Effects of smoking on implant success in grafted maxillary sinuses
Joseph Y. K. Kan, DDS,a Kitichai Rungcharassaeng, DDS, MS,a Jaime L. Lozada, DDS,b and Charles J.Goodacre, DDS, MSDc
School of Dentistry, Loma Linda University, Loma Linda, Calif.
Statement of the problem. Cigarette smoking has been identified as a significant risk factor for dental implant treatment.
Purpose. This retrospective study evaluated the effect of smoking and the amount of cigarette consumption on the success rates of the implants placed in grafted maxillary sinuses.
Material and methods. Sixty patients (16 smokers and 44 nonsmokers) were evaluated for the effects of smoking on osseointegrated implants placed in 84 grafted maxillary sinuses that contained a total of 228 endosseous root-form implants. Seventy implants were placed in 26 maxillary sinuses in smokers, whereas 158 implants were placed in 58 sinuses in nonsmokers. The number of implant failures and the amount of cigarette consumption were recorded.
Results. Of the 228 implants, 205 (89.9%) remained in function, after a mean follow-up period of 41.6 months (2 to 60 months). There was a significantly higher cumulative implant success rate in nonsmokers (82.7%) than in smokers (65.3%) (P=.027). Overall cumulative implant success rate was 76%. There was no correlation between implant failures and the amount of cigarette consumption (P>.99).
Conclusion. Within the limitations of this study, cigarette smoking appeared to be detrimental to the success of osseointegrated implants in grafted maxillary sinuses regardless of the amount of cigarette consumption. (J Prosthet Dent 1999;82:307-11.)
aAssistant Professor, Department of Restorative Dentistry.
bProfessor and Director, Advanced Education in Implant Dentistry.
cProfessor and Dean.
CLINICAL IMPLICATIONS
Cigarette smoking has been associated with factors that have negative impact on dental
health. The results of this study suggested that cigarette smoking might compromise
the success of implants placed in grafted maxillary sinuses.
Poor bone quality and quantity, in addition to anatomic variations, are often encountered during implant placement in the posterior maxilla. Maxillary
posterior bone atrophy, along with pneumatization of the maxillary sinus after the loss of dentition, can prevent the placement of implants of ideal length. Implant failure rates as high as 35% have been reported in type IV quality bone commonly found in the posterior maxilla. 1-7 In 1980, Boyne and James8 advocated placing autogenous marrow and cancellous bone from the iliac crest into the pneumatized maxillary sinus to increase the amount of bone for implant placement. Since then numerous surgical techniques and graft materials have been suggested for this procedure.9-17 Published data
regarding implant success in grafted maxillary sinuses is limited, relatively short-term and involves small patient populations.15,17-27 However, results are favorable and comparable to implants placed in adjacent nongrafted sites regardless of techniques, graft materials used, and whether the implants were placed simultaneous with or subsequent to the maxillary sinus grafting.20,23,26,27 Cigarette smoking has been associated with several factors that have a negative impact on dental health. Toxic by-products of cigarette smoking such as nicotine, carbon monoxide, and hydrogen cyanide have
long been implicated as risk factors for impaired healing. 28 Nicotine is known to compromise healing by reducing the proliferation of red blood cells, fibroblasts, and macrophages,29 and increasing platelet adhesiveness, which causes microclots and decreases microperfusion.30 In addition, nicotine can also produce cutaneous vasoconstriction. Carbon monoxide competitively inhibits the binding of oxygen from hemoglobin and reduces the amount of oxygen transported to the periphery.29 The primary effect of hydrogen cyanide is inhibition of the enzyme systems necessary for oxidative metabolism and transport at the cellular level.30 The harmful effects of nicotine include vasoconstriction and decreased tissue perfusion because of the release of epinephrine and norepinephrine. 31,32 Epinephrine is an important cofactor in the formation of chalones or wound hormones that inhibit epithelialization.33
In 1977, Mosely and Finseth30 first reported the detrimental effects of smoking on wound healing when they observed smokers with hand wounds. Since then cigarette smoking had been reported to cause delayed healing and pain in extraction sites,34 increased marginal bone loss,35,36 impaired response to periodontal treatment,37 and increased gingival bleeding.35,36,38 Furthermore, smokers have been associated with a higher incidence of refractory periodontitis39 and with reduced healing response after guided tissue regeneration therapy in deep infra bony pockets.40 Recent studies have identified cigarette smoking as a significant risk factor for dental implants.6,31,41-45 In 1993, Bain and Moy6 evaluated 2194 Brånemark implants placed in various areas of the mouth and noted significantly greater overall implant failures occurred in smokers (11.28%) than in nonsmokers (4.76%). De Bruyn and Collaert41 determined that maxillary implant failures before loading were significantly higher in smokers (9%) than in nonsmokers (1%). Gorman et al42 investigated the correlation between smoking and implant failures between the time of surgical placement and second stage surgery and demonstrated that smokers had twice the implant failure rate as nonsmokers.
The amount of cigarette consumption has also been associated with higher implant failures.43,44 Fartash et al43 published a prospective study on mandibular implant overdentures, citing higher implant failures in heavy smokers (30 to 40 cigarettes per day) with type IV bone. In addition, Linquist et al44 reported significantly greater marginal bone loss around implants in smokers with high cigarette consumption (>14 cigarettes per day) than those with low cigarette consumption (<14 cigarettes per day).
As one might expect, cigarette smoking and the amount of cigarette consumption may potentially alter the favorable implant success rates found in grafted maxillary sinuses, but the available data are limited. Small et al46 evaluating 76 implants placed in grafted maxillary sinuses after 5 years, reported complications in 2 patients who were heavy smokers. They suggested heavy smoking was a contraindication for patients undergoing this procedure.
However, no studies have comprehensively examined the effects of smoking, and the amount of cigarette consumption on the success rate of a large number of implants placed in grafted maxillary sinuses. Therefore, the purpose of this study was to evaluate these factors.
MATERIAL AND METHODS
This retrospective study involved a group of patients who had completed both surgical and prosthodontic phases of treatment at the Center for Prosthodontics and Implant Dentistry, Loma Linda University School of Dentistry, and were provided with prostheses supported by implants placed in grafted maxillary sinuses.
A total of 118 patients were treated, and 60 of the 118 patients who were able to return for follow-up were included in the study. There were 27 male and 33
female patients, between the ages of 41 and 84 years (mean age of 64.6 years). Two hundred twenty-eight implants were placed in the grafted maxillary sinuses supporting 69 prostheses, which had been in function from 2 to 60 months (mean postprosthetic time of 41.6 months). One hundred fifty-eight implants were placed in 58 maxillary sinuses in 44 nonsmokers, whereas 70 implants were placed in 26 maxillary sinuses in 16 smokers.
At the follow-up examination, the number and time of implant failures were recorded. Implant failures were judged according to the success criteria proposed by Smith and Zarb,53 where applicable. Panoramic and periapical radiographs were evaluated by 2 investigators at the time of follow-up examination and compared with the radiographs made at the time of prosthesis placement. Implant prostheses were not removed for individual
implant mobility tests unless significant bone loss, peri-implant radiolucency, persistent pain, discomfort, and/or infection were evident. The history of patient smoking and the amount of cigarette consumption during and/or after the surgery were recorded. Smoker group was divided into 2 subgroups: low cigarette consumption group (<15 cigarettes per day), and high cigarette consumption group (³15 cigarettes per day). Data were analyzed with the SPSS software (SPSS Inc, Chicago, Ill.). The cumulative implant success rates were calculated with a Kaplan-Meier life table analysis. Effects of smoking on implant success were compared using the log-rank test. The effect of the amount of cigarettes consumed on implant success was compared using the chi-square test. Statistical significance was denoted when P<.05.
RESULTS
Of the 228 implants placed, 205 remained in function after a mean follow-up period of 41.6 months. Twelve of the 70 implants (17.1%) placed in the
smoker group and 11 of the 158 implants (7.0%) placed in the nonsmoker group were classified as failures. There were significant differences in the cumulative implant success rates between smokers (65.3%) and nonsmokers (82.7%) (P=.027). The overall cumulative implant success rate was 76.0%. (Table I and Fig. 1). There was no correlation between implant failure and the amount of cigarette consumption in the smoker group (Table II).
Discussion
The overall cumulative success rate of the implants placed in grafted maxillary sinuses in this study was 76.0% for the combined smoker and nonsmoker
groups after a mean follow-up period of 41.6 months. These data also represented an absolute implant success rate of 89.9% (205 of 228). Others have reported comparable absolute implant success rates when placing implants in grafted maxillary sinuses. Tidwell et al20 reported 190 of 203 implants (93.6%) remained stable over 32 months. Wheeler et al26 reported 5 failures of 66 implants (92.8% success rate), whereas Bloomqvist et al23 noted an 83% implant success rate when using similar procedures. These data are slighter higher than the long-term implant success rates reported for
implants placed in the posterior maxilla, which usually consists of type IV bone, without sinus grafting surgery. Jaffin and Berman2 reported a 64.7% (66 of 102) implant success rate in type IV bone over a 5-year period, whereas Engquist et al1 and Smedberg et al7 noted 73.7% (146 of 198) and 63.6% (21 of 33), respectively, at a 2-year follow-up. Twelve of 70 implants (17.1%) placed in the smoker group and 11 of 158 implants (7.0%) placed in the
nonsmoker group were classified as failures. This corresponds to the results reported by Bain and Moy,6 in which the implant failure rate in the posterior maxilla for smokers (19.10%) was twice that of nonsmokers (10.93%).6 The necessity of bone grafting in this pro-cedure may create an additional factor to further compromise the implant success in smokers.
The amount of cigarette consumption has been suggested as a factor affecting implant success rates. Linquist et al44 and Fartash et al43 independently showed that heavy smokers (>14 and 30 to 40 cigarettes per day, respectively) had greater marginal bone loss around implants and higher implant failure rates. However, this trend was not supported by the results of this study. The implant failure rates were the same (17.1%) in both the high (³15 cigarettes per day) and low (<15 cigarettes per day) cigarette consumption groups. Within the context of this study, cigarette smoking appeared to be detrimental to the success of osseointegrated implants placed in grafted maxillary sinuses. Numerous smoking cessation protocols have been proposed
to improve surgical outcomes in smokers. Miller48 cited comparable graft success between smokers who stopped smoking immediately before and up to
2 weeks after the periodontal surgery and nonsmokers. Webster et al49 suggested that abstinence from smoking several weeks before and 2 weeks after surgery might result in proper healing of the surgical sites. Riefkohl et al50 recommended that patients stop smoking 1 day before and 5 days after plastic surgery to allow for nicotine clearance. Bain, in 1996, suggested a protocol in which the patients were to stop smoking 1 week before and 8 weeks after osseointegrated implant surgery. In his prospective study, he reported significantly lower implant failure rates in smokers who followed his protocol (11.8%) than those who did not follow the smoking cessation protocol (38.5%).51
Conclusion
Within the limits of this study, the following conclusions were drawn:
1. After a mean postprosthetic follow-up time of 41.6 months (range of 2 to 60 months), 205 of 228 implants placed in grafted maxillary sinuses remained
successfully integrated, corresponding to an absolute success rate of 89.9%.
2. There were significantly higher cumulative implant success rates in non-smokers (82.7%) than in smokers (65.3%) (P=.027). The overall cumulative
implant success rate was 76.0%.
3. No correlation was noted between the levels of cigarette consumption (<15 cigarettes per day vs ³15 cigarettes per day) and implant failures in the smoker group (P>.99).
We thank Mr Shinichiro Maruo for his assistance in the statistical analysis.
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Reprint requests to:
DR JOSEPH Y. K. KAN
DEPARTMENT OF RESTORATIVE DENTISTRY
SCHOOL OF DENTISTRY
LOMA LINDA UNIVERSITY
LOMA LINDA, CA 92350
FAX: (909)824-4803
E-MAIL: jkan@sd.llu.edu
Copyright © 1999 by The Editorial Council of The Journal of Prosthetic
Dentistry.
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