Int. J. Oral Maxillofac. Surg.

2015; 44: 892901

http://dx.doi.org/10.1016/j.ijom.2015.02.013, available online at http://www.sciencedirect.com

Systematic Review and Meta-Analysis

Dental Implants

Implant survival rates, marginal V. Moraschini1, G. Velloso2,

D. Luz1, E. Porto Barboza1
1
Department of Periodontology, School of

bone level changes, and Dentistry, Fluminense Federal University,

Niteroi, Rio de Janeiro, Brazil; 2Sao Leopoldo
Mandic College, Niteroi, Rio de Janeiro, Brazil

complications in full-mouth
rehabilitation with flapless
computer-guided surgery: a
systematic review and meta-
analysis
V. Moraschini, G. Velloso, D. Luz, E. Porto Barboza: Implant survival rates,
marginal bone level changes, and complications in full-mouth rehabilitation with
flapless computer-guided surgery: a systematic review and meta-analysis. Int. J. Oral
Maxillofac. Surg. 2015; 44: 892901. # 2015 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This systematic review evaluated the implant survival rate, changes in
marginal bone level, and complications associated with guided surgery for the
treatment of fully edentulous patients followed up for longer than 1 year. A
comprehensive literature search was conducted in MEDLINE/PubMed and the
Cochrane Central Register of Controlled Trials (CENTRAL) to retrieve studies
published up until July 2014 that met predefined eligibility criteria. Thirteen studies
were included. In studies on the guided surgery technique, a survival rate of 97.2%
Key words: guided surgery; flapless surgery;
and a mean marginal bone loss of 1.45 mm were found during 14 years of follow-
implant survival; marginal bone level; dental
up. However, associated complications, such as implant loss, prosthesis or surgical implants.
guide fractures, and low primary stability, were often found, and there is a learning
curve to achieve treatment success. Further longitudinal comparative studies should Accepted for publication 11 February 2015
improve the technique and its success rate. Available online 17 March 2015

Since the development of osseointegrated contemporary implant dentistry has been In the last few years, clinical studies
implants1 and the publication of the first the investigation of less invasive and more have reported excellent results for the
longitudinal studies evaluating their suc- predictable surgical techniques that result techniques developed to replace bone re-
cess and survival,2,3 the primary focus of in reduced treatment times. generation procedures and avoid implant

0901-5027/070892 + 010 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Rehabilitation with flapless computer-guided surgery 893

placement close to critical anatomical
areas, such as the maxillary sinus and
the mandibular nerve. Krekmanov et al.
described a distal implant inclination
technique for use in cases where implant
placement in the posterior region is con-
traindicated.4 The combination of distal
tilted implants, immediate prosthetic
loading, and a smaller number of
implants has recently been recommended
for use with All-on-Four (four implants)5
and Novum (three implants)6 systems,
which have survival rates comparable
to those of conventional techniques.
However, the accurate placement of
tilted implants or implants close to im-
portant anatomical areas using free-hand
techniques remains a challenge for sur-
geons.
The advent of cone beam computed
tomography (CBCT) has contributed to
the development of guided surgery tech-
niques.7 The use of CBCT to plan the
placement of implants and the use of
surgical guides, aided by specific soft-
ware, preclude the use of a flap. The
advantages of not raising a mucoperiosteal
flap are reduced surgery times, fewer post-
operative complications such as pain and
bleeding, and greater patient comfort.8
Moreover, recent studies have found bet-
ter healing and lower rates of alveolar and
peri-implant bone loss when using this
technique.9,10
This systematic review and meta-anal-
ysis evaluated implant survival rates,
changes in marginal bone levels, and
complications associated with guided
surgery for the treatment of fully edentu-
lous patients followed up for longer than 1
year.
Materials and methods
Development of a protocol
The method used in this systematic review
was adapted from the Preferred Reporting
Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines11 and the
recommendations made by Needleman.12
Clinical questions were developed and
organized according to the PICO13 frame-
work for evidence-based practice.
Focused question
The focused question was What are
the implant survival rates, marginal peri-
implant bone changes, and complications
of guided surgery for the treatment of fully
edentulous patients after a 1-year follow-
up?
Search strategy
The search strategy was adapted from the
PRISMA guidelines (http://www.prisma-
statement.org). The electronic search and
the PICO strategy are shown in Table 1.
Selection criteria
Randomized clinical trials (RCTs), con-
trolled clinical trials (CCTs), prospective
and retrospective cohort studies, and
case series (with 10 cases) were sought.
The following inclusion criteria were ap-
plied: (1) studies in the English language;
(2) studies in edentulous humans over 18
years of age (maxilla and/or mandible);
(3) studies with a minimum follow-up of 1
year; (4) studies with the inclusion of at
least 10 volunteers.
Animal studies, cadaver studies, case
series (<10 cases), reports of techniques,
implants installed in areas of bone regen-
eration, studies with a follow-up period
of <1 year, studies in patients with decom-
pensated systemic diseases, studies in
patients using bisphosphonates, studies
that only analyzed accuracy, and those
including patients with periodontal dis-
ease without prior treatment, were exclud-
ed.
Screening process
Two independent reviewers (V.M.F. and
G.V.) searched for and screened studies by
first analyzing titles and abstracts. In a
second phase of the study, the complete
texts were selected for careful reading and
analysis according to eligibility (inclusion
and exclusion) criteria for future data ex-
traction. Differences between reviewers
were resolved by discussion and consen-
sus. Cohens kappa was used to measure
the agreement of searches made by the two
reviewers.
Quality assessment
The NewcastleOttawa (NOS) scale, avail-
able at http://www.ohri.ca/programs/
clinical_epidemiology/nosgen.pdf, was
used to evaluate the quality of non-random-
ized studies (prospective and retrospective
cohort studies) included in this review. A
score ranging from 1 to 9 was assigned to
each study, according to the items assessed
by the scale.
Heterogeneity assessment and data
extraction
Data on the study design, follow-up time,
participant characteristics, methods, im-
plant survival, prosthesis survival, marginal

Table 1. Systematic search strategy (PICO strategy).

What are the implant survival rates, marginal peri-implant bone changes, and complications of guided surgery for
Focus question the treatment of fully edentulous patients after a 1-year follow-up?
Search strategy
Population (1) MeSH terms: edentulous jaws OR edentulous maxilla OR edentulous mandible OR edentulous ridge OR
complete edentulism OR rehabilitation edentulous OR edentulous implant
Intervention (2) MeSH terms: guided surgery OR guided implant OR implant guided OR implant guided surgery OR dental
implant guided OR dental implant guided surgery OR flapless implant surgery OR flapless surgery OR full arch
rehabilitation
Text words: full mouth rehabilitation OR computer-assisted implant surgery OR immediate loading OR full arch
restoration OR flapless guided implant surgery, flapless computer guided implant surgery OR immediate loading
OR immediate function
Comparisons Not applicable
Outcomes (3) MeSH terms: survival OR implant survival OR dental implant survival OR dental implant complications OR
implant accuracy OR dental implant accuracy OR implant bone resorption OR dental implant bone loss OR
prospective study OR retrospective study OR randomized controlled trial OR controlled trial
Search combination 1 AND 2 AND 3
Database search
Language English
Electronic databases MEDLINE/PubMed and Cochrane Central Register of Controlled Trials (CENTRAL)
MeSH, medical subject heading.
894 Moraschini Filho et al.
bone changes, guided surgery, and reported
complications were extracted to evaluate
data heterogeneity. When data were not
clear, an e-mail message was sent to the
authors requesting clarification.
Data analysis
Quantitative analyses and subsequent
meta-analysis were only possible for mar-
ginal bone level, as these were the only data
that could be combined significantly. The
pooled marginal bone loss was calculated
using OpenMeta[Analyst] software (Agen-
cy for Healthcare Research and Quality,
USA), together with the random effect
model to define the relative weight of each
study according to the mean marginal bone
level values, standard deviations (SD), and
number of implants in each study. The 95%
confidence interval (95% CI) was calculat-
ed for each outcome. Statistical homoge-
neity was calculated using the Cochran
Q-test combined with P-values and I2 sta-
tistics. Heterogeneity was measured at the
levels of 25%, 50%, and 75% and classified
as low, medium, and high.14 When signifi-
cant heterogeneity was found (P < 0.10),
the random-effects model was used. Data
that could not be pooled, such as implant
survival, accuracy, and complications,
were analyzed using descriptive (qualita-
tive) statistics.15
Results
Search results
The initial search yielded 1658 titles
from MEDLINE/PubMed and 42 from the
Cochrane Central Register of Controlled
Trials. After the first evaluation, 30
complete articles were selected. After care-
ful reading, 17 studies were excluded be-
cause they did not meet the eligibility
criteria.1632 Reasons for exclusion are
shown in Table 2. Therefore, 13 studies
published between 2005 and 2014 were
included in this systematic review.3345
The selection process is illustrated in Fig. 1.
The analysis of potential studies for
inclusion according to titles and abstracts
revealed the agreement between reviewers
to be 0.97 (k), and for the selected articles
to be 0.90 (k); thus agreement was almost
perfect according to the criteria of Landis
and Koch.46
Assessment of heterogeneity
Preliminary examination of the selected
studies revealed considerable heterogene-
ity. Information about each study and the
study characteristics are shown in Table 3.
Table 2. Excluded studies. to 4 years, and the mean follow-up was
Reason for 22.6 months.
rejection Authors
Partial Rocci et al.16
Methods, evaluation, and study
rehabilitation Yong and Moy17 outcomes
Van de Velde et al.18 Three virtual surgery systems were used in
Berdougo et al.19 the studies included in this review: Nobel-
Jeong et al.20
Vasak et al.21
Guide (Nobel Biocare AB, Sweden),3339,
4245
Doan et al.22 Materialise (Materialise NV, Leu-
Giordano et al.23 ven, Belgium).40 and Sinterstation HiQ
(3D Systems, Rock Hill, SC, USA).41
Implants placed Merli et al.24 Only two studies used Morse-taper con-
in areas of bone Meloni et al.25
regeneration Tahmaseb et al.26
nection implants,39,40 and all other studies
Meloni et al.27 used external hex implants. The implants
Meloni et al.28 were 718 mm long and 3.35.0 mm in
diameter. In all studies, an intermediate
Flap surgery Lindeboom and abutment was used. Analysis of prosthetic
van Wijk29
Giordano et al.23
procedures revealed that nine studies used
Malo et al.30 an immediate prosthesis,33,35,36,38,4044
whereas four studies used immediate-
Free-hand surgery Rousseau31 loading provisionals.34,37,39,45 The defini-
Removable Vercruyssen et al.32 tive prostheses were manufactured 412
prosthesis
months after surgery.
(overdenture)
Patient follow-up included clinical
examinations with visual inspection,3345
probing,42,43 peri-apical radiographs,3337,
Study design, population, and duration 39,40,4245
panoramic radiographs,35,41,42,44
of follow-up
CBCT scans,40,41 analysis of primary and
secondary implant stability using a torque-
Of the studies included, 10 were prospec-
meter,39,40,44,45, resonance frequency,42,43
tive cohort studies33,34,36,38,4045 and three
and questionnaires about participant satis-
were retrospective cohort studies.35,37,39
faction.33,39,44
No RCT was selected for this review.
The number of participants ranged from Assessment of quality
12 to 52, with a total of 329; they ranged in
The quality of the studies selected was
age from 34 to 92 years. Four studies did
not report the participant distribution assessed using the NewcastleOttawa
according to gender.33,34,36,42 Six studies scale (NOS). The score assigned to each
study is shown in Table 3.
did not mention whether smokers were
included.34,37,38,41,44,45 Two thousand
Implant survival
and nineteen surface-treated implants
were placed in the maxilla or mandible. All studies included in this review
The duration of follow-up ranged from 1 reported cumulative survival rates. The
Fig. 1. Flow diagram (PRISMA format) of the screening and selection process.
 Rehabilitation with flapless computer-guided surgery 895

Table 3. Main characteristics of selected studies.

Year of publication No. of
Study design participants Age range Number of implants
Duration of Gender Mean age, Implant system
Study follow-up Dropouts years Jaw Smokers Implant size
van Steenberghe 2005 27 3489 Maxilla 5 184
et al.33 Prospective NR 63 Nobel Biocare
1 year 3 3.75  7, 8.5, 10, 11.5, 13, 15 mm
4.0  7, 8.5, 10, 11.5, 13, 15 mm
Malo et al.34 2007 23 NR Maxilla (18) NR 92
Prospective NR NR Mandible (5) Nobel Biocare
1 year 0 NR
Komiyama et al.35 2008 29 4290 Maxilla (21) 5 176
Retrospective 20 M/9 F 71 Mandible (10) Nobel Biocare
3 years 0 3.75  7, 10, 11.5, 13, 15, 18 mm
4.0  10, 11.5, 13, 15, 18 mm
Johansson et al.36 2009 52 3785 Maxilla 5 312
Prospective NR 72 Nobel Biocare
1 year 2 3.75  10, 11.5, 13, 15 mm
4.0  10, 11.5, 13, 15 mm
Puig37 2010 30 3584 Maxilla (25) NR 195
Retrospective 6 M/24 F 53 Mandible (17) Nobel Biocare
1 year 0 Diameter of at least 3.3 mm
and length of at least 10 mm
Gillot et al.38 2010 33 4680 Maxilla NR 211
Prospective 12 M/21 F 61 Nobel Biocare
14 years NR 4.0  7, 8.5, 10, 11.5, 13,
15, 18 mm
Meloni et al.39 2010 15 4070 Maxilla 5 90
Retrospective 5 M/10 F 52 Nobel Biocare
1.4 years 0 4.3  10 to 13 mm
5.0  10 to 13 mm
Dhaese et al.40 2012 13 3672 Maxilla 5 78
Prospective 11 M/2 F 53 Astra Tech
1 year 0 NR  8, 9, 11, 13, 15 mm
Di Giacomo 2012 12 4171 Maxilla (NR) NR 60
et al.41 Prospective 4 M/8 F 60 Mandible (NR) AS Technology
2.5 years 0 3.75  10, 15 mm
4.0  10, 15 mm
Komiyama et al.42 2012 29 4492 Maxilla (19) 3 165
Prospective NR 72 Mandible (10) Nobel Biocare
1 year 3 NR
Landazuri-Del 2013 16 4973 Mandible 0 64
Barrio et al.43 Prospective 6 M/10 F 59 Nobel Biocare
1 year 0 4.0  10, 11.5, 13, 15 mm
Marra et al.44 2013 30 NR Maxilla (30) NR 312
Prospective 12 M/18 F NR Mandible (30) Nobel Biocare
3 years 0 3.3  8.5 to 18 mm
3.75  8.5 to 18 mm
4.0  8.5 to 18 mm
Browaeys et al.45 2014 20 3574 Maxilla (9) NR 80
Prospective 6 M/14 F 55 Mandible (11) Nobel Biocare
3 years 0 3.75  10, 11.5, 13, 15 mm
4.0  10, 11.5, 13, 15 mm
Implants per MBL, mean
Guided surgery patient Implant (SD), mm Prosthesis
Study system Insertion torque CSR (%) Radiography Opposing dentition CSR (%) NOS
van Steenberghe NobelGuide 58 100 1.15 (1.05) All kinds of opposing 100 7
et al.33 NR Peri-apical dentition
Malo et al.34 NobelGuide 4 97.8 1.9 (1.5) All kinds of opposing 100 6
NR Peri-apical dentition
896 Moraschini Filho et al.

Table 3 (Continued )
Implants per MBL, mean
Guided surgery patient Implant (SD), mm Prosthesis
Study system Insertion torque CSR (%) Radiography Opposing dentition CSR (%) NOS

Komiyama et al.35 NobelGuide NR 89.2 NR All kinds of opposing 83.9 5

NR NR dentition
Johansson et al.36 NobelGuide NR 99.4 1.3 (1.28) All kinds of opposing 96.2 6
NR Peri-apical dentition
Puig37 NobelGuide 4 97.9 NR All kinds of opposing 100 7
NR NR dentition
Gillot et al.38 NobelGuide NR 98.1 NR All kinds of opposing 100 6
NR NR dentition
Meloni et al.39 NobelGuide NR 97.8 1.81 (0.18) All kinds of opposing NR 6
3545 N cm Peri-apical dentition
Dhaese et al.40 Materialise 56 98.7 NR All kinds of opposing NR 7
Maximum NR dentition
of 50 N cm
Di Giacomo et al.41 Sinterstation HiQ NR 98.3 NR All kinds of opposing 91.6 6
NR NR dentition
Komiyama et al.42 NobelGuide NR 98.2 1.2 (1.4) All kinds of opposing 100 7
Mean of Panoramic dentition
maxilla = 62.0 ISQ
Mean of
mandible = 70.6 ISQ
Landazuri-Del NobelGuide 4 90.6 0.83 (0.14) Removable total denture NR 7
Barrio et al.43 Mean of 80  6 ISQ Peri-apical
Marra et al.44 NobelGuide NR 97.8 1.9 (1.3) Implant-supported 100 6
3050 N cm Peri-apical and prosthesis
panoramic
Browaeys et al.45 NobelGuide 4 100 1.61 (1.4) All kinds of opposing 100 6
Maximum = 50 N cm Peri-apical dentition
CSR, cumulative survival rate; F, female; ISQ, implant stability quotient; M, male; MBL, marginal bone loss; NOS, NewcastleOttawa Scale; NR,
not reported; SD, standard deviation.

presence of the implant at the sites
where they had been placed was scored
as survival (quantitative analysis).4749
All studies calculated the cumulative
survival rate using a life-table analysis.
Survival ranged from 89.2%35 to
100%33,45 (mean cumulative survival
rate = 97.2% (SD 3.49)) at a mean fol-
low-up time of 22.6 months. Implant
loss was classified as early (<4 months),
delayed (424 months), or late (>2
years), as suggested by ten Bruggenkate
et al.48 (Table 4). Of the total implant
losses (n = 51), most (58.8%) were clas-
sified as delayed.

Table 4. Descriptive overview of the implant cumulative survival rates.

Number of implants placed Number of implants failed Failure typea Reported
Study CSR%
Maxilla Mandible Total Maxilla Mandible Total Early Delayed Late
van Steenberghe et al.33 184 0 184 0 100
Malo et al.34 72 20 92 2 2 2 97.8
Komiyama et al.35 124 52 176 10 9 19 8 11 89.2
Johansson et al.36 312 0 312 2 2 2 99.4
Puig37 128 67 195 2 2 4 4 97.9
Gillot et al.38 211 0 211 4 4 1 2 1 98.1
Meloni et al.39 90 0 90 2 2 2 97.8
Dhaese et al.40 78 0 78 1 1 1 98.7
Di Giacomo et al.41 22 38 60 1 1 1 98.3
Komiyama et al.42 NR NR 165 3 3 1 2 98.2
Landazuri-Del 64 64 6 6 6 90.6
Barrio et al.43
Marra et al.44 177 135 312 6 1 7 3 3 1 97.8
Browaeys et al.45 36 44 80 0 100
CSR, cumulative survival rate; NR, not reported.
a
Early, <4 months; delayed, 424 months; late, >2 years.

Fig. 2. Meta-analysis forest plot of the studies that analyzed marginal bone loss; confidence interval (CI) of 95%.
Fig. 3. Meta-analysis forest plot of the studies that analyzed marginal bone loss, where more than five implants were used on each arch; confidence
interval (CI) of 95%.
Marginal bone loss
Marginal bone loss was evaluated in eight
studies33,34,36,39,4245. Peri-apical33,34,36,39,
4345
and panoramic42,44 radiographs were
used to evaluate bone level changes using
the implant platform33,34,36,39,4345 or
screw42 as a reference in relation to the
alveolar bone crest. Variation ranged from
0.83 mm43 to 1.9 mm34,44 at follow-up visits
13 years (mean 18.5 months) after the
procedure. The pooled marginal bone loss
was 1.45 mm (95% CI 1.021.89 mm), and
heterogeneity was substantial (I2 = 95%;
P < 0.001) (Fig. 2). The studies that used
more than five implants on each arch and
those that used the All-on-Four concept,
when analyzed separately, had pooled
values of 1.47 mm (95% CI 1.161.79
mm) (I2 = 97%; P < 0.001) (Fig. 3) and
1.43 mm (95% CI 0.682.18 mm) (I2 =
97%; P < 0.001) (Fig. 4), respectively.
The greatest relative weight in the group
of studies was 12.8%.43
Fig. 4. Meta-analysis forest plot of the studies that analyzed marginal bone loss, where the All-on-Four concept was used; confidence interval
(CI) of 95%.
Rehabilitation with flapless computer-guided surgery
Complications
Of the 13 studies evaluated, only one did
not report any complication.45 The com-
plications reported were divided into three
categories: surgical, postoperative, and
prosthetic.
Surgical complications
Low primary implant stability was the
most common surgical complication in
the different studies. Two studies found
an association between low torque at in-
sertion into type IV bone and implants
placed in the maxilla.38,41 In contrast,
insertion torque greater than 50 N cm
was associated with fracture of surgical
guides35,37,39 and implant platforms.43
The differences in virtual surgery planning
and guide manufacturing and prototyping,
revealed difficulties in the placement
of surgical templates38 and implant fenes-
tration37 at the time of placement. The
897
accuracy of the three-dimensional (3D)
guided surgery systems was evaluated in
two studies40,41 using the parameters
shown in Fig. 5. Coronal differences of
0.91 mm to 1.35 mm (mean 1.13 mm, SD
0.31), apical differences of 1.13 mm to
1.79 mm (mean 1.46 mm, SD 0.46), and
angle differences of 2.608 to 6.538 (mean
4.568, SD 2.77) were found after CBCT
images obtained for preoperative virtual
planning and after implant placement
were combined using specific CAD soft-
ware (Mimics 9.0, Materialise;40 Rhino
4.0, McNeel41) (Table 5).
Postoperative complications
Of the 2019 implants placed in the studies
reviewed, 2.53% (n = 51) were lost.3444
Approximately 37.2% of the losses of the
implants occurred due to failure in osseoin-
tegration (early losses). Other complications
including infection and fistulas33,35,37
(7.8%), low primary stability34,37,38,40,41
898 Moraschini Filho et al.

Discussion
In this study, survival rates, marginal bone
changes, and complications related to
implants placed using flapless guided sur-
gery for the treatment of fully edentulous
patients were evaluated in a systematic
review of the literature. Thirteen prospec-
tive and retrospective studies met the eli-
gibility criteria. Each study was classified
using the NOS quality scale, and the mean
score was 6.30 (SD 0.63) of a maximum of
9 points. All of the studies had a duration
of follow-up of at least 1 year, which is the
initial time reference for analysis of sur-
vival in implant dentistry.5052
All implants were placed without raising
a flap to preserve the tissues as much as
possible and to ensure greater postoperative
comfort for the patient. Previous studies of
flapless procedures have found low rates of
complications, such as bleeding, flap dehis-
cence, and pain, and therefore a low use of
Fig. 5. Parameters used to analyze the accuracy of the implant placement, by matching the
analgesics.33,44,53 However, a recent sys-
software planned implant position with the final position of the implant in the patients jawbone.
The following abbreviations were used: 1, coronal deviation; 2, angle deviation; and 3, apical tematic review54 analyzed the level of mar-
deviation. ginal bone resorption and found that there
were no significant differences between
flapped and flapless procedures, and it
Table 5. Accuracy of the surgical guides.
remains unclear which procedure has more
advantages. All studies in this review used
Number of Deviation, mean (SD) immediate definitive or provisional load-
Study System implants
ing. The advantages of immediate loading
Coronal, mm Apical, mm Angular, 8
are the significant reduction in treatment
Dhaese et al.40 Materialise 78 0.91 (0.44) 1.13 (0.52) 2.60 (1.61) time and number of surgical procedures,
Di Giacomo Sinterstation 60 1.35 (0.65) 1.79 (1.01) 6.53 (4.31) and the positive psychological effect that it
et al.41 HiQ
has on the patient.55 The use of provisional
SD, standard deviation. prostheses was justified by possible
osseointegration failures and post-surgical
soft and hard tissue resorption, as well as
(9.8%), persistent pain33,39,41 (1.9%), and
peri-implantitis34,37,44 (13.7%), were also
reported and associated with losses. Muco- Table 6. Complications (type and number of occurrences).
sitis was the most frequent biological com- Number of
plication33,38,42 and was related to poor Complications occurrences References
hygiene of the volunteers.
Surgical Surgical guide fracturea 7 35,37,39,43

complications Misfit of the surgical guidea 6 36,38

Low primary stability of implantsb 10 34,37,38,40,41

Prosthetic complications Implant fractureb 1 43

Fenestrationb 4 41

The most frequent prosthetic complication

was fracture, which occurred in cases of Postoperative Implant lossb 51 3444
33,39,41
complications Prolonged postoperative pain 13
both provisional34,37,39 and definitive Mucositis 14 33,38,42
prostheses.41,43,44 Fracture of the resin Marginal fistula or infection 7 33,35,37
element,33,37,38 screw loss or loosen- Peri-implantitisb 5 34,37,44

ing,33,34,37,38,42,43 extensive occlusal Absence of keratinized mucosa 6 42

adjustments,35,36,38,41,43 loss of implant c 34,37,39,41,43,44

Prosthetic Prosthesis resin fracture 28
and abutment fit33,36,42 or of abutment complications Prosthesis resin element fracturec 22 33,37,38
and prosthesis fit,35,36,43 and midline de- Extensive adjustment of occlusionc 10 35,36,38,41,43
viation33,41 were also frequent. The cumu- Midline deviationc 2 33,41

lative survival rate of the prosthesis ranged Loose retaining screw 26 33,34,37,38,42,43

from 83.9%35 to 100%.33,34,37,38,42,44,45 Misfit of the abutmentbridge 28 35,36,43

Three studies did not report findings for
the prosthetic cumulative survival a
rate.39,40,43 All complications reported in b
c
the studies can be viewed in Table 6.
33,36,42
Misfit of the abutmentimplant 4
Total number surgical guided = 373.
Total number of implants = 2019.
Total number of prostheses = 373.

the opportunity for functional and aesthetic
adaptation for the patient.34,37,39,40,45
Six studies did not report whether
smokers were included.34,37,38,41,44,45 This
information is fundamental in the analysis
of survival data and marginal bone
changes, because there is solid evidence
in the current literature of the negative
association between smoking and implant
survival.5658 The analysis of the studies
included in this review showed that the
mean cumulative survival rate was 97.2%
(SD 3.49) over 14 years of follow-up.
This mean value is comparable to those
found in longitudinal studies with similar
protocols, but in which free-hand techni-
ques were used.5961 Most failures oc-
curred at 424 months after the
procedure, which defines them as delayed
failures. These failures were associated
with implants presenting a low primary
stability or placed in patients exhibiting
parafunctional habits or who did not fol-
low instructions in the first months after
immediate prosthetic loading.
Hard tissues were evaluated using
radiographs. The progression and amount
of marginal bone resorption are important
data for the diagnosis of peri-implant
health. According to some authors,62 op-
timal implant health includes a marginal
bone loss of less than 0.2 mm in the first
year after loading. Other authors63 suggest
that marginal bone loss should be less than
2 mm as early as when the baseline radio-
graph is obtained, regardless of the load-
ing time. In the studies included in this
review, the mean marginal bone loss was
1.45 mm (SD 0.38). No study reported the
standardization methods used for the
radiographs. Four studies35,41,42,44 used
panoramic radiographs, which may make
interpretation difficult, particularly when
examining the anterior region of the max-
illa.64 When analyzed separately, the stud-
ies that used the All-on-Four concept
found a low mean marginal bone loss
(1.43 mm, SD 0.55) during a follow-up
of 13 years.
Despite the advantages of 3D guided
procedures, 3D deviations are expected at
the time of implant placement.40,41
According to Dhaese et al.,40 linear
and angular deviations always occur in
guided surgeries, and short implants usu-
ally have less marked apical deviations
than long implants. Several studies have
confirmed their findings.6367 In the pres-
ent review, the two studies40,41 that ana-
lyzed the accuracy of guided surgery did
not describe the method used to control
and standardize the position of volunteers
during pre- and postoperative CBCT im-
aging.
Rehabilitation with flapless computer-guided surgery
The complications included in this re-
view are similar to those reported in pro-
spective and retrospective studies using
flapped free-hand surgeries. However, at-
tention should be paid to possible fenes-
tration due to deviations from the original
plan when placing the implants, which
may affect surgical and prosthetic results.
The most commonly reported complica-
tion was implant loss, followed by pros-
thesis fracture. Due to the smaller number
of laboratory phases, virtual surgery usu-
ally results in a lack of fit, loss of passivity,
and the need for extensive occlusal adjust-
ments, particularly when tilted implants
are used. Few studies have evaluated the
survival and success of prostheses placed
using computer-aided techniques.8
In conclusion, the analysis of the studies
included in this review revealed a high
cumulative survival rate (97.2%) and a
low marginal bone loss (1.45 mm) during
14 years of follow-up. However, associ-
ated surgical and prosthetic complications
are often found, and there is a learning
curve to achieve treatment success. Fur-
ther longitudinal comparative studies
should be conducted to improve this tech-
nique and its success rate.
Funding
The authors declare that no funding was
provided for the elaboration of this study.
Competing interests
The authors declare that there was no
conflict of interest during the elaboration
of this study.
Ethical approval
Not required the study did not involve
human subjects.
Patient consent
Not required the study did not involve
human subjects.
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Address:
Vittorio Moraschini
Department of Periodontology
School of Dentistry
Fluminense Federal University
Rua Mario dos Santos Braga
30
Centro
Niteroi
Rio de Janeiro
Cep. 24020-140
Brazil
Tel: +55 2130268190
E-mail: vittoriomf@terra.com.br