research paper on dental implants

• Open access
• Published: 28 June 2021

A novel surgical model for the preclinical assessment of the osseointegration of dental implants: a surgical protocol and pilot study results

• Noura M. AlOtaibi   ORCID: orcid.org/0000-0001-5362-1888 1 , 2 ,
• Michael Dunne 3 ,
• Ashraf F. Ayoub 1 &
• Kurt B. Naudi 1  

Journal of Translational Medicine volume  19 , Article number:  276 ( 2021 ) Cite this article

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Dental implants are considered the gold standard replacement for missing natural teeth. The successful clinical performance of dental implants is due to their ability to osseointegrate with the surrounding bone. Most dental implants are manufactured from Titanium and it alloys. Titanium does however have some shortcomings so alternative materials are frequently being investigated. Effective preclinical studies are essential to transfer the innovations from the benchtop to the patients. Many preclinical studies are carried out in the extra-oral bones of small animal models to assess the osseointegration of the newly developed materials. This does not simulate the oral environment where the dental implants are subjected to several factors that influence osseointegration; therefore, they can have limited clinical value.

This study aimed to develop an appropriate in-vivo model for dental implant research that mimic the clinical setting. The study evaluated the applicability of the new model and investigated the impact of the surgical procedure on animal welfare.

Materials and methods

The model was developed in male New Zealand white rabbits. The implants were inserted in the extraction sockets of the secondary incisors in the maxilla. The model allows a split-mouth comparative analysis. The implants’ osseointegration was assessed clinically, radiographically using micro-computed tomography (µ-CT), and histologically. A randomised, controlled split-mouth design was conducted in 6 rabbits. A total of twelve implants were inserted. In each rabbit, two implants; one experimental implant on one side, and one control implant on the other side were applied. Screw-shaped implants were used with a length of 8 mm and a diameter of 2 mm.

All the rabbits tolerated the surgical procedure well. The osseointegration was confirmed clinically, histologically and radiographically. Quantitative assessment of bone volume and mineral density was measured in the peri-implant bone tissues. The findings suggest that the new preclinical model is excellent, facilitating a comprehensive evaluation of osseointegration of dental implants in translational research pertaining to the human application.

The presented model proved to be safe, reproducible and required basic surgical skills to perform.

Clinical relevance

Scientific rationale for the study : the use of in-vivo models to assess a new dental implant is essential to study osseointegration, inflammation or immunological reactions within a live model. Animal model is a crucial step for translational research and is challenging both technically and biologically. Most of in-vivo studies evaluated the oral implants in long bones, which is not relevant to clinical application,

Principal findings : we successfully introduced a new model for dental implants investigation in rabbits' maxilla, which solves the issues associated with previous models,

Practical implications : to explore biological efficacy of modified implants, an appropriate model is required that resembles the clinical situation before considering human applications.

The replacement of missing teeth with dental implants is considered the gold standard approach for oral rehabilitation [ 1 ]. Despite the significant success rates of the currently-used dental implants, researchers are exploring new materials and investigating the effects of surface modifications (micro-geometries) on direct bone formation around implants in the maxilla and mandible “osseointegration” [ 2 , 3 ]. Several new materials have been approved for the fabrication of dental implants; however, some have been tested in preclinical models that do not completely replicate the clinical environment. Multiple large animals have been previously considered for the preclinical assessment of the osseointegration of dental implants, these include; dogs, pigs, sheep and non-human primates [ 4 ]. There are major drawbacks which limit the routine use of large animals to asses of the osseointegration of dental implants such as; expense, limited availability, handling difficulties, need for specialized housing centers and specially trained staff as well as ethical considerations related to protected species [ 4 , 5 , 6 , 7 ]. Moreover, there is a risk of cross-infection of tuberculosis and other zoonotic diseases [ 6 , 8 ]. Small animals, in comparison, are easier to handle, less expensive to acquire and maintain and have a satisfactory bone turnover rate to study osseointegration [ 6 , 9 ]. They also do not require specialized housing and are available in athymic, transgenic and knockout strains [ 10 ].

Rabbits are mammalian animals which are biologically comparable to humans [ 11 ]. The rabbit’s maxilla is similar in morphology to the human one; embryologically it develops by intramembranous ossification. Another added advantage is the fact that the rabbit is classified as a small animal and so can be housed in a small animal facility, but it is large enough to allow the testing of the osseointegration of dental implants. Rabbits are considered a reliable model for studies related to bone regeneration, periodontal wound healing and the integration of dental implants [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ].

The available evidence suggests that osseointegration of oral implant is substantially dissimilar from osseointegration in long bones [ 17 ]. At present many preclinical investigations of dental implants are carried out in the long bones and the cranium [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. These are of a limited clinical application because the oral cavity represents a challenging environment for implant osseointegration; thus, dental implants should be tested in the maxilla and mandible to investigate the impact of the saliva, oral microbiology and the biting forces on the osseointegration process [ 17 ]. Therefore, there is a need to develop a clinically valid experimental model for the testing of dental implants [ 9 ].

Our goal was to recapitulate the unique environment of implant osseointegration in the oral cavity using a rabbit model for future dental implants research. Anatomically, the two primary maxillary incisors are fully erupted on the anterior part of the rabbit maxilla, in addition, two secondary incisors are barely visible on their palatal surface and are known as peg teeth (Fig. 1 ). The lower incisors occlude against these secondary incisors. The main function of the secondary incisors is controlling the overeruption of the lower incisors and shaping their edges [ 26 ]. Hypothetically, the extraction of these secondary incisors will not affect the animal welfare and simultaneously subject the implants to indirect load from the lower incisors.

Cadaveric maxilla of rabbit. a Illustration of position of the secondary incisors behind the primary incisors. b The proposed implant positions in the sockets of the extracted secondary incisors

In the presented study, the implants were inserted in the extraction sockets of the secondary incisors in the maxilla. The model allows a split-mouth comparative analysis. In order to validate the experimental method and the sample size, the pilot study was conducted.

Ethics approval

Approval was obtained from the Animal Welfare and Ethical Review Board of the University of Glasgow and licensed by the UK Home Office under the (Animals (Scientific Procedures Act) 1986). The in-vivo study was carried out at the Small Animals Research Unit-Biological Services, University of Glasgow. All animal husbandry regulations and ARRIVE guidelines for preclinical studies were followed.

This study was carried out on 6 male New Zealand white rabbits, the weight of each one ranged from 2.8 to 3.7 kg. The rabbits, provided by Envigo, UK, were acclimatized for two weeks before surgery. Each rabbit was housed separately in a standard cage and maintained in a room with controlled temperature under 12 h light-dark cycles.

Sample size calculation

The resource equation method was used to estimate the required number of animals [ 27 ]:

E= (12)–2 = 10, which is considered an adequate sample size according to Festing and Altman [ 28 ].

Study design

A randomized, controlled, split-mouth study was performed. In each rabbit, two implants were inserted; an experimental implant on one side, and a control one on the other side. These were randomly assigned to the right and left extraction sockets of the secondary maxillary incisors (Fig. 1 ) using a computer randomization programme. A total of twelve implants were inserted in 6 rabbits. The implants were screw shaped mini-implants, 8 mm in length and 2 mm in diameter. The experimental implants were made of medical-grade polyetheretherketone material provided by Invibio Biomaterial Solutions, UK and the implants were manufactured by Ensinger, UK. The titanium implants (controls) were supplied by Cimplant Co., Seoul, Korea.

Anaesthesia

The rabbits were anaesthetised by subcutaneous (SC) injection of Narketan (ketamine) (15 mg/kg) and Domitor (medetomidine) (0.25 mg/kg). After 10 min, an oral endotracheal tube was inserted and fixed on the right side around the mandible and the neck using a bandage. Ophthalmic lubricant Viscotears Liquid Gel was applied on both eyes. General anaesthesia was maintained using isoflurane and oxygen at a ratio of 1:1. To reverse the muscle relaxant action, Antisedan (atipamezole) (0.25 mg/kg) was injected intramuscularly (IM) and an infraorbital nerve block were administered (Additional file 1 : Fig. S1). Body temperature was monitored pre- and postoperatively, as well as for three days postoperatively using a rectal digital thermometer.

Implementation of the surgical model

The surgical technique was developed, refined, and finalized following preliminary cadaveric experimentation.

A throat pack was inserted to secure the endotracheal tube in place and minimize the leakage of oral fluids. Oral disinfection was done using chlorhexidine solution Vetasept (Chlorhexidine Gluconate 0.5 % Surgical Scrub Solution Animalcare Ltd, York, UK). The surgical site was draped in the standard manner (Additional file 1 : Fig. S1). Local anaesthesia was injected in the palatal mucosa using 2% Xylocaine DENTAL with epinephrine 1:80,000, (DENTSPLY Pharmaceutical, York, UK). The secondary incisors were luxated using a 19-gauge needle to sever the periodontal ligaments around the teeth and to reduce the chance of root fracture (Fig. 2 a, b). A rectangular palatal flap was raised (approximately 1 cm x 0.8 cm x 1 cm) from the first premolar of one side to the contralateral first premolar by performing a full-thickness incision in the palatal mucosa with a No.15 blade, the mucoperiosteal flap was raised using a periosteal elevator to expose the bone. An H-shape flap was obtained by cutting anterior releasing incisions which were extended labially (Fig. 2 c). The loosened secondary incisors were extracted using college tweezers or root forceps (Fig. 2 d, e). The primary incisors were trimmed 5 mm from the incisal edge using a fissure carbide bur which facilitated the insertion of the dental implants parallel to the longitudinal axis of the secondary incisor. Fractures of the roots of the secondary incisors during the extraction was one of the challenges of the surgical technique which was managed with the delicate application of a 19-gauge needle to luxate and cut the periodontal ligament around these incisors and drilling of the remaining root fragments using a fissure bur if fracture happened.

Operative protocol. a Secondary incisors (arrows). b Secondary incisors luxated with a 19-gauge. c H-shape flap design. d Extraction performed using root forceps. e Alternative extraction method using college tweezers. f Extraction sockets (arrows) and extracted secondary incisors at upper left corner. g Final placement of implants in the maxilla. h Reflected flap closed primarily using bio-absorbable sutures

The extraction sockets were prepared using a low-speed 1.5 mm twist drill to a depth of 8 mm under copious saline irrigation. The implants were inserted manually in the prepared sockets (Fig. 2 g). Primary stability was determined clinically, the mobility was checked using a dental probe, the implants were immobile and achieved primary stability within the sockets. The muffled sound on percussion conformed the primary stability of the implants. Before suturing, the surgical site was irrigated with saline. The reflected flap was sutured primarily over the implants using bio-absorbable sutures (Vicryl Rapide suture, Ethicon) size 3–0 in an interrupted manner (Fig. 2 h). The surgical procedure for each rabbit took between 20 and 30 min.

Analgesia and postoperative care

Following surgery, the rabbits were housed in a recovery cage overnight then were returned to their standard cage the next day. They were inspected daily in the postoperative period for the assessment of behavioral changes indicating distress, and the weight was recorded. The signs of pain and discomfort postoperatively were assessed using the rabbit grimace scale, the necessary analgesia was provided following consultation with the Named Veterinary Surgeon (NVS) of the unit. Soft food was provided during the first three postoperative days followed by gradual introduction of semi-solid diets.

The rabbits were humanely euthanatized after eight weeks with an overdose of pentobarbitone sodium (140 mg/kg) according to the Schedule 1 method. The euthanasia of the animals occurred in seconds, which was confirmed by cardiac arrest and cessation of involuntary reflexes. The maxillae were explanted and the surrounding soft tissue was dissected from the bone (Fig. 5 ). Bone formation around the dental implants was evaluated using µ-CT followed by histological assessment.

Micro-computed tomography and histological assessments

The anterior part of the maxilla was harvested, fixed in 10% formaldehyde solution, then dehydrated in a series of graded ethanol before resin embedding. Following fixation, the bony segments with the dental implants were imaged using micro-computed tomography (µ-CT). Micro-CT images of bone samples were obtained using a SkyScan 1072 scanner (Bruker, Germany), SHT 11 Megapixel camera and a Hamamatsu 80 kV (100 µA) source at 80 kV, 1050 msec (exposure time), 6.75 μm (resolution), 0.2° (rotation step), and 180° (rotation angle). No filter was applied to the X-Ray source. The three-dimensional regenerated bone was reconstructed from micro-CT images using the CTAn software package (Skyscan). An annular region of a thickness of 100 µm from the implant surface was considered the region of interest (ROI), parameters such as percent bone volume (BV/TV) and bone mineral density (BMD) were measured. Measurements of the bone density were based on two phantoms of calcium hydroxyapatite (CaHA) with known mass concentrations of 0.25 g/cm3 and 0.75 g/cm3 were scanned under the same scanning setting. This allowed the calibration of the attenuation of the study samples based on the linear interpolation between the two known densities. The BV/Total Volume (TV) was calculated using the formula: BV/TV (%) = bone volume in the band / total tissue volume of the selected band. After complete curing of the resin, the specimens were sectioned using a precision saw, into blocks of a thickness of 200 µm. The blocks were trimmed to 50µm for histological assessment.

Statistical analysis

All quantitative data are expressed as mean ± standard deviations. Statistical analysis was performed using GraphPad Prism 8 software. Normal distribution was tested using Shapiro-Wilk normality test followed by two-tailed paired t-test for parametric data and Mann-Whitney U test for non-parametric data. Statistical significance was accepted at p < 0.05.

Clinical findings

The surgical procedures were completed uneventfully in the 6 cases. All cases recovered well with minimal postoperative complications. All rabbits started to eat normally and regained ≥ 96% of their preoperative weight at one week postoperatively (Fig. 3 ). The weight loss was associated with pain and inability to eat. All rabbits recovered by the third week and regained their preoperative weight and behaviour. The surgical site was accessible for inspection and was regularly monitored during the healing period allowing for maintenance of oral hygiene (Fig. 4 ). The upper primary incisors regrew to their average length within ten days postoperatively. The implants remained submerged and covered by healthy gingiva throughout the study period. None of the cases encountered unexpected implant failure or developed wound dehiscence around the implants or any signs of infection.

Chart of individual bodyweight of rabbits during the study period

Clinical image demonstrating complete healing with healthy gingival coverage in one of the cases postoperatively

Gross examination of the retrieved bone sample and implants

The colour and texture of the gingival tissue appeared healthy and did not reveal signs of inflammation or any adverse tissue response. In all the cases, no fibrous tissue was found around both implants (Fig. 5 ). Upon dissection of the soft tissues, no bony overgrowth nor marginal bone resorption was observed around the implants. All implants were stable and immobile, which provided a preliminary indication of osseointegration. The stability was tested clinically by evaluating the mobility of the implants using a dental probe and listening for the muffled sound normally heard on percussion of osseointegrated implants [ 29 ].

Gross examination of the retrieved bone sample. a Close-up of lateral view of explanted anterior maxilla of one of the cases illustrating the complete bone coverage of both implants. b Close-up view showing no bone overgrowth nor marginal bone resorption around both implants. c Superior view showing intact bone with no bone perforation by the implants

Micro-CT analysis

The reconstructed 3D images of the µ-CT scans clearly demonstrated the position of the implants in the maxilla and showed close contact, with no fibrous tissue, between the implants and the surrounding bone (Fig. 6 ). The µ-CT captured the implants' location and allowed for the comparison of the two different implants simultaneously (Fig. 6 b). The µ-CT assessments demonstrate no signs of infection or implant failure in any of the cases. In the current model, the contact between implants and surrounding bone is evaluated in three dimensions (Fig. 6 b–d). Upon closer inspection, the bone tissue was on direct contact with implants' surface showing homogeneous radiodensity along the implant-tissue interface. The newly formed tissue in direct contact with the surface of the experimental implant has the same micro-structure and radiopacity to the rest of the jaw bones and similar to the bone around the control implants. Therefore, it is not unreasonable to conclude that the formed tissue on the implants' surface is bony in nature, thus confirms the osseointegration of the implants.

The radiographic images demonstrating the position of the implants in the presented model. a Three-dimensional reconstruction of the model in cadaveric rabbit using X-ray computed tomography system (XCT). b Representative microtomographic axial slice of the µ-CT image from rabbit maxilla. c Representative microtomographic sagittal slice of the µ-CT image from rabbit maxilla in colour scale. d Representative microtomographic coronal slice of the µ-CT image

Quantitative analysis of µ-CT data reveals that the mean bone mineral density (BMD) of the peri-implant bone was 0.32 ± 0.04 g.cm −3 for the experimental implants and 0.45 ± 0.15 g.cm −3 for the control implants (Fig. 7 a, b), the difference was not statistically significant; t(5) = 2.5, (P = 0.05) with a moderate non-significant correlation coefficient between the two groups within the same animal (r = 0.39, P = 0.22). The percentage of peri-implant bone volume (BV/TV) was 19.7 ± 3.7 % for the experimental implants which is not statistically significant than that in the control group, which was 15.8 ± 7.5 %; t(5) = 1.77, (P = 0.14). A positive strong correlation was detected for bone formation related to the tested and control implants (r = 0.73, P = 0.05). There was a consistent increase of BV/TV in the experimental implant to the control implant of each rabbit (Fig. 7 d). There were no statistical differences in osseointegration at 8 weeks between experimental and control implants in rabbit maxilla.

The Quantitative µ-CT analysis. a Bone mineral density (BMD) data are presented as mean ± SD and were analyzed with paired t-test. No statistical differences were seen between the two types of dental implants. b Results of paired t-tests of BMD demonstrating the pattern of the relationship between the experimental and titanium implants. The pair of implants inserted in anterior maxilla of each rabbit are connected by a line. c Data are presented as mean ± SD and were analyzed with paired t-test. No statistical differences were seen between the two types of dental implants. d Results of paired t-tests of BV/TV demonstrating the pattern of the relationship between the experimental and titanium implants. The pair of implants inserted in anterior maxilla of each rabbit are connected by a line, ns = not significant

Undecalcified bone sectioning was achievable parallel to the long axis of the implants. Both implants were centralized in the bone, demonstrating direct bone tissue attached to the implants (Additional file 1 : Fig. S2).

Collectively, the presented model allowed for the evaluation of the bone-implant interface in three dimensions. The three-dimensional CT of the maxilla showed the location of the two implants clearly, without overlap facilitating for the comparative analysis of different implants.

The primary goal of this research was to develop a reliable animal model to test the osseointegration of dental implants that overcomes the limitations of previous studies. To our knowledge, the presented model is the first to report on the application of a split-mouth design in rabbits for testing the osseointegration of dental implants in the maxilla.

Our findings provide a new perspective on the clinical simulation of the osseointegration model in in-vivo that is relevant to many therapeutic areas, including oral implantology, periodontology, prosthodontics, and maxillofacial surgery. In contradistinction to previous studies, our preclinical model provides a unique and reproducible preclinical setting to assess implant healing process utilizing a clinically relevant environment. The presented animal model allows the understanding of how the process of osseointegration is influenced by the environment of the oral cavity, including the presence of saliva and its associated microorganisms, during the surgery as well as the indirect forces of mastication. This better simulates the actual clinical scenario. Furthermore, it standardized the environmental and biological factors that may impact on the quality and pattern of bone regeneration around dental implants within the same animal [ 30 , 31 ]. The model is also readily adaptable in medical conditions that may affect bone healing, such as diabetes and osteoporosis [ 32 , 33 ]. One drawback of the current model is the fact that the implants are left submerged and not directly communicating with the oral environment. However, the submerge protocol is one of the available surgical approaches for dental implants [ 34 ]; it would be beneficial to evaluate the osseointegration in a non-submerged setting. Future studies should explore the development of abutments that would fit on these implants to allow for complete replication of the clinical picture.

All animals regained their preoperative weight within a short period of time. The surgical site was easily accessible through the conventional intraoral approach. There was minimal blood loss and low morbidity compared to other dental implant models as no extraction of primary teeth, lateralization of the inferior alveolar nerves or excessive bone removal were required [ 16 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. The presented model was designed considering the three fundamental principles of animal research; replacement, reduction and refinement. Also, the rabbits were considered to be a cost-effective animal model in comparison to larger animals [ 9 ].

Several animal models have been considered for the evaluation of dental implants and the testing of osseointegration, these include mice, rats, rabbits, dogs, minipigs and sheep [ 3 , 23 , 43 , 44 , 45 ]. However, in many of these models the implants were placed in extraoral locations. Dental implants have been placed in the extraction sockets of the rabbit mandibular teeth by a handful of authors [ 16 , 37 , 39 , 40 , 41 , 42 ]. Munhoz et al. in 2017 evaluated the impact of xenograft (Gen-Ox) on the osseointegration of dental implants after the extraction of the lower incisors bilaterally [ 16 ]. The removal of the lower incisors may, however, have compromised the animal welfare, the rabbits are lagomorph animals which are entirely herbivorous, and the lower incisors are crucial for chewing and biting of food [ 26 ].

Despite the close similarity, differences between the human and rabbit maxilla with regards to bone composition, mineral density and fracture toughness exist [ 46 , 47 ]. Nonetheless, the intramembranous bone healing is similar in the two species [ 4 , 14 , 48 ]. In this model, the insertion of the dental implant in the maxilla was ideal in that it allowed for the evaluation of trabecular bone healing compared to the mandible and calvarial bones which are made up of compact bone [ 14 ]. The rabbit's maxilla has sufficient bone height and width for the placement of custom implants. The placement of implants in this anatomical region allows for the indirect mechanical loading of the tested implants from the biting forces of the lower incisors which is comparable to the clinical scenario and essential for studying osseointegration. No extraction of the primary teeth is required (only secondary incisors); therefore, the surgical trauma is minimal, and the animal welfare is not compromised. Based on the rat model used for orthopedic research, the optimum bone volume required for implant stability is 1 mm around an implant with a diameter of 2.6 mm, in tibial bone of approximately 5 mm width [ 18 , 49 ]. According to the findings of the cadaveric experimentation, the available bone in the premaxilla allows placement of implants up to 8 mm in length and 2 mm diameter without damaging the adjacent primary incisors. The implant diameter for the presented model was 2 mm which is commercially available for orthodontic skeletal anchorage [ 50 ]. The results did not show bone resorption or exposure of the implant threads upon clinical and radiographical examination; this confirms that the thickness of the bone, size of the implant and socket dimension were suitable for the presented study. It has been shown that bone remodeling of the extraction socket walls during healing is essential for the initial stability of the immediate implants. However, initial bone resorption of the extraction socket during bone remodelling may cause the early loss of the dental implant [ 51 ]. Therefore more than 1 mm thickness of the bone is recommended to avoid failure of osseointegration [ 52 , 53 , 54 ].

The presented approach, a split-mouth design, allows two different types of dental implants to be tested simultaneously. This, eliminated anatomical variations, and avoided bias in the assessment of osseointegration and the inter-subject variability [ 30 ]. This also resulted in a reduction of the number of the rabbits needed for the study by 50% which follows the recommendations of the international guidelines for preclinical studies. Furthermore, the experimental implant can be easily randomly allocated to one side of the maxilla [ 30 ]. The accessibility of the anterior part of the maxilla facilitated the surgical procedure and reduced the realted morbidity.

The quantitative µ-CT parameters used in this study which were measures of BV/TV and BMD are indicators of the bone healing and osseointegration of dental implants. These are standard parameters used by several studies evaluating osseointegration [ 1 , 55 ], or bone regeneration around the implants [ 56 , 57 ]. The nature of in-vivo investigation mandates minimizing the number of animals as possible to draw a conclusion; however, larger numbers may prove actual differences and give more statistical power. Based on the data obtained from this pilot study, the sample size calculation can be performed for future studies.

One of the constraints for this model is the limited number of histological sections that can be obtained parallel to the longitudinal axis of the implant due to its small diameter (2 mm), this could be overcome with, multiple cross-sectional cuts. A minimum of 3–4 histological slices per implant is recommended for the 3D prediction of bone-implant contact in histological studies [ 58 ].

This model could also allow for the evaluation of osseointegration in compromised environments such as poorly controlled diabetes, osteoporosis and other immunocompromised conditions [ 32 , 33 , 59 ].

Conclusions

The presented innovative model for the assessment of the osseointegration of dental implants in the rabbit maxilla is safe, reproducible, can be standardized, requires minimal surgical skills, is readily achievable with basic instrumentation and is simple to implement. The postoperative morbidity is minimal and has no associated mortality. It provides easy access to the surgical site, enables testing of the osseointegration within the maxilla and under indirect mechanical biting forces. This suggests that it may be a useful model for future preclinical implant assessment, particularly if abutments are developed to allow for direct communication of the implants with the oral environment.

Availability of data and materials

The datasets of this study are available from the corresponding author upon request.

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Acknowledgements

The authors are grateful to the College of Medical, Veterinary and Life Sciences for providing technical support for their help and assistance in providing the animals in the cadaveric stage. The authors would also like to thank Dr. Alice Macente for her generous help with the XCT imaging of the cadaveric model. We acknowledge the valuable support of the Centre for Ultrasonic Engineering, University of Strathclyde for the µ-CT facilities used in this research specifically Prof. James Windmill and Dr. Andrew Reid. Also, we thank Prof. Gordon Blunn for his expertise and help with the histological sectioning of the samples. The authors would like to thank KSU Deanship of Scientific Research for funding and supporting this research through the initiative of DSR Scholarship.

This study is supported by a studentship for one of the authors from King Saud University (KSU) through the Deanship of Scientific Research (DSR) Scholarship, Saudi Arabia.

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NA, KN and AA designed the study. NA and KN performed the cadaveric procedure. NA defined the final protocol. NA, KN and AA were responsible for the in-vivo surgery and performing the procedure. MD and NA carried out general anaesthesia and post-operative care. MD took the intraoperative photographs. NA prepared the manuscript. KN and AA were responsible for revising the manuscript critically for valuable intellectual contents. All authors have read and approved the final manuscript.

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Figure S1. Preoperative Protocol. (a) Oral intubation and tube fixation method around the lower jaw. (b) Ophthalmic lubricant application. (c) Infraorbital nerve block. (d) The rabbit is draped in universal manner. Figure S2. Gross assessment of one of the explanted maxillae during preparation (cut with precision saw) for histological assessment. (a, b) The bone tissue appeared well integrated with both implants. No gap was visible between the host bone and the implants in these unstained histological sections.

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AlOtaibi, N.M., Dunne, M., Ayoub, A.F. et al. A novel surgical model for the preclinical assessment of the osseointegration of dental implants: a surgical protocol and pilot study results. J Transl Med 19 , 276 (2021). https://doi.org/10.1186/s12967-021-02944-w

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Current technology for identifying dental implants: a narrative review

• Mohammad Ali Saghiri   ORCID: orcid.org/0000-0002-5064-7828 1 , 2 ,
• Peter Freag 3 ,
• Amir Fakhrzadeh 4 ,
• Ali Mohammad Saghiri 5 &
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This paper outlines the current status and mechanism for identifying dental implants, with emphasis on future direction and updated technology, and covers the existing factors influencing the identification of implant systems.

A search was performed on the current methods of identifying dental implants between January 2000 through Feb 2020 using online databases for articles published in English. The search was performed using the Google, Rutgers library, PubMed, MEDLINE databases via OVID using the following keywords: implant types identification by x-ray imaging, forensic identification of dental implant, surface types, threaded, non-threaded, software identification, recent technologies, which evaluated different methods in the identification of dental implants and its clinical importance for the dentist and the patient. Of the 387 articles found in initial search results, 10 met the inclusion criteria set for this review. These 10 studies were directly related to the identification of different implant systems. Many studies have indicated identifying dental implants as problematic due to many confounding factors, and the difficulty in finding the specific parts for the dental implant itself. The contribution of digital dentistry is critical. Factors like increasing number of implant manufacturers, dental tourism, and cost, make it difficult to detect and match dental implants by dentists during the chairside time.

These factors give rise to the need for a new system to help clinicians in decision making. Artificial intelligence seems to have shown potential to help in this case. However, detailed regulatory mechanisms are still needed for diagnosis and analysis.

Dental implants have become a popular choice of treatment in replacing individual lost teeth or entire dentitions. According to the American College of Prosthodontists (A, people with low income or education have fewer remaining teeth (ACP 2020 ). Also, 27.27% of seniors over age 65 have no remaining teeth (NIH 2020 ). Every year, more than 800,000 individual implants are installed in the United States (US), and more than 1.8 million in the European Union (EU) (Insights et al. 2027 ). This number is expected to increase considerably (NIH 2020 ) due to an increase in the geriatric population and the number of general dentists and specialists performing the procedure. Dental implant therapy is an invasive, lengthy, and precise procedure. Each of the components used in this process are specific to the original implant down to the manufacturer, type and size since most implant companies have a unique library of implant designs, sizes, and platforms. The amount of time it takes for an implant procedure from start to final restoration can be as long as a year in most patients and can cost upwards of $4000 per implant (site AAID. 2020 ). Since an implant contains many different components (Cappare et al. 2019 ; Takeuchi et al. 2018 ), it may be difficult to replace it without the knowledge of the implant type.

The major problem with this process is that clinicians often find patients who have had implants placed in other U.S. dental offices or from areas abroad without any records regarding the identification of the implant system (Fox News 2020 ). Due to the cost of dental implant therapy in the US, more patients are traveling overseas to have implants placed and subsequently come back to the U.S. to have the implants restored. Currently, identification of the specific implants, without patient records based on radiographic or clinical observation is difficult because of a lack of identifying markers on implants. This problem doesn’t just arise during the implant restoration process but is also a cause for concern when implant complications arise. The need for improved methods for accurate implant recognition is widely understood by clinicians and patients who have encountered these issues.

All the currently used methods for implant identification and classification are time-consuming and not very accurate. The most current and frequently used method for identifying dental implants is a website (whatimplantisthat. 2020 ) that simply provides photos of hundreds of X-rays that clinicians must search through individually to try to help in identifying their patient's implant after they input descriptive features of the implant to narrow down their search field. Lack of an established and efficient system for identifying dental implants, keeping all the different confounding factors including dental tourism, increasing number of implant manufacturers, and cost in mind, has proven to be a hurdle in systemized and timely identification of implants during the chairside time. Developing innovative methods to identify these previously placed implants based on radiographic and clinical data, will spare millions of patients and clinicians the difficult task of deciding whether to proceed with the very invasive unpredictable procedures to remove and replace unidentifiable implants, restore and rehabilitate them with mismatched components. This calls for identification and revaluation of the current technology for identifying dental implants so pave way for it. This paper, therefore, aims to, analyze the existing technology, the new upcoming technology, and its future direction, covering the existing factors influencing the identification of implant systems: manufacturing, patient, and imaging factors.

Materials and methods

In this review, the methods for identifying dental implants and their clinical importance for the dentist and the patient are assessed. The factors influencing dental implant survival rates and in extension, leading to an increased need for a centralized database for implants are also assessed. The main aspect of this review is to evaluate the methods in identifying dental implant systems worldwide and describing the limitations within these current methods.

Inclusion and exclusion criteria

The inclusion criteria were studies accepted and published in the English language between January 2000 through Feb 2020. The inclusion criteria included the scientific in-vivo, in-vitro articles, reviews, systematic reviews, case reports, and clinical trials with controlled study design. Studies were also included that had identified the dental implant systems, implant systems manufacturer identification, forensic radiographic identification, global dental implant market varsity, major implant manufactures, and factors affecting implant maintenance.

The exclusion criteria were studies that were published before January 2000 and through Feb 2020. Criteria also excluded the studies that focused on other restoration types to replace missing teeth. Also, excluded studies that mainly focused on other aspects of implant surgical techniques, impression systems, that do not affect the identification of the implant system.

Search methodology

A literature search was performed electronically using the Google, Rutgers library, PubMed, MEDLINE databases via OVID using the keywords mentioned in the PubMed and MeSH headings for articles published in the English language from January 2000 through Oct 2019 that evaluated the method for identification of dental implants and its clinical importance for the dentist and the patient. The keywords included were: implant types, x-ray imaging, forensic, implant surface types, threaded, non-threaded, software identification, automated diagnosis. Some of the most relevant article’s full texts and reference lists were evaluated for eligibility.

Of the 387 articles found in initial search results, only 10 met the inclusion criteria set for this review. These 10 studies were directly related to the identification of different implant systems, which are presented in Table 1 . The relevant full-text articles and the reference lists of the related articles were evaluated to supplement the search as well. The assessment of the eligibility and finding related data were performed by two reviewers independently.

Upon analysis of the literature selected, different technologies for classifying and building a database for dental implants were found like the Implant Recognition Software (IRS), to identify implants in a person’s mouth, a method to identify threaded implants, non-threaded implants using radiographic images, a method to identify the design of selected dental implants, dental implant manufacturer database, a method to identify implants from Italy. The complications arising due to dealing with unidentified implants reiterating the need for a new system was found along with finding a potential solution in terms of a suggestion for companies to place individual serial numbers rather than batch numbers on the implants, and the filling out an implant record file by the patients to keep better tabs of the implants to build a database.

Identification technology for different implant systems

The articles and studies discussed in this scientific review are distributed as shown in Fig.  1 a. G. Michelinakis et al. ( 2006 ) created a webpage at Manchester University, United Kingdom, and collected all data available for root-formed implants obtained from the Google search engine ‘ www.google.co.uk ’ and the AltaVista search engine ‘ www.altavista.com ’, as shown in Table 2 . The webpage involved a detailed search of the World Wide Web (web) for implant manufacturing companies, with the initial search period being from November 2002 to June 2003 and updates commenced in February 2004 and ended in April 2004; a total of a 10-month search period. Implant types after April 2004 were not included. The data from this period was classified according to the implant type, body shape, implant design, abutment connection type, threaded or non-threaded, the surface type, polished collar, the diameter and length available for each system. The details of each implant system, according to each manufacturer, were then collected and stored in the IRS. This data, though collected from 21 different countries, produced a total of only 231 different implant designs. IRS ideally made it possible for the dentist and the lab workers to identify each dental implant system. However, because the IRS online tool was only updated during a limited time period, this system is no longer as beneficial as it was during that time.

a Schematic of the studies involved in the review; b Three studies conducted by Sahiwal et al. (Sahiwal et al. 2002a ; Sahiwal et al. 2002b ; Sahiwal et al. 2002c ) describing different types of implants: Threaded and Non-threaded including the macro design of each

Another study by Sahiwal et al. ( 2002a ) documented various x-ray photos with different horizontal rotations and vertical angulations to the x-ray beam for each implant system, shown in Fig.  1 b. This study was for the threaded implants identification only. In this study, about forty-four implants “3.7 mm D*10 mm L” were collected, twenty-eight of which identified as threaded from more than fifty implant industry companies. Radiographic x-rays were taken in 0°, 30°, 60°, and 90° horizontal rotation with − 20°, − 10°, 0°, + 10°, and + 20° vertical inclination relative to the x-ray beam. This resulted in the production of twenty photos for each implant but at 20° vertical inclination. However, the x-ray photos were distorted and unrecognizable, so the observation was made only from − 10° and + 10° vertical inclination. They made tables describing each coronal part, middle part, apical part of each implant at vertical inclinations of − 20 to + 20, and − 10 to + 10 of the screw chambers. These tables were meant for the dental professional to match the description of their patient's implant x-ray to the tables provided in this study to identify what threaded implant they are working with. As for the non-threaded implants, Sahiwal et al. ( 2002b ) documented the features of different types of non-threaded dental implants in which they used the same protocol as described in the threaded study. More than fifty implant manufacturers were contacted, and out of forty-four implant that were donated, sixteen were non-threaded with "3.7 mm D*10 mm L" dimensions, as shown in Fig.  1 b.

Sahiwal et al. ( 2002c ) also studied the Macro design and the morphology of endosseous dental implants. In this study forty-four implants of size: "3.75mmD*10 mm" were donated and then classified into threaded and non-threaded, and tapered and non-tapered implants, as shown in Fig.  1 b. They examined each implant individually into 3 sections: coronal third, middle third, and apical third of the fixture. Then a table was formed describing each section of the fixture. This comparative method gives the dentist a database feature for each design and help in the radiographic identification for each system. However, as shown in Table 2 , the limitation of all three studies by Sahiwal et al. ( 2002a , b , c ) was that identifying the implants was cumbersome. These tables were limited to the forty-four implants that were donated and there is no software available making it prone to human error. This is not an up to date method and hence a more exact method is still required for more accurate identification of implants.

According to a study by Mansour et al . ( 2019 ), possibility of identifying the batch numbers, even if they were not engraved in dental implants, making antemortem dental records of dental implants more easily accessible to establish a comparative dental identification. In addition, the reported case presents the supplementary data yielded through estimating the epigenetic age using DNA (deoxyribonucleic acid) methylation as well as the biogeographical origin using Y-Haplotype and mitochondrial DNA analyses. Our results demonstrate that expanded oral implant investigations that also include implants extraction and comprehensive microscopic measurements can lead to identifying their batch numbers despite the numerous number of implants systems manufactured and distributed worldwide. Data saved by dental implant manufacturers can be very supportive and represent additional reference data for dental identification, when antemortem dental records are still missing.

Nuzzolese et al. ( 2008 ) studied the radiographic dental implants recognition for geographic evaluation within human identification. This study was carried out in Italy; the researchers created an archive of radiographic photos of Italian dental implants taken at horizontal rotations of 0º, 30º, and 60 º and combined with -20º, -10º, 0º, + 10º, and + 20º vertical inclination. They summarized the data into fifteen photos for each implant system. The observation was only in a -10º and + 10º vertical inclination; this study shows the survey of the distribution of the implant market over Italy thus give a clue of the geographic identification. However, the implant information was solely collected from Italy, geographically limiting this study.

According to Morais et al . ( 2015 ), a dental implant recognition novel computer-aided framework was suggested. They used this method for a segmentation strategy for semi-automatic implant delineation and a machine learning approach for the recognition of an implant model design. Although the segmentation technique was the focus of the recent study, preliminary details of the machine learning approach were also reported. Two different scenarios were used to validate the framework: (ACP 2020 ) comparison of the semi-automatic contours against implant’s manual contours of 125 x-ray images; and (NIH 2020 ) classification of 11 known implants using a large reference database of 601 implants. In experiment 2, 91% of the implants were successfully recognized while reducing the reference database to 5% of its original size. The segmentation technique achieved accurate implant contours. Although the results of the preliminary classification proved the concept of the current work it had limitations like the lack of detecting distinct features on implants; this software, though a step in the right direction, still needs an expansion of implants details in the database.

The current methods are limited to the dentists worldwide but not only does the dental field benefit from the identification of different implant system but also the forensic field gains significantly by classifying implant systems as it may provide the missing link to complete the picture (Bush and Miller 2011 ). For example, the identification of a disaster victims from their dental records is a well-established technique. In cases in which dangerous high temperatures from fires causes destruction of the structural integrity of the dentition, implants prove to be the only recognizable features. A study by Berketa et al. ( 2010a ) talks about how efficiency of implant recognition can be increased if the implant manufacturers were to place individual serial numbers rather than batch numbers on them. In another one of his studies (Berketa et al. 2010b ), he talks about how the Implant recognition software in its current form was of little benefit for radiographic assessment of dental implants for forensic odontologists. One way to improve this has been suggested by Daher et al. ( 2009 ) where they how an Implant Record Form filled by the patients would prove to be highly beneficial in keeping track of them.

Certain websites can be helpful in the task of identifying implants, as mentioned before. Sites such as whatimplantisthat (whatimplantisthat. 2020 ), Osseosource (OSSEOsource 2020 ), and Whichimplant (no longer available) are open source search engines that allow identification of implants through its radiographic photos. "Exotic encounters with dental implants: managing complications with unidentified systems" a case report by Mattheos et al. ( 2012 ), reported a 55-year-old male patient, with a dental implant from outside the country needed implant therapy. He identified his implant through these websites using his x-rays. A dental implant identification app was also launched three years after the conception of whatimplantisthat.com based on it (Kent Howell 2013 ). This app made its dental database easily accessible on the go to help better dental care provided by clinicians. In recent times, with the increasing utilization of artificial intelligence (AI) in various fields, a website which uses cloud-based AI to help dentist interpret x-ray images to find 30% more pathologies by specially developed machine learning algorithms (Tuzoff and Denti 2017 ). Though currently, the app and site whatimplantisthat.com is the most accurate and time-saving method, the AI website is a step in the right direction, and incorporating its featured to create an implant database will revolutionize this field.

Factors associated with the difficulty in the identification of implant systems

Implant market size and manufacture variety (fig.  2 a).

a Summarization of the factors associated with the complexity of implant identification. b Distribution of patient factors. c The failure types of implant-supported restorations

According to Dental Implants Statistics, the global dental implants market is likely to arrive at USD 13.01 billion by 2023 from USD 9.50 billion in 2018, at a CAGR of 6.5% (MarketsandMarkets™ 2023 ). The need for dental implants is growing; over 69% of Americans ages 34 to 44 years old have at least one tooth missing. More than 35 million people have an edentulous jaw or both (Gaille 2018 ). Additionally, according to the National Institute of Dental and Craniofacial Research, 24% of elderly people above 74 years old already have lost all their teeth (NIH 2020 ). During the period of 2014 to 2017, major players adopted product launches to strengthen their product portfolio and widen their customer base, followed by agreements, partnerships, and collaborations (Markets et al. 2023 ). Institute Straumann AG (Straumann) (Switzerland), DENTSPLY Sirona Inc. (DENTSPLY Sirona) (US), Zimmer Biomet Holdings, Inc. (Zimmer Biomet) (US), Danaher Corporation (US), AVINENT Implant System (AVINENT) (Spain), being the predominant players in the current dental implant market (Marketwatch 2024 ). The implants by various companies differ from each other subtly and accurate model is hard to detect even by an experienced eye. The difficulties with the identification of dental implants are increasing along with the rapid exponential growth of its market with the armamentarium for each system varying along with it.

Dental tourism: cost and age (Fig.  2 b)

Dental tourism is a major impacting factor that many clinicians are facing in identifying dental implant systems of each patient. There are many reasons why patients choose to receive implant restorations outside of the United States, first being the cost factor. 3–4 percent of the world’s population travels across borders receive healthcare; it is estimated that this industry is growing by 25 percent per year (Aircare Air Ambulance and Medical Escort Services 2020 ). It is estimated that 1.3 million Americans left the US for medical care in 2016; about 50 percent went to Mexico for dental procedures and another 15 percent traveled for cosmetic procedures (28). The ages of patients vary as well. Most statistics show that older patients are more likely to consider traveling for healthcare, but VISA surveyed over 30,000 people, 18 to 34 years of age, results pointed to about 88% of the total respondents made trips at least once per year, sometimes three times, for healthcare procedures (28). Statistics show that 400,000 Americans crossed international borders for dental care. According to a study, (Moeller et al. 2010 ), in 2016, uninsured low-income patients are less likely to receive dental services or may only have non-major dental care. The cost factor prevents most of uninsured patients to have dental treatment.

Restoration factors

Failure of the restoration supported by an unknown implant system (fig.  2 b).

Prosthetic failure may be due to an implant supported overdenture failure, FPD (fixed partial denture) failure, biological restoration failure, or an occlusion restoration failure. Failure of the restoration supported by an unknown implant system includes Peri-implantitis, restoration loosening, and fracture and implant structural damage. They may occur in implant-supported single or splinted crowns, bridges, overdentures, or fixed dentures (Gong 2018 ).

Implant supported overdenture failure (Fig.  2 b)

According to José Balaguer et al. ( 2015 ), overdentures were examined over 95 months (ranging from 36 to 159 months) with an overall success rate of 96.1%: 91.9% in the maxilla and 98.6% in the mandible, this being a significant difference (P < 0.05). Over the 13-year follow-up, 14 implants failed (3.9%), 12 due to peri-implantitis, and 2 due to implant fracture average duration of loading before failure was 52 months. The survival rate is not perfect, which implies that a dental professional may need to replace the overdenture leading to clinicians needing information pertaining to the implant system which is critical for accurately replacing the denture. According to Vahidi F et al. ( 2015 ), even with the success rate, implant-supported removable prostheses require episodic maintenance making it a critical factor and hence making the need for a systematic classification and database for implants indispensable irrespective of the need for replacement.

Fixed partial denture (FPD) failure

According to Bjarni E. Pjetursson et al. ( 2012 ), the meta-analysis of these studies indicated an estimated survival of implants supporting FPDs of 95.6% after 5 years and 93.1% after 10 years. The survival rate of implant supported FDPs was 95.4% after 5 years and 80.1% after 10 years of function. The success rate of metal-ceramic implant-supported FDPs was 96.4% after 5 years and 93.9% after 10 years (Sadid-Zadeh et al. 2015 ). Only 66.4% of the patients were free of any complications after 5 years. The most frequent complications in all implant supported restorations over the 5-year observation period is shown in Table 3 . These mechanical complications can be developed from even a single tooth restoration or fixed partial denture restoration supported by implants. Failure types of implant supported restoration are broadly shown in Fig.  2 c.

Aesthetic, biological restoration, mechanical and occlusion restoration failures (Fig.  2 c)

These two factors are correlated. Aesthetic failure due to gingival recession, which is a biological component, over an implant will affect the aesthetic aspect, especially in the front teeth. Aesthetic failures can be categorized as gingival failures or emergence profile failure and white-tissue failures (Fuentealba and Jofre 2015 ). According to Sailer et al. ( 2015 ), the feldspathic based porcelain should be limited to applications in the anterior region due to metal showing and zirconia ceramic crowns should not be considered as a primary option due to their high frequency of technical problems. Avoiding biological failures is critical in maintaining the health of the periodontium. The number of dental implants is increasing, a healthy peri-implant soft and hard tissues are required for the stability and survival of dental implants (Algraffee et al. 2012 ). Biological restoration failure includes the complication of peri-implantitis. The restoration itself can be lacking in the biological component (i.e. implant surface is rough). Daubert et al. ( 2015 ) found in his study that one in four patients and one in six implants have peri-implantitis after 11 years. According to Lee CT et al. ( 2017 ), peri-implant diseases were prevalent and the occurrence of peri-implantitis increased with time. According to Bergmann et al. ( 2014 ), dental implants are situated into an ever-changing environment in which teeth can continue to move around but the implants are ankylosed. Teeth may continue to erupt, leaving the implants in infraocclusion or move medially away from an implant which requires modification of the restoration. All these failures are components in which identifying the implant system is essential for everyone.

Systemic conditions and habits (Fig.  2 b)

The systemic conditions and the drugs used in the treatment of various conditions influence the implant restoration success rate; also, habits like smoking and bruxism have an impact on the success of the restoration. According to Manor et al. ( 2017 ), medically compromised people go ahead with surgery increasing failure rate. Certain medications involved in medical treatment can also be a factor. According to Chrcanovic et al. ( 2016 ), antidepressants are a statistically significant predictor for implant failure. Smoking is another factor as it is shown that implant restorations in smokers have a high failure rate, risk of postoperative infection, and marginal bone loss. With that said, smoking is not an absolute contraindication for implant treatment, but patients should be advised of the high risk of failure (Keenan and Veitz-Keenan 2016 ). Diabetes mellitus is also associated with a high risk of peri-implantitis, independently of smoking, but not with peri-implant mucositis, according to Monje et al. ( 2017 ). More research must be done because there is not yet a clear association between diabetes and implant failure (Naujokat et al. 2016 ). Bruxism may also significantly increase the implant failure rate and the complications of implant-supported restorations (Chatzopoulos and Wolff 2018 ). These conditions and habits hence affect the implant success rate and make their identification important.

Imaging factors (Fig.  2 a)

The problem in identifying an implant with a standard 2D (NIH 2020 ) x-ray is that 3D (Insights et al. 2027 ) spatial information is necessary for identification (Perlea et al. 2016 ). Additionally, the unknown implant insertion angle inside the jawbone, the horizontal rotation, the vertical inclination, and the direction of the x-ray beam were also contributing factors that need to be accounted for while photographing and documenting the data as it is important for the interpretation and identification of the implant x-ray photo as shown by Indira G. Sahiwal et al. ( 2002a , b ). Choi JW et al. ( 2011 ) confirmed that for a 3D x-ray, the use of CBCT (cone beam computed tomography—diagnostic aid used when the conventional x-rays fail as a diagnostic tool (Shah et al. 2014 )) should be preferred over a CT (computed tomography) image but it has a high radiation dose. According to Michele M Vidor et al . ( 2017 ), radiographic image of the bone-implant interface is influenced by two factors, the radiographic system, and the processing filter employed. The results from this study are that conventional radiographs or digital images with application of high-pass filters such as “Caries2” and “Endo” could help enhance diagnosis on the implant-bone interface on intraoral radiographs so it could help too in the identification of different implant systems and hence aid in the identification of different implant systems. Its flexibility with output formats, calibration of magnified images, and instantaneous results make it a highly efficient method (Gupta et al. 2015 ). According to Narra et al. ( 2015 ), Micro-CT was found to be a valuable tool for the morphologic evaluation of retrieved dental implants. Therefore, imaging factors influence the identification and indexing of current dental implants.

According to the growing rate of the implant market and the significant increase of the implant manufacturer's design, the identification of different implant systems has become a critical issue. Not only the growth of different implant designs has been deemed an issue but also the global increase in patients in need of treatment.

The maintenance factor needed in the post-implant treatment for every system is different within each armamentarium therefore; the clinicians and the lab technicians need to know exactly which system they are dealing with. Implants are a restoration that needs maintenance. Some patients who have medical conditions like diabetes and epilepsy are at greater risk for implant restoration failure. These patients need maintenance of periodontal health, which makes the identification for the implant restoration critical.

The development of a new and extensive database for implants is vital for successful implant therapies. The current technologies include limited databanks either due to lack of samples or geographical restrictions. Others are either with a limited period or only give 2D data where 3D information for implants are needed. Given the lacking current technology, keeping a tab on all the implants is very difficult and development needs to be made to design a more efficient, exhaustive, and accurate system.

The identification based on radiographic imaging needs more information about the horizontal rotation and vertical inclination of the fixture inside the jawbone. Digital radiography has shown to be highly effective in taking implant images due to its calibration of magnified images. Using digital imaging radiographic photos with high resolution and high pixelation is important to make the identification easier. Software programs or mobile applications based on documentation technology make it easier and more efficient for the dentist to use which saves significant chair side time and cost. More research is needed to cover the market variety and the update for the database is mandatory and essential for the awareness of dental implant global production.

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

American dental association

American college of prosthodontists

United States of America

European union

Implant recognition software

United Kingdom A

Deoxyribonucleic acid

Fixed partial denture

2 Dimensional

3 Dimensional

Cone beam computed tomography

Computed tomography

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Acknowledgements

This publication is dedicated to the memory of Dr. H. Afsar Lajevardi (Saghiri and Saghiri 2017 ), a legendary Pediatrician (1953–2015). We will never forget Dr. H Afsar Lajevardi’s kindness and support. The views expressed in this paper are those of the authors and do not necessarily reflect the views or policies of the affiliated organizations. The authors hereby announced that they have active cooperation in this scientific study and preparation of the present manuscript. The Authors confirm that they have no financial i nvolvement with any commercial company or organization with direct financial interest regarding the materials used in this study. The Authors confirm that they have nothing to disclose. MAS acknowledges being a recipient of the New jersey health foundation award.

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Saghiri, M.A., Freag, P., Fakhrzadeh, A. et al. Current technology for identifying dental implants: a narrative review. Bull Natl Res Cent 45 , 7 (2021). https://doi.org/10.1186/s42269-020-00471-0

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• Automated identification
• Dental implants
• Restorations

Research on implants and osseointegration

Affiliations.

• 1 Department of Oral Pathology, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina.
• 2 National Research Council (CONICET), Buenos Aires, Argentina.
• 3 Department of Radiobiology, National Atomic Energy Commission, Buenos Aires, Argentina.
• PMID: 30892769
• DOI: 10.1111/prd.12254

Osseointegration was originally defined as a direct structural and functional connection between ordered living bone and the surface of a load-carrying implant. It is now said that an implant is regarded as osseointegrated when there is no progressive relative movement between the implant and the bone with which it is in direct contact. Although the term osseointegration was initially used with reference to titanium metallic implants, the concept is currently applied to all biomaterials that have the ability to osseointegrate. Biomaterials are closely related to the mechanism of osseointegration; these materials are designed to be implanted or incorporated into the living system with the aims to substitute for, or regenerate, tissues and tissue functions. Objective evaluation of the properties of the different biomaterials and of the factors that influence bone repair in general, and at the bone tissue-implant interface, is essential to the clinical success of an implant. The Biomaterials Laboratory of the Oral Pathology Department of the School of Dentistry at the University of Buenos Aires is devoted to the study and research of the properties and biological effects of biomaterials for dental implants and bone substitutes. This paper summarizes the research work resulting from over 25 years' experience in this field. It includes studies conducted at our laboratory on the local and systemic factors affecting the peri-implant bone healing process, using experimental models developed by our research team. The results of our research on corrosion, focusing on dental implants, as well as our experience in the evaluation of failed dental implants and bone biopsies obtained following maxillary sinus floor augmentation with bone substitutes, are also reported. Research on biomaterials and their interaction with the biological system is a continuing challenge in biomedicine, which aims to achieve optimal biocompatibility and thus contribute to patient health.

Keywords: biomaterials; bone substitutes; failed dental implants; osseointegration; peri-implant bone healing.

© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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• Osseointegration
• Sinus Floor Augmentation*
• Dental Implants

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• UBACyT 0020130100332BA/University of Buenos Aires/International
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Effectiveness, Esthetics, and Success Rate of Dental Implants in Bone-Grafted Regions of Cleft Lip and Palate Patients: A Systematic Review and Meta-Analysis

Ankita pathak.

1 Prosthodontics and Crown & Bridge, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Mithilesh M Dhamande

Seema sathe, smruti gujjelwar.

Congenital clefts impair function and appearance, thus impacting a patient's social and mental health. A multidisciplinary team that can offer comprehensive treatment from infancy through maturity and beyond can successfully address these abnormalities. Dental rehabilitation is very important for these patients; these abnormalities should be identified and must be treated accordingly. Hence it is of utmost importance to know the success rate and changes in quality of life from patient satisfaction in order to plan future treatment goals when coming across such cases. The aim of this article is to determine success rate, esthetics, and patient satisfaction in implant-based oral rehabilitation in bone-grafted regions of cleft patients. Registration was carried out in PROSPERO (International Prospective Register of Systematic Review) with registration number CRD42022329861 on May 7, 2022. Medical Subject Headings (MeSH) terms such as cleft lip, cleft palate, survival rate, and dental implants were used to handpick articles via an electronic database. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to compile all the data gathered from an electronic database. According to the collected data, 93.5% of the survival rate with dental implants was noted irrespective of the type of bone grafts used. Also, improvement in quality of life was achieved in these patients. Effectiveness, esthetics, and success rate are very well achievable with implants in cleft patients. Although the aesthetics are not equivalent to that of dental implants in normal patients, patient satisfaction is still satisfactory in patients with dental implants in bone-grafted regions of cleft lip and palate.

Introduction and background

Cleft lip and palate (CLP) are genetically predisposed developmental defects. These anomalies were discovered through inherited genomic mapping. Orthodontists play a wide range of roles, starting with infant orthopedic nasoalveolar molding and continuing through adolescence. Orthodontic space closure with concurrent aesthetic restorative contouring is the preferred therapy [ 1 ]. Orthodontic therapy in cleft individuals achieves only 50% to 75% closure of the residual gap, necessitating dental prostheses to close the remaining space [ 2 - 3 ]. A cleft is often surgically treated with bone grafting, which supports the eruption of canines, allows for orthodontic tooth movement, and provides an opportunity for planning and placing implants. In particular, the iliac bone is regarded as the gold standard for this reconstruction as it provides strong mechanical strength for fixation stabilization and a higher potential for osteogenesis [ 4 ].

Reconstruction is often performed during the mixed dentition stage when 2/3 of the root of the canine is developed. Since individuals continue to develop until early adulthood, surgical treatment with implants is not the ultimate viable choice for repairing midline diastema in previous cleft cases [ 5 ]. Fixed partial dentures and removable partial dentures (FPDs and RPDs) should be considered where implant placement is not possible. However, each of them has drawbacks, especially concerning tooth wear and cosmetic flaws [ 6 ]. The absence of a papilla and scarring of the soft tissue can cause esthetic (black triangle) and phonetic (air leakage) issues. In reaching a satisfactory esthetic result, optimal three-dimensional implant positioning is crucial, but it is also known that a good esthetic outcome is the result of the combination of harmonious teeth, gingival appearance, and lip shape.

The gingival tissue is of fundamental importance because the quantity and quality of the keratinized gingiva around the prosthetic abutments and implants creates a barrier against inflammation and facilitates oral hygiene [ 7 ]. Optimum three-dimensional implant location is crucial in achieving a desirable esthetic result. Dental implant-based rehabilitation provides a suitable solution; however, its success depends on the quality and quantity of the residual bone. Hence, it is important to know what will be the success rate and esthetics of dental implants in bone-grafted regions of cleft lip and cleft palate [ 8 ]. The goal of this systematic review was to determine the esthetics, efficacy, and success rate of dental implants in syndromic CLP patients. It also aimed to list various grafting sources and the likely outcomes associated with other criteria indirectly contributing to assessing esthetics, success rate, and patient satisfaction.

First, the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to conduct the current systematic review [ 9 ]. The current review was conducted by following the patient population, intervention, comparison, and outcome (PICO) standards [ 10 ]; where P: unilateral and bilateral CLP patients with missing permanent teeth in the cleft region; I: dental implant-based rehabilitation in bone-grafted regions of cleft lip and cleft palate; C: no comparison groups; O: success rate, esthetics, and patient satisfaction of dental implants in bone grafted regions of CLP patients. Final research question: what are success rate, esthetics, and patient satisfaction in patients rehabilitated with dental implants in bone-grafted regions of cleft lip and cleft palate patients? The systematic review was carried out by predefined analytic, exclusion, and inclusion criteria and was filed with the International Prospective Register of Systematic Review (PROSPERO) under the registration number CRD42022329861 (Record ID: 329861).

The data extraction and search strategy were carried out through electronic databases such as PubMed, Google Scholar, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), Web of Science, etc. MeSH terms dental implants, cleft lip, and cleft palate were used in an advanced search. Filters were applied for English language and human studies. Inclusion criteria included the average age of patients 21 years old, articles published in the English language, prospective and retrospective studies, randomized control trials, and the utility of implants for dental rehabilitation in cleft patients. Exclusion criteria were incomplete studies, incomplete and unpublished randomized control trials, letters, editorials, abstracts only, animal studies and in-vitro studies, cleft associated with syndromes, and papers or studies in which clinical parameters were not discussed. Figure ​ Figure1 1 shows the PRISMA flow chart showing the selection of studies for the review and meta-analysis. Table ​ Table1 1 shows a summary of the inclusion and exclusion criteria. The Joanna Briggs Institute (JBI) critical appraisal tool was used to reduce the risk of bias. Two reviewers independently examined the aforementioned available literature, and selection criteria & exclusion criteria were documented using the JBI tool [ 11 ]. In the event of a dispute, a third party requested an independent assessment article in question, and the item was included or omitted based on a majority judgment.

A total of nine studies were included for qualitative synthesis of data and two studies for meta-analysis of systematic review. A total of 308 implants were placed; implants were placed on a total of 227 cleft patients (an average of 1.31 implants per patient) in the included studies. The mean age of the patients was 21 years. An average survival rate of 93.5% was extracted from the studies. According to the included studies, the follow-up period is six months to five years. As per the reported literature, the anterior iliac crest is the gold standard site for bone grafts in cleft patients. In the reported literature by Leven et al., in cases such as atrophic maxilla, where dental implants are not the ultimate treatment choice in these patients, zygomatic implants are considered. He concluded in his study that a high success rate can be achieved when dental implants are replaced by zygomatic implants [ 12 ]. Table  2 shows included studies in the present systematic review​​​.

IPS: patient-specific implant; IABH: interdental alveolar bone height

Result of meta-analysis

The result of the Meta-analysis of the two studies suggests no significant difference in the change of marginal bone level in the implant area in both the cases and the control, suggesting equal effectiveness of the implant in both cleft and non-cleft groups. (Random-effects: difference in means = 2.87, 95% CI= -0.37 to 0.041; p = 0.09). The result of the individual study suggests no significant difference in the marginal bone level -0.04±0.04 in the cleft group and -0.02±0.04 in the control group. Similarly in the other study, 0.03±0.05 and 0.5±0.07 were in the cleft group and the control group, respectively. Bone loss is also seen in other studies, but it didn’t affect the integrity of the implants. Study confirms that the success rate of the implants is achieved when bone loss is less than 1.5 mm and 1.9mm [ 21 - 23 ]. Figure ​ Figure2 2 shows the results of the meta-analysis, viz., a forest plot comparing mean marginal bone loss (MBL) in cleft patients. Also, a funnel plot (Figure ​ (Figure3) 3 ) shows MBL in cleft patients and other patients in follow-up after implant. 

SD: standard deviation; MBL: marginal bone loss

Landes 2006: Landes et al., 2006 [ 13 ]; Alberga 2020: Alberga et al., 2020 [ 18 ]

SE: standard error; MD: mean difference; MBL: marginal bone loss

Most of the studies included in the systematic review performed bone grafting using either autogenous iliac crest (AUIC) or allergenic bone grafts, which have shown excellent outcomes in managing cleft patients [ 12 - 20 ].

Discussion 

The existing database emphasizes the multiple benefits of dental implants in CLP patients [ 12 - 20 ]. Other parameters assessed by the authors included in the review are summarised in Table ​ Table3 3 .

As given in the literature by Takahashi et al., 2008, the evaluation of dental implants is done by the assessment of alveolar bone height [ 14 ]. Their study, as well as the study done by Savoldelli et al., 2022, used the interdental alveolar bone height (IABH) index for the assessment of bone height, as shown in Table ​ Table4. 4 . In the two studies, the success rate of implants was 90% and 100%, respectively [ 14 , 19 ].

IABH: inter alveolar bone loss

Achievement of Considerable Esthetics After Rehabilitation With Implants

In terms of esthetics, it’s well understood that soft tissue scars and an absence of interdental papilla can lead to less-than-desirable esthetic results [ 24 - 28 ]. Although the optimal 3D placement of the implant is important for attaining a desirable cosmetic result, it’s understood that a good esthetic outcome is the result of a combination of harmonious teeth, the ultimate zenith of gingiva and healthy gingiva, and perfect lip line and contour [ 7 ]. Enhancements in esthetics boost the patient’s self-perception and improve quality of life [ 28 - 30 ]. These lower scores are most likely the outcome of a less favorable preoperative condition, including the formation of scar tissue. In patients with an alveolar cleft, the implant placement is frequently accentuated, putting them at risk of less desired cosmetic consequences.

Patient Satisfaction 

To determine patient satisfaction, a self-administered questionnaire and an implant esthetic crown index were used. The implant crown esthetic index (range 0-5) was used to assess patient satisfaction. Compared to the pink aesthetic score, deemed overly strict for CLP patients [ 31 ], the implant crown aesthetic index was well-matched for patients with CLP.

Factors Considered in Determining Therapeutic Success of Implants

The notion of implant success has evolved throughout the field of implantology. Unlike past philosophies that emphasized a single component as the driving factor for success, the present philosophy regards the implant-prosthetic complex as a single entity, valuing clinical and radiological criteria, prosthesis, esthetics, and function equally. In the current review research, there was a lack of mutual agreement on documented characteristics to determine implant success. Although disputed, the breadth of connected gingiva is frequently seen as a crucial determinant of implant success. Although the value of connected gingiva does not determine a patient's capacity to maintain hygiene, lower values have been demonstrated to cause higher plaque formation, irritation, bleeding of the gingiva, and periodontal problems, all detrimental to implant health [ 31 , 32 ]. Upto 2 mm or larger of gingiva is assumed adequate for peri-implant health. After analysis, every author agreed that there was an improvement in aesthetics and soft tissue profile [ 33 ].

Analysis of the Success Rate of Placed Implants

A success rate of 95% to 100% is achievable as per the available literature, except for case studies for assessing implant success. Therefore, a high success rate can be observed along with bone grafting in the cleft regions, showing that it is frequently linked with a significant risk of complications [ 34 ]. According to the study, implants in the anterior region of the maxilla showed a 2.1% - 6.2% failure rate [ 35 , 36 ]. Implants in the maxillary region failed at a much greater incidence than those in the mandible when subjected to rapid stress. In type III bone, a higher failure rate was observed, i.e., 3% in the anterior region of the maxilla, which may explain the relatively high failure rate in the anterior region of the maxilla. Follow-up periods vary from six months to 40 months [ 37 ].

Limitation 

There are very less studies including intervention as well as control groups. Due to this, less literature is available for meta-analysis. A low level of evidence is available to generate a meta-analysis. Therefore, more randomized control trials should be conducted in the future.

Future direction 

Retrospective and prospective studies are included in the present systematic review. The majority of studies contain only intervention groups only. However, more randomized control trials should be performed to highlight the effectiveness and survival rate of implants in cleft patients.

Conclusions

Patient satisfaction is comfort to the patient, and comfort to the patient is a token of appreciation to the clinician. The longevity of implants in cleft patients has reported a high survival rate in the literature database. The negligible difference in bone loss compared to other cases shows great success. In a correct graft, the optimum gap between the implant placement and selection of implant provides a high success and survival rate. This systematic review intended to understand and explore the survival rate of implants in cleft regions. A major finding from the included literature highlights no significant change in MBL in cleft and non-cleft patients. This data strongly suggests equal effectiveness of implants in both groups. However, more clinical trials are required in this field to buttress the evidence.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Ankita Pathak, Mithilesh M. Dhamande, Seema Sathe, Smruti Gujjelwar

Acquisition, analysis, or interpretation of data:   Ankita Pathak, Mithilesh M. Dhamande, Seema Sathe, Smruti Gujjelwar

Drafting of the manuscript:   Ankita Pathak, Mithilesh M. Dhamande, Seema Sathe, Smruti Gujjelwar

Critical review of the manuscript for important intellectual content:   Ankita Pathak, Mithilesh M. Dhamande, Seema Sathe, Smruti Gujjelwar

Supervision:   Ankita Pathak, Mithilesh M. Dhamande, Seema Sathe, Smruti Gujjelwar

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• Research Summary
• Published: 16 February 2015

Summary of: Advances in orthodontic anchorage with the use of mini-implant techniques

• Andrew DiBiase 1  

British Dental Journal volume  218 ,  pages 178–179 ( 2015 ) Cite this article

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• Dental implants
• Orthodontics

Informs that orthodontic mini-implants (OMIs) provide reliable anchorage in all three dimensions (antero-posterior, transverse and vertical).

Reports that OMIs are well accepted and tolerated by both adult and adolescent patients, with minimal morbidity.

Highlights that optimum use of OMIs requires an understanding of orthodontic biomechanics, particularly in terms of the effects of altered traction positions.

Orthodontic mini-implants (OMIs) represent a new form of anchorage provision and appear to provide a variety of benefits for both anchorage-demanding and complex orthodontic cases. This paper reports the latest perspectives on OMIs in terms of the emerging clinical evidence base coupled with their varied clinical applications.

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R. R. J. Cousley and P. J. Sandler British Dental Journal  2015; 218 : E4

Editor's summary

BDJ themed issues are intended to focus on a particular field of dentistry, in this case orthodontics, highlighting advances in the area and putting these into context for the general dentistry community and specialists alike. This particular research paper certainly fulfils that brief. In it the authors highlight and summarise an especially important advance in the field, namely orthodontic mini-implants. As Andrew DiBiase mentions in his commentary on this research review, this discovery and application is a seminal moment in orthodontics.

Research is a funny thing. When we are not involved in it ourselves it can seem niche and far-removed from our everyday lives. But as soon as we become more involved or it is applied to something we can use, the results are wondrous. In this case, if you were being elaborate, you could claim that the research behind of the useful application of orthodontic mini-implants started out with Newton in the late seventeenth century and his work on forces. Another stand out piece of research which laid the paving stone for mini-implants was Bothe, Beaton and Davenports' work on titanium implants in the 1940s. So that very basic research over hundreds of years has provided patients and practitioners alike with a whole new concept to play with in terms of anchorage in orthodontic treatments.

The articles in this special issue of the Journal reinforce that so much of orthodontics is linked to psychological and psychosocial aspects of people's lives. Thus, where possible, it is useful if the treatment itself does not compound these problems for patients. For example, if a child patient is required to require headgear, this can single them out even further from their peer group as being different, at a stage in their lives where being different is not always welcome. However, the anchorage provided by mini-implants is much more discrete and so the patient is happier and compliance is improved. As the authors point out in this paper, mini-implants also provides more versatile anchorage and opens up the possibility of controlling tooth movements in three dimensions.

One of the most exciting aspects of research is the fact that it often opens up new avenues for exploration which could lead to further new applications and ideas. Though sometimes we tire of reading 'further research required' at the end of research papers, this is really a positive thing. Indeed, in the case of orthodontic mini-implants this translates as 'boundless possibilities for the future' of orthodontics!

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 218 issue 3.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

We were both introduced to orthodontic skeletal anchorage when (osseointegrating) palatal implants became available in the late 1990s. Subsequently, when OMIs were introduced we could see the clear advantages of these smaller, non-integrating skeletal fixtures in terms of their small size, ease of insertion, low morbidity, and wider options in the range of anatomical insertion sites and anchorage/traction applications. This led one of us (RC) to design a mini-implant system to overcome some of the perceived initial practical limitations, and the other (JS) to focus on randomised controlled trials comparing these new forms of anchorage with conventional options such as headgear. This approach in the UK mirrors technical and research efforts in other countries, notably Korea, Japan, Germany, the USA and Brazil. Overall this means that twenty-first century orthodontic patients, presenting with anchorage-demanding and/or complex treatment requirements, now have a much wider range of treatment options available to them, as illustrated here.

2. What would you like to do next in this area to follow on from this work?

We aspire to use both our clinical and research expertise to consolidate mini-implant success rates and refine their clinical applications. For example, while OMIs have a high overall success rate, there are still anatomical sites (eg mandibular sites in adolescents) where the failure rate is relatively high. In terms of clinical applications, the most recent novel OMI application is bone-anchored expansion of the palate where dramatic mid-face expansion has been demonstrated by case reports. Our aspiration is that this work is progressed in terms of both clinical technique refinements and research of the long-term maxillary and dental changes.

Over the hundred years or so that is the history of modern orthodontics there have been several seminal moments that have irreversibly changed the way orthodontics is practised: the use of direct bonding to place fixed appliances and the development of the straight wire appliance to mention just a few. It appears we are living through one of those moments now with the introduction of skeletal anchorage, most notably in the form of mini-implants. Unlike implants used in prosthodontics, orthodontic mini-implants are not designed to osseointegrate. Rather they rely on mechanical retention, meaning they can be small allowing placement in numerous locations in the alveolar bone and palate, including interdentally. They are easy to place under local anaesthetic, can be loaded immediately and left in place for as long as they are needed and are simple to remove.

In the UK Richard Cousley and Jonathan Sandler have been in the vanguard of this revolution providing not only clinical guidance and expertise but also the research to back this up. In this article they outline the use of mini-implants in contemporary orthodontic practice, giving a brief summary of the literature in this area. While much has been published, until recently there has been a paucity of proper clinical research. One the authors has undertaken one of the first proper clinical trials in this area, the findings of which are discussed. These have shown that the use of mini-implants is safe, predictable, provides excellent anchorage and is very acceptable to patients. In addition, the technique does not rely on good patient co-operation which is needed in more conventional forms of anchorage control, such as headgear.

The article goes on to describe the use of mini-implants in a variety of clinical scenarios:

Anchorage reinforcement

Molar distalisation

Protraction of teeth to close space in hypodontia cases eliminating the need for prosthetic replacement of missing teeth

Correction of a centreline discrepancy by the unilateral use of a mini-implant

Correction of an anterior open bite.

Each is illustrated with a clinical example. The final clinical case demonstrates the use of mini-implants placed palatally to intrude the buccal segments to close an anterior open bite, which conventionally would have required surgery to impact the maxilla. This shows the impact mini-implants are having in orthodontics, extending the envelope of what tooth movements are possible and the severity of malocclusion that is orthodontically treatable without recourse to orthognathic surgery. Indeed, we live in exciting times.

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DiBiase, A. Summary of: Advances in orthodontic anchorage with the use of mini-implant techniques. Br Dent J 218 , 178–179 (2015). https://doi.org/10.1038/sj.bdj.2015.92

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Published : 16 February 2015

Issue Date : 13 February 2015

DOI : https://doi.org/10.1038/sj.bdj.2015.92

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