EAO Supplement Working Group 4 - EAO CC 2015 Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review

Clinical outcomes of implants placed with transcrestal maxillary sinus elevation: a systematic review and meta-analysis

This systematic review and meta-analysis assesses the clinical outcomes of implants inserted during or following transcrestal sinus lifts. The study protocol was prospectively registered on PROSPERO (CRD42024504513). PubMed, Web of Science, Embase, and Scopus databases were searched up to 21 February 2024, and randomised clinical trials utilising transcrestal sinus lifts were included. Qualitative and quantitative syntheses were conducted. A random effects model was used to pool the survival rate of implants placed with transcrestal sinus lifts using hand osteotomes without grafting, along with meta-regression and subgroup analyses. Funnel plots and Egger's linear regression were used to explore possible publication bias. Probabilities of less than 0.05 were considered significant. A total of 1807 records were identified after the initial search. Seventeen studies were included with 10 of them considered for meta-analysis. Studies used hand osteotomes, a combination of piezoelectric and hand osteotomes, drills, and smart lifts for sinus elevation. Only studies that used hand osteotomes reported subsequent vertigo and dizziness in patients. The meta-analysis showed a 100% (95% CI: 99% to 100%) survival rate for both grafted and non-grafted transcrestal sinus lifts using hand osteotomes. Meta-regression showed that follow-up time did not significantly affect the implants' survival. Subgroup analyses showed no significant difference between bone-level and tissue-level implants and one-stage or two-stage implants. On considering the limitations of this study it can be concluded that closed maxillary sinus elevation can be considered a relatively safe technique that is associated with a high survival rate. However, caution should be taken when using hand osteotomes because of a higher rate of sinus lining perforation and reported patient vertigo.

Clinical Performance of Extra-Short (≤5.5 mm) Compared to Longer Implants Splinted under the Same Prosthesis: A Randomized Clinical Trial

Objective: This randomized controlled split-mouth trial compared the performance of 5.5 mm length implants (test group; TG) splinted within the same fixed prosthesis as longer implants (≥6.5 mm; control group; CG) in posterior regions. Methods: The primary hypothesis was that implant length does not affect marginal bone loss (MBL) one year post-implantation, while the secondary hypotheses included implant survival, peri-implant clinical variables, and prosthetic complications. Fifteen patients (eight males, seven females) with a mean age of 67 ± 9 years were included. Results: No significant difference in the implant position between groups (p = 0.808) was observed. Implant diameters ranged from 3.00 to 4.25 mm, and the most common bone type was type I (67%). Bone density (p = 0.574) and implant insertion torque (p = 0.888) were similar between groups. Mesial MBL (mean: -0.1; range: -1.19 to 0.24 for TG, and -0.03; -1.75 to 0.45 for CG; p = 0.955) and distal MBL (mean: -0.05; range: -1.41 to 0.27 for TG, and 0.08; -1.45 to 0.72 for CG; p = 0.118) did not show statistical differences. There were no implant failures or technical complications. Conclusions: These findings suggest that 5.5 mm length implants could be a viable option for use in posterior regions, providing similar clinical outcomes to longer implants one year post-implantation.

Short (≤6 mm) compared with ≥10-mm dental implants in different clinical scenarios: A systematic review of randomized clinical trials with meta-analysis, trial sequential analysis and quality of evidence grading

AIM

To systematically identify, synthesize and critically summarize the available scientific evidence from randomized controlled trials (RCTs) regarding whether short (≤6 mm) perform as well as long (≥10 mm) implants regarding implant survival, marginal bone loss, and biologic and prosthetic complications in different clinical scenarios.

MATERIALS AND METHODS

Cochrane Collaboration's risk of bias tool and the GRADE approach were applied. Results were synthesized using random-effects meta-analyses assessed by trial sequential analyses.

RESULTS

Forty reports on 19 RCTs comprising 2214 (1097 short; 1117 long) implants were included. Moderate/high certainty/quality evidence demonstrated similar 5-year survival rates for ≤6-mm and ≥10-mm implants in non-augmented bone and full-mouth rehabilitation in either jaw, and for 6-mm implants in the maxilla instead of sinus lift. Nevertheless, the evidence for 5-year survival rates remains inconclusive or insufficient for the remaining combinations of implant lengths and clinical scenarios. They include 4-mm and 5-mm implants as alternatives to sinus lift as well as placing all implant lengths ≤6 mm instead of vertical ridge augmentation with long implants. Marginal bone level and short- and long-term biologic or prosthetic complications were similar.

CONCLUSIONS

Based on moderate/high certainty/quality evidence from 5-year RCTs, implants ≤6 mm may be viable alternatives to ≥10-mm implants in either jaw in native bone and full-arch rehabilitation, and 6-mm implants may be used as an alternative to sinus lift.

TRIAL REGISTRATION

PROSPERO ID: CRD42021254365.

Short Implants and Indirect Sinus Lift Versus Direct Sinus Lift With Standard-Length Implants: A Case Report

The choice of implant length in relation to the available bone quality and quantity and biting force is a critical factor in the success of implants and longevity of the prosthesis. Long implants have always been considered more desirable in this respect but in patients with advanced alveolar bone resorption, their placement is problematic due to the anatomic boundaries. This holds more true in relation to the posterior maxilla wherein the residual crestal bone height is usually compromised due to pneumatizing sinus floor. In this study, we have incorporated the use of short implants in conjunction with indirect sinus lift for cases with severely resorbed posterior maxillary edentulous regions to avoid direct sinus lift surgery and increase patient comfort. A 63-year-old patient had tooth 16 missing and wanted implant rehabilitation. The residual alveolar bone height was 3 mm. Short implant placement after indirect sinus lift was achieved with good primary stability. Prosthetic loading was performed after six months. One year follow-up showed no complaints or discomfort. In cases where the residual alveolar bone height of the edentulous space in the posterior maxilla was less than 4 mm, the use of indirect sinus lift with placement of short implants (height < 6 mm) proved to be advantageous over a direct sinus lift procedure with delayed placement of standard-length implants. This technique was less time-consuming, less surgically morbid, and more economical. The patient compliance was superior and no complaints were faced in a one-year follow-up period.

Additive Manufacturing Titanium Dental Implants Placed in Sinuses Grafted with 70HA:30-TCP: A One-Year Retrospective Study for Evaluation of Survival Rate

The present short-term retrospective study evaluated the implant survival rate and peri-implant bone loss around additive-manufactured titanium implants placed in sinuses grafted with Plenum Osshp (Plenum Bioengenharia, Jundia, SP, Brazil) (70HA:30β-TCP) material. A total of 39 implants were inserted after 23 sinus floor elevation procedures in 16 consecutive patients. Prosthetic rehabilitation included fixed partial prostheses (three units), single crowns (eleven units), and fixed full arches (three units). Clinical and radiographic parameters of implant-supported restorations were evaluated after at least one year of occlusal loading. The implant-crown success criteria included the absence of pain, suppuration, and clinical mobility, an average distance between the implant shoulder and the first visible bone contact (DIB) < 1.0 mm from the initial surgery, and the absence of prosthetic complications at the implant-abutment interface. The overall cumulative implant survival rate was 97.43%. No prosthetic complications at the implant-abutment interface were reported. After one year, the mean DIB was 0.23 mm ± 0.14. Within the limits of this retrospective study, it can be concluded that 70 HA:30 β-TCP allowed stable and reliable bone support to maintain healthy conditions around titanium dental implants produced by additive manufacturing.

Single crown restorations supported by 6-mm implants in the resorbed posterior mandible: A 10-year prospective case series

PURPOSE

To assess marginal bone level changes, implant and restoration survival, condition of the peri-implant mucosa, and the patient's satisfaction with the single restoration supported by a 6-mm long implant in the posterior mandible after 10 years in function.

MATERIALS AND METHODS

Twenty-one consecutive patients missing premolars or molars in the posterior mandible, with a bone volume consisting of a width of at least 6 mm and an estimated height of 8 mm between the top of the ridge and alveolar nerve, were included. Each patient received one or more 6-mm implants. After 3 months, the implants were restored with custom-made titanium abutments and cemented zirconia-based porcelain crowns. The clinical examination and radiograph data were assessed at restoration placement and after 12, 60, and 120 months. The patients answered a questionnaire to score their satisfaction before treatment and after 12, 60, and 120 months with the restoration in function.

RESULTS

A total of 31 implants were placed. Implant survival was 100%. The 10-year mean marginal bone loss was 0.18 mm (SE: 0.08). The plaque, calculus, gingiva, and bleeding indices scores were low as was the mean pocket probing depth. The patients' satisfaction was high.

CONCLUSION

The 10-year follow-up data of this limited case series study reveal that 6-mm dental implants inserted in the resorbed posterior mandible provide a solid basis for single tooth restorations.

Short and Extra Short Dental Implants in Osseous Microvascular Free Flaps: A Retrospective Case Series

There is limited information regarding implant and prosthetic survival after osseous microvascular free flap (OMFF). This case series aims to describe the placement of short and extra short implants in osseous microvascular free flaps to support prostheses, and present an up to 40-month retrospective follow-up. Short and extra short dental implants were placed in six fibula free flaps (FFF) and in two microvascular deep circumflex iliac artery (DCIA) flaps. In total, 27 short and extra short dental implants have been placed into two different types of free flaps. Kaplan-Meyer (K-M) survival analyses were performed to evaluate the survival and success outcomes of implants and prostheses. Out of the eight patients reconstructed with free flap, five were rehabilitated with prostheses, one patient has a temporary prosthesis, and two patients are in the process of prosthetic rehabilitation. Twenty-seven implants were followed up for up to 40 months, and K-M analyses showed 100% implant survival probability (95% confidence interval: 100%), while the implant success probability was 91.0% (95% confidence interval: 68.6-97.7%). Short and extra short dental implants placed in OMFF presented high survival and success rates in a retrospective case series after up to 40 months.

Randomized controlled multi-centre study comparing shorter dental implants (6 mm) to longer dental implants (11-15 mm) in combination with sinus floor elevation procedures: 10-year data

AIM

To compare implant survival and complication rates between shorter and standard-length implants with sinus augmentation and restored with single crowns, at 10 years of loading.

MATERIALS AND METHODS

One-hundred and one patients (137 implants) with a ridge height of 5-7 mm in the posterior maxilla were randomly assigned to two treatment modalities: shorter implants (6 mm) (group short [GS]) or standard-length implants (11-15 mm) with sinus grafting (group graft [GG]). Following the insertion of final restorations, patients were regularly recalled for up to 10 years. Assessed outcomes encompassed implant survival, marginal bone levels (MBLs), biological and technical parameters and patient-reported outcome measures (OHIP-49 = Oral Health Impact Profile). Non-parametric statistical analysis was used to analyse the data.

RESULTS

For the 5- to 10-year follow-up period, 77 patients with 105 implants (GS: 36 patients/48 implants; GG: 41/57) were available for re-examination (drop-out rate 21%). Implant survival rates at the patient level were 96.0% (GS; 2 failures) and 100% (GG) (inter-group p = .24). Median MBLs amounted to 0.00 mm (min 0.00; max 3.25; GS) and 0.00 mm (min 0.00; max 4.55; GG) (inter-group p = .73). Technical complications predominantly occurred within the first 5 years (inter-group p > .05). Peri-implantitis rates were 4.2% (GS) and 13.3% (GG) (intergroup p = .37). Median OHIP-49 scores were 7.00 (0.00; 39.00; GS) and 9.00 (0.00; 196; GG) (inter-group p = .61) at 10 years.

CONCLUSIONS

Based on similar 10-year implant survival rates, reduced patient morbidity and lower costs, the use of shorter dental implants might well serve as an alternative treatment concept to longer implants placed in conjunction with sinus grafting for patients with a limited ridge height in the posterior maxilla. Study register: https://clinicaltrials.gov/ct2/show/NCT01030523.

Outcomes of treatment with short dental implants compared with standard-length implants: a retrospective clinical study

BACKGROUND

The size of dental implants is a key success factor for appropriate osseointegration. Using shorter implants allows the possibility of avoiding complex surgical procedures and reduces the morbidity of treatment. Shorter implants also enable implant-prosthetic rehabilitation after maxillofacial reconstructions where only limited bone is available. In this study, the success rates of short implants were examined and compared to those of standard-sized implants.

METHODS

Patients who received dental implants between 2007 and 2016 at the Department of Oro-Maxillofacial Surgery and Stomatology Semmelweis University were enrolled in the study. Several clinical parameters were recorded and supplemented with radiological examinations. The data were statistically analysed.

RESULTS

Thirty-four patients with a total of 60 implants were included. The average time after prosthetic loading was 39.33 ± 21.96 months in the group with 8-mm implants and 41.6 ± 27.5 months in the group with > 8-mm implants. No significant differences were observed between the two groups in terms of probing depth (short implants, 2.84 ± 0.09 mm; standard implants, 2.91 ± 0.35 mm) or mean marginal bone loss (short implants, 1.2 ± 1.21-mm mesially and 1.36 ± 1.47-mm distally; standard implants: 0.63 ± 0.80-mm mesially and 0.78 ± 0.70-mm distally).

CONCLUSIONS

In this study, the success rate of short dental implants was comparable to that of standard-sized implants. Consequently, it can be claimed that the long-term success of short dental implants does not differ significantly from the long-term success of standard implants.

The influence of vertical ridge augmentation techniques on peri-implant bone loss: A systematic review and meta-analysis

INTRODUCTION

The primary aim of this systematic review was to investigate and compare the outcomes of different vertical ridge augmentation (VRA) techniques in relation to peri-implant bone loss (PBL), after at least 12 months of functional loading.

MATERIAL AND METHODS

The search was conducted to find all the studies about VRA and measurements of PBL with at least 12 months follow-up. Three pairwise meta-analysis (MA) was performed to completely evaluate the outcomes.

RESULTS

A total of 42 studies were included, of which 11 were randomized clinical trials (RCTs). RCTs were available only for guided bone regeneration (GBR), onlay, and inlay techniques. The weighted mean estimate (WME) of PBL value was found to be 1.38 mm (95% confidence interval [95% CI]: 1.10-1.66) after a mean follow-up of 41.0 ± 27.8 months. GBR, Inlay, Onlay, osteodistraction, and SBB represented in weight 32.9%, 30.6%, 25.0%, 7.6%, and 3.9%, respectively; and their WME (95% CI) were 1.06 (0.87-1.26) mm, 1.72 (1.00-2.43) mm, 1.31 (0.87-1.75) mm, 1.81 (0.87-1.75) mm, and 0.66 (0.55-0.77) mm, respectively. Among the secondary outcomes, the analysis was conducted for vertical bone gain, healing complication rate, surgical complication rate, implant survival, and success rate.

CONCLUSIONS

The primary findings of the meta-analysis, based on the changes between final and baseline values, showed that the peri-implant bone loss could be influenced by the type of intervention but there is a need to evaluate in RCTs the behavior of the peri-implant bone levels after long-term follow-up for all techniques.

Single crowns in the posterior maxilla supported by either 11-mm long implants with sinus floor augmentation or by 6-mm long implants: A 10-year randomized controlled trial

OBJECTIVES

To compare the clinical performance of single crowns in the posterior maxilla supported by either 11-mm long implants combined with maxillary sinus floor augmentation (MSFA) surgery or by 6-mm long implants during a 10-year follow-up period.

MATERIALS AND METHODS

Subjects were randomly allocated to receive one 11-mm long implant in combination MFSA or to receive one 6-mm long implant without any grafting. Twenty-one implants in 20 patients were placed in the 6-mm group and 20 implants in 18 patients were placed in the 11-mm group. Both groups were followed by clinical and radiographic examinations up to 10 years. Patients' satisfaction was also scored before treatment.

RESULTS

Two patients died and eight patients moved during the follow-up. Two patients lost an implant in the 6-mm group and one implant was lost in the 11-mm group (implant survival 89.5% and 90.9%, respectively). From loading to 10 years' follow-up, mean ± SE marginal bone loss in the 6-mm group and 11-mm group was 0.18 ± 0.10 mm and 0.26 ± 0.12 mm, respectively, without a significant difference between the groups at 10 years (p = .650). In both groups, indices scores for plaque, calculus, gingiva and bleeding were low as well as mean pocket probing depth. Patients' satisfaction at 10 years was high in both groups; mean overall satisfaction in the 6-mm group and 11-mm group was 9.6 ± 0.6 and 9.2 ± 0.8, respectively (p = .168).

CONCLUSIONS

Placement of 6-mm implants or 11-mm implants combined MFSA are equally successful during a 10-year follow-up period when applied for supporting a single restoration.

The influence of truncated-conical implant length on primary stability in maxillary and mandibular regions: an in vitro study using polyurethane blocks

OBJECTIVES

This in vitro study is aimed at assessing whether implant primary stability is influenced by implant length in artificial bone with varying densities.

MATERIALS AND METHODS

A total of 120 truncated-conical implants (60 long-length: 3p L, 3.8 × 14 mm; 60 short-length: 3p S, 3.8 × 8 mm) were inserted into 20, 30, and 40 pounds per cubic foot (PCF) density polyurethane blocks. The insertion torque (IT), removal torque (RT), and resonance frequency analysis (RFA) values were recorded for each experimental condition.

RESULTS

In 30 and 40 PCF blocks, 3p S implants exhibited significantly higher IT values (90 and 80 Ncm, respectively) than 3p L (85 and 50 Ncm, respectively). Similarly, RT was significantly higher for 3p S implants in 30 and 40 PCF blocks (57 and 90 Ncm, respectively). However, there were no significant differences in RFA values, except for the 20 PCF block, where 3pS implants showed significantly lower values (63 ISQ) than 3p L implants (67 ISQ) in both the distal and mesial directions.

CONCLUSIONS

These results demonstrated that the implant's length mainly influences the IT and RT values in the polyurethane blocks that mimic the mandibular region of the bone, resulting in higher values for the 3p S implants, while the RFA values remained unaffected. However, in the lowest density block simulating the maxillary bone, 3p L implants exhibited significantly higher ISQ values.

CLINICAL RELEVANCE

Therefore, our data offer valuable insights into the biomechanical behavior of these implants, which could be clinically beneficial for enhancing surgical planning.

Sinus floor augmentation using crestal approach in conjunction with hydroxyapatite/cross-linked collagen sponge: A pilot study

BACKGROUND

Different biomaterials were suggested for sinus floor augmentation (SFA). Recently, new materials were launched showing true bone formation without remnants.

PURPOSE

The aim of this prospective study was to evaluate an hydroxyapatite-based, sugar cross-linked collagen sponge (OSSIX™ Bone) in transcrestal SFA (t-SFA).

MATERIALS AND METHODS

Twenty-four patients with edentulous posterior maxilla and residual bone height (RBH) >4 mm underwent t-SFA with OSSIX™ Bone as grafting material and simultaneous implant placement. The implant Stability Quotient (ISQ) was measured by resonance frequency analysis (RFA) directly after implant insertion and at 6 months. Differences in bone height (BH) and volume were determined in CBCT and x-rays at baseline versus 1 year of follow-up. Graft volume was evaluated by tridimensional reconstructions. Linear regression analysis was used to evaluate the effect of bucco-palatal sinus dimension, RBH, and length of the implant protruding (PIL) into the sinus, on the graft height (GH) changes up to 1 year, and on the graft volume at 1 year. Autocorrelation between time lag and augmented bone volume was evaluated through time series analysis correlograms. Health-related quality-of-life outcomes were captured.

RESULTS

Twenty-two patients completed the study. The mean RBH measured at baseline was 5.81 ± 2.2 mm. The mean graft volume was 1085.8 ± 733.4 mm3 . The mean GH, measured in the immediate post-operative period, at 6 and 12 months respectively, was 7.24 mm ±1.94; 6.57 mm ± 2.30; 5.46 mm ± 2.04. The mean ISQ measured after the implant placement was 62.19 ± 8.09, and 6 months later was 76.91 ± 4.50. There was a significant correlation between buccolingual dimension and graft volume at 1 year. Neither buccolingual volume nor RBH had a significant effect on GH change, while the PIL showed a significant positive correlation (P = 0.02 and P = 0.03 at 6 and 12 months, respectively). The correlograms indicated no significant correlation, meaning that there is no tendency for graft volume to increase or decrease over time, therefore suggesting graft stability, at least up to one year of follow-up. 86% of patients had no chewing interference.

CONCLUSION

Within the limitations of the study, OSSIX™ Bone could be considered a valid material for SFA due to its manageability and its positive results in promoting new bone formation with long-term stability. T-SFA is confirmed as a less invasive and less painful method.

Rehabilitation of distal extension maxillary ridges with fixed and removable implant-supported prostheses: Preliminary 12-month randomized clinical trial

PURPOSE

This trial evaluated clinical outcomes of fixed and removable implant-supported prostheses for rehabilitation of atrophied distal extension maxillary ridges.

MATERIALS AND METHODS

A total of 54 participants with atrophied distal extension maxillary ridges were randomly assigned into three groups (n = 18/group). Group I (SLF); participants treated with fixed restoration supported by three long implants after sinus augmentation, Group II (SF); participants treated with fixed restoration supported by one long and two short implants, and Group III (OD): participants treated with removable partial denture assisted by one long implant that was placed mesial to maxillary sinus (IARPD). Modified plaque index (MPI), modified gingival index (MGI), pocket depth (PD), implant stability (IS), and crestal bone loss (CBL) were measured after prosthesis insertion (T0), 6 (T6), and 12 months (T12) after insertion. Patient satisfaction was measured at T12 using a visual analog scale (VAS).

RESULTS

The implant survival rates were 96.8%, 92.4%, and 84.6% for SLF, SF, and OD groups respectively. The SLF recorded the highest MPI, MGI, PD, and IS values, followed by the SF, and the OD showed the lowest values. The OD recorded the highest CBL followed by the SF and the SLF showed the lowest CBL. With exception of satisfaction with surgery and cleaning, SLF and SF groups recorded significantly higher patient satisfaction than the OD for all VAS questions.

CONCLUSION

Fixed restorations supported with either long or short implants were associated with improved implant stability, reduced bone loss, and increased patient satisfaction compared to implant-assisted RPDs. However, implant-assisted RPDs were associated with more favorable peri-implant soft tissue health and increased satisfaction with surgery, healing, and cleaning.

Treatment alternatives for the rehabilitation of the posterior edentulous maxilla

Rehabilitation of the edentulous maxilla with implant-supported fixed dental prostheses can represent a significant clinical challenge due to limited bone availability and surgical access, among other factors. This review addresses several treatment options to replace missing teeth in posterior maxillary segments, namely the placement of standard implants in conjunction with maxillary sinus floor augmentation, short implants, tilted implants, and distal cantilever extensions. Pertinent technical information and a concise summary of relevant evidence on the reported outcomes of these different therapeutic approaches are presented, along with a set of clinical guidelines to facilitate decision-making processes and optimize the outcomes of therapy.

Effect of short implant crown-to-implant ratio on stress distribution in anisotropic bone with different osseointegration rates

OBJECTIVE

This study aimed to provide evidence for the clinical application of single short implants by establishing an anisotropic, three-dimensional (3D) finite element mandible model and simulating the effect of crown-to-implant ratio (CIR) on biomechanics around short implants with different osseointegration rates.

METHODS

Assuming that the bone is transversely isotropic by finite element method, we created four distinct models of implants for the mandibular first molar. Subsequently, axial and oblique forces were applied to the occlusal surface of these models. Ultimately, the Abaqus 2020 software was employed to compute various mechanical parameters, including the maximum von Mises stress, tensile stress, compressive stress, shear stress, displacement, and strains in the peri-implant bone tissue.

RESULTS

Upon establishing consistent osseointegration rates, the distribution of stress exhibited similarities across models with varying CIRs when subjected to vertical loads. However, when exposed to inclined loads, the maximum von Mises stress within the cortical bone escalated as the CIR heightened. Among both loading scenarios, notable escalation in the maximum von Mises stress occurred in the model featuring a CIR of 2.5 and an osseointegration rate of 25%. Conversely, other models displayed comparable strength. Notably, stress and strain values uniformly increased with augmented osseointegration across all models. Furthermore, an increase in osseointegration rate correlated with reduced maximum displacement for both cortical bone and implants.

CONCLUSIONS

After fixing osseointegration rates, the stress around shorter implants increased as the CIR increased under inclined loads. Thus, the effect of lateral forces should be considered when selecting shorter implants. Moreover, an implant failure risk was present in cases with a CIR ≥ 2.5 and low osseointegration rates. Additionally, the higher the osseointegration rate, the more readily the implant can achieve robust stability.

Maxillary sinus floor augmentation: a review of current evidence on anatomical factors and a decision tree

Maxillary sinus floor augmentation using lateral window and crestal technique is considered as predictable methods to increase the residual bone height; however, this surgery is commonly complicated by Schneiderian membrane perforation, which is closely related to anatomical factors. This article aimed to assess anatomical factors on successful augmentation procedures. After review of the current evidence on sinus augmentation techniques, anatomical factors related to the stretching potential of Schneiderian membrane were assessed and a decision tree for the rational choice of surgical approaches was proposed. Schneiderian membrane perforation might occur when local tension exceeds its stretching potential, which is closely related to anatomical variations of the maxillary sinus. Choice of a surgical approach and clinical outcomes are influenced by the stretching potential of Schneiderian membrane. In addition to the residual bone height, clinicians should also consider the stretching potential affected by the membrane health condition, the contours of the maxillary sinus, and the presence of antral septa when evaluating the choice of surgical approaches and clinical outcomes.

Extra-short implants (≤ 6.5 mm in length) in atrophic and non-atrophic sites to support screw-retained full-arch restoration: a retrospective clinical study

PURPOSE

Increasing scientific evidence support extending the application of short dental implants to non-atrophic dental arches. The purpose of this study has been the evaluation of extra-short implants (≤ 6.5 mm in length) that were placed in atrophic and non-atrophic anatomical sites to support the same prosthesis.

METHODS

For that, a retrospective study was conducted by including complete dentures that were solely supported by extra-short implants in the maxilla and/or the mandible. Clinical data about patients, implants, anatomy, and prosthesis were obtained. Statistical analysis was performed to assess implant- and prosthesis-survival, changes in the marginal bone level and prosthetic complications.

RESULTS

A total of 87 implants in 15 screw-retained complete dentures were assessed. None of the prostheses nor the extra-short implant failed during the follow-up of 27.2 ± 15.4 months. The changes in the mesial and distal marginal bone level were + 0.15 ± 0.51 mm and + 0.11 ± 0.50 mm, respectively. Comparing the implants according to the availability of sufficient bone to place longer implants, indicated the absence of significant differences in the changes of the mesial marginal bone level. However, the changes in the distal marginal bone level showed a statistically significant difference in favor of implants that were placed in non-atrophic sites. Two events of screw loosening were reported that were resolved by retightening the screws.

CONCLUSIONS

Implant- and prosthesis-related outcomes support the use of extra-short implants in atrophic and non-atrophic site to support complete prosthesis.

Efficacy of Two Different Hydrodynamic Sinus Lift Systems for Atraumatic Elevation in Immediate Implant Placement

Purpose

To evaluate the efficacy of two hydrodynamic sinus lifting procedures and to successfully place immediate implants in maxillary posterior sites that have a compromised native bone as a result of periodontal or endodontic disease.

Patients and Methods

A total of 26 patient sites were enrolled with 13 sites each in the Minimally Invasive Antral Membrane Balloon Elevation (MIAMBE) and Drill Integrated Hydrodynamics for the transcrestal sinus floor elevation (DIHSFE) groups who received transcrestal sinus floor elevation followed by immediate implant placement. Clinical parameters such as sinus membrane perforations, nasal bleeding, postoperative sinusitis, VAS scores at Day-7 for pain and discomfort, primary implant stability and time taken were evaluated.

Results

The DIHSFE had greater sinus membrane perforations and incidence of nasal bleeding when compared with MIAMBE with (p = 0.066) and (p = 0.141). Post-operative sinusitis was evident in both the groups with (p = 0.619). The mean VAS score was statistically significant between both the groups (p ≤ 0.005). The insertion torque values, and mean time taken for surgical procedure was not statistically significant between groups.

Conclusion

The present study highlighted that MIAMBE is superior to DIHSFE in its ability to cause less severe patient morbidities and post-operative complications.

6 mm short versus 11 mm long inter-foraminal implants in the full-arch rehabilitation of edentulous non-atrophic mandibles: 5-year results from a multicenter randomized controlled trial

OBJECTIVE

The aim of this multicenter parallel-group randomized controlled trial is to compare, in the same clinical scenario, 6 mm short with 11 mm long implants for the rehabilitation of completely edentulous non-atrophic mandibles.

MATERIALS AND METHODS

Thirty patients in three study centers received a fixed full-arch mandibular rehabilitation supported by five inter-foraminal implants, with no need for bone augmentation procedures. Patients were randomly allocated (1:1 ratio), at the time of surgery, to test (6 mm implants) or control group (11 mm implants). After 3 months, a screw-retained full-arch prosthesis was positioned (baseline). Peri-implant marginal bone level change (MBLc, primary outcome) together with implant and prosthesis survival rate, and biological/technical complications (secondary outcomes) were evaluated up to 5 years.

RESULTS

Twenty seven patients were controlled at 5 years (3 drop-outs). No implant or prosthesis loss occurred. No significant intergroup difference for biological/technical complications (p > .05, Fisher's exact test) and no significant intragroup and intergroup difference in the MBLc values were registered (test -0.03 ± 0.17 mm and control -0.13 ± 0.32 mm at 5-years; p > .025, one-sided Mann-Whitney U-test).

CONCLUSIONS

When used in comparable anatomic, surgical, and prosthetic conditions, no difference in the clinical and radiographic outcomes between 6-mm and 11-mm implants was observed at 5 years of follow-up. Short implants showed to be a reliable option for the rehabilitation of completely edentulous non-atrophic mandibles. There is growing clinical evidence supporting the use of short implants, even in the case of non-atrophic sites.

A Randomized Clinical Trial Comparing Implants Placed in Two Different Biomaterials Used for Maxillary Sinus Augmentation

The objective of this study was to compare marginal bone loss, surgical and clinical complications, and dental implant survival rate in bilateral maxillary sinus augmented by autologous or porcine xenograft. A randomized controlled clinical trial using split-mouth design enrolled 12 consent adult patients (59.7 ± 8.7 years), who received bilateral maxillary sinus floor augmentation for oral rehabilitation with implant-supported prosthesis. Each patient received both the autologous bone from the mandible (control) or porcine xenograft (test) during the random bilateral sinus lift surgery. A total of 39 dental implants were placed in the posterior maxilla of the 12 patients after 6 months, being rehabilitated after the respective osseointegration period. Both graft materials demonstrated a high implant survival rate at 12 months: 95% for the xenograft side, only 1 implant without osseointegration, and 100% for the autologous side. Radiographic bone loss was low and similar for both groups: control group with a mean of 0.063 ± 0.126, and test group with a mean of 0.092 ± 0.163. No major surgical-related complications have occurred. Only one patient had several prosthetic complications due to fractures of prosthetic components. The maxillary sinus augmentation procedure, both with autologous bone and porcine xenograft materials, is an excellent clinical option procedure for the prosthetic rehabilitation of atrophic maxillae, with low marginal bone loss after one year follow-up, few clinical complications, and a high implant survival rate.

Short Implants versus Standard Implants and Sinus Floor Elevation in Atrophic Posterior Maxilla: A Systematic Review and Meta-Analysis of Randomized Clinical Trials with ≥5 Years' Follow-Up

Background and objectives: The aim of this systematic review with meta-analysis was to assess the performance of short implants in comparison with standard implants and sinus floor elevation in atrophic posterior maxilla. Materials and methods: The protocol of the study was registered in the PROSPERO database (CRD42022375320). An electronic search on three databases (PubMed, Scopus, Web of Science) was performed to find randomized clinical trials (RCTs) with ≥5 years' follow-up, published until December 2022. Risk of bias (ROB) was calculated using Cochrane ROB. A meta-analysis was performed for primary (implant survival rate, ISR) and secondary outcomes (marginal bone loss, MBL; biological and prosthetic complications). Results: Of 1619 articles, 5 RCTs met the inclusion criteria. The ISR showed a risk ratio (RR) of 0.97 [0.94, 1.00] (CI 95%), p = 0.07. The MBL indicated a WMD of -0.29 [-0.49, -0.09] (CI 95%), p = 0.005. Biological complications showed a RR of 0.46 [0.23, 0.91] (CI 95%), p = 0.03. Prosthetic complications showed a RR of 1.51 [0.64, 3.55] (CI 95%), p = 0.34. Conclusions: The available evidence suggests that short implants might be used as an alternative to standard implants and sinus floor elevation. After 5 years, in terms of ISR, standard implants and sinus floor elevation showed a higher survival rate comparted to short implants, although statistical significance was not achieved. Future RCTs with long-term follow-up are needed to draw a clear conclusion on the advantages of one method over another.

Radiographic density changes may be associated with overloading and implant loss on short implants: A 5-year analysis of a randomized controlled clinical trial

OBJECTIVES

To analyze changes in radiographic bone density around short implants with and without cantilevers at 5 years post-loading.

MATERIALS AND METHODS

Thirty-six patients with two adjacent posterior missing teeth participated in this randomized controlled clinical trial. All patients were randomly allocated to receive either two short implants (6 mm) with single-unit restorations (group TWO) or one single short implant (6 mm) with a cantilever restoration (group ONE-C). Patients were followed up at 6 months, 1, 3, and 5 years. Radiographic analysis was performed, through an arbitrary gray scale value (GSV) of the peri-implant bone, assessing the changes in radiographic density between groups and between time points. Differences in GSV between groups and over time were calculated using a generalized estimating equation to allow for adjustments for the correlation within individuals and between time points.

RESULTS

At 5 years, 26 patients remained in the study (15 in group ONE-C; 11 in group TWO). Implant survival rates were 80.4% in group TWO and 84.2% in group ONE-C (p = 0.894). The radiographic analysis revealed that GSVs increased in both groups over time (p < 0.001). The overall radiographic density was higher in group ONE-C than in group TWO in the maxilla (p = 0.030). Conversely, in the mandible, these significant differences between the groups were not found (p > 0.05). Compared to the implants that survived, the implants that failed demonstrated a distinct radiographic density pattern (p < 0.05).

CONCLUSION

Within the limitations of the present study, the radiographic bone density in the maxilla appears to increase distinctly around short implants when cantilevers are used. In contrast, the radiographic density in the mandible appears to be unaffected by the use of a cantilever, suggesting a lower threshold of adaptation to occlusal forces and thus a higher susceptibility to overload and implant loss at earlier time points.

Short and Ultra-Short Implants, in Association with Simultaneous Internal Sinus Lift in the Atrophic Posterior Maxilla: A Five-Year Retrospective Study

Recent short-term studies suggested the use of short and ultra-short implants in association with a modified osteotome sinus floor elevation (internal sinus lift) technique for the treatment of edentulous resorbed posterior maxilla. The aim of this retrospective study was to investigate this hypothesis in locking-taper implants with a mid-term follow-up of 5 years. Overall, 155 implants (32, 100, and 23 of, respectively, 5.0 mm, 6.0 mm, and 8.0 mm length) were positioned in the atrophic upper maxilla of 79 patients, and 151 implants were loaded with single crowns. Overall implant survival after 5 years was 94.84%. Implant survival for each length group was 93.75%, 94%, and 100% for 5.0, 6.0, and 8.0 mm length, respectively. Preoperative residual crestal bone height of 4.45 (1.3) mm increased to 9.25 (2.13) mm after implant placement and settled at 6.35 (1.73) mm after loading and at 5.25 (1.68) mm at follow-up. Elevation of the Schneiderian membrane was 4.8 (2.46) mm after implant placement, 3.06 (1.3) mm after loading, and 1.46 (1.06) mm at follow-up. Mean variations of peri-implant crestal bone loss and first bone-to-implant contact point were, respectively, -0.36 (1.3) mm and -0.62 (1.15) mm. It can be confirmed that internal sinus lift procedure revealed stable bone gain and negligible resorption at mid-term follow-up for atrophic upper crests with reduced height.

Simultaneous placement of short implants (≤ 8 mm) versus standard length implants (≥ 10 mm) after sinus floor elevation in atrophic posterior maxillae: a systematic review and meta-analysis

Purpose

The objective of this meta-analysis was to compare the clinical outcomes of using short implants (≤ 8 mm) inserted with osteotome sinus floor elevation (OSFE) and standard implants (≥ 10 mm) inserted with sinus floor elevation (SFE) in atrophic posterior maxillae with insufficient residual bone height (RBH).

Methods

An electronic search was performed on PubMed, EMBASE, and the Cochrane Library from 1994 to July 2022, in combination with a manual search of references in relevant articles. Randomized controlled trials (RCTs) that compared the clinical results between short and standard implant placement with SFE were included. The primary outcomes were implant survival rate and marginal bone loss (MBL); the secondary outcome was complication rate.

Results

Three RCTs were included, totaling 138 short and 156 standard implants. The results of the meta-analysis showed no significant differences between the short and standard implant groups in survival rate (RR = 1.02, 95% CI   0.96–1.08, p = 0.570), MBL (MD = − 0.13, 95% CI   − 0.32 to 0.07, p = 0.190) and complication rate (intra-surgical complication: RR = 1.14, 95% CI   0.46–2.83, p = 0.770; post-operative complication: RR = 1.34, 95% CI   0.71–2.55, p = 0.370).

Conclusions

Using short implants (≤ 8 mm) combined with OSFE might be an alternative to standard implants (≥ 10 mm) with SFE when the RBH of the posterior maxilla is insufficient. Based on a short-term clinical observation, short implants with OSFE show good results in terms of survival rate, MBL, and complication incidence.

Graphical Abstract

Results at the 1-Year Follow-Up of a Prospective Cohort Study with Short, Zirconia Implants

The objective of this study was to clinically and radiologically evaluate the performance of a short (8 mm), 1-piece, zirconia implant after an observation period of 1 year in function. A total of 47 patients with 1 missing tooth in the position of a premolar or molar were recruited. Short (8 mm), 1-piece, zirconia implants were placed and loaded after a healing period of 2 to 4 months with monolithic crowns made of 3 different materials. Implants were followed up for one year and clinically and radiologically assessed. A total of 46 implants were placed. One was excluded since no primary stability was achieved at implant placement. At the 1-year follow-up, mean marginal bone loss 1 year after loading was 0.05 ± 0.47 mm. None of the implants showed marginal bone loss greater than 1 mm or clinical signs of peri-implantitis. A total of 2 implants were lost during the healing phase and another after loading, resulting in a survival rate of 93% after 1 year. All lost implants showed a sudden increased mobility with no previous signs of marginal bone loss or peri-implant infection. The short, 8 mm, zirconia implants showed stable marginal bone levels over the short observation period of 1 year. Although they revealed slightly lower survival rates, they can be suggested for the use in sites with reduced vertical bone. Scientific data are very limited, and long-term data are not yet available, and therefore, they are needed.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Short Implants versus Longer Implants with Sinus Floor Elevation: A Systemic Review and Meta-Analysis of Randomized Controlled Trials with a Post-Loading Follow-Up Duration of 5 Years

This study compared the outcome of fixed prostheses supported by short implants (<8 mm) and longer implants (≥8 mm) with an elevated sinus floor after 5 years of follow-up. The literature searches were performed electronically and manually in PubMed, EMBASE, and Web of Science databases to identify relevant articles published from 1 January 2013 to 31 January 2020. We selected eligible studies using inclusion criteria and assessed their quality. From 1688 identified studies, five randomized controlled trials were included. Between the short implant group and the control group, the implant failure-related pooled risk ratio (RR) was 3.64 (p = 0.07). The RR for technical complications was 2.61 (p = 0.0002), favoring longer implants. Marginal peri-implant bone loss after 1 and 5 years of function showed statistically significant less bone loss at short implants (1 year: mean difference = 0.21 mm; p < 0.00001; 5 years: mean difference = 0.26 mm; p = 0.02). The implant failure and the biological failure of both groups were similar after 5 years of follow-up. Short implants could be an alternative to long implants with an elevated sinus floor for atrophic maxillae in aging populations. Studies with larger trials and longer periods of follow-up (10 years) remain essential.

Predicting the Risk of Dental Implant Loss Using Deep Learning

AIM

To investigate the feasibility of predicting dental implant loss risk with deep learning (DL) based on preoperative cone-beam computed tomography.

MATERIALS AND METHODS

Six hundred and three patients who underwent implant surgery (279 high-risk patients who did and 324 low-risk patients who did not experience implant loss within 5 years) from January 2012 to January 2020 were enrolled. Three models, a logistic regression clinical model (CM) based on clinical features, a DL model based on radiography features, and an integrated model (IM) developed by combining CM with DL, were developed to predict the 5-year implant loss risk. The area under the receiver operating characteristic curve (AUC) was used to evaluate the model performance. Time to implant loss was considered for both groups, and Kaplan-Meier curves were created and compared by the log-rank test.

RESULTS

The IM exhibited the best performance in predicting implant loss risk [AUC = 0.90, 95% confidence interval (CI) 0.84-0.95], followed by the DL model (AUC = 0.87, 95% CI 0.80-0.92) and the CM (AUC = 0.72, 95% CI 0.63-0.79).

CONCLUSION

Our study offers preliminary evidence that both the DL model and IM performed well in predicting implant fate within 5 years and thus may greatly facilitate implant practitioners in assessing preoperative risks.

Histomorphometric evaluation of different graft associations for maxillary sinus elevation in wide antral cavities: a randomized controlled clinical trial

OBJECTIVES

Pneumatization of the maxillary sinus can make it difficult, if not impossible, to install osseointegrated implants, and undertake their eventual functional rehabilitation, which may ultimately require regenerative techniques to achieve. This randomized controlled study proposed conducting a histological evaluation of the behavior of different graft materials in wide maxillary sinuses, at a height of 8 to 10 mm from the alveolar ridge, combined with bone remnants less than 3mm.

MATERIALS AND METHODS

Thirty-six patients underwent a sinus elevation procedure through the lateral window. The sinuses were randomly filled with the following materials (n=12/group): group 1, xenogenic bone + autogenous bone (ratio 70:30, respectively); group 2, xenogenic bone + L-PRF; and group 3, xenogenic bone. At 8 months, bone biopsies of engrafted sites were harvested and analyzed histomorphometrically in order to quantify newly formed bone tissue.

RESULTS

The results showed a greater area of newly formed bone for G1, averaging 2678.37 (1116.40) μm², compared with G2 at 984.87 (784.27) μm², and G3 at 480.66 (384.76) μm² (p < 0.05). Additionally, fewer xenogenic bone particles and a large amount of connective tissue were observed in G2.

CONCLUSIONS

In maxillary sinuses with large antral cavities, autogenous bone combined with xenogenic bone seems to demonstrate better graft remodeling and improve bone formation, compared with the addition of L-PRF.

CLINICAL RELEVANCE

L-PRF produces few advantages regarding new bone formation in the wide maxillary sinuses.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (REBEC) number RBR-2pbbrvg.

Short versus Longer Implants in Sites without the Need for Bone Augmentation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

The present systematic review and meta-analysis aims to analyse the clinical performance of short compared to longer implants inserted in sites without the need for bone augmentation.

METHODS

The protocol of the present PRISMA-driven meta-analysis was registered on PROSPERO (CRD42021264781). Electronic and manual searches were performed up to January 2022. All Randomized Controlled Trials (RCTs) comparing short (≤6 mm) to longer (≥8.5 mm) implants placed in non-atrophic and non-augmented sites were included. The quality of the included studies was assessed using the Cochrane risk of bias tool for randomized clinical trials (RoB 2) and the quality of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. A meta-analysis was performed on implant survival rate, marginal bone level change (MBLc), and technical and biological complications at the available follow-up time points. The power of the meta-analytic findings was determined by trial sequential analysis (TSA).

RESULTS

From 1485 initial records, 13 articles were finally included. No significant difference was found in the survival rate between short and long implant at any follow-up (moderate quality of evidence). Significantly more bone loss for long implants at 1 and 5 years from implant placement and more technical complications with short implants at 10 years were found. No other significant inter-group differences in terms of MBLc and biological complications were detected.

CONCLUSIONS

Moderate evidence exists suggesting that short implants perform as well as longer ones in the rehabilitation of edentulous sites without the need for bone augmentation. Further long-term, well-designed RCTs, however, are still needed to provide specific evidence-based clinical recommendations for an extended use of short implants in non-atrophic sites.

Survival rates of ultra-short (<6 mm) compared with short locking-taper implants supporting single crowns in posterior areas: A 5-year retrospective study

Background

Short and ultra‐short implants represent a predictable treatment, in terms of implant survival, with patients presenting insufficient available bone volumes. Moreover, single crown restorations represent a gold standard in terms of oral hygiene.

Purpose

The aim of this retrospective study was to evaluate implant survival, marginal bone loss, and peri‐implant complications in 333 locking‐taper short and ultra‐short implants.

Materials and Methods

Implants were placed in the maxillary and mandibular posterior regions of 142 patients. Clinical and radiographic examinations were performed at 5‐year recall appointments.

Results

All implants placed consisted of 8.0‐, 6.0‐, and 5.0‐mm length, 38.14%, 34.53%, and 27.33%, respectively. Three hundred thirty‐two implants (one early failure) were rehabilitated with single crowns in 141 patients. In 45.48% of the implants the crown‐to‐implant ratio was ≥2, with a mean value of 1.94. Overall implant‐based survival after 5 years of follow‐up was 96.10%: 96.85%, 95.65%, and 95.60% for 8.0‐, 6.0‐, and 5.0‐mm length implants, respectively (p = 0.82). Overall patient‐based survival was 91.55%. Regarding crestal bone level variations, average crestal bone loss and apical shift of the “first bone‐to‐implant contact point” position were 0.69 and 0.01 mm, respectively. Setting the threshold for excessive bone loss at 1 mm, during the time interval from loading to follow‐up, 28 implants experienced loss of supporting bone greater than 1 mm: 19 of them (67.85%) were surgically treated with a codified surgical regenerative protocol. After 60 months, a peri‐implantitis prevalence of 5.94% was reported, with an overall implant success of 94.06%: 95.93%, 92.73%, and 93.10% for 8.0‐, 6.0‐, and 5.0‐mm length implants, respectively (p = 0.55).

Conclusion

Long‐term outcomes suggest that short and ultra‐short locking‐taper implants can be successfully restored with single crowns in the posterior area of the maxilla and mandible.

Short versus standard implants associated with sinus floor elevation: An umbrella review of meta-analyses of multiple outcomes

STATEMENT OF PROBLEM

Bone loss in the edentulous posterior maxilla complicates dental implant placement. In spite of the evidence available, there is continued uncertainty about the benefit of short implants for different outcomes.

PURPOSE

The purpose of this review was to evaluate the existing evidence for short and standard implants in association with sinus floor elevation regarding implant survival, marginal bone loss, and complications by using an umbrella review of the evidence across meta-analysis of interventional studies.

MATERIAL AND METHODS

Medline, Scopus, and Cochrane Library were searched to identify systematic reviews and meta-analyses comparing short implants and standard implants associated with sinus floor elevation. Data extraction and methodological quality (AMSTAR-2) was assessed by 2 authors independently. Outcomes were categorized and tabulated to assess effectiveness. Qualitative data were analyzed using thematic synthesis. The certainty of the evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From 2011 studies, 7 systematic reviews (66 studies) were included as per the eligibility criteria. There was no statistically significant difference between groups for implant survival (risk ratio=1.08; P=.79), and the qualitative analysis did not show differences for prosthetic outcomes. Standard implants were associated with fewer prosthetic complications in the quantitative analysis (risk ratio=3.27; P<.01), but no difference was found between the treatments in the qualitative analysis. Short implants showed reduced marginal bone loss (0.98 ±0.12 mm; mean difference=-0.22; P<.01) and better biologic outcomes (risk ratio=0.16; P<.01). Patient satisfaction was similar for both groups, whereas costs and time for the procedure favored short implants. The quality of the evidence was graded as "critically low" (57.1% of the reviews) and "low." There was a high certainty of evidence for implant survival, whereas marginal bone loss and complications had moderate certainty.

CONCLUSIONS

Short implants had a better or equal performance compared with standard implants for all outcomes assessed. However, assumptions were based on reviews with low or critically low quality of the evidence, suggesting the development of high-quality systematic reviews in this field.

Posterior jaws rehabilitation with < 7mm-short implants. A review

INTRODUCTION

The results with shorter and shorter implants have been revolutionizing the implantology scenario and are worthy of being well-analyzed and understood. This review aims to add further knowledge about the last 10-years observation period on < 7mm-short implants in the posterior atrophic jaws, better defining the indication of their use.

METHODS

From a Medline database research, systematic reviews, controlled and no- controlled trials (CT, n-CT) with ≥ 3years-follow-ups on <7 mm / ≥ 5mm-short implants (group A), and clinical studies with ≥ 1year-follow-up on 4mm-short implants (group B) were considered. The outcomes, in terms of implant survival rate (SR), marginal bone loss (MBL), and complications were analyzed according to the duration of follow-ups, implant site (maxilla and mandible), type of prosthesis (single crown or splinted units), vertically impaired or normal sites.

RESULTS

Thirty-four trials (28 for group A and six for group B) were selected. Group A: a mean follow up of 5,8 (3-10) years came out; pre-and post-loading SR range was 94.4- 100% and 89.6-100%, respectively; the range of MBL was 0.12-1.49; 50% of CT found less statistically significant surgical complications in comparison with standard implants (ST) in reconstructed sites, while major prosthetic problems were recorded with short -implants (SH) in 37.5% of CT; in no atrophied sites, a mean SR range of 86.7-100 % vs. 88-100 % and a total bone loss of 2 vs.1.6 for SH vs.ST emerged. Group B: the overall mean follow-up period was 2,3 years, and the pre-and post- SR ranges were 93-100 % and 87.5-100 %, respectively. The MBL range was 0.02- 0.63 mm. All RCT reported significantly fewer surgical complications with SH than with ST in reconstructed mandibles within one year. No prosthetic complications were reported for up to 5 years using no pontics or cantilevers fixed bridges.

CONCLUSIONS

Similar or even better results for SH than ST in terms of post-loading SR and MBL came out for < 7mm/ ≥ 5mm-short implants in atrophic bone regardless of the prosthetic solutions, with less surgical complications but a few more prosthetic problems; the good results up to 5 years for 4mm-short implants in mandibles are associated with splinted and no-risk prosthetic solutions.

Two short implants versus one short implant with a cantilever: 5-Year results of a randomized clinical trial

Aim

To test whether or not the use of a short implant with a cantilever results in similar clinical and radiographic outcomes compared to two adjacent short implants with single tooth reconstructions.

Materials and methods

Thirty‐six patients with two adjacent missing teeth in the posterior region were randomly assigned to receive either a single 6‐mm implant with a cantilever (ONE‐C) or two 6‐mm implants (TWO). Fixed reconstructions were inserted 3–6 months after implant placement and patients were re‐examined up to 5 years (FU‐5).

Results

A total of 26 patients were available for re‐examination at FU‐5. The survival rate amounted to 84.2% in ONE‐C and to 80.4% in TWO (inter‐group: p = .894). Technical complication rates amounted to 64.2% (ONE‐C) and to 54.4% (TWO) (inter‐group: p = 1.000). From baseline to FU‐5, the median changes of the marginal bone levels were 0.13 mm in ONE‐C and 0.05 mm in TWO (inter‐group: p = .775). Probing depth, bleeding on probing, and plaque control record values showed no significant differences between the two treatment modalities (p > .05).

Conclusions

Short implants with a cantilever render similar clinical and radiographic outcomes compared to two adjacent short implants at 5 years, however, they tend to fail at earlier time points suggesting an overload of the implants. Considering the modest survival rates, the clinical indication of either treatment option needs to be carefully evaluated. ClinicalTrials.gov (NCT01649531).

Tilted versus axial implant distribution in the posterior edentulous maxilla: A CBCT analysis

OBJECTIVES

This study aimed to determine whether distally angulating an implant is a successful strategy to avoid the maxillary sinus and the need for bone augmentation, while increasing the anterior-posterior (A-P) implant distribution in the edentulous maxilla.

MATERIALS AND METHODS

In 115 patients with edentulous maxillae, virtual implant planning was performed utilizing cone-beam computer tomographs. Axial (8 mm length) and tilted (12 mm length) dental implants with 30-degree and 45-degree angulation were virtually positioned to avoid entering the maxillary sinus, while maximizing A-P distribution. Measurements were made between the tilted and axial implants to assess the change in A-P distribution of implants at the implant and abutment levels.

RESULTS

Forty-seven sites (20.4%) were not able to have either treatment modality with insufficient bone for implant placement. Axial implants were placed more distally than 45-degree and 30-degree tilted implants in 24% and 42% of sites, respectively. The average change in A-P spread measured at the implant level, for 30- and 45-degree tilted implants was -0.25 mm (95% CI -0.76, 0.26) and 1.9 mm (95% CI 1.4, 2.3), respectively. When measured from the center of each multi-unit abutment the average increase in A-P distances for tilted implants appears larger in the 30-degree and 45-degree groups by 0.97 mm and 1.74 mm, respectively compared to measurements at the implant level.

CONCLUSIONS

Angulating 12 mm implants provides a limited increase in A-P distribution of implants in edentulous rehabilitation in most situations. In certain patients, the use of 8mm axial implants may provide a greater A-P spread.

Are implant-supported removable partial dentures a suitable treatment for partially edentulous patients? A systematic review and meta-analysis

STATEMENT OF PROBLEM

A consensus on the clinical performance of implant-supported removable partial dentures (ISRPDs) is lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the clinical performance of ISRPDs in terms of the implant survival rates, marginal bone loss, and patient-reported outcome measures (PROMs).

MATERIAL AND METHODS

Four electronic databases (MEDLINE/PubMed, EMBASE, Web of Science, and Cochrane Library) were independently searched by 2 reviewers for articles published up to December 2020. A single-arm meta-analysis was performed to evaluate the implant survival rates and marginal bone loss by using the R program. The Cochrane collaboration tool was used to evaluate the risk of bias of randomized controlled trials (RCTs), and the Newcastle-Ottawa scale for non-RCT studies.

RESULTS

Sixteen studies were included, with a total of 334 participants and a mean age of 58 years. The participants received a total of 581 dental implants, 475 conventional and 106 mini-implants. All included studies reported implant survival rate above 90% (range: 92% to 100%). Meta-analysis indicated a high proportion of implant survival rates of 3% (95% confidence interval [CI]: 2% to 5%) and a low mean raw score of marginal bone loss 0.98 mm (CI: 0.61 to 1.36 mm). Compared with conventional RPDs, improved patient quality of life and satisfaction were reported by studies that evaluated ISRPDs. RCT studies exhibited a low risk of bias for most domains, while most non-RCT studies were classified as good quality.

CONCLUSIONS

ISRPDs exhibited high implant survival rates and acceptable bone loss with improvement in the quality of life and satisfaction of patients when compared with conventional RPDs. Therefore, they can be considered suitable for the rehabilitation of partially edentulous patients.

Short vs. regular length implants to rehabilitate partially edentulous mandible: a 2-year prospective split-mouth clinical study

Many studies have evaluated short implants (SIs); however, it is still unclear whether SIs are reliable and can be used to simplify surgical and prosthetic protocols with successful clinical outcomes. The aim of this non-random, conveniently sampled, prospective, split-mouth study was to compare the clinical outcomes when short (SI) (≤8 mm) or regular-length implants (RIs) (>10 mm) were used in the posterior mandible two years after the delivery of splinted reconstructions. Each participant (N=10) received four implants in the posterior mandible; two SIs were placed on one side, and two RIs were placed contra-laterally. Implants were restored with splinted, screw-retained, porcelain-fused-to-metal reconstructions. Survival and success rates, peri-implant marginal bone level (MBL), and soft tissue parameters were evaluated. No participant drop-outs were recorded. Both types of implants showed 100% success and survival rates. From prosthetic delivery to 24 months post-loading, bone remineralization of +0.40 mm for the SIs and +0.36 mm for the RIs was observed without statistically significant differences in MBL between the implant types (p=0.993). SIs showed significantly higher (p=0.001) clinical attachment level (CAL) and probing depth (PD) values. Chipping occurred in one situation in the RI group resulting in a 97.5% prosthetic success rate, which was 100% for the SIs. After 2 years, SIs with splinted reconstructions showed comparable clinical outcomes to those of RIs. Further long-term controlled clinical studies with balanced experimental designs evaluating random and larger populations are required to corroborate these findings.

The Impact of Dental Implant Length on Failure Rates: A Systematic Review and Meta-Analysis

The present review aimed to evaluate the impact of implant length on failure rates between short (<10 mm) and long (≥10 mm) dental implants. An electronic search was undertaken in three databases, as well as a manual search of journals. Implant failure was the outcome evaluated. Meta-analysis was performed in addition to a meta-regression in order to verify how the risk ratio (RR) was associated with the follow-up time. The review included 353 publications. Altogether, there were 25,490 short and 159,435 long implants. Pairwise meta-analysis showed that short implants had a higher failure risk than long implants (RR 2.437, p < 0.001). There was a decrease in the probability of implant failure with longer implants when implants of different length groups were compared. A sensitivity analysis, which plotted together only studies with follow-up times of 7 years or less, resulted in an estimated increase of 0.6 in RR for every additional month of follow-up. In conclusion, short implants showed a 2.5 times higher risk of failure than long implants. Implant failure is multifactorial, and the implant length is only one of the many factors contributing to the loss of an implant. A good treatment plan and the patient’s general health should be taken into account when planning for an implant treatment.

Single-crown restorations supported by short implants (6 mm) compared with standard-length implants (13 mm) in conjunction with maxillary sinus floor augmentation: a randomized, controlled clinical trial

BACKGROUND

The purpose of the present study was to test the H0-hypothesis of no difference in the clinical and radiographical treatment outcome of single-crown restorations supported by short implants compared with standard length implants in conjunction with maxillary sinus floor augmentation (MSFA) after 1 year of functional implant loading. Forty patients with partial edentulism in the posterior part of the maxilla were randomly allocated to treatment involving single-crown restorations supported by short implants or standard length implants in conjunction with MSFA. Clinical and radiographical evaluation were used to assess survival of suprastructures and implants, peri-implant marginal bone loss (PIMBL), biological, and mechanical complications.

RESULTS

Both treatment modalities were characterized by 100% survival of suprastructures and implants after 1 year. Mean PIMBL was 0.60 mm with short implants compared with 0.51 mm with standard length implants after 1 year of functional loading. There were no statistically significant differences in survival of suprastructure and implants, PIMBL, and mechanical complications between the two treatment modalities. However, a higher incidence of biological complications was associated with standard length implants in conjunction with MSFA.

CONCLUSION

Within the limitations of the present study, it can be concluded that single-crown restorations supported by short implants seems to be comparable with standard length implants in conjunction with MSFA. However, long-term studies are needed before final conclusions can be provided about the two treatment modalities.

TRIAL REGISTRATION

Clinicaltrials.Gov ID: NCT04518020 . Date of registration: August 14, 2020, retrospectively registered.

Survival Rates of Splinted and Nonsplinted Prostheses Supported by Short Dental Implants (≤8.5 mm): A Systematic Review and Meta-Analysis

PURPOSE

To evaluate and compare the implant survival rates, marginal bone loss, and mechanical complications of prostheses supported by splinted and nonsplinted short implants (≤8.5 mm).

MATERIAL AND METHODS

Electronic database (MEDLINE, CENTRAL, Web of Science, and EMBASE) and manual searches up to May 2021 were conducted to identify studies comparing splinted and nonsplinted short implants (≤8.5 mm). The primary outcome was implant survival rate. Secondary outcomes were marginal bone loss and mechanical complications. The quality of included studies and risk-of-bias were assessed according to the Newcastle-Ottawa Scale. A random-effects model was used to analyze the data.

RESULTS

Twelve studies fulfilled the inclusion criteria and featured 1506 short implants (596 nonsplinted and 910 splinted) with a follow-up time ranging from 1 to 16 years. Quantitative analysis found no statistically significant differences between splinted and nonsplinted short implants (≤8.5 mm) for survival rate (RR = 0.98; 95% CI 0.96, 1.01; p = 0.26)) and marginal bone loss (SMD = -0.08; 95% CI - 0.23, 0.07; p = 0.28). Veneer chipping, abutment screw breakage, screw loosening, and loss of retention were reported in the selected studies as common complications. However, no statistically significant difference was found between splinted and nonsplinted short implants (RR = 0.56; 95% CI 0.20, 1.54; p = 0.26).

CONCLUSIONS

Within the limitations of the present meta-analysis, it might be concluded that splinted short implants (≤8.5 mm) do not present superior performance in survival rate, marginal bone maintenance and prevention of mechanical complications compared with single-unit prostheses.

Ultra-short versus standard-length dental implants in conjunction with osteotome-mediated sinus floor elevation: A randomized controlled clinical trial

BACKGROUND

The ability to restore missing teeth with dental implants is dictated by the available bone and by the presence of anatomical structures. The potential to insert ultrashort implants avoids additional surgical procedures and its inherent complications. The last European Association of Dental Implantologists consensus in 2016 defined ultrashort implants and standard-length dental implants as <6 and >8 mm, respectively.

PURPOSE

The present study aimed to investigate whether single standing ultrashort dental implants (US) could provide a viable therapeutic alternative to osteotome mediated sinus floor elevation in combination with standard-length dental implants (SL) 10 mm in posterior maxillary rehabilitation with reduced bone height.

MATERIALS AND METHODS

The study was conducted as a prospective parallel group controlled clinical trial with a 12 month follow-up, where 48 implants were randomized into two groups; US-group (5.5 mm) and SL-group (10 mm) implants placed with osteotome-mediated sinus floor elevation. Crestal bone loss (CBL) was defined as the study's primary outcome, while implant survival, buccal bone thickness, implant stability, probing depth, gingival recession, and adverse effects were assessed as secondary outcomes.

RESULTS

Mesial CBL was 1.13 ± 0.52 mm in SL- and 0.72 ± 0.52 mm in US-group (P = .021), while distal CBL was 1.44 ± 0.72 mm in SL- and 0.91 ± 0.69 mm in US-group at 12 months (P = .0179). Regarding implant stability, probing depth, and gingival recession there was no statistically significant difference between the two groups. Regarding implants' survival, three implants were lost in the US-while only one implant was lost in the SL-group (P = .6085; Fisher's exact test). Nevertheless, the ultrashort implants were associated with a tripling of the failure rate and uncertainty where the true failure rate is uncertain (relative risk 3.0; confidence interval 0.3-26.8).

CONCLUSIONS

Within the current trial's limitations, US-appear appear promising as they are associated less postoperative discomfort, minimal invasiveness and less CBL. However, larger sample size is required to determine whether the ultrashort have an acceptable survival rate.

Failure Risk of Short Dental Implants Under Immediate Loading: A Meta-Analysis

PURPOSE

Currently, there is no clear clinical evidence that short implants are suitable for immediate loading. Therefore, this meta-analysis aims to evaluate whether immediate loading increases the failure risk of short dental implants.

MATERIALS AND METHODS

This meta-analysis was registered at PROSPERO (CRD 42020195890). PubMed, Embase, and Cochrane Library databases were searched to collect all clinical studies comparing the failure rates of short dental implants (<10 mm) and standard implants (≥10 mm) under the condition of immediate loading and studies comparing the failure rates of short dental implants under immediate loading versus early or delayed loading. All of the clinical studies with available relevant data were eligible for inclusion. The Cochrane Risk of Bias tool was adopted to evaluate the risk of bias for the randomized controlled trial (RCT), while Newcastle-Ottawa Quality Assessment Scale (NOS) was used for the observational studies (OS). The OR value of each included study and its 95% CI were pooled to estimate the failure risk of short dental implants under immediate loading. The heterogeneity among studies was evaluated through Cochran's Q test and I² .

RESULTS

Seventeen studies, 5 RCTs and 12 OS studies, with a total of 2461 dental implants were analyzed. Four of the RCT studies were of low risk of bias and one was of unclear risk, while all of the OS studies were of moderate or high quality. Compared with standard implants, short implants did not have an increased failure risk under immediate loading (OR: 1.38, 95% CI: 0.67-2.84, p = 0.997, fixed model). In addition, the OR value of implant failure for short implants under immediate loading compared to that for short implants under early or delayed loading was 1.22 (95% CI: 0.33-4.55, p = 0.104, random model), which was also not significantly different.

CONCLUSIONS

There is not enough evidence to show that short dental implants under immediate loading may have higher implant failure risk compared to standard implants under immediate loading and short implants under early or delayed loading. Therefore, an immediate loading protocol may not increase the failure risk of short dental implants.

Short Dental Implants (≤8.5 mm) versus Standard Dental Implants (≥10 mm): A One-Year Post-Loading Prospective Observational Study

Background: Recent data have shown that short dental implants can be the preferred treatment in most of cases of posterior atrophic alveolar ridges, offering higher survival and lower complication rates than long implants. The survival rates, stability, and marginal bone level changes were compared between short implants (7 and 8.5 mm) and standard-length implants (≥10 mm). Methods: Prospective observational study in which adult patients requiring ≥1 osseointegrated implants to replace missing teeth were recruited consecutively. A clinical examination was performed on the day the definitive prosthesis was placed and after 6 and 12 months. Implant stability quotient (ISQ), marginal bone level (MBL) changes, and the correlation between these parameters and the characteristics of the implants were evaluated. Results: A total of 99 implants were inserted (47 short, 52 standard) in 74 patients. The 12-month survival rate was 100%. ISQ values showed a similar pattern for both types of implants. No correlation was found between ISQ changes after one year and MBL values, nor between the latter and the characteristics of the implants. Conclusions: With clinical treatment criteria, shorter implants (7 and 8.5 mm in length) can be just as useful as standard-length implants in atrophic alveolar ridges, demonstrating similar rates of survival, stability, and crestal bone loss.

Clinical Outcome of Dental Implants after Maxillary Sinus Augmentation with and without Bone Grafting: A Retrospective Evaluation

(1) Background: The purpose of the present study was to retrospectively evaluate and compare the outcome of two sinus augmentation grafting protocols using a xenograft or blood clot alone over a 72-month follow-up. (2) Methods: Patients who received simultaneous lateral sinus floor augmentation and implant placement were included. Subjects were divided into two groups according to the grafting material, namely xenograft or blood clot, and into sub-groups based on the residual alveolar bone height (RABH) below the maxillary sinus, namely 4 to 6 mm or >6 mm. Kaplan-Meier survival estimates were calculated for each material group and for each sub-group at 1, 3, and 6 years. (3) Results: In total, 289 implants inserted in 136 patients with a one-stage procedure were considered. A total of 35 failures were registered. Overall survival rates were 94.2% for xenograft and 85.9% for blood clot alone at 1 year, 91.1% and 81.6% at 3 years, and 91.1% and 78.7% at 6 years. (4) Conclusions: In patients with 4-6 mm RABH, graftless interventions exploiting blood clot alone were not as successful as those using xenograft. When the RABH is low, sinus floor augmentation associated with grafting materials should be preferred whenever possible.

Two-Year Follow-Up of 4-mm-Long Implants Used as Distal Support of Full-Arch FDPs Compared to 10-mm Implants Installed after Sinus Floor Elevation. A Randomized Clinical Trial

BACKGROUND

In edentulous patients, bone resorption cannot allow the installation of standard implants and it is demanded to use short implants in the residual alveolar bone or longer implants in grafted bone.

AIM

To compare the survival and bone level changes of standard plus short 4-mm implants used as distal support of a maxillary full-arch fixed dental prostheses (FDPs) with standard (10-mm) implants placed in association with a bilateral sinus floor augmentation procedure.

MATERIAL AND METHODS

Full-arch FDPs supported by six implants were randomly placed in both groups. In the control group, all implants were 10 mm long and 4.1 mm in diameter. The distal implant in both sides of the maxilla was installed after 4 months from bilaterally sinus floor elevation. In the test group (short group), the distal implant in both sides of the maxilla was 4 mm long and 4.1 mm in diameter. No sinus floor elevations were performed in the test group. Clinical assessments and X-rays were taken at prosthesis delivering and after 6, 12, 18, and 24 months. Patient-reported outcome measures (PROMs) were also evaluated before surgery and after 6, 12, and 24 months.

RESULTS

The changes over time of the bone level for the short implants were -0.01 ± 0.11 mm, -0.04 ± 0.13 mm, -0.17 ± 0.29 mm, and -0.28 ± 0.37 mm after 6, 12, 18, and 24 months from prosthesis delivering, respectively. For the standard implants, bone changes were -0.21 ± 0.33 mm (p = 0.103), -0.30 ± 0.32 mm (p = 0.023), -0.40 ± 0.37 mm (p = 0.144), and -0.54 ± 0.49 mm (p = 0.128), respectively. A statistically relevant difference was found only at 12 months after loading between the two groups.

CONCLUSIONS

Similar results on implant survival rate and marginal bone loss were observed for the short and standard implants, placed in association with a bilateral sinus floor augmentation procedure, used as distal support of a maxillary full-arch FDP. A statistically relevant difference was found only at 12 months after loading between the two groups (p = 0.023).

Patient-reported outcomes and complication rates after lateral maxillary sinus floor elevation: a prospective study

Objectives

Oral surgery morbidity is highly variable based on patients’ characteristics and kind of surgical intervention. However, poor data are available in the literature regarding patient outcomes after oral surgery. The aim of this retrospective study was to evaluate patient-reported outcome and complication rates after maxillary sinus floor elevation.

Materials and methods

Data from the records of patients undergoing maxillary sinus elevation have been collected from a private dental office. Patient-reported outcome has been assessed using a 100-mm visual analog scale to evaluate the post-operative pain (VAS_pain) experienced in the first week following surgery and visual rating scales to evaluate discomfort level (VRS_discomfort: 0 to 4) and willingness to repeat the same surgical procedure (VRS_willingness: 0 to 3). Analgesics intake, swelling onset and duration, and ecchymosis have been also recorded.

Results

VAS_pain showed moderate values in the first 2 days (< 50) post-surgery, with a tendency to progressively decrease over the next 2 days. Average assumption of painkillers was 3.93 ± 3.03. Discomfort level (VRS_discomfort) after surgery was low (median: 1; IR: 1–0), while willingness to undergo the same surgical procedure was very high (77.63% of patients). Swelling and ecchymosis were experienced by 97.36% and 51.32% of patients, respectively, with a mean duration of 4.09 ± 1.43 and 2.21 ± 2.31 days, respectively. Membrane perforation occurred in 4 cases. Other post-operative complications were not observed.

Conclusions

Maxillary sinus grafting is a safe procedure, with a low complication rate and moderate morbidity that is well tolerated by patients. Particular attention is needed in case selection, surgical planning and operator expertise.

Clinical relevance

The analysis of patient-reported outcomes can be of great help in surgical planning and in providing correct and adequate treatment.