36.00 ª 2019 Elsevier Inc. All rights reserved. doi: https://doi.org/10.1016/ j.jebdp.2019.05.002
180
Volume 19, Number 2
Key Study Factor The clinical trials compared the immediate implant placement in healthy versus periapically or periodontally infected sites in the esthetic zone.
Main Outcome Measure Implant failure rates, bone level changes, and gingiva level changes.
Main Results Of 31 articles selected, 9 articles were included in this review, and 22 articles were excluded. Nine studies reported implant failure rate; 6 studies were conducted to assess the outcome of immediately placed implants in sockets with or without periapical pathology. In 1 study, the prognosis for immediate dental implants
The Journal of EVIDENCE-BASED DENTAL PRACTICE
placed in fresh sockets with or without periodontal lesions was investigated. The other 2 studies analyzed the treatment outcomes of immediate implant placement in sites demonstrating periodontal or periapical pathology. Clinical parameters such as bone levels and gingival esthetics were assessed in 4 studies.
Publication bias was assessed despite the fact that fewer than 10 studies were included in this systematic review. Guidelines for conducting funnel plot asymmetry tests recommend the inclusion of at least 10 studies to maintain sufficient power for distinguishing chance from real asymmetry.4
A total of 1735 participants (infected group, n 5 758; noninfected group, n 5 977) were included in this metaanalysis. The pooled data showed nonstatistically significant differences between the failures rates of the infected and noninfected groups (relative risk 5 1.68; 95% confidence interval, 0.87 to 3.26; P 5 .124). Similarly, nonstatistically significant differences were found in bone and gingiva level changes between the 2 groups at all follow-up time points.
The results of this review must be interpreted with caution because of the small sample sizes of the included studies. Three of included studies are of retrospective design and are associated with a high risk of bias. Moreover, the presence of heterogeneity between the included studies might affect treatment outcomes. These confounders include different implant systems with variable designs and surfaces placed in different tooth regions, different loading protocols, and the use of different augmentation materials. Moreover, this review included retrospective studies that are associated with a high risk of bias.
COMMENTARY AND ANALYSIS Immediate implant placement in a healthy tooth extraction socket is well documented to have predictable survival rates and satisfactory esthetic outcomes.1,2 However, teeth needing extraction are often associated with periapical or periodontal infection, resulting in a risk of microbial interference that may inhibit osseointegration and lead to implant failure.3 The strength of this systematic review and meta-analysis include the authors’ use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following this methodology helps to ensure a more consistent, higher quality outcome. The reviewers performed a thorough and comprehensive search strategy, including searching databases as well as hand searching to identify any additional relevant publications. More than 1 reviewer screened titles and abstracts, extracted data, and assessed the quality of the included trials. Disagreements were resolved by discussion between the authors. The weaknesses of this review include the lack of identification of any prior published review protocol, which is an important prerequisite in conducting a systematic review and enhances the transparency of its search strategy. The authors did not indicate whether they searched the gray literature. The search was limited to English-language articles, which results in language bias and might omit important studies. However, the extent and effects of language bias may have diminished recently because of the shift toward publication of studies in English. Higgins et al4 reported that review authors may want to search without language restrictions, and decisions about including reports from languages other than English may need to be taken on a case-by-case basis.
Implications for Dental Practice With increased demand for the restoration of hopeless teeth in the esthetic zone and a high proportion of these teeth being associated with periapical or periodontal infection, immediate implant placement tends to be a safe choice and carry a clinically acceptable prognosis, provided that the treatment plan has been carefully considered. The following prerequisites should be considered: proper prescription of systemic antibiotics, use of an oral rinse before and after surgery, thorough debridement of the extraction sockets, and effective load management of interim and definitive restorations. The evidence of this systematic review is limited. Welldesigned randomized clinical studies that follow the Consolidated Standards of Reporting Trials statement, include a larger sample size, have a longer follow-up duration, and take into consideration possible confounding factors that are needed to clarify the effect of immediate implant placement in an infected site.
REFERENCES 1. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: implant survival. Int J Oral Maxillofac Implants 1996;11(2):205-9. 2. Tortamano P, Camargo LOA, Bello-Silva MS, Kanashiro LH. Immediate implant placement and restoration in the esthetic zone: a prospective study with 18 months of follow-up. Int J Oral Maxillofac Implants 2010;25(2):345-50. 3. Quirynen M, Gijbels F, Jacobs R. An infected jawbone site compromising successful osseointegration. Periodontol 2000 2003;33(1):129-44.
June 2019
181
The Journal of EVIDENCE-BASED DENTAL PRACTICE 4. Higgins JPT, Altmn DG, Gøtzsche P, et al. Cochrane bias methods group, Cochrane statistical methods group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J 2011;343: d5928.
182
Volume 19, Number 2
REVIEWER AHMED YASEEN ALQUTAIBI, BDS, MDSc, PhD Assistant Professor of Prosthodontics, College of Dentistry, Taibah University, Saudi Arabia, [email protected]; [email protected]
REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS
LIMITED EVIDENCE SUGGESTS THAT THE IMMEDIATE PLACEMENT OF DENTAL IMPLANTS INTO INFECTED SITES VERSUS NONINFECTED SITES IN THE ESTHETIC ZONE SHOW COMPARABLE CLINICAL RESULTS For patients who need immediate implant treatment in the esthetic zone, does the insertion of a dental implant into an infected site hold more risk than insertion into a healthy site and what can be done during treatment to improve the prognosis? REVIEWER
AHMED YASEEN ALQUTAIBI
A
SORT SCORE B C
N/A
SORT, Strength of Recommendation Taxonomy.
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Immediate placement of dental implants into infected versus noninfected sites in the esthetic zone: A systematic review and meta-analysis. Chen H, Zhang G, Weigl P, Gu X. J Prosthet Dent 2018; 120(5):658-71.
LEVEL OF EVIDENCE 1 2 3 See page 8A for complete details regarding SORT and LEVEL OF EVIDENCE grading system.
SUMMARY Selection Criteria
SOURCE OF FUNDING This study was funded by the authors.
A thorough search was conducted between January 2009 and October 2017 in the PubMed, ISI Web of Knowledge, and Cochrane Library databases along with cross-checking of the identified article references. Clinical trials that were published in English and included a follow-up period of at least 1 year were selected.
TYPE OF STUDY/DESIGN Systematic review and analysis.
The titles and abstracts of eligible articles were screened by 2 reviewers. Full text was assessed when the studies met the eligibility criteria. Studies were included after agreement, and in cases of disagreement, consensus was reached through discussion among the authors.
meta-
KEYWORDS Immediate implant placement, Esthetic zone, Periapical lesion, Periodontal lesion, Failure rate J Evid Base Dent Pract 2019: [180-182] 1532-3382/$36.00 ª 2019 Elsevier Inc. All rights reserved. doi: https://doi.org/10.1016/ j.jebdp.2019.05.002
180
Volume 19, Number 2
Key Study Factor The clinical trials compared the immediate implant placement in healthy versus periapically or periodontally infected sites in the esthetic zone.
Main Outcome Measure Implant failure rates, bone level changes, and gingiva level changes.
Main Results Of 31 articles selected, 9 articles were included in this review, and 22 articles were excluded. Nine studies reported implant failure rate; 6 studies were conducted to assess the outcome of immediately placed implants in sockets with or without periapical pathology. In 1 study, the prognosis for immediate dental implants
The Journal of EVIDENCE-BASED DENTAL PRACTICE
placed in fresh sockets with or without periodontal lesions was investigated. The other 2 studies analyzed the treatment outcomes of immediate implant placement in sites demonstrating periodontal or periapical pathology. Clinical parameters such as bone levels and gingival esthetics were assessed in 4 studies.
Publication bias was assessed despite the fact that fewer than 10 studies were included in this systematic review. Guidelines for conducting funnel plot asymmetry tests recommend the inclusion of at least 10 studies to maintain sufficient power for distinguishing chance from real asymmetry.4
A total of 1735 participants (infected group, n 5 758; noninfected group, n 5 977) were included in this metaanalysis. The pooled data showed nonstatistically significant differences between the failures rates of the infected and noninfected groups (relative risk 5 1.68; 95% confidence interval, 0.87 to 3.26; P 5 .124). Similarly, nonstatistically significant differences were found in bone and gingiva level changes between the 2 groups at all follow-up time points.
The results of this review must be interpreted with caution because of the small sample sizes of the included studies. Three of included studies are of retrospective design and are associated with a high risk of bias. Moreover, the presence of heterogeneity between the included studies might affect treatment outcomes. These confounders include different implant systems with variable designs and surfaces placed in different tooth regions, different loading protocols, and the use of different augmentation materials. Moreover, this review included retrospective studies that are associated with a high risk of bias.
COMMENTARY AND ANALYSIS Immediate implant placement in a healthy tooth extraction socket is well documented to have predictable survival rates and satisfactory esthetic outcomes.1,2 However, teeth needing extraction are often associated with periapical or periodontal infection, resulting in a risk of microbial interference that may inhibit osseointegration and lead to implant failure.3 The strength of this systematic review and meta-analysis include the authors’ use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following this methodology helps to ensure a more consistent, higher quality outcome. The reviewers performed a thorough and comprehensive search strategy, including searching databases as well as hand searching to identify any additional relevant publications. More than 1 reviewer screened titles and abstracts, extracted data, and assessed the quality of the included trials. Disagreements were resolved by discussion between the authors. The weaknesses of this review include the lack of identification of any prior published review protocol, which is an important prerequisite in conducting a systematic review and enhances the transparency of its search strategy. The authors did not indicate whether they searched the gray literature. The search was limited to English-language articles, which results in language bias and might omit important studies. However, the extent and effects of language bias may have diminished recently because of the shift toward publication of studies in English. Higgins et al4 reported that review authors may want to search without language restrictions, and decisions about including reports from languages other than English may need to be taken on a case-by-case basis.
Implications for Dental Practice With increased demand for the restoration of hopeless teeth in the esthetic zone and a high proportion of these teeth being associated with periapical or periodontal infection, immediate implant placement tends to be a safe choice and carry a clinically acceptable prognosis, provided that the treatment plan has been carefully considered. The following prerequisites should be considered: proper prescription of systemic antibiotics, use of an oral rinse before and after surgery, thorough debridement of the extraction sockets, and effective load management of interim and definitive restorations. The evidence of this systematic review is limited. Welldesigned randomized clinical studies that follow the Consolidated Standards of Reporting Trials statement, include a larger sample size, have a longer follow-up duration, and take into consideration possible confounding factors that are needed to clarify the effect of immediate implant placement in an infected site.
REFERENCES 1. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: implant survival. Int J Oral Maxillofac Implants 1996;11(2):205-9. 2. Tortamano P, Camargo LOA, Bello-Silva MS, Kanashiro LH. Immediate implant placement and restoration in the esthetic zone: a prospective study with 18 months of follow-up. Int J Oral Maxillofac Implants 2010;25(2):345-50. 3. Quirynen M, Gijbels F, Jacobs R. An infected jawbone site compromising successful osseointegration. Periodontol 2000 2003;33(1):129-44.
June 2019
181
The Journal of EVIDENCE-BASED DENTAL PRACTICE 4. Higgins JPT, Altmn DG, Gøtzsche P, et al. Cochrane bias methods group, Cochrane statistical methods group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J 2011;343: d5928.
182
Volume 19, Number 2
REVIEWER AHMED YASEEN ALQUTAIBI, BDS, MDSc, PhD Assistant Professor of Prosthodontics, College of Dentistry, Taibah University, Saudi Arabia, [email protected]; [email protected]