1. #696
Implants with Sinus Augmentation-The Merit of Bone Grafting? A Systematic Review
Karim M. Fawzy El-Sayed1, 2
Dagmar E. Slot3
Shaimaa Nasr1
Samah Bahaa1
Christof E Dörfer1
Clinic for Conservative Dentistry and Periodontology, School of Dental Medicine, Christian Albrechts University of Kiel, Germany
2) Oral Medicine and Periodontology Department, Faculty of Oral and Dental Medicine Cairo University, Egypt
3) Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam & VU University Amsterdam, The Netherlands
Objectives
Dental implants’ placement in the maxillary posterior region with reduced bone quality and quantity presents a challenging clinical situation, frequently requiring maxillary sinus floor elevation. In the context of evidence-based decision-making, the aspect of cost-benefit is of pronounced significance and should be taken into consideration, when a medical procedure, as in the case of bone-graft-assisted maxillary sinus floor augmentation in combination with dental implants’ placement is routinely advocated among clinicians. The present study’s aim was to systematically asses the current evidence on the effect of non-grafted compared to graft-assisted maxillary sinus floor elevation on implants’ survival/failure, endosinus bone gain, crestal bone loss and bone density around dental implants.
Methods
MEDLINE-PubMed, Cochrane-CENTRAL and EMBASE databases as well as grey literature were searched up to November 2015 for randomized-controlled-trials-(RCTs) and controlled-clinical-trials-(CCTs), evaluating dental implants placed in combination with maxillary sinus elevation without and with bone grafting. Implants’ survival/failure served as primary outcome, while endosinus bone gain, crestal bone loss and bone density around dental implants as secondary outcomes. To assess possible bias, the Cochrane risk of bias tool (Higgings and Green, 2009) was used. Data were extracted and a meta-analysis performed where appropriate.
Results
Independent screening of 3180 papers resulted in six eligible experiments (Altintas et al., 2013, Nedir et al., 2013/Nedir et al., 2015, Si et al., 2013, Lai et al., 2010, Esposito et al., 2010/Felice et al., 2009, Borges et al., 2011) (Figure 1). The six experiments evaluated 485 implants in 300 participants. Heterogeneity was observed between experiments. One experiment showed low, three unclear and two high risk of bias (Table 1). Implants’ survival/failure, endosinus bone gain, crestal bone loss and bone density around dental implants showed no significant long-term differences between maxillary sinus floor elevation without and with bone grafting (Figure 2A-F). Altogether, the recommendation for non-grafted sinus floor elevation in combination with dental implants’ placement in the maxillary posterior region was considered ‘moderate’ based on the quality and body of evidence (Table 2).
Figure 2: Forrest Plots of the performed meta-analysis, meta-analysis for (A) implant survival, (B) implant failure, (C,D) endosinus bone gain and (E,F) crestal bone loss around dental implants without (test) and with (control) bone-graft-assisted sinus floor augmentation. Study data, mean and standard deviations (SD), Odds Ratio (OR) and 95% confidence intervals (95%CI), relative weight (%), pooled effect estimates for different outcomes (bold) from random- and fixed-effect meta-analysis are presented. Heterogeneity was assessed by chi-square test and the I2-statistic. Z overall test statistics, p level of significance.
Figure 1: Search and selection results
Study
Selection bias
Performance bias
Detection bias
Attrition bias
Reporting bias
Other bias
Random allocation
Baseline characteristics
Allocation concealment
Masking of participants/ personnel
Masking of examiner
Incomplete outcome data
Free of selective reporting
Reporting of follow up period
Altintas et al., 2013
Low
Unclear
High
Esposito et al., 2010/
Felice et al., 2009
Si et al., 2013
Lai et al., 2010
Nedir et al., 2013/
Nedir et al., 2015
Borges et al., 2011
Determinants of GRADING
Sinus augmentation
Study design
CCT/RCT
Risk of bias (methodological limitations)
Low to high
Consistency
Rather consistent
Directness
Generalizable
Precision
Rather precise
Reporting bias
Possible
Magnitude of the effect
Absent
Strength of the recommendation based on the quality and body of evidence
Moderate
Table 1: Methodological, validity and quality scores and estimated potential risk of bias of the included studies. Risk of bias according to Cochrane Risk of Bias Tool for RCTs (Higgings and Green, 2009).
Table 2: Estimated evidence profile (GRADE, 2015) and appraisal of the strength of the recommendation regarding the adjunctive effect of sinus augmentation when dental implants are placed.
Conclusion
Within current systematic review’s limits, non-grafted maxillary sinus floor elevation seems to be characterized by high implants’ survival and new bone formation, comparable to bone-graft-assisted maxillary sinus floor elevation. Further long-term clinical and radiographic studies (10 years and beyond) focusing on patient-relevant outcome measures are needed, before definitive conclusions can be made.
Clinic for Conservative Dentistry and Periodontology, School of Dental Medicine
Christian Albrechts-Universität zu Kiel
Arnold-Heller-Str. 3, Haus 26, Kiel, Germany
IADR General Session and Exhibition (June 22-25, 2016) , Seoul, Republic of Korea