Dental implant fractures - aetiology, treatment and case report

Potential applicability of virtual reality in implant dentistry: a narrative review

Dental implants have a high success rate but face challenges such as improper positioning, implant fracture, and tissue damage, often due to the lack of surgical proficiency. Virtual reality (VR) technology has emerged as a transformative solution in implant dentistry, offering a three-dimensional (3D), immersive environment for both educational and clinical applications. Initially used as a teaching aid, VR now facilitates comprehensive preoperative planning and precise implant placement, minimizing procedural errors. VR systems enhance student and novice surgeon training by providing a risk-free platform for skill development. Clinically, VR aids in accurate implant positioning through computer-guided surgical stents and simulation of surgical fields, improving patient outcomes by reducing complications. Furthermore, VR enhances patient education and communication, offering visual representations of treatment plans, thereby increasing patient satisfaction and understanding. Despite its benefits, VR integration faces challenges, including high costs, steep learning curves for experienced surgeons, and potential disruption of patient-clinician interactions. Developing affordable, compact VR systems and integrating VR early in dental curricula will facilitate widespread adoption and revolutionize implant dentistry by improving both surgical training and patient care. The review covers the historical development and current progress of VR with an overview of applications of VR in implant dentistry, its benefits in implant dentistry, challenges, and future perspectives.

Application of virtual reality in dental implants: a systematic review

BACKGROUND AND OBJECTIVE

A treatment approach that is widely used as a permanent and natural replacement for missing or extracted teeth is dental implants .VR is a computer-generated simulation that creates a three-dimensional (3D) image or environment. Advances in VR -based learning allow learners and students to practice and also help professionals plan a wide variety of surgical procedures, including the correct placement of dental implants. Therefore, in this systematic review, our aim was to investigate and evaluate the available virtual reality tools for dental implants and their effectiveness.

MATERIALS AND METHODS

Studies published up to 01/30/2023 which report the applications of using virtual reality technology in dental implants, were reviewed in three databases, including PubMed, Web of Science, and Scopus. All studies with evidence reporting the role of virtual reality technology in the field of dental implants were included in our analyses, written in English and published in peer-reviewed form, are included. Theoretical articles, and letters that did not provide original data, as well as studies that reported incomplete information, were excluded. Two reviewers independently assessed search results, extracted data, and assessed the quality of the included studies, and decisive agreement was reached by discussion and consultation with the third researcher. Narrative synthesis was undertaken to summarize and report the findings.

RESULTS

Out of 1633 initial search results, nine were included in the present study based on the inclusion criteria. The focus of seven studies was on teaching and learning, and two studies have examined the implant planning procedure. The most commonly used hardware and software were head-mounted display and Unity3D, respectively. In almost all studies, the results showed that the use of virtual reality-based systems improves and enhances the skills of users, including dental students and specialists.

CONCLUSIONS

Our findings showed that VR is an effective method for teaching and planning the implant process. Although the use of VR technology is limited for various reasons such as cost, it can increase the skills of dental professionals in performing dental implants.

A diagnostic accuracy study on an innovative auto-edge detection technique for identifying simulated implant fractures on radiographic images

Implant fracture is a rare but devastating complication of treatment in partially or fully edentulous patients which requires prompt diagnosis. Nevertheless, studies on defining the most accurate technique for the detection of implant fractures are lacking. In the present study, the Canny edge detection algorithm was applied on multiple radiographic modalities including parallel periapical (PPA), oblique periapical (OPA), and cone beam CT (CBCT) with and without metal artifact reduction (MAR) to examine its accuracy for diagnosis of simulated implant fractures. Radiographs were taken from 24 intact implants and 24 implants with artificially created fractures. Images were evaluated in their original and Canny formats. The accuracy of each radiograph was assessed by comparison with a reference standard of direct observation of the implant. The greatest area under the receiver operating characteristic curve belonged to Canny CBCT with MAR (0.958), followed by original CBCT with MAR (0.917), original CBCT without MAR = Canny CBCT without MAR = Canny OPA (0.875), Canny PPA (0.833), original PPA = original OPA (0.792), respectively. The Canny edge detection algorithm is suggested as an innovative method for accurate diagnosis of clinically suspected implant fractures on CBCT and periapical radiographies.

German S3 guideline on the use of dental ceramic implants

PURPOSE

Based on the excellent long-term data, dental implants made of titanium are considered the international implantological standard for replacing missing teeth. However, ceramic implants made of zirconia (ZrO₂) have experienced a renaissance in the last 15 years due to constant innovations in materials and products, with material properties and soft tissue- and osseointegration behavior comparable to those of titanium. However, one limitation concerning ceramic implants is the lack of reliable long-term data, especially in the case of two-piece implant systems. As there is an increasing demand for ceramic implants from practitioners and patients, the German Society for Implantology (DGI) has decided to develop a guideline on the use of dental ceramic implants at the highest available evidence level with the involvement of experts in this field.

METHODS

Statements and recommendations were prepared after conducting a systematic literature search and an independent assessment process involving the relevant clinical literature from 2008 to 2021. The adopted recommendations and statements are summarized in this guideline.

RESULTS AND CONCLUSIONS

It confirms the feasible use of one-piece zirconia implants as an addendum/alternative to titanium implants. No final conclusion regarding the application of two-piece ceramic implant systems could be drawn on the basis of the existing data, thus its use can only be recommended after the patient has been informed in detail about the lack of long-term clinical data.

Removal of osseointegrated dental implants: a systematic review of explantation techniques

OBJECTIVES

This systematic review aims to evaluate current literature regarding available techniques for removal of osseointegrated implants in terms of explantation's success, complications, and bone loss.

MATERIAL AND METHODS

Two reviewers conducted a systematic literature search through electronic databases (PubMed and EMBASE), complimented by manual and grey literature searches. Successful explantation was defined as the primary outcome. Complications and availability of residual bone for immediate implantation were defined as secondary outcomes.

RESULTS

Eighteen articles, comprising 372 implants and 241 patients, were included. Five techniques were identified: reverse torque, trephines, burs, piezosurgery, and laser-assisted explantation. Peri-implantitis was the most common reason for explantation, followed by crestal bone loss, fracture, and malpositioning. The reverse torque was the most frequently reported technique (284 implants) with 87.7% success rate. Burs were used for explantation of 49 implants with a 100% success rate, while trephines were utilized for removal of 35 implants with 94% success. Piezosurgery (11 implants) and Er.Cr:YSGG laser (1 implant) showed 100% success. One study reported perforation of the sinus floor following trephine explantation, while another reported fracture of 3 implants following reverse torque application. Further analysis was hindered by the quality of the available studies and their lack of data.

CONCLUSIONS

Reverse torque seems the most conservative, and in the authors' opinion, should be the first choice for explantation despite its inferior success rate. Additional studies with randomized controlled designs and larger sample sizes are required.

CLINICAL RELEVANCE

Dental implants have become the leading choice to replace missing teeth with gradually increasing numbers of complications and failures. An effective, conservative, and economic explantation technique is necessary to allow a successive implant placement.

Comparative in vivo study of alloy titanium implants with two different surfaces: biomechanical and SEM analysis

OBJECTIVES

The purpose of this study was to evaluate the biomechanical behavior of the interface formed between bone and implants with machined surfaces (MS) and those modified by Al₂O₃ sandblasting and acid etching (SBAS).

MATERIALS AND METHODS

Before surgery, topographic characterization was performed by SEM-EDX and by mean roughness measurements. Ten Albinus rabbits received randomly 20 Ti-6Al-4V implants on its right and left tibiae, with one implant placed in each tibia. After implant insertion, the implant stability quotient (ISQ) was measured by means of resonance frequency analysis (RFA). After 3 and 6 weeks, the ISQ was again measured, followed by torque removal measurements. Analysis of variance and Tukey tests were used to analyze the data. The surface of the implants removed was evaluated by SEM-EDX. Immunohistochemical analysis of osteopontin (OPN) and osteocalcin (OC) protein was performed in bone tissue.

RESULTS

The topographic characterization showed differences between the analyzed surfaces, and the mean roughness values of SBAS group were statistically higher than MS. Overall, higher statistically significant ISQ values were observed in the SBAS group compared to the MS group (p = 0.012). The intra-group comparison of ISQ values in the SBAS group showed statistically significant differences between 0 and 3 weeks (p = 0.032) and 0 and 6 weeks (p = 0.003). The torque removal measurements of group SBAS were statistically higher when compared with the torque removal measurements of group MS in the time intervals of 3 weeks (p = 0.002) and 6 weeks (p < 0.001). SEM-EDX of the implant surfaces removed in SBAS group showed greater bone tissue covering and mean values atomic in percentage of Ca, P, and O statistically superior (p < 0.05) than MS group. Immunohistochemical reactions showed intense OC immunolabeling at 6 weeks postoperative for SBAS group.

CONCLUSIONS

The topographical modifications made in group SBAS allowed a better mechanical interlocking between the implant and bone tissue.

Fatigue lifetime prediction of a reduced-diameter dental implant system: Numerical and experimental study

OBJECTIVE

To validate the fatigue lifetime of a reduced-diameter dental implant system predicted by three-dimensional finite element analysis (FEA) by testing physical implant specimens using an accelerated lifetime testing (ALT) strategy with the apparatus specified by ISO 14801.

METHODS

A commercially-available reduced-diameter titanium dental implant system (Straumann Standard Plus NN) was digitized using a micro-CT scanner. Axial slices were processed using an interactive medical image processing software (Mimics) to create 3D models. FEA analysis was performed in ABAQUS, and fatigue lifetime was predicted using fe-safe^® software. The same implant specimens (n=15) were tested at a frequency of 2Hz on load frames using apparatus specified by ISO 14801 and ALT. Multiple step-stress load profiles with various aggressiveness were used to improve testing efficiency. Fatigue lifetime statistics of physical specimens were estimated in a reliability analysis software (ALTA PRO). Fractured specimens were examined using SEM with fractographic technique to determine the failure mode.

RESULTS

FEA predicted lifetime was within the 95% confidence interval of lifetime estimated by experimental results, which suggested that FEA prediction was accurate for this implant system. The highest probability of failure was located at the root of the implant body screw thread adjacent to the simulated bone level, which also agreed with the failure origin in physical specimens.

SIGNIFICANCE

Fatigue lifetime predictions based on finite element modeling could yield similar results in lieu of physical testing, allowing the use of virtual testing in the early stages of future research projects on implant fatigue.

Cellular behaviours of bone marrow-derived mesenchymal stem cells towards pristine graphene oxide nanosheets

OBJECTIVES

Graphene oxide (GO), the derivative of graphene with unique properties, has attracted much attention for applications in dental implants. The aim of this study was, by two biomimetic cell culture methods, to investigate the quantitative relationship between the concentration of pristine GO nanosheets and their cellular behaviours towards bone marrow-derived mesenchymal stem cells (BMSCs).

MATERIALS AND METHODS

The cells were firstly characterized according to their morphology, self-renewal capabilities and multipotency. Subsequently, adhesion density, proliferation, alkaline phosphatase activity and mineralization of BMSCs treated with various concentrations of GO were analysed. In addition, osteogenic-related proteins were measured for further verification of the GO-induced osteogenic differentiation.

RESULTS

Pristine GO nanosheets inhibited the proliferation of BMSCs at a high concentration of 10 μg/mL during the first 3 days with two seeding methods and facilitated proliferation of BMSCs at a low concentration of 0.1 μg/mL after 5 days with a sequential-seeding method compared to a co-seeding method. Analogously, osteogenic differentiation was promoted when BMSCs were treated with 0.1 μg/mL of GO. Both the proliferation and differentiation showed concentration-dependent behaviour. Interestingly, Wnt/β-catenin signalling pathway appeared to be involved in osteogenic differentiation induced by pristine GO nanosheets.

CONCLUSIONS

Pristine GO nanosheets at a concentration of 0.1 μg/mL provide benefits to promote BMSCs proliferation and osteogenesis under a sequential-seeding method, contributing to the use of GO for dental implantation.

Restoration: Implant with Devastated Platform through Metal Post

Case Presentation. Implant prostheses are a successful treatment for replacing missing teeth. However, this treatment modality can have biological and mechanical complications causing serious problems for the dentist, as demonstrated in this clinical case. The patient presented with a fractured screw and a severely damaged implant hex connection that corresponded to the second premolar, upper left, stating that she unsuccessfully tried to remove the prosthetic screw, which was most likely to have been loose. After clinical and radiographic review, it was decided to remove small fragments of the fractured prosthetic screw inside the implant head. Removal by conventional methods was unsuccessful but was eventually achieved through use of a bur. Then it was possible to make a cast post (gold-palladium) and develop a fixed prosthesis (silver-palladium), which were attached with luting cement. A cast post (gold-palladium) was made and a fixed prosthesis was developed (silver-palladium), which were attached with luting cement, the same ones that can present mechanical complications such as fractures between the third and fourth thread of the implant, loosening of the abutment, and/or the prosthetic screw in individual crowns, most frequently in partially edentulous patients, mainly in the premolar and molar regions of the maxilla. Conclusion. Therefore the present technique used in this case is very simple, noninvasive, and useful to readers.

Implant success lies in complications management: A report of two cases

At present, implant supported or retained prostheses are considered as a first therapeutic alternative for patients. Although the success rate of dental implants is very high, no treatment is without complications; same applies to implants also. Implant failure can be due to biological factors, i.e., loss of osseointegration or due to technical complications. This case report presents implant complications involving both factors along with the management of these cases. In implant supported overdenture patient, loss of implant on the right side and implant body fracture of the left side implant is reported and in another patient abutment screw fracture and its management is reported.