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Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.02.016, available online at http://www.sciencedirect.com

Systematic Review Paper Dental Implants

Longevity of dental implants in type IV bone: a systematic review

M. C. Goiato, D. M. dos Santos, J. F. Jr. Santiago, A. Moreno, E. P. Pellizzer Department of Dental Materials and Prosthodontics, Aracatuba Dental School, UNESP – Universidade Estadual Paulista, Aracatuba, Sa˜o Paulo, Brazil

M. C. Goiato, D. M. dos Santos, J. F. Jr. Santiago, A. Moreno, E. P. Pellizzer: Longevity of dental implants in type IV bone: a systematic review. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Bone quality and quantity are important factors with regard to the survival rate of dental implants. The aim of this study was to conduct a systematic review of dental implants inserted in low-density bone and to determine the survival rate of dental implants with surface treatments over time. A systematic review of the literature was undertaken by two independent individuals; the Medline/PubMed database was searched for the period July 1975 to March 2013. Relevant reports on bone quality and osseointegration of dental implants were selected. The search retrieved 1018 references, and after inclusion and exclusion criteria were applied, 19 studies were selected for review. A total of 3937 patients, who had received a total of 12,465 dental implants, were analyzed. The survival rates of dental implants according to the bone density were: type I, 97.6%; type II, 96.2%; type III, 96.5%; and type IV, 88.8%. The survival rate of treated surface implants inserted in lowdensity bone was higher (97.1%) than that of machined surface implants (91.6%). Surface-treated dental implants inserted in low-density bone have a high survival rate and may be indicated for oral rehabilitation. However, more randomized studies are required to better evaluate this issue.

Currently, the predictability of oral rehabilitations using dental implants is high.1,2 Dental implants have been used for overdentures, fixed partial and total dentures, and maxillofacial prostheses, as well as immediate dental loading.3,4 However, with regard to the rehabilitation of low density bone, great diversity exists among dental implants from different companies, with different surface treatments and connections.3,5 The dental implant survival rate may be related to the quality and quantity of bone 0901-5027/000001+09 $36.00/0

in the dental arch. There are various classifications for the quality and quantity of bone reported in the literature, including the bone type (I–IV)6 and density (heavy or soft),7 as well as type V bone.8 Lekholm and Zarb6 established a precursor classification for organizing bone tissue into four categories with different degrees of density. This classification allowed the quality of bone tissue to be related to the stability of an implant. Furthermore, it is possible to develop instruments and surgical techniques appropriate for each

Keywords: dental implants; alveolar bone; implant-supported dental prosthesis; randomized controlled trial. Accepted for publication 25 February 2014

specific situation. In the previous decade, Bahat8 proposed a subdivision of the classification of type IV bone, referring to bone type V in situations with a complete absence of cortical tissue (upper and lower). Moreover, there is a classification that considers the bone as dense (highdensity), normal (moderate-density), or soft (low-density).7,9 One of the main methods used to determine the density of bone tissue is based on the perception of the clinician at the time of preparation of the surgical bed.7

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

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There is no agreement among researchers about the predictability of dental implants inserted in low-density bone.3 Some prospective studies have reported survival rates and bone loss to be similar for implants inserted in poor-quality bone and in good-quality bone.3 Also, surface treatments can improve the survival rate of dental implants in type IV bone,10 enhancing osseointegration, and this may be related to bone quality and quantity and associated systemic factors.11 Surface-treated dental implants may show a better survival rate in poor-quality bone.10 However, this improvement has yet to be demonstrated with certainty.12 Previous studies that have evaluated dental implants with machined surfaces in excellent-quality bone have found a high predictability for rehabilitation. However, when analyzed under conditions of lowdensity bone, this surface was found to have a higher propensity to fail.13 Therefore, a study to assess patients who have received dental implants performed with the PICO design (participants, interventions, comparisons, and outcomes) is warranted, in order to determine the predictability of implants inserted in poor-quality bone and the longevity of rehabilitation with surface-treated implants. Two hypotheses were tested: (1) the survival rate of dental implants inserted in low-density bone is lower than that in better quality bone (types I–III) and (2) the survival rate of treated surface implants in low-density bone is higher compared to machined surface implants. Materials and methods Procedure

The authors selected the articles based on inclusion and exclusion criteria. All disagreements were resolved through discussion, and decisions were made by consensus. This systematic review was performed in accordance with the PRISMA statement,14 and also followed models proposed in the literature.15,16 Search strategy

A search of the English language literature was conducted by two independent individuals (MCG and JFSJ) using the PubMed/Medline database, covering the period July 1975 to March 2013. The keywords ‘dental implants’ and ‘quality bone’ were used. A broad search strategy was pursued. Studies were selected based on their titles and abstracts according to the exclusion criteria for abstracts

and full-text articles. Agreement between the readers was determined statistically, and any conflicts were resolved by discussion or analysis of a third reader (EPP). This procedure was applied at all selection steps. The full-text articles were evaluated by the readers using a pilot test form. The authors of the articles were not contacted. Study selection

The studies were selected on the basis of their titles and abstracts; prospective and retrospective studies as well as randomized controlled trials (RCTs) were included. The total sample of selected studies was then evaluated and studies were included or excluded. Participants, interventions, comparisons, and outcomes (PICO), according to the PRISMA statement, were determined to organize a clear clinical question and to focus on suitability for inclusion. ‘Participants’ were patients who had been rehabilitated with dental implants. The ‘intervention’ was dental implants inserted in poor-quality bone (type IV or soft). ‘Comparisons’ were dental implants inserted in normaldensity bone and types I–III bone. Finally, ‘outcomes’ evaluated were the survival rate and suitable protocols for implant placement. Inclusion/exclusion criteria

The inclusion criteria for the studies were the following: English language; more than five patients who received dental implants in poor-quality bone (type IV), according to the Lekholm and Zarb6 classification, or in soft bone; survival rates of dental implants reported. In addition, these studies had to show comparison parameters (control group) with types I to III bone or normal-density bone. Thus, we included studies that used the classification of Lekholm and Zarb6 (bone types I–IV), the classification of Bahat,8 who added bone type V, and the classification by Trisi and Rao,7 cited by Testori et al.,9 which categorizes the bone type as dense, normal, or soft. The exclusion criteria were the following: duplicated studies; animal studies; studies of patients during orthodontic treatment; mini-implants; studies related to advanced bone reconstruction surgery; zygomatic implants; studies showing only soft tissue grafting; peri-implantitis; in vitro assays and biomechanical studies; reported cases including patients with osteoporosis, bisphosphonates, radiotherapy, chemotherapy, and cleft palate; studies showing only prosthesis fabrication

without analysis of the bone tissue characteristics; studies that analyzed only primary stability; studies evaluating magnetic resonance and computed tomography images without verifying bone quality; and systematic reviews. Reliability and quality assessment

The assessment of the quality of the methodology was performed in accordance with the PRISMA statement.14 The studies were ranked in categories as follows: RCTs, prospective studies, and retrospective studies. Independent researchers conducted the development of the systematic review; the different studies were analyzed and discussed, and disagreements were resolved. The assessment of risk quality and bias was performed to eliminate studies that concealed data on bone quality and did not define success criteria for dental implants. Data analysis

The following data were collected for each article: first author, year, study design, implant surfaces, number of patients, age, where the implants were inserted, implant geometry, implant number, follow-up, type of oral prosthesis, survival rate in different bone types (I–IV) or by bone density (normal and soft), and number of lost implants. Studies reported results for type IV bone compared to other bone types (I–III) for rehabilitation with dental implants. The data collected were related to the survival outcome of each study. Data synthesis

Data were recorded qualitatively to allow comparisons among the selected studies (N = 19). The total number of implants in low-density bone was calculated, as well as the survival rate in type IV bone compared with the other types (types I–III) or density of bone (normal and soft). Furthermore, the survival rate was calculated for treated surface implants (double etching, micro-texturing) and machined surface implants inserted in poor-quality bone. Results General outcomes

The literature search of PubMed/Medline identified 1018 references; after excluding animal studies, 826 studies were selected for the data synthesis. After an analysis of the titles according to the inclusion and

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

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Longevity of dental implants in type IV bone

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Fig. 1. Flow diagram of the literature search strategy.

exclusion criteria and the elimination of duplicate references, 39 full-text papers were selected for the eligibility assessment. Some of the full-texts were then excluded: studies that showed only partial data (bone quality criteria not well defined), studies with only two categories of bone quality (good or bad, and type IV or other types), studies that evaluated type IV bone without parameters (control), and studies involving bone grafting. Therefore, after the full texts of the articles had

been examined, 19 studies were included in the review. The literature research process is shown in Fig. 1. The 19 studies selected for review were published during the period 1992–2008. The reasons for exclusion of 20 of the articles evaluated are shown in Table 1.10,17–35 Survival rate

Table 2 summarizes the main data collected in this study.3,8,9,11,13,36–49 Among

Table 1. Reasons for the exclusion of 20 articles. Reason There were no reported quality criteria or bone quantity available Bone quality classification into only two bone types Low-density bone analysis without comparisons with the others Failure rate did not include bone type Similar or duplicate data

References 10,17–28 29 30–33 34 35

the 19 studies, 13 were prospective studies, three were retrospective studies, and three were RCTs. The dental implant surface treatments included machined, double-etching, anodic oxidation (TiUnite), sprayed with titanium plasma (SLActive), and titanium dioxide (TiOblast). A total of 3937 patients, with a mean age of 55.2 years, were studied. The anterior regions of the maxilla and mandible were the main areas in which the dental implants were inserted (Table 2). A total of 12,465 dental implants were inserted in the 3937 patients, and the mean follow-up was 53.7 months (range 12–252 months). There were 535 failures/losses of dental implants and the survival rate was 95.7% (Fig. 2 and Table 3). The main factors related to failure/loss of dental implants were: systemic factors and surgical protocol,3 tobacco use,3,36,48

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

Type of study

Surface

Aalam and Nowzari3

Prospective

(TiUnite) (Osseotite) Machinedb

Alsaadi et al.11

Retrospective

(TiUnite) Machined

Bahat8

Prospective



Bergkvist et al.36

Prospective

Spray plasma titanium

Collaert and De Bruyn37

Prospective

Fischer et al.13

Minimum implant size, mm

Sites

Follow-up, months

Type of prosthesis

198

24

Single-unit and fixed prosthesis, overdentures

100%

6946

252



D1: D2: D3: D4:

94.86% 97.87% 96.38% 92.67%



D2: D3: D4: D5:

89.7% 94.8% 96.9% 67.0%

52.8

Anterior and premolar

7c



Anterior and posterior

3.3 and 0.05

D4 > D2 D1 > D2 P < 0.001

35



D2: 100% (30) D3 and D4: 96.6% (116)

5



Fixed dentures

D1: D2: D3: D4:

100% 100% 100% 100%

0



12

Single-unit and fixed prosthesis

D1: D2: D3: D4:

100% (1) 100% (29) 100% (20) 66.6% (3)

1



379

32

Fixed dentures

D1: D2: D3: D4:

100% (17) 86.3% (101) 99.23% (130) 97.7% (131)

18



3.75  7

478

12

Single-unit and fixed prosthesis

D1: D2: D3: D4:

100% (12) 99.36% (158) 99.56% (230) 96.15% (78)

5



Premolar and molar

4.1  8

383

36

Single-unit and fixed prosthesis

D4: 100% (28) D1, D2, and D3: 97.0% (355)

10

51

Anterior, premolar and molar



102

48

Single-unit and fixed prosthesis

D2: 100% (24) D3: 94.11% (51) D4: 100% (27)

3



40–47

Anterior, posterior

3.75  7

264

36

Single-unit and fixed prosthesis

D2: 96.51% (86) D3: 91.51% (165) D4: 100% (10)

17



(78) (348) (194) (3)

P = 0.7519

Goiato et al.

Reference

Number of patients

Mean age, years

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Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

Table 2. Data summary of the 19 studies selected reporting dental implants inserted in low-density bone.



133

Ivanoff et al.44

Retrospective



Johns et al.45

Prospective



Khang et al.46

RCT

Raghoebar et al.47

40

P < 0.05

D2: 95.65% (23) D3: 90.49% (221) D4: 92.72% (55)

26

P > 0.05

Overdenture

D1, D2 and D3: 96.46% (453) D4: 71.92% (57)

32

P < 0.05

36

Single-unit and fixed prosthesis and overdenture

Good-quality boned (93.8%)e (87.8%)f Poor-quality boned (96.8%)e (84.8%)f

36

P < 0.05

170

36

Fixed dentures and overdentures

D1: D2: D3: D4:

12



66

12

Single-unit and fixed prosthesis

D2: 100% (7)g, 100% (3)h D3: 95.74% (47)g, 92.68% (41)h D4: 91.6% (12)g, 54.54% (11)h

22

P < 0.05

269

53.7

Single-unit and fixed prosthesis

D1: D2: D3: D4:

100% (3) 94.93% (79) 95.0% (160) 92.59% (27)

12

405

36

Single-unit and fixed prosthesis

Dense: 98.48% (66) Normal: 98.12 (266) Soft: 95.89% (73)

9

32–76





510

36

Overdenture

D1: D2: D3: D4:

67

59

Anterior, premolar and molar

3.75  7

299

60

Single-unit and fixed prosthesis, overdentures

133

57

Anterior and posterior

47

510

60

Doubleetching Machined

97

60

Anterior and posterior

3.25  7

432

Prospective

Machined

83

56

Anterior

3.75  10

Rocci et al.48

RCT

TiUnite Machined

44

51

Premolar and molar

7c

Tawil and Younan49

Prospective

Machined

111

53.6

Anterior, premolar and molar

3.3  6

Testori et al.9

Prospective

Microtexturization acid (Osseotite)

175

53.5

Premolar and molar

3.25  7

RCT, randomized controlled trial. a D1, type 1; D2, type 2; D3, type 3; D4, type 4 (Lekholm and Zarb6 classification). b TiUnite: anodic oxidation; Osseotite: double etching. c Diameter not reported. d Classification in dense/normal bone (good-quality bone) and soft bone (poor-quality bone). e Dual-acid etched surfaced implants. f Machined-surfaced implants. g TiUnite implants. h Machined implants.

92.3% 89.5% 92.5% 55.0%

(13) (95) (146) (40)

92.3% (13) 95.69% (93) 94.73% (57) 42.85% (7)



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Prospective

Longevity of dental implants in type IV bone

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

Hutton et al.43

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Fig. 2. Kaplan–Meier survival curve for dental implants in the 19 studies selected.

biomechanics hampered by the number of implants used,8 peri-implantitis,36 low primary stability,13 and mobility and infection in the region without immediate solution.9 In five of the studies, the deficient bone quality was associated with statistically significant data.11,43,45,46,48 Rocci et al.48 reported that tobacco use had an influence on the loss of dental implants (P = 0.02), but no influence on treated surface implants (P = 0.15) (Table 2). The minimum implant size used was 3.25 mm in diameter and 6 mm in length. All 19 selected studies evaluated short implants and reported high survival rates and no loss of dental implants, with the exception of one article.49 Tawil and Younan49 reported two implant failures in the maxilla (total of 30 implants), with no significant difference compared to the mandible. Short implants were used more cautiously in the maxilla as compared to the mandible, in situations of limited bone height (less than 8 mm), limited bone width (less than 7 mm), and poor-quality bone (type IV). Regarding the prosthesis fabricated, the presence of a single prosthesis, fixed partial and total dentures, and overdentures was verified. Prosthetic complications

were rarely reported. However, Ivanoff et al.44 observed the presence of fistulas, porcelain fractures, postoperative infections, implant fracture, and screw loosening, and that two patients were unsatisfied with the final prosthesis. Bone quality

With regard to the differences in bone quality,6 a statistically significant lower dental implant survival rate was observed in type IV bone in five studies.11,43,45,46,48 Some of these studies evaluated machined surface implants compared to treated surface implants11,46,48; Johns et al.45 did not report the implant surface used. Other studies did not observe a significant difference (P  0.05) in survival rate among dental implants with different treatment surfaces (TiUnite and SLActive and machined) inserted in type IV bone compared to other bone areas.3,40,44 Survival rates for each bone region are shown in Table 2. There was a reduction in the survival rate for implants inserted in type IV and type V bone without cortical bone.8 Figure 3 shows the survival rates for all bone types (I–V). The survival rate was 88.8% for the 1338 implants inserted

Table 3. Survival analysis showing the cumulative survival rate of the dental implants for the 19 studies selected. Follow-up intervals of the study, months 0–6 6–12 12–24 24–36 36–48 48–60 60–144 144–250 >250

No. of implants in each interval 12,465 12,465 12,437 12,437 12,295 12,292 12,217 12,182 11,930

No. of failures in each interval 0 28 0 142 3 75 35 252 0

Survival rate within each interval (%)

Cumulative survival rate (%)

100.00 99.77 100 98.85 99.97 99.38 99.71 97.93 100

100.00 99.77 99.77 98.63 98.61 98.01 97.72 95.70 95.70

in type IV bone from the 13 studies that reported these data. Implants inserted in types I (97.6%), II (96.2%), and III (96.5%) bone showed survival rates >95% (Fig. 3). However, studies such as that by Alsaadi et al.,11 reported that dense bone of poor quality may be an important factor in implant loss.3 Also, Grunder et al.42 found more failure in type III bone (8.5% for the maxilla, 8.3% for the mandible) than in type II bone (4.8% for the maxilla, 2.3% for the mandible). However, there was no statistically significant difference for implant failure, bone density and quality, tooth loss, implant type, area, or surgical protocol (P > 0.05). Some studies also observed that bone tissue quality was not related to the survival rate. The studies reviewed showed similar survival rates for dental implants with surface treatments,9,36,37,39,41 however the small number of implants inserted in type IV bone compared to other bone types was a limitation observed.8,39,40,42,43,45,48 Surface

Aalam and Nowzari3 found no significant difference (P > 0.05) in survival rates among TiUnite and machined surface implants, and also suggested that tobacco use may have influenced osseointegration. However, in that study there was no information on the exact numbers of implants inserted in low-density bone.3 Other studies reported statistically significant lower survival rates for machined surface implants compared to TiUnite48 and double-etching.46 Khang et al.46 reported a significantly higher survival rate after 36 months (P < 0.01) with double-etched surface implants (95.0%) compared to machined surface implants (86.7%). Some authors did not report the implant surface treatments used.43–45 However, four studies involving 7642 implants showed differences between those that were surface-treated (anodic oxidation and double-etching) and those that had machined surfaces; the cumulative survival rates for surface-treated implants and machined surface implants were 97.1% and 91.6%, respectively (Fig. 4). Therefore, surface-treated implants may be more suitable for oral rehabilitation. Discussion

The survival of dental implants used for oral rehabilitation was found to be high (95.7%) in this analysis of two decades. In addition, the results are similar to those

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

YIJOM-2869; No of Pages 9

Longevity of dental implants in type IV bone

Fig. 3. Survival rates for implants inserted in the different bone areas in the 13 studies reporting these data.8,11,13,36–42,44,45,47 The total numbers of dental implants inserted were as follows: type 1, n = 1359; type 2, n = 3818; type 3, n = 4248; type 4, n = 1338; and type 5, n = 3.

Fig. 4. Survival rates for implants with different surface treatments in the four studies reporting these data.3,11,46,48

obtained in another systematic review.1 Both tested hypotheses were accepted: the survival rate of dental implants inserted in low-density bone was found to be lower than in better quality bone (types I–III), and the survival rate of treated surface implants in low-density bone was higher than that of machined surface implants. Poor-quality bone can be related to a lower survival rate of implants in that area, but this is not always statistically significant. Studies reported in the literature have shown that bone quality is an important factor in the predictability of implants.24,45 Therefore, rehabilitation with a dental implant in poor quality bone is of greater concern. Solutions for these cases include inserting a greater number of implants and more careful consideration of the implant size.8 Also, greater care should be taken when working with dental implants in low-density bone (type IV) and high-density bone (type I) to avoid the heating of bone tissue during milling.11 In addition, Turkyilmaz et al. suggest that the adequate use of milling systems and choice of implant geometries for the posterior region of the maxilla and mand-

ible with low-density bone improves the primary stability of dental implants and increases the survival rate.50 Some important factors were analyzed in these 19 selected studies regarding bone loss and implant predictability. Collaert and De Bruyn37 did not find a significant difference (Pearson correlation) for bone loss by gender, periodontal disease history, or bone quality. There was no significant difference for gender, bone quality, tobacco use, or periodontal disease regarding survival rates or bone remodelling. However, there was bone loss in smokers only 3 years after rehabilitation.37 Ganeles et al.40 suggested that the high survival rate in immediate loading (98.0%) was due to suitable presurgical examinations and the parameters used during the surgical procedures, greater primary stability, the use of implants with adequate dimensions, and an optimized implant surface. These factors together may expand and accelerate the maturation of bone tissue. Also, Hutton et al.43 claimed that age, gender, and study area were not associated with higher failure rates (P > 0.05). Implant loss was found not to be associated with bruxism

7

or premature wear of the prosthesis over an implant.45 Among systemic factors analyzed, tobacco use was found to decrease the survival rate and increase the bone loss in some studies.3,48 Also, peri-implantitis was another complication that may have caused implant failure.34,36 Surface treatment improved the survival rate of the dental implants in low-density bone due to the closer contact between the cells and the titanium, resulting in better biological and biomechanical effects for bone tissue.40 Jeong et al.32 stated that surface-treated implants may be better for low-density bone. In addition, dental implants with large diameters and sizes could be better for reducing the cantilevers in low-quality bone,8 and short implants with machined surfaces may show a lower survival rate.17,28 Also, the surface treatment can optimize the biomechanics of the implant, improving the biomechanical contact.46 In an analysis of the risks and bias of the studies included in this sample, three studies distributed patients into randomized groups40,46,48; however, there was no objective relationship in the distribution of the patients randomized. Two studies applied a method of randomization to the distribution of the numbers of implants.42,44 Other studies used a method of randomization at the time of evaluation of the radiographs.8,36 Nevertheless, nine studies did not use any method of tion.3,13,37– randomiza39,41,43,47,49 Yet only three retrospective studies were considered.11,18,44 The dropout of patients and the reasons for this were reported in only two studies.9,45 The term ‘double-blind study’ was not used, but one study used the concept of blinded assessment of the radiographs.40 It is known that greater primary stability generally occurs with better bone quantity and quality. There was no contraindication to immediate loading in cases of adequate primary stability.13 The studies reviewed showed limitations in terms of the small numbers of implants inserted in type IV bone compared to other bone types, and some studies did not clearly show the survival and failure rates for each bone area. More randomized studies are necessary to better evaluate this issue. In conclusion, implants with treated surfaces inserted in type IV bone may have a better survival rate as compared to machined implants. Funding

None.

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

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Competing interests

None declared. Ethical approval

Not required. Patient consent

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Address: Marcelo Coelho Goiato Department of Dental Materials and Prosthodontics Aracatuba Dental School UNESP Jose´ Bonifa´cio 1193 Aracatuba Sa˜o Paulo 16015-050 Brazil Tel.: +55 18 36363287; Fax: +55 18 36363245 E-mail: [email protected]

Please cite this article in press as: Goiato MC, et al. Longevity of dental implants in type IV bone: a systematic review, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.02.016

Longevity of dental implants in type IV bone: a systematic review.

Bone quality and quantity are important factors with regard to the survival rate of dental implants. The aim of this study was to conduct a systematic...
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