UNIVERSIDADE VEIGA DE ALMEIDA
PROGRAMA DE PÓS-GRADUAÇÃO STRICTO SENSU
MESTRADO PROFISSIONAL EM ODONTOLOGIA
OSMAR DE AGOSTINHO NETO
AVALIAÇÃO CLÍNICA E RADIOGRÁFICA DE PACIENTES SUBMETIDOS
À TERAPIA IMPLANTAR COM CARREGAMENTO IMEDIATO EM MAXILA
EDÊNTULA: UM ESTUDO RETROSPECTIVO COM ACOMPANHAMENTO
DE ATÉ CINCO ANOS
RIO DE JANEIRO
2014
OSMAR DE AGOSTINHO NETO
MESTRADO PROFISSIONAL EM ODONTOLOGIA
ÁREA DE CONCENTRAÇÃO: REABILITAÇÃO ORAL
AVALIAÇÃO CLÍNICA E RADIOGRÁFICA DE PACIENTES SUBMETIDOS
À TERAPIA IMPLANTAR COM CARREGAMENTO IMEDIATO EM MAXILA
EDÊNTULA: UM ESTUDO RETROSPECTIVO COM ACOMPANHAMENTO
DE ATÉ CINCO ANOS
Artigo apresentado ao Programa de
Pós-graduação - Stricto Sensu Mestrado
Profissional
em
Odontologia - Universidade Veiga
de Almeida, como parte dos
requisitos para obtenção do título
de Mestre em Odontologia. Área de
concentração - Reabilitação Oral.
Orientadora: Profa. Dra. Cleide Gisele Ribeiro
RIO DE JANEIRO
2014
UNIVERSIDADE VEIGA DE ALMEIDA
SISTEMA DE BIBLIOTECAS
Rua Ibituruna, 108 – Maracanã
20271-020 – Rio de Janeiro – RJ
Tel.: (21) 2574-8871 Fax.: (21) 2574-8922
FICHA CATALOGRÁFICA
A275a
Agostinho Neto, Osmar de.
Avaliação clínica e radiográfica de pacientes submetidos à terapia
implantar com carregamento imediato em maxila edêntula: um
estudo retrospectivo com acompanhamento de até cinco anos.
/ Osmar de Agostinho Neto, 2014.
54 f.; 30 cm
Dissertação (Mestrado) –Universidade Veiga de Almeida, Mestrado
em Odontologia, Reabilitação Oral, Rio de Janeiro, 2014.
Orientadora: Profa. Dra. Cleide Gisele Ribeiro
1. Implantes dentários. 2. Edentulismo. 3. Carga imediata I. Ribeiro,
C. G. II. Universidade Veiga de Almeida, Mestrado em Odontologia,
Reabilitação Oral. III. Título
CDD – 617.6
DeCS
Ficha Catalográfica elaborada pelo Sistema de Bibliotecas da UVA
Biblioteca Maria Anunciação Almeida de Carvalho FOLHA DE APROVAÇÃO
OSMAR DE AGOSTINHO NETO
AVALIAÇÃO CLÍNICA E RADIOGRÁFICA DE PACIENTES SUBMETIDOS
À TERAPIA IMPLANTAR COM CARREGAMENTO IMEDIATO EM MAXILA
EDÊNTULA: UM ESTUDO PILOTO
Artigo apresentado ao Programa de
Pós-graduação - Stricto Sensu Mestrado
Profissional
em
Odontologia - Universidade Veiga
de Almeida, como parte dos
requisitos para obtenção do título
de Mestre em Odontologia. Área de
concentração - Reabilitação Oral.
Aprovado em 19 de março de 2014.
BANCA EXAMINADORA
__________________________________________
Profa. Dra. Cleide Gisele Ribeiro
Universidade Veiga de Almeida
__________________________________________
Prof. Dr. Eduardo José Veras Lourenço
Universidade Veiga de Almeida
__________________________________________
Prof. Dr. George Miguel Spyrides
Universidade Federal do Rio de Janeiro
Dedico este trabalho a minha família, especialmente a minha esposa
Livia Mayer que suportou e entendeu os períodos de ausência, além da
valiosa ajuda e apoio compartilhada na organização deste trabalho.
AGRADECIMENTOS
Ao
Coordenador
do
Programa
de
Mestrado
Profissional
em
Odontologia, Prof. Dr. Antônio Carlos Canabarro Andrade Júnior, pela
dedicação e grande estrutura disponibilizada aos alunos.
A minha Orientadora Profa. Dra. Cleide Gisele Ribeiro, obrigado pela
dedicação, incentivo, ensinamentos, horas dedicadas à elaboração do
trabalho, confiança, oferecendo todo suporte necessário por meio do
conhecimento e experiência.
Ao grupo de professores do Mestrado, pela paciência, ensinamentos,
senso crítico e orientações.
Ao professores do Departamento de Prótese e Materiais Dentários da
Faculdade de Odontologia da Universidade Federal do Rio de Janeiro, em
especial a Profa. Silvana Marques Miranda Spyrides, que gentilmente liberou
minhas obrigações durante os horários do curso, além de toda dedicação e
orientação.
Aos profissionais da Faculdade de odontologia da Universidade
Federal de Juiz de Fora, que ajudaram com o fornecimento de dados para a
realização desse trabalho.
Aos
meus
colegas
e
alunos
do
Curso
de
Mestrado,
pelo
compartilhamento de experiências e bons momentos durante o decorrer do
curso.
RESUMO
A carga imediata em implantes inseridos em mandíbulas edêntulas é
um método eficiente, confiável e previsível. Contudo, existem poucos
trabalhos disponíveis que tenham avaliado a longevidade deste tipo de
procedimento
na
maxila.
O
objetivo
deste
trabalho
foi
avaliar,
retrospectivamente, as características clínicas e radiográficas de pacientes
que foram submetidos a um protocolo cirúrgico para instalação de implantes
dentais com carga imediata através de próteses fixas parafusadas
metaloplásticas na maxila. Dez pacientes foram aleatoriamente selecionados
na clínica de especialização em implantodontia da Universidade Federal de
Juiz de Fora, Brasil. Foram avaliados 59 implantes através de radiografias
periapicais para a avaliação da perda óssea ao redor dos implantes, e
avaliação clínica, do índice de placa e da satisfação dos pacientes em relação
ao tratamento. Os resultados demonstraram que a maioria dos implantes
avaliados tinham ausência de perda óssea, queixa subjetiva de dor, sensação
de corpo estranho ou parestesia. A taxa de sobrevivência acumulada dos
implantes foi de 94,9% e a taxa de sobrevivência das próteses foi de 100%. A
média de satisfação com o tratamento foi de 9,5 (escala de 0 a 10). Concluiuse que a realização de um protocolo de 5 ou 6 implantes e a instalação
imediata de uma prótese fixa parafusada metaloplástica pode ser considerado
um método seguro e eficaz para a reabilitação de maxilas edêntulas, com um
alto nível de satisfação em relação ao tratamento, demonstrado pelos
pacientes.
Palavras-chave: implantes dentários, edentulismo, carga imediata.
ABSTRACT
Immediate loaded implants inserted in edentulous jaws is an efficient,
reliable and predictable method. However, there are few studies available that
have evaluated the longevity of this type of procedure in the maxilla. The aim
of this study was to evaluate retrospectively the clinical and radiographic
characteristics of patients who have been submitted through a surgical
protocol for installation of dental implants and immediate screw-retained
metaloplastic fixed prostheses in the maxilla. Ten patients were randomly
selected from Implantology Specilization Clinic of Universidade Federal de
Juiz de Fora, Brasil. A total of 59 implants were evaluated through periapical
radiographs to assess bone loss around implants, besides clinical evaluation,
plaque index and the satisfaction of patients regarding treatment. The results
showed that the majority of the evaluated implants had no bone loss,
subjective complaints of pain, or foreign body sensation or paresthesia. The
cumulative survival rate of implants was 94.9% and denture survival rate was
100%. The mean satisfaction with treatment was 9.5 (scale from 0 to 10). It
was concluded that it could be considered safe and effective to perform the
protocol of 5 or 6 implants and immediate loaded placement of a metaloplastic
screw-retained fixed prosthesis for the rehabilitation of edentulous maxillae,
with a high satisfaction level related to treatment shown by patients.
Keywords: Dental implants, edentulism, loading protocol
SUMÁRIO
1- Introdução
10
2- Materiais e métodos
12
2.1- Procedimento clínico
12
2.2- Critérios avaliados
13
2.2.1- Avaliação radiográfica
13
2.2.2- Avaliação clínica
14
2.2.3- Avaliação da satisfação em relação ao tratamento
14
3- Resultados
16
4- Discussão
20
5- Conclusão
25
6- Normas da revista escolhida para publicação
26
7- Artigo – versão em inglês
33
8- Referências
50
1- INTRODUÇÃO
Desde a introdução do protocolo original de Branemark para a
reabilitação de pacientes edêntulos, um grande número de modificações da
abordagem clínica tem sido feitas ao longo dos anos com o objetivo de
atender as necessidades dos pacientes, melhorar os resultados clínicos, e
reduzir o tempo total do tratamento1.
De acordo com as recomendações de Branemark et al.2 (1969), o
carregamento de implantes dentais deve ser realizado em um segundo
estágio cirúrgico, após um período de cicatrização médio estabelecido em três
meses para a mandíbula e seis meses para a maxila, ao longo do qual os
implantes permanecem cobertos, tempo este considerado fundamental para a
osseointegração e o sucesso clínico.
Todavia, Chiapasco (2004)3 e Morton et al.4 (2004) ressaltaram que a
espera para se submeter um implante à carga não foi baseada cientificamente
e sim, clinicamente. Além disso, com a evolução da forma e do tratamento da
superfície dos implantes, novas técnicas foram desenvolvidas, tornando-se
possível a realização do procedimento de carga imediata.
Protocolos de aplicação de carga para implantes dentais têm sido foco
de discussão desde a descoberta da osseointegração e diversas conferências
têm sido realizadas no intuito de divulgar recomendações para a pesquisa
científica. A partir do relatório da Conferência de Consenso da ITI realizada
em 2008, o termo carga imediata refere-se ao carregamento de implantes no
período anterior a uma semana subsequente à instalação dos implantes
dentais5.
Alguns critérios devem ser seguidos para que os implantes possam ser
submetidos à carga imediata, tais como a estabilidade primária do implante, o
10 uso de restaurações provisórias que promovam esplintagem e controlem a
carga mecânica aplicada aos implantes, bem como a prevenção da remoção
de restaurações provisórias durante o período de cicatrização recomendado5.
A literatura tem considerado o procedimento de carga imediata como uma
modalidade de tratamento viável e com altas taxas de sobrevivência para
várias indicações, desde que boa qualidade óssea esteja presente6 e a
estabilidade primária do implante seja obtida3,7,8.
Em
mandíbulas
edêntulas,
a
carga
imediata
tem
sido
bem
documentada e muitos estudos têm demonstrado a sua previsibilidade9,10,11
enquanto somente poucos estudos em longo prazo relacionados a carga
imediata em maxilas edêntulas foram relatados na literatura
12,13,14
. Em geral,
a maxila edêntula apresenta características macroscópicas e microscópicas
diferentes da mandíbula. Além disso, a qualidade do tecido ósseo na região
localizada entre os forames mentuais é essencialmente diferente do osso
maxilar,
que
apresenta
um
tecido
ósseo
mais
trabecular
e
consequentemente, uma menor densidade15. Em função disso, podemos
presumir que a obtenção da estabilidade primária dos implantes inseridos na
maxila se torna mais difícil16.
O presente trabalho teve por objetivo avaliar, retrospectivamente, as
características clínicas e radiográficas de pacientes que foram submetidos a
um protocolo cirúrgico para instalação de implantes dentais com carga
imediata através de próteses fixas parafusadas, a fim de se determinar a
eficácia e a longevidade deste tratamento.
11 2- MATERIAIS E MÉTODOS
Este projeto de pesquisa foi aprovado pelo Comitê de Ética em
Pesquisa em Seres Humanos da Universidade Federal de Juiz de Fora (sob o
número: 222/2010). Foram selecionados 10 pacientes de ambos os sexos,
que receberam próteses híbridas em maxilas edêntulas suportadas por
implantes dentais de hexágono externo (Conexão Sistemas de Prótese, São
Paulo, Brasil) submetidos a carga imediata. Estes procedimentos foram
realizados na Clínica de Especialização em Implantodontia da Faculdade de
Odontologia da UFJF há, no mínimo dois anos e, no máximo, cinco anos.
Todos os pacientes receberam informações quanto à finalidade da pesquisa e
após a assinatura do Termo de Consentimento Livre e Esclarecido, foram
solicitadas aos pacientes radiografias periapicais, realizadas na Clínica de
Radiologia da Faculdade da mesma universidade.
2.1 - Procedimento clínico
Após planejamento protético e cirúrgico detalhado, os tamanhos dos
implantes foram selecionados. Foi realizada anestesia local com lidocaína a
2% com epinefrina (Alphacaine 100, DFL Indústria e Comércio S.A., Rio de
Janeiro, Brasil) seguida de uma incisão no meio da crista óssea dividindo o
tecido ceratinizado. Após exposição do tecido ósseo, os sítios foram
preparados e implantes instalados na região inter-sinusal para cada paciente
de acordo com as recomendações do fabricante (Tabela 1). Após a colocação
dos implantes de hexágono externo, pilares do tipo Micro-unit (Conexão
Sistema de Próteses, Arujá, São Paulo, Brasil) foram parafusados nos
implantes com torque de 20 Ncm e instalados sobre eles os transferentes dos
pilares. Após esse procedimento, foi realizada a sutura. Utilizando o guia
12 multifuncional confeccionado a partir da duplicação da prótese do paciente, foi
realizada a moldagem do paciente com poliéter (Impregum, Penta Soft, 3M
ESPE AG, Seefeld, Germany) e feito registro intermaxilar. Dentro de 48 horas
após a cirurgia, uma prótese fixa parafusada metaloplástica (resina acrílica
com infra-estrutura metálica) foi instalada e dado torque de 10 Ncm nos
parafusos protéticos. Mínimos ajustes foram necessários para obtenção de
contatos oclusais estáveis.
2.2- Critérios avaliados:
2.2.1- Avaliação radiográfica
De posse das radiografias periapicais, dois examinadores especialistas
em Implantodontia após calibração (análise de concordância Kappa= 0,8),
avaliaram a perda óssea ao redor dos implantes, adaptando os critérios de
Kwakman et al.(1998)17. A perda óssea foi classificada de acordo com a
seguinte escala:
Escore 0: ausência de aparente perda óssea,
Escore 1: redução do nível ósseo não excedendo um terço do
comprimento do implante,
Escore 2: redução do nível ósseo excedendo um terço do comprimento
do implante, mas não excedendo metade do seu comprimento,
Escore 3: redução do nível ósseo excedendo metade do comprimento
do implante,
Escore 4: Ausência de osso ao redor do implante.
13 2.2.2- Avaliação Clínica
Para a avaliação clínica dos implantes dentais, os pacientes tiveram
suas próteses removidas. Seguindo-se os critérios de Buser et al.18(1990),
foram considerados os seguintes critérios: (1) ausência de queixas subjetivas
persistentes, tais como dor, sensação do corpo estranho, e/ou o parestesia,
(2) ausência de infecção periimplantar recorrente com supuração e (3)
ausência de mobilidade. Para o registro do depósito de placa, aqui chamado
de Índice de Placa (mPi) foi utilizada uma escala de 0 a 3, apresentada por
Mombelli et al.19 em 1987:
Escore 0: ausência de depósitos de placa;
Escore 1: placa visível apenas após correr a sonda sobre a superfície
livre da gengiva marginal do implante;
Escore 2: placa clinicamente visível;
Escore 3: placa abundante.
2.2.3- Avaliação da satisfação em relação ao tratamento
Após a avaliação clínica e radiográfica dos implantes e a reinstalação
das próteses dentais, um questionário adaptado de Schropp e Isidor de 2008
foi aplicado a fim de se determinar o grau de satisfação do paciente em
relação às próteses sobre implante, em termos de conforto mastigatório,
aparência, estética, capacidade de limpeza, adaptação e satisfação com o
tratamento de forma geral. As questões foram consideradas em uma escala
visual analógica (VAS), com a expressão mais negativa no ponto zero e a
mais positiva no ponto dez. 20
14 Os dados obtidos foram submetidos à análise estatística descritiva, em
Software SPSS 12.0 (SPSS Inc., Chicago, USA).
Figura 1: Escala visual analógica utilizada no estudo.
Figura 2: Questionário aplicado aos pacientes.
15 3- RESULTADOS
Dez pacientes (4 homens e 6 mulheres) participaram do estudo,
totalizando 59 implantes avaliados (Tabela 1). A média de idade encontrada
foi de 57,8 anos.
Tabela 1: Número total de implantes.
Distribuição dos implantes de acordo com o comprimento e diâmetro
Comprimento(mm)
Diâmetro
(mm)
10,0
11,5
13,0
Total
19
15
25
59
3,75
A avaliação radiográfica revelou que 72,9% (frequência observada
igual a 43) dos implantes não apresentaram perda óssea aparente, sendo
classificados como escore 0 e 27,1% (frequência observada igual a 16)
apresentaram uma redução do nível ósseo não excedendo um terço do
comprimento do implante (Tabela 2).
Tabela 2: Distribuição da frequência dos escores da perda óssea avaliada
radiograficamente.
Percentual
Percentual
Frequência
válido
acumulado
Score 0
(Ausência de
43
72,9
72,9
aparente perda
óssea)
Perda
Score 1
óssea
(Redução do
nível ósseo <1/3
16
27,1
100,0
do comprimento
do implante)
Total
59
100,0
16 A partir da avaliação clínica, observou-se que em 96,6% (frequência
observada igual a 57) dos implantes não houve queixa subjetiva de dor,
sensação de corpo estranho ou parestesia. Já em 3,4% (frequência
observada igual a 2) houve queixa de dor (Tabela 3).
Tabela 3: Distribuição de frequência dos implantes quanto à presença ou
ausência de queixas subjetivas de dor, sensação de corpo estranho ou
parestesia.
Percentual
Percentual
Frequência
válido
acumulado
Queixas
Ausentes
57
96,6
96,6
Presentes
2
3,4
100,0
Total
59
100,0
Em relação à infecção periimplantar, 5,1% (frequência observada igual
a 3) dos implantes apresentaram sinais deste quadro clínico e 94,9%
(frequência observada igual a 56) não apresentaram infecção (Tabela 4).
Tabela 4: Distribuição de frequência quanto à presença ou ausência de
sinais clínicos de infecção.
Percentual
Percentual
Frequência
válido
acumulado
Sinais
de
Infecção
Ausentes
56
94,9
94,9
Presentes
3
5,1
100,0
Total
59
100,0
Quanto à mobilidade, apenas 5.1% dos implantes (frequência
observada igual a 3) apresentaram, levemente, esta condição, enquanto os
outros 94,9% (frequência observada igual a 56) não apresentaram (Tabela 5).
17 Tabela 5: Distribuição de frequência quanto à presença ou ausência de
mobilidade.
Percentual
Percentual
Frequência
válido
acumulado
Ausentes
56
94,9
94,9
Mobilidade Presentes
3
5,1
100,0
59
100,0
Total
A avaliação do índice de placa demonstrou que 15,3% (frequência
observada igual a 9) não apresentaram depósitos de placa, classificados
como escore 0; 57,6% (frequência observada igual a 34) exibiram depósitos
de placa apenas após correr a sonda sobre a superfície livre da gengiva
marginal do implante (escore 1) e 27,1% (frequência observada igual a 16)
apresentaram placa clinicamente visível, sendo classificados como escore 2.
Nenhum paciente apresentou placa abundante (escore 3) (Tabela 6).
Tabela 6: Distribuição de frequência dos escores de Índice de Placa (mPI).
Índice
de placa
(mPI)
Score 0
(ausência de
depósitos)
Score 1
(placa visível
após
sondagem)
Score 2
(placa
clinicamente
visível)
Total
Frequência
Percentual
válido
Percentual
acumulado
9
15,3
15,3
34
57,6
72,9
16
27,1
100,0
59
100,0
18 O teste Qui-quadrado de Pearson (índice de correlação=0,8) revelou
associação positiva entre o índice de placa e a perda óssea ao redor dos
implantes (p = 0.016). A taxa de sobrevivência acumulada dos implantes foi
de 94,9% e a taxa de sobrevivência das próteses foi de 100%.
Para a avaliação subjetiva da satisfação dos pacientes em relação ao
tratamento, adotou-se a média dos valores obtidos em cada amostra. Em
relação ao resultado final da prótese, a média de satisfação foi de 7,4. Quanto
ao tempo para adaptação ao uso da prótese, a média foi de 8,1. Para a
aparência estética, o valor médio foi de 7,0. Quanto à mastigação, a média foi
de 8,4. Quanto ao grau de dificuldade para a higienização da prótese, o valor
médio foi de 4,1. Em relação à experiência com o tratamento, a média dos
valores foi de 7,8 e quanto à possibilidade de voltar atrás e refazer o
tratamento, a média encontrada foi de 9,5 (Tabela 7).
Tabela 7: Média, desvio- padrão e erro- padrão dos níveis de satisfação
dos pacientes em relação ao tratamento (VAS)
Questão
Média
Desvio- padrão Erro- padrão
Você ficou satisfeito com o
resultado
final
da
sua
7.4
2.119
0.670
prótese?
Quando você se acostumou
8.1
1.663
0.526
com a sua prótese?
De forma geral, você está
satisfeito(a) com a aparência
7.0
3.127
0.989
estética da sua prótese?
Como está a sua mastigação
após a colocação dessa
8.4
2.119
0.670
prótese?
Qual o grau de dificuldade na
4.1
3.281
1.038
higienização dessa prótese?
Como foi a sua experiência,
de forma geral, com o
7.8
3.393
1.073
tratamento?
Se pudesse voltar atrás, você
faria
o
tratamento
9.5
1.581
0.500
novamente?
19 4- DISCUSSÃO
Devido à menor qualidade óssea do rebordo maxilar em relação ao
osso mandibular, a reabilitação do arco superior edêntulo através de próteses
implantossuportadas é sempre uma terapia desafiadora, principalmente em
casos de edentulismo por tempo prolongado. Em determinadas situações, são
necessárias alternativas terapêuticas, como a utilização de cantiléveres
distais, implantes de menor comprimento, enxerto ósseo e cirurgia para a
elevação do assoalho do seio maxilar, bem como a utilização de áreas
anatômicas específicas para a instalação dos implantes, como a região
pterigóidea e o zigoma21. Contudo, na presença de tecido ósseo suficiente
para a instalação dos implantes sem a necessidade de terapias alternativas
para obtenção de tecido ósseo, o protocolo de carga imediata possibilita a
redução do número de procedimentos cirúrgicos e do tempo de tratamento22.
Embora o osso maxilar apresente menor densidade óssea nas regiões
posteriores21 e possua um padrão de reabsorção palatal que dificulta a
obtenção do paralelismo entre os implantes dentais6, diversos são os relatos
científicos de sucesso clínico a partir de protocolos que utilizam 4 a 6
implantes em maxila edêntula, suportando uma prótese submetida a carga
imediatamente
após
a
instalação
dos
mesmos6,8,14,21,23,24.
Sendo
a
estabilidade primária do implante considerada como um dos fatores mais
importantes para a osseointegração 3,6,7,8,25,26.
Em nosso estudo foram encontradas taxas de sobrevivência das
próteses (100%) e dos implantes dentais (96.6%) semelhantes aos relatos da
literatura3,6,23,24. Atualmente, o carregamento imediato de implantes dentais é
uma realidade nos consultórios de implantodontistas, principalmente pelo fato
20 de proporcionar ao paciente uma redução no tempo total do tratamento7.
Diversos são os relatos de pesquisas científicas qualificando a carga imediata
em pacientes totalmente edêntulos como segura e eficaz3,6,8,21,22,23,24,26,27
Testori et al.1 (2013) no entanto, não acreditam que a aplicação de
carga imediata em maxilas seja sempre a melhor alternativa, a partir do
momento que constataram uma significante taxa de insucesso relacionada
não somente à aplicação imediata de força mastigatória, mas também à idade
do paciente, ao tipo de retenção da prótese, e à razão que levou à exodontia
(dentes com doença endoperiodontal levaram à maior taxa de insucesso dos
implantes substitutivos). Resultados similares atingiram Andesson et al.28
(2013), com mais de 10% de insucessos em implantes com carga imediata
em maxilas, no entanto atingindo 100% de aproveitamento dos implantes
instalados em mandíbulas.
Browaeys et al.29 (2011) por sua vez registraram perdas da ordem de
2,1%, tanto em implantes maxilares quanto mandibulares, mas ainda assim a
maior perda foi registrada em maxilas. No fim de seu estudo longitudinal, a
perda acumulada foi de 9%, sendo considerados como insucesso todo e
qualquer implante que tenha sido perdido ou apresentado mobilidade.
A principal causa para a falha de implantes dentais parece ser a
micromovimentação durante o período de cicatrização, resultante de próteses
provisórias desajustadas, bem como da mastigação de alimentos duros,
levando
a
uma
excessiva
movimentação
que
compromete
a
osseointegração6.
Para Testori et al.1 no entanto, os implantes submetidos tanto a
colocação imediata em alvéolos frescos e carga imediata teve uma taxa de
sobrevivência cumulativa menor e estatisticamente significativa do que outras
21 combinações. No entanto, Peñarrocha-Oltra30 et al tiveram três implantes
perdidos colocados imediatamente pós-extração e imediatamente carregadas,
porém estatisticamente não significativo quando foi analisada a combinação
de protocolo de carga e tipo de sítio receptor. O tabagismo também foi
relacionado como fator de considerável prevalência de insucesso de
implantes osseointegrados31.
A taxa de sucesso se mostra alta tanto em implantes instalados
axialmente quanto em implantes inclinados instalados em região posterior de
maxila32,33.
A avaliação radiográfica do estudo relatado neste artigo revelou que
72,9% dos implantes não apresentaram perda óssea aparente e 27,1%
apresentaram uma redução do nível ósseo não excedendo um terço do
comprimento do implante. Li et al.,8 avaliaram as alterações ósseas de 111
pacientes submetidos a carga funcional imediata através de próteses
provisórias, em maxilas e mandíbulas edêntulas e a média de perda óssea
marginal foi de 0,07 mm após um ano. Browayes et al.29 verificaram perda
óssea periimplantar média da ordem de 1,2mm nos dois primeiros anos de
seu estudo, não tendo avanço desta medida nos anos subsequentes. Em
osso enxertado houve perda média de 0,3mm além este padrão.
A avaliação do índice de placa (mPI), neste estudo, demonstrou que
apenas 15,3% dos implantes não apresentaram depósitos de placa. Contudo,
nenhum paciente apresentou placa abundante. Uma associação positiva foi
encontrada entre o índice clínico mPI e a perda óssea avaliada em
radiografias. A placa bacteriana foi, assim, considerada como um dos fatores
etiológicos mais importantes para o aparecimento de uma doença
periimplantar. Concordam com essa inferência Ferreira Jr. et al.34 que
22 avaliaram a correlação de três índices clínicos de inflamação gengival (índice
gengival - GI, índice de sangramento sulcular, GI modificado por Mombelli) e
o índice de placa modificado por Mombelli (mPI) com a real condição
histológica periimplantar, concluindo que o mPI foi o único índice
correlacionado estatisticamente de forma positiva com as alterações
histológicas, podendo ser um bom parâmetro para se monitorar a saúde
periimplantar18. Agliardi et al.33, trataram 32 pacientes com dois implantes
axiais na região anterior da maxila e quatro implantes inclinados instalados
posicionados nas paredes anteriores e posteriores dos seios maxilares,
suportanto uma prótese total fixa com infra-estrutura metálica e foram
observados por pelo menos três anos, onde o índice de placa e sangramento
periimplantar
reduziram
significantemente
durante
o
período
de
acompanhamento.
A avaliação da satisfação dos pacientes em relação ao tratamento
executado demonstrou que a grande maioria dos pacientes encontra-se
satisfeita em relação ao resultado final da prótese. De forma semelhante, Zani
et al.35 e Brennan et al.36 avaliaram o impacto da saúde bucal na qualidade
de vida de pacientes tratados através de overdentures e próteses totais fixas
implantossuportadas, concluindo que os pacientes tratados com próteses
totais, removíveis ou fixas, estão satisfeitos com o tratamento. Em nosso
estudo, apenas o grau de dificuldade para a higienização da prótese pode ser
considerado como insatisfação. Marra et al.24 (2013) também reportaram
satisfação elevada dos pacientes estudados, principalmente por estes terem
usado anteriormente próteses totais convencionais que eram deficientes em
termos de estabilidade, suporte e retenção. Agliardi et al.33 (2013) verificaram
que a função mastigatória foi considerada excelente por 90,6% dos pacientes
23 de seu estudo, enquanto as funções estética e fonética foram laureadas por
87,5% dos mesmos.
24 5- CONCLUSÃO
Dentro das limitações deste estudo e a partir dos achados clínicos e
radiográficos, concluiu-se que a realização do protocolo cirúrgico com 5 a 6
implantes dentais e a imediata instalação de uma prótese fixa parafusada
metaloplástica demonstrou ser uma terapia segura e eficaz para a reabilitação
de maxilas edêntulas, o que relaciona-se a um alto nível de satisfação em
relação ao tratamento, demonstrado pelos pacientes.
25 6- NORMAS DA REVISTA ESCOLHIDA PARA PUBLICAÇÃO
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32 7- ARTIGO – VERSÃO EM INGLÊS
Formatado para o periódico: Journal of Prosthodontics
Clinical and radiographic evaluation of patients submitted to immediate
loading of implants placed in the edentulous maxilla: retrospective study
with a follow up to five years.
Osmar de Agostinho Neto, DDS, MS student, University Veiga de Almeida,
Rio de Janeiro, Brazil
Cleide Gisele Ribeiro, DDS, MS, PhD Professor, Federal University of Juiz de
Fora, Juiz de Fora, Brazil
Corresponding author:
Profª. Drª Cleide Gisele Ribeiro
Faculdade de Odontologia da Universidade Federal de Juiz de Fora -FO/UFJF
Departamento de Clínica Odontológica
Rua José Lourenço Kelmer, Campus Universitário
Bairro São Pedro, Juiz de Fora, Minas Gerais, Brasil
CEP: 36036-900
Telephone: +55-32-2102-3882
E-mail: [email protected]
Disclosure
The authors of the manuscript entitled “Clinical and radiographic
evaluation of patients submitted to immediate loading of implants placed in the
edentulous maxilla: a pilot study” claim to have no conflict of interest in
personal, commercial, academic, political or financial orders in the manuscript,
in any company or any of the products mentioned in this article.
33 Abstract
Immediate loaded implants inserted in edentulous jaws is an efficient,
reliable and predictable method. However, there are few studies available that
have evaluated the longevity of this type of procedure in the maxilla. The aim
of this study was to evaluate retrospectively the clinical and radiographic
characteristics of patients who have been submitted through a surgical
protocol for installation of dental implants and immediate screw-retained
metaloplastic fixed prostheses in the maxilla. Ten patients were randomly
selected from Implantology Specilization Clinic of Universidade Federal de
Juiz de Fora, Brasil. A total of 59 implants were evaluated through periapical
radiographs to assess bone loss around implants, besides clinical evaluation,
plaque index and the satisfaction of patients regarding treatment. The results
showed that the majority of the evaluated implants had no bone loss,
subjective complaints of pain, or foreign body sensation or paresthesia. The
cumulative survival rate of implants was 94.9% and denture survival rate was
100%. The mean satisfaction with treatment was 9.5 (scale from 0 to 10). It
was concluded that it could be considered safe and effective to perform the
protocol of 5 or 6 implants and immediate loaded placement of a metaloplastic
screw-retained fixed prosthesis for the rehabilitation of edentulous maxillae,
with a high satisfaction level related to treatment shown by patients.
Keywords: Dental implants, edentulism, loading protocol
34 Introduction
Since the introduction of Branemark’s original protocol to edentulous
patients rehabilitation, a major number of clinical approach modifications have
taken place throughout time aiming to reach patients’ needs, improve clinical
results, and reduce total treatment time.1
According to the recommendations of Branemark et al.2 in 1969, dental
implant loading should be performed in a second surgical stage, after a mean
healing period established as being three months for the mandible and six
months for the maxilla, throughout which the implants remained covered, this
time being considered fundamental for osseointegration and clinical success
to occur.
Nevertheless, Chiapasco (2004) 3 and Morton et al. (2004) 4 pointed out
that waiting to load an implant was not scientifically but clinically based,
justifying the increasing number of researches that evaluated certain situations
in which this period could be reduced without causing harm in the long term.
Furthermore, with the advancement in the shape and surface treatment
implants, new techniques have been developed, making it possible to perform
the immediate loading procedure.
Loading protocols for dental implants have been the focus of discussion
since the discovery of osseointegration, and various conferences have been
held with the purpose of divulging recommendations for scientific research.
From the report of the ITI Conference of Consensus held in 2008, immediate
loading refers to implant loading in the period before one week after dental
implant placement5.
Some criteria must be followed in order to submit implants to immediate
loading, such as primary stability of the implant, the use of provisional
35 restorations that promote splinting and control the mechanical load applied on
implants, as well as preventing the removal of temporary restorations during
the recommended healing period5.
The literature has considered the immediate loading protocol a feasible
treatment modality with high survival rates for various indications, provided
that there is good bone quality present6, and primary stability of the implant is
obtained 3,7,8.
When it comes to mandibles, immediate loading have been
documented and many studies have shown its predictability9, 10, 11 while only a
few long term studies have been related to immediate loading in edentulous
maxilla in the literature12,
13, 14
. Usually, edentulous maxilla presents different
macroscopic and microscopic features from the mandibles. Besides, bone
quality in the region between mentual foramen is essentially different from
maxillar bone, which shows a more trabecular bone tissue and, therefore
lower density15. On that basis, we can presume that the obtention of primary
stability of implants in the maxilla is more difficult.16
The aim of the present study was to evaluate the clinical and
radiographic characteristics of patients who were submitted to a surgical
protocol for the placement and immediate loading of implants in the maxillary
arch using a screw-retained prosthesis, in order to determine the efficacy and
longevity of this treatment.
36 Materials and Methods
After approval of this research Project by the Ethics Committee on
Research in Human Beings, of the Federal University of Juiz de Fora, Protocol
No. 222/2010, 10 patients of both genders, who were submitted to surgical
therapy for the placement and immediate loading of external hexagon dental
implants (Conexão Sistemas de Prótese, São Paulo, Brazil) in the maxilla
using screw-retained prostheses, at the Specialization Clinic in Implant
Dentistry of the UFJF School of Dentistry, a minimum of two years and a
maximum of five years ago, were randomly selected. They were contacted by
telephone, and invited to have their dental implants evaluated. Immediately,
during the first contact, all patients were provided with information as regards
the purpose of the research and after signing the Term of Free and Informed
Consent, they were asked to have periapical radiographs taken at the
Radiology Clinic of the UFJF School of Dentistry.
Clinical Procedure
After surgical and prosthetic detailed planning, implant sizes were
selected. Local anesthesia was administered with 2% lidocaine with
epinephrine (Alphacaine 100, DFL Indústria e Comércio S.A., Rio de Janeiro,
Brazil) followed by an incision in the middle of the bone crest to divide the
keratinized. After exposure of the bone tissue, the sites were prepared and
implants were placed in each patient’s inter-sinus region in accordance with
the implant manufacturers’ recommendations (Table 1). After placement of the
external hexagon implants, screws were tightened onto the Microunit
abutments (Conexão Sistema de Próteses, Arujá, São Paulo, Brasil) with a
torque of 20 Ncm and the transfers were placed on them. After this procedure,
37 suturing was performed. Using the multifuntional guide fabricated from a
duplication of the patient’s denture, the patient’s impression was taken with
polyether material (Impregum, Penta Soft, 3M ESPE AG, Seefeld, Germany)
and the intermaxillary record was made. Within 48 hours after surgery, a
metaloplastic screwed fixed prosthesis (acrylic resin with metal infrastructure)
was put into place and the prosthetic screws were tightened with a torque of
10. Minimal adjustments were necessary to obtain bilateral stable occlusal
contacts.
Radiographic Evaluation
Two examiners, specialists in implant dentistry, after calibration
(analysis of concordance of Kappa = 0,8), examined the periapical
radiographs to evaluate bone loss around the implants, comparing the
radiographic images of the present follow-up period with those taken at the
time of implant placement, adapting the Kwakman et al. (1998) criteria
17
.
Bone loss was classified according to the following scale:
Score 0: absence of apparent bone loss,
Score 1: reduction in bone level not exceeding one third of implant length,
Score 2: reduction in bone level exceeding one third of implant length, but not
exceeding half its length,
Score 3: reduction in bone level exceeding half of implant length,
Score 4: absence of bone around the implant.
Clinical Evaluation
For clinical evaluation of the dental implants, the patient’s dentures
were unscrewed. According to the criteria of Buser et al. (1990)
18
, the
38 following factors were considered: (1) absence of persistent subjective
complaints, such as pain, foreign body sensation, and/or paresthesia, (2)
absence of recurrent peri-implant infection with suppuration and (3) absence
of mobility.
To Record plaque deposits, here referred to as the Plaque index (mPi)
a scale from 0 to 3, presented by Mombelli et al.19 in 1987, was used:
Score 0: absence of plaque deposits,
Score 1: visible plaque only after running the probe over the free
marginal gingiva surface of the implant. Implants with surfaces treated with
titanium spray in this area,
Score 2: clinically visible plaque,
Score 3: abundant plaque.
Evaluation of satisfaction with treatment
After clinical and radiographic evaluation of the implants and reinsertion of the dental prostheses, an adapted questionnaire from Schropp ans
Isidor, 2008 was applied in order to determine the degree of patient
satisfaction with the implant supported denture, in terms of masticatory
comfort, esthetic appearance, cleaning capacity, fit and satisfaction with
treatment in a general manner. The questions were considered on a visual
analog scale (VAS), with the most negative expression on point zero and the
most positive on point ten.20
The data obtained were submitted to descriptive statistical analysis
using SPSS 12.0 Software (SPSS Inc., Chicago, USA).
39 Figure 1: Visual Analog Scale used at work.
Figure 2: Questionnaire applied to patients.
40 Results
Ten patients (4 men and 6 women) participated in the study, totaling 59
implants evaluated (Table 1). The mean age was 57.8 years. Radiographic
evaluation revealed that 72.9% (frequency observed equal to 43) of the
implants presented no apparent bone loss, being classified as Score 0 and
27.1% (frequency observed equal to 16) presented a reduction in bone level
not exceeding one third of the implant length (Table 2).
Table 1: Total number of implants.
Distribution of implants according to the length and diameter
Length (mm)
Diameter
3,75
10,0
11,5
13,0
Total
19
15
25
59
(mm)
Table 2: Frequency distribution of scores of bone loss assessed radiographically.
Frequency
Bone
score 0
(Absence of apparent bone
loss)
Loss
Score 1
Percent
Cumulative
Percent
43
72,9
72,9
(Reduction of bone level less
than 1/3 of implant length)
16
27,1
100,0
Total
59
100,0
From the clinical evaluation it was observed that in 96.6% (frequency
observed equal to 57) of the implants there was no subjective complaint of
41 pain, foreign body sensation or paresthesia. Where as in 3.4% (frequency
observed equal to 2) there was complaint of pain (Table 3).
Table 3: Frequency distribution of the implants for the presence or absence
of subjective complaints of pain, foreign body sensation or paresthesia.
Frequency
Complaints
Percent
Cumulative Percent
Absent
57
96,6
96,6
Present
2
3,4
100,0
Total
59
100,0
With regard to peri-implant infection, 5.1% (frequency observed equal to
3) of the implants presented signs of this clinical condition, and 94,9%
(frequency observed equal to 56) presented no infection (Table 4).
Table 4: Frequency distribution for the presence or absence of clinical signs
of infection.
Frequency
Percent
Cumulative Percent
Absent
56
94,9
94,9
Signs of infection Present
3
5,1
100,0
59
100,0
Total
As regards mobility, only 5.1% of the implants (frequency observed
equal to 3) slightly presented this condition, while the other 94.9% (frequency
observed equal to 56) showed no mobility (Table 5).
42 Table 5: Frequency distribution for the presence or absence of mobility.
Mobility
Frequency
Percent
Cumulative Percent
Absent
56
94,9
94,9
Present
3
5,1
100,0
Total
59
100,0
The plaque index evaluation demonstrated that 15.3% (frequency
observed equal to 9) presented no plaque deposits, classified as Score 0;
57.6% (frequency observed equal to 34) plaque deposits only after running the
prove over the free marginal gingiva surface of the implant (Score 1) and
27.1% (frequency observed equal to 16) presented clinically visible plaque,
being classified with Score 2. No patient presented abundant plaque (Score 3)
(Table 6).
Table 6: Frequency distribution of scores for Plaque Index (MPI).
Frequency
Percent
Cumulative
Percent
9
15,3
15,3
Score 1
(visible plaque after
probing)
34
57,6
72,9
Score 2
(plaque clinically
visible)
16
27,1
100,0
Total
59
100,0
Score 0
(absence of deposits)
Plaque
Index
(mPI)
Pearson’s Chi-Square test (correlation index = 0,8) showed positive
association between the plaque index and bone loss around implants (p =
43 0.016). The cumulative survival rate of implants was 94.9% and the denture
survival rate was 100%. For subjective evaluation of patient satisfaction with
treatment, the mean of values obtained from each sample was adopted as the
measure representative of the sample. As regards the end result of the
denture, the mean satisfaction was 7.4. With reference to time taken to adapt
to the use of the denture, the mean was 8.1. For esthetic appearance the
mean value was 7.0, and for mastication it was 8.4. As regards the degree of
difficulty of cleaning the denture, the mean value was 4.1. With regard to
experience with treatment, the mean of values was 7.8 and for the possibility
of going back and re-doing treatment, the mean found was 9.5 (Table 7).
Table 7: Mean, standard deviation and standard error of the levels of patient
satisfaction in relation to treatment (VAS)
Question
Mean
Standard
Deviation
Standard Error
Were you satisfied with the end
result of your dentures?
7.4
2.119
0.670
When you get used to your
dentures?
8.1
1.663
0.526
Overall, are you satisfied with
the aesthetic appearance of
your dentures?
7.0
3.127
0.989
How is your mastication after
the
placement
of
this
prosthesis?
8.4
2.119
0.670
What degree of difficulty in
cleaning of dentures?
4.1
3.281
1.038
How was your experience in
general, with the treatment?
7.8
3.393
1.073
If you could go back, would
you do the treatment again?
9.5
1.581
0.500
44 Discussion
Due to the lower bone quality of the maxillary in comparison with the
mandibular ridge, rehabilitation of the edentulous maxillary arch by means of
implant supported prosthesis is always a challenging therapy, particularly in
cases of edentulism in which the teeth have been missing for many years. So
that in certain situations, alternative therapeutic modalities are required, such
as the use of distal cantilevers, shorter implants, bone grafts and maxillary
sinus lift surgery may be required, as well as the use of specific anatomic
areas for implant placement, such as the pterygoid and zygomatic regions21.
However, in the presence of sufficient bone tissue for implant placement
without the need for alternative therapies to obtain bone issue, the immediate
loading protocol makes it possible to reduce the number of surgical
procedures and treatment time22.
Although maxillary bone is less dense in the posterior regions21 and has
a palatal resorption pattern that makes it difficult to obtain parallelism between
dental implants6, with the advancement in implant loading protocols, there
have been various scientific reports of clinical success with protocols that use
4 to 6 implants in the edentulous maxilla, supporting a denture immediately
after their placement
6, 8,14,21,23,24
. Primary stability of the implant is considered
one of the most important factors for osseointegration3, 6,7,8,25,26.
In the present study denture and dental implant survival rates were
found similar to those mentioned in the literature
3, 6, 23, 24
(100% and 96,6%
respectively). At present, immediate loading of dental implants is a reality in
implant dentistry offices, particularly due to the fact of providing the patient
with a result in the short term and avoiding a second surgical intervention7.
45 There are various reports of scientific researches qualifying immediate loading
as safe and efficient 3, 6, 8, 21, 22, 23, 24, 26, 27.
Testori et al, 1(2013) nevertheless, didn’t believe that maxilla immediate
loading was the best alternative, from the moment that found significant failure
rate related not only to immediate chewing strength, but also to patient’s age,
denture’s retention type, and the reason that led to extraction (endoperiodontal disease led to a major failure rate of following implants). Similar
results have been found by Anderson et al.
28
(2013), with more than 10% of
failure on maxilla immediate loaded implants, although reaching 100%
success on mandibles implants.
Browaeys et al.
29
(2011) on the other hand registered 2,1% loss, both
in maxilla and mandible implants, but still bigger loss was registered in maxilla.
In the end of their long term study, the accumulated loss was 9%, and it was
considered failure every implant that had been lost or had presented mobility.
The main cause of dental implant failure appears to have been
micromovement during the healing period, resulting from maladjustment of the
provisional dentures, and chewing hard food, leading to excessive movement
that compromised osseointegration6.
To Testori et al.1, nonetheless, implants submitted to immediate
placement into fresh sockets or immediate loading had a lower cumulative
survival rate and significant statistically than other combinations. Although,
Peñarrocha-Oltra et al.
30
had three lost implants, these placed right after
extraction and immediately loaded, but not statistically significant when
analized the combination protocol / reception site type. Smoking habit was
also related as a high prevalence factor of failure on osseointegrated
46 implants31. The success rate is shown high for both implants placed axially
inclined as for implants placed in the posterior maxilla32, 33.
The radiographic evaluation of the study reported in this article revealed
that 72.9% of the implants presented no apparent bone loss, being classified
as Score 0 and 27.1% presented a reduction in bone level not exceeding one
third of implant length. Li et al.8 in 2009, evaluated the bone alterations in 111
patients submitted to immediate functional loading through provisional
dentures in edentulous maxillae and mandibles, and mean marginal bone loss
was 0.07 mm after one year. Browayes et al
29
found peri-implant bone loss of
1,2mm on the first two years of their study this measure didn’t grow on the
following years though. On grafted bone there was loss of 0,3mm besides this
pattern.
The plaque index (mPI) evaluation in this study demonstrated that
15.3% of the implants presented no plaque deposits and were classified as
Score 0. No patient presented abundant plaque. A positive association (p =
0.016) was found between the clinical plaque index mPI and bone loss
evaluated in radiographs. Bacterial plaque was therefore considered one of
the most important etiological factors for the appearance of peri-implant
disease. In agreement with this inference were Ferreira Jr. et al. (2009) 34 who
evaluated the correlation of three clinical indices of gingival inflammation
(gingival index - GI, sulcus bleeding index, GI modified by Mombelli) and
plaque index modified by Mombelli (mPI) with the real histological peri-implant
condition, and concluded that the mPI was the only index statistically
correlated in a positive manner with the histological alterations, and could be a
good parameter for monitoring per-implant health. Agliardi et al.33 (2013)
treated 32 patients with two axial implants in the anterior maxilla and four tilted
47 implants positioned at the anterior and posterior walls of the maxillary sinuses,
supporting a total prosthesis fixed with metal infrastructure and were observed
for at least three years, where the plaque index and peri-implant bleeding
decreased significantly during the follow-up period.
Assessment of patient satisfaction in relation to the treatment performed
showed that the vast majority of patients is satisfied in relation to the final
outcome of the prosthesis. Similarly, Zani et al.35 and Brennan et al.36
assessed the impact of oral health on quality of life of patients treated by total
overdentures and fixed prostheses implant supported, concluding that patients
treated with total, removable or fixed prostheses, are satisfied with the
treatment. In our study, only the degree of difficulty for the cleaning of the
prosthesis can be considered as dissatisfaction.
Marra et al.24 (2013) also reported high satisfaction of patients, mainly
because they have previously used conventional total prostheses that were
deficient in terms of support, stability and retention. Agliardi et al.33 (2013)
found that masticatory function was considered excellent by 90.6% of patients
in their study, while the aesthetic and phonetic functions were honored by
87.5% of them.
48 Conclusion
Within the limitations of this study, and from the clinical and
radiographic findings, it was concluded that at the Implant Dentistry Clinic of
the UFJF School of Dentistry, performing the protocol composed of 5 to 6
dental implants and the immediate insertion of a metaloplastic screw-retained
fixed prosthesis was demonstrated to a safe and effective therapy for the
rehabilitation of edentulous maxillae, which was related to a high level of
satisfaction with treatment demonstrated by the patients.
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54