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Mar 20, 2024 // 17 min read

“Oral Medicine” at the 7th ITI Consensus Conference: A Narrative Review of the Findings of Group 3

Yukihiro Takeda

Bilal Al-Nawas

France Lambert

DOI: 10.3290/iti.fi.45731

anti-resorptive drugs dental implant materials transmucosal abutment materials clinical and biological outcomes complications

Abstract

The topic of Group 3 was "Oral Medicine", which addressed the influence of both material- and anti-resorptive drug-associated factors on clinical and biological outcomes and complications in implant dentistry. Focused questions addressed the following 3 categories: (1) Implant materials other than titanium (alloys); (2) Transmucosal abutment materials other than titanium (alloys); (3) Medications affecting bone metabolism. After more than 2 years of preparation as well as 72 hours of lively debate between almost 100 experts in the field of implant dentistry, Group 3 defined the following statements and recommendations:

Zirconia is a valid alternative to titanium as a material for implants and transmucosal components, allowing soft and hard tissue integration with clinical outcomes comparable to titanium (up to 5 years) – identified by implant survival, marginal bone loss and peri-implant probing depths. However, the current state of evidence remains limited, especially for 2-piece implant designs. Based on expert opinion, zirconia transmucosal components might be preferred in the esthetic zone.

Administration of low-dose anti-resorptive drugs (ARD) did not show any negative impact on early implant outcomes, but careful follow-up and supportive care is recommended in order to prevent peri-implant medication-related osteonecrosis of the jaw and implant-related sequestration. However, existing dental implants without peri-implant pathology should not be removed. In addition, withholding anti-resorptive drugs (drug holiday) for implant placement is not recommended.

For further details, please refer to the 7th ITI Consensus Conference Group 3 Consensus Report and review articles that can be downloaded from the ITI website.

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Introduction

Every 5 years, the ITI conducts a Consensus Conference to review the current state of evidence in areas of interest in implant dentistry. For the 7th ITI Consensus Conference, based on input from the editors of several dental journals as well as ideas proposed by the members of the Steering Committee, the following five topics were selected: Surgical Techniques, Technology, Oral Medicine, Patient Benefits, and Implant Placement and Loading Protocols. Group 3, which discussed “Oral Medicine”, was headed up by two group leaders, Prof. Bilal Al-Nawas and Prof. France Lambert and three main authors, Dr. Isabelle Laleman, Dr. Stefan Roehling, and Prof. Yong-Dae Kwon, assisted by experts in the field from all over the world. The question “why oral medicine?” is based on the fact that all treatment providers must have a deep understanding of which materials are biocompatible and what kind of medication has an effect on implant treatment in both the short and the long term. Thus the objectives of Group 3 were to address the influence of both material- and antiresorptive drug-associated factors on clinical and biological outcomes and complications in implant dentistry. Focused questions addressed the following 3 categories:

Implant materials other than titanium (alloys)
Transmucosal abutment materials other than titanium (alloys)
Medications affecting bone metabolism

Three systematic/narrative reviews formed the basis for discussion within the working group and were prepared and reviewed before the Consensus Conference. The reviews were discussed within the group, and Consensus Statements, clinical recommendations and patient-oriented questions and answers were formulated and then presented to the plenary for approval. The working group also prepared recommendations for future research. The aim of this narrative review is to highlight and present the findings and recommendations of Consensus Conference Group 3 and how to potentially implement these in everyday clinical practice.

Fig. 1a: Evolution of zirconia implant from 2004 to 2023 (1-piece and 2-piece) (Image editing credit: Stefan Roehling)

Fig. 1b: At the beginning of 2004, 1-piece zirconium dioxide ceramic (zirconia) was established on the market as an implant material and various generations of zirconia implants emerged until 2014 (Image editing credit: Stefan Roehling)

Fig. 1c: 2-piece zirconia implants were introduced to the market in 2008 to offer more flexible treatment options (Image editing credit: Stefan Roehling)

Fig. 1d: Current zirconia implant designs (1-piece and 2-piece) in 2023 (Image editing credit: Stefan Roehling)

Fig. 2: The population, intervention, comparison, outcome, and time (PICOT) question for review article 1. P: Patients with dental implants; I: Implant materials other than titanium; C: Titanium implant; O: Primary outcome = survival rate, secondary outcome = marginal bone loss, probing depth, technical and biological complications; T: at least 5 years

Fig 3a: Application of one piece zirconia implant. Prosthetically-driven implant placement is required for a cement-retained restoration (Photo credit: France Lambert)

Fig. 3b: 1-piece zirconia implants require cement retention. Parallel implant placement is critical especially for 3-unit implant-fixed dental prostheses (Photo credit: France Lambert)

Fig. 4a: Clinical case 1: 1-piece zirconia implant-supported single crown. Patient presented with hopeless #24 and wanted a metal-free treatment option. Clinical situation 8 weeks after extraction (Photo credit: Stefan Roehling)

Fig. 4b: A zirconia 1-piece implant system was selected at the patient’s request (Straumann®︎ PURE Ceramic Implant, 1-piece implant, Straumann Group, Basel, Switzerland) (Photo credit: Stefan Roehling)

Fig. 4c: Peri-implant soft tissue conditions 3 months after implant placement (Photo credit: Stefan Roehling)

Fig. 4d: Clinical situation at cementation of definitive monolithic zirconia crown 4 months after implant placement. In the restorative phase, a defined cementation protocol was required: cement draining hole and application of superfloss to remove excess cement (Photo credit: Stefan Roehling)

Fig. 4e: Delivery of implant-supported single crown 4 months after implant placement (Photo credit: Stefan Roehling)

Fig. 4f: Follow-up 5 years after implant placement, exhibiting healthy peri-implant tissue condition (Photo credit: Stefan Roehling)

Fig. 4g: Radiographic image 5 years after implant placement (Photo credit: Stefan Roehling)

Fig. 5a: Clinical case 2: 1-piece zirconia implant-supported single crown and 3-unit implant fixed dental prosthesis. Patient injured front teeth by trauma and wanted a metal-free treatment option (Photo credit: Stefan Roehling)

Fig. 5b: After placement of three 1-piece zirconia implants for single and 3-unit fixed partial dentures (Photo credit: Stefan Roehling)

Fig. 5c: Porcelan-fused zirconia single crown and 3-unit fixed dental prosthesis were cemented on zirconia 1-piece implant by prosthodontist Dr. Thomas Borer (Photo credit: Stefan Roehling)

Fig. 5d: Radiographic image shows perfect adaptation on implant-prosthesis interface (Photo credit: Stefan Roehling)

Fig. 6: The population, intervention, comparison, outcome, and time (PICOT) question for review article 2. P: Patients with dental implants; I: Implant abutment materials other than titanium; C: Titanium abutment; O: Primary outcome = marginal bone loss, probing depth, secondary outcome = abutment survival, biological and technical complications, and esthetic outcomes; T: At least 1 year

Fig. 7: Both zirconia and titanium transmucosal abutments are clinically comparable in terms of biological complications and patient-reported esthetic outcomes

Fig. 8a: Zirconia abutments can be advantageous if the soft tissue exhibits a thin biotype. Image of a porcelain fused directly onto a zirconia abutment

Fig. 8b: Image of screw with zirconia crown and zirconia abutment. Zirconia abutments require an internal metal screw although it is not exposed to any hard and soft tissue

Fig. 9: It must be noted that “high-polished” zirconia shows better soft tissue attachment than glazed or rough surfaces. If ceramic glaze or other restorative materials are considered, it is recommended to place these materials submucosally as coronally as possible

Fig. 10: Typical anti-resorptive drugs (bisphosphonates and denosumab)

Fig. 11: The population, exposure, comparison, and outcome (PECO) question for review article 3. P: In patients before or after implant installation; E: Exposure to medications known to alter bone metabolism (BP, denosumab, MTX, and CS); C: No medication; O: Primary outcome = Implant failure, biological complications (peri-implant marginal bone level, soft tissue reaction), and co-morbidities (type of medication, therapy length, and other medications), Secondary outcome = factor associated with implant failure

Table 1: Example of the typical dosage for high- and low-dose ARD

Fig. 12a: After more than 10 years of healthy function, implant-related sequestration/MRONJ occurred in a patient who had taken high-dose bisphosphonates for the last 3 years. Clinical image of necrotic bone and inflamated peri-implant soft tissue around a single bone level external dental implant

Fig. 12b: The radiographic image shows a clear separation line between the necrotic bone with the dental implant and the surrounding natural bone. The adjacent implant does not show clear signs of necrosis

Fig. 13a: Implant-related sequestration/MRONJ occurred at mandibular tissue level implant for implant overdenture after some years of function. Clinical situation after resection of necrotic bone with dental implant

Fig. 13b: Radiographic image shows severe destruction of bony structure after resection of necrotic bone with dental implant

Fig. 14a: Implant-related sequestration/MRONJ occurred at 8-unit implant-fixed dental prosthesis supported by 4 bone level internal dental implants after some years of function. Radiographic image shows healthy peri-implant hard tissues

Fig. 14b: Radiographic image shows severe destruction of bony structure around the mandibular 4 bone level internal dental implants

Fig. 14c: Clinical image of extended necrotic bone and inflamed peri-implant soft tissue aound bone level internal dental implant

Fig. 15: Theory of implant-related sequestration/MRONJ introduced in review article 3 (Kwon at al. 2023)