What is Systematic Review and Meta Analysis??

Systematic review- It is a specific search strategy, lists what will be included and excluded in
articles selected

Meta-Analysis- Looks at studies from a systematic review

Purpose-Combines similar studies and pulls data to get a statistically significant result

INTRODUCTION

• Dental implants are an effective treatment option for partially or totally edentulous
patients and provide functional recovery and improved esthetics.

• Branemark et al described 2-piece dental implants designed to be used with a 2-step

surgical procedure.

• In recent years, this concept has been modified to simplify and increase the
effectiveness of treatment and patient comfort.

TWO-PIECE IMPLANT

Inserted into the bone after raising a soft-tissue flap

Repositioned to cover the implant during healing

After healing period, transmucosal abutment

They were originally designed for-

• submerged healing, which is related to less bone resorption; this occurs because there are
minimal risk of infection,

• better adaptation to soft tissues

• Marginal bone remodelling

ONE-PIECE IMPLANT

• They were designed to incorporate the transmucosal abutment .

• Advantages-

 Lack of microgap between implant and abutment

 reduced accumulation of microorganisms,

  reduced surgical time, and a straightforward restorative technique

 Designed for immediate function as well as for immediate placement after tooth
extraction, and can be surgically placed with or without a flap

 Advantages of immediate-function protocol over the late-treatment protocol includes-

 Fewer surgical interventions,

 shorter treatment time, and

 reduced trauma to the patient

Long-term studies have demonstrated high survival rates with dental implants for various
indications; however, few clinical randomized clinical trials (RCTs) have evaluated the
differences between implant systems.

• Therefore, the purpose of this systematic review and meta-analysis was to evaluate 1-
piece versus 2-piece implants.

• The null hypotheses were that no differences would be found between 1- and 2-piece
implants in terms of marginal bone loss (MBL), implant survival rate, or complications.

MATERIALS AND METHOD

• This systemic review is based on PRISMA.

• The methods for this systematic review were registered on the international prospective
register of systematic reviews (PROSPERO) under the number: CDR42018095721.

• Eligible studies included randomized controlled trials (RCTs) and/or prospective trials.
The studies needed to have at least 30 participants, to compare 1-piece or 2- piece
implants in the same study (direct comparison), and to be published in English.

• The (PICO) question was, “Do patients who receive 1-piece implants show similar
marginal bone loss, survival rates, and complications as those who receive 2-piece
implants?”

• The primary outcomes were MBL, while implant survival rates and prosthetic
complications were secondary outcomes.
 • Two independent researchers (J.P.J.O.L., C.A.A.L.) performed the electronic searches in
the PubMed/ MEDLINE, Web of Science, and Cochrane Library databases for articles
published up to May 2018 using the following descriptors and Boolean operators:
“Dental implants AND one piece and two piece.” To complement this search, the same
investigators manually reviewed articles published in the following discipline-specific
journals. Clinical Implant Dentistry and Related Research, Clinical Oral Implants
Research, International Journal of Oral and Maxillofacial Implants.

• Initially, the studies were selected according to eligibility criteria based on the title. A
third author (J.M.L.G.) analyzed differences and disagreements among the researchers,
and a consensus was reached through discussion.

• The kappa statistics was calculated to determine interexaminer agreement during the
selection process of studies retrieved from the PubMed/MEDLINE, Web databases of
Science, and the Cochrane Library databases.

• Two investigators (J.P.J.O.L., C.A.A.L.) assessed the quality and risk of bias of the RCTs
included in this systematic review using The Cochrane Risk of Bias Tool which checks
for

• -selection bias (random sequence generation and allocation)

• -performance bias(blinding of participants and personnel)

• -detection bias(blinding of outcome assessment)

• -attrition bias(incomplete outcome data)

• -Reporting bias(selective reporting)

• -other bias

• The meta-analysis was based on the Mantel- Haenszel and inverse variance methods. The
implants survival rates were analyzed by using a dichotomous outcome, measured
according to risk ratio (RR) and MBL, through the continuous outcome evaluated
according to the mean difference (MD), both with corresponding 95% confidence interval
(CI).

 
RESULTS

• A total of 5 studies evaluating 1-piece and 2-piece implants, published between 2006 and
2018 were selected: 4 RCTs and a randomized prospective trial. The studies evaluated a
total of 434 implants 360 titanium and 74 zirconia which were placed in 270 participants
with a mean age of 54.70 years.

• The mean follow-up period was 4 years.

• Three of the studies evaluated one of the arches, maxilla or mandible, and 2 studies
assessed both arches. Single crowns, fixed partial dentures, and overdentures were
evaluated
All selected studies evaluated mean MBL (mm) around the implants after a minimum of 2 years
of follow-up (range: 2 to 6 years). The meta-analysis found no significant difference between 1-
piece and 2-piece implants in relation to MBL

•
 • Regarding implant survival rate, the assessed studies reported 8 failures (1.95%), of
which 3 were 1-piece implants and 5 were 2-piece implants. Quantitative analysis
showed no significant difference between 1- piece and 2-piece implants

Common types of prosthetic complications -

 Ceramic chipping

 loss of cement retention,

 loosening of screws, and loss of screw-access restorations

DISCUSSION

• This systematic review evaluated the clinical outcomes of 2 different implant systems (1-
and 2-piece implants) in terms of MBL and survival rate, as well as prosthetic
complications. The findings indicated no difference between 1-piece and 2-piece implants
in terms of MBL, implant survival rate, or prosthetic complications, and the null
hypothesis tested was accepted.

• Broggini et al reported that 2-piece implants are more susceptible to MBL than 1-piece
implants, perhaps because a microgap between the implant and abutment at the level of
the bone crest in implants with abutments may stimulate bone loss
 • Heijdenrijk et al evaluated the feasibility of using an intermediate implant system in a
nonsubmerged procedure compared with the intermediate implant placed using the
traditional submerged procedure and 1-piece implants placed by using a nonsubmerged
procedure.

After 5 years of follow-up, no association was found between the microgap level and the
amount of bone loss, suggesting that 2-piece implants placed by using a nonsubmerged
procedure may be as predictable as when used in a submerged or 1-piece procedure.

• According to a systematic review, MBL of 1 mm to 1.5 mm is considered acceptable in

the first year after implant placement. In each subsequent year, an average MBL of 0.2
mm is acceptable. Thus, the MBL in both groups was within an acceptable range, and the
first null hypothesis was accepted as there were no differences between single- and
intermediate-body implants in terms of MBL.

Fracture and chipping of the ceramics was observed in the assessed studies-

• use of ceramics for posterior restorations,

• the inclusion of patients with bruxism, and

• excessive occlusal load on the implant

• Screw loosening and abutment fracture were also reported. However, despite the
complications reported, the studies evaluated were consistent with acceptable
complication rates, and complications were not significantly different between the groups
(1-piece and 2- piece).

• Survival rate was 94.7% for 1-piece and 97.5% for 2-piece implants.

• Although a small difference in the survival rate between implant systems has been
reported, the quantitative analysis showed no significant differences in implant survival
rate between the 1-piece and 2-piece implants.

• One study evaluated zirconia dental implants, reporting no significant differences

between the 1- and 2-piece implants tested. However, according to a recent systematic
review, care is needed when comparing zirconia with titanium implants, especially after a
short follow-up period, because zirconia exhibits aging properties and presents a greater
risk of long-term fracture.

CRITICAL APPRAISAL

• Although authors have compared one piece & 2 piece implants but all the studies have
used different implant systems therefore the comparative results may not be upto the
mark.
CONCLUSION

• Within the limitations of this systematic review, the following conclusions were drawn:

– No significant difference was found between 1- and 2-piece implants in terms of

MBL, survival rate, or prosthetic complications.

– Because of the small number of studies and short follow-up periods, further
comparative studies with longer follow-up periods are necessary.