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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 59-71

The clinical outcome of bone cement in dental implant insertion – A systematic review


Department of Post Graduate Education, Goethe University, Frankfurt, Germany

Date of Submission29-May-2020
Date of Acceptance16-Jun-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. Mrugank Shah
Flat No. 601, Maa Tulsi Vihar, Road No. 8. Daulat Nagar, Borivali (E), Mumbai - 400 066, Maharashtra
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_11_20

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   Abstract 

Introduction: To accelerate the process of restoring dental implants, achieving primary stability is of prime importance for effective osseointegration. The various bone substitute materials such as autograft (golden standard), allograft, xenograft, and alloplast are used to improve the stability of an implant and also as an aid in bone formation. The use of bone cements, among the alloplast material, is a relatively new premise in oral implantology. These have been extensively used in orthopedic surgery to secure an implanted prosthesis and to replace or bind bone fragments, resulting from trauma, and to fill cavities. This article aims to review the literature for the use of bone cements in oral implantology and evaluate its prospective use in future to secure dental implants.
Materials and Methods: PubMed search was carried out using keywords such as “Bone Cements,” “Oral Implantology,” “Cements Fix Implants with Bone,” and “Cements to Grow Bone.” Of the 1422 articles, 1015 were selected after eliminating the duplicates. After applying the inclusion and exclusion criteria, 383 abstracts were assessed for relevance, of which 17 full-text articles were selected. Five articles were excluded with reasons and 12 eligible articles were included in the systematic review.
Results: Eight studies out of the 12 concluded that bone cement could be a viable alternative to allogenic or other graft materials tested. Four articles were inconclusive or showed no significant difference. However, the quality of available evidence was poor as 10 out of the 12 studies were animal trials and 2 were in vitro studies. Due to considerable heterogeneity of data, meta-analysis could not be done.
Conclusion: Bone cements can be considered a possible alternative to the existing graft materials. However, further research including controlled trials with human subjects needs to be undertaken to establish its potential.

Keywords: Bone, bone cements and, cements fix implants with bone, cements to grow, oral implantology


How to cite this article:
Shah M. The clinical outcome of bone cement in dental implant insertion – A systematic review. J Dent Implant 2020;10:59-71

How to cite this URL:
Shah M. The clinical outcome of bone cement in dental implant insertion – A systematic review. J Dent Implant [serial online] 2020 [cited 2021 Feb 25];10:59-71. Available from: https://www.jdionline.org/text.asp?2020/10/2/59/303914


   Introduction Top


Dental implants are extensively used in clinical practice for restoration of lost teeth and maxillofacial defects. Dental implants help restore the form, function, and esthetic of natural teeth and soft tissue. Since the introduction of osseointegration and dental implants protocols by Branemark et al.,[1] clinicians have attempted to expedite the treatment time and provide functional artificial teeth which would last for longer duration of time. The original protocol used to be to wait for 12 months from extraction to restoration of implant with final crown. The original protocol involved healing of extraction site, placement of two-stage submerged implant, and then restoration of implant after 3–6 months of healing period. This protocol has been modified over the last few years to single-stage placement. In recent time, even immediate placement in extraction socket with immediate loading has been successfully advocated. This concept is appealing because it reduces surgical procedure and time required prior to final restoration. Immediate extraction and immediate implantation with immediate function reduces discomfort of multiple surgeries and multiple visits and results in enhanced patient satisfaction.

Multiple studies have shown primary stability to be the prerequisite for successful osseointegration of dental implants.[2] Primary stability is typically defined as the stability of an implant immediate after its placement.[3] Implants with no primary stability or spinning implants can become surrounded by fibrous encapsulation and fail to osseointegrate.[4] Hence, good primary stability is considered an important predictor for successful osseointegration. The amount of primary stability attained is influenced by various factors, including the bone quantity and quality, implant surface characteristics, implant geometry, operator skills, and surgical technique.[5],[6],[7],[8],[9],[10],[11] Achieving good primary stability is a great challenge [Figure 1][12] in patients with poor quantity and quality of alveolar bone and some diseases such as osteoporosis.[13] Placement of dental implants in atrophic maxilla and mandible is difficult because of less height and width, hence existence of sufficient bone volume is significantly important for dental implant placement.[14] Currently, united efforts are focusing on augmenting and accelerating bone formation around orthopedic and dental implants through the implantation of different bone substitutes/grafts and/or by altering the implant surface with osteoinductive coatings, with a vision of improving and expediting the formation of mechanical stability (primary stability).[15],[16]
Figure 1: Comparing Primary Stability in Anterior & Posterior Maxilla. Undecalcified slides of an 85-year old unembalmed fresh human male cadaver who received exploratory dental implants within 48 hours of death. (Left) The dental implant in the anterior maxilla was primarily stable and shows intimate contact with the cortical bone. (Right) The dental implant in the posterior maxilla was initially unstable; the area shows thin cortical bone and sparse trabecular bone. The gap between the surrounding bone and the implant might have been created as a result of fracture of low-quality bone during surgical drilling and self-threading procedures

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It is now well acknowledged that implants with appropriate surface topography and chemistry are in a huge demand for increasing cell growth, attachment, and tissue formation, and the administration of suitable structural materials at dental implant defects should eventually amplify the osseointegration process of dental implants for their immediate loading and lasting success.[16],[17],[18],[19],[20],[21],[22],[23],[24]

Ideal grafting materials should be biocompatible, and possess osteogenic, osteoconductive, and osteoinductive properties.[25],[26],[27],[28] So far, a number of grafting materials such as autografts, allografts, xenografts, and alloplastic bone substitutes have all been exercised to provide structural base of osseous tissue to provide better foundation for dental implants.[16],[29] Autografts are considered golden standards in implant and reconstructive surgery because they maximally match the above requirements. Autogenous bone has its own drawbacks because of its limited supply, unpredictability, and donor site morbidity. In addition, autografts require additional surgery from oral cavity or iliac crest at a secondary site far from the surgical site, which makes initial surgery more complex.[30],[31] Therefore, a considerable variety of biocompatible and suitable bone substitutes have been developed and proposed for augmenting/inducing bone regeneration.[32],[33],[34],[35],[36],[37],[38],[39] While these can work as substrate alternatives, the disadvantage, especially lack of osteoinductivity, has seriously restricted their clinical applications in implant dentistry.[16],[29],[30] Allografts are considered good alternative because of large volume of available material, which can be used under local anesthesia only. Still, allograft needs a prolonged period for bone regeneration, and the danger of infection and rejection may be higher.[40] Hence, xenogeneic bone grafts, which are easier to handle, have been engaged using biomaterials such as animal bone or coral tissue.[41],[42] On the contrary, the use of allograft and xenograft is limited because of the risks of evoking an immune response and by the prospective induction of transmissible diseases.

Another possibility lies in utilizing synthetic biomaterials (alloplast), which may be simple to produce and injectable.[43],[44] An ideal alloplast, which is derived synthetically for peri-implant grafting, has not been identified. Immediate placement of implants after extraction of a large molar is a challenge. Concerted efforts are made to accelerate the process of implant therapy by choosing a graft material that is biocompatible and can predictably secure the implant immediately by bonding to both implant and bone. And it should also have the properties of rapid resorption and complete replacement by bone.[45]

Among the synthetic alloplast materials, tricalcium phosphate, hydroxyapatite (HA), and a calcium phosphate (CaP) compound such as CaP cement (CPC) have excellent osteoconductivity and biocompatibility.[46],[47],[48],[49] CPC grafting materials have benefits such as biocompatibility, controlling biological absorption ability, fabrication into functional shapes, and easy to process.[50] Porous CPC alone as an alloplastic grafting material has been extensively used, including a maxillofacial reconstruction, alveolar ridge augmentation, and cranial defect reparation.[28],[51],[52]

Artificial joints are fixed with bone cements. In 1958, Dr. John Charnley[53] first started to use self-curing poly methyl methacrylate (PMMA) cement in total hip replacement and succeeded in anchoring femoral head prostheses in the femur. Since this major breakthrough, to date, PMMA-based acrylic bone cement (ABC) is the most popular bone cement. Moreover, in the early 1980s, Brown and Chow first invented the category of biodegradable bone cements, knows as CPCs.[54] These cements form a very important zone by filling the free space between the bone and the prosthesis. Due to their optimal rigidity, cements can evenly cushion the forces working against the bone. The close connection between the bone and the cement as well as the cement and the prosthesis leads to an excellent distribution of the stresses and interface strain energy. The transmission of the forces bone to implant and implant to bone is the primary function of the bone cement.[55] In fact, “cement” is a misnomer on the grounds that the term cement is used to represent a substance that bonds two things together. Bone cements have no inherent adhesive properties, but instead, they depend on the close mechanical interlock between the prosthesis and irregular bone surface.[56] Functions of bone cements can be described briefly in order as fixation of artificial joints, anchoring of the implant to the bone, load transfer from the prosthesis to the bone, optimal stress/strain distribution, and release of antibiotics.[55] Better understanding of alternative alloplast material such as bone cements and its use in oral implantology might help reduce treatment time and patient discomfort.

In this article, we aim to summarize the bone cements that are currently available in the market and have been used in orthopedics to bond the bone and implant, thus aiding in increasing primary stability and providing stable osseous base to load them immediately. This has reportedly reduced patient treatment time and discomfort. Furthermore, we aim to review the research carried out in this field to assess the scope of bone cements in the clinical practice of oral implantology. We have also attempted to discuss the future perspectives on the development of bone cements for use in oral implantology.


   Materials and Methods Top


Objective of the study

The main objective of this study was:

  • To understand the use of bone cements to increase the primary and/or secondary stability of dental implants, which might help reduce treatment time and patient discomfort
  • To review the research done on the use of bone cements in the placement of dental implants.


Study procedure [Figure 2]
Figure 2: Flowchart

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Search strategy

A Medline (PubMed) search was performed for studies published in scientific journals from January 2003 up to September 2015. The search was limited to English language publications.

Search terms

The following search terms of “Cements alternative for Bone Grafting,” “Bone Cements Dental Implants,” “Cements Fix Implants with Bone,” “Cements to Grow Bone,” “Bone Cements Grow Bone,” “Dental Implants Bone Cements,” “Light Cured Bone Cements,” “Advanced Bone Cements,” “Advanced Bone Cements Dental Implants,” “Dental Implants Bone Cements” along with Boolean operators “and,” “or” were used.

Thereafter, the search results from the subject (two subject groups) were combined with each other using the Citavi 5 (Swiss Academic Software GmBH) version 5.1.0.0 Wädenswil, Switzerland, and duplicates were removed.

Inclusion and exclusion criteria

Inclusion criteria

The following journals were included:

  • Bone cements journal
  • Bio-medical and tissue engineering journals
  • Journal of Biomechanics
  • Orthopedic journals.


All the animal and human studies with research on bone cements were included in this review.

Exclusion criteria

The exclusion criteria were:

  • Case series
  • Case report
  • Reports based on patient chart reviews, questionnaires, or interviews
  • Papers considering endodontic cements and restorative cements
  • Papers published before 2003
  • Letters to the editor or editorials.


Data extraction

A data extraction sheet as an Excel Table [Table 1] was used to extract the relevant data from the included publications. The following criteria were recorded:
Table 1: Description of the included studies

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  • Author
  • Title of study
  • Type of study/study design
  • Year of publication
  • Mean follow-up time
  • Reason/conclusion.



   Results Top


Search results

A PubMed search using keywords mentioned above was done. Articles were searched on September 15, 2015, and the following results were obtained pertaining to each keyword:

  1. Cements alternative for Bone Grafting – 62
  2. Bone Cements Dental Implants – 272
  3. Cements Fix Implants with Bone – 10
  4. Cements to Grow Bone – 33
  5. Bone Cements Grow Bone – 32
  6. Dental Implants Bone Cements – 280
  7. Light Cured Bone Cements – 112
  8. Advanced Bone Cements – 265
  9. Advanced Bone Cements Dental Implants – 6
  10. Dental Implants Bone Cements – 350


Results from the above search terms were imported through Citavi 5 version 5.1.0.0 (Swiss Academic Software GmBH) into excel, and duplicates were removed. A total of 1015 articles were obtained and tabulated in an excel sheet. After initial screening of titles of all the 1015 articles, 383 articles were obtained after eliminating all the duplicates. A total of 383 abstracts were screened to obtain 17 articles pertaining to bone cements. Five studies were excluded after applying the inclusion and exclusion criteria.

The following are the reasons for exclusion:

  • Studies could not be accessed – 01
  • Articles describing biomaterial and manufacturing technique – 02
  • No detailed information on bone cements and articles describing implant surfaces – 02.


In this review, the only one human study obtained could not be accessed through electronic database search.

Date of publication

The 17 studies were published in between the years 2003 and 2015.

Type of study

From the selected 12 studies, eight (Zou et al., 2012; E. M Ooms et al., 2003; Wang et al., 2010; Shelke et al., 2013; Lin Dan-Jae et al., 2011; Baier et al., 2013; Winge et al., 2011; Baier et al., 2013; and Arisan et al., 2010) (66.66%) studies were prospective animal studies, one (Seong et al., 2011) (8.33%) study was an animal study/ex vivo, one (Seung-Yun Shin et al., 2014) (8.33%) study was an animal study/in vitro, and two (Vayron et al., 2013 and Smeets et al., 2010) (16.66%) studies were of in vitro study design.

Type of bone cement

In this review, eight (66.66%) articles (Zou et al., 2012; E. M Ooms et al., 2003; Wang et al., 2010; Seung-Yun Shin et al., 2014; Seong et al., 2011; Shelke et al., 2013; Lin Dan-Jae et al., 2011; and Baier et al., 2013) out of the 12 do support the hypothesis for the use of bone cements to stabilize dental implants.

Out of the 12 (100%) studies which were included in the review, eight (Zou et al., 2012; E. M Ooms et al., 2003; Wang et al., 2010; Seung-Yun Shin et al., 2014; Lin Dan-Jae et al., 2011; Winge et al., 2011; Baier et al., 2013; and Arisan et al., 2010) (66.66%) articles discussed about CaP-based CPC, one (Shelke et al., 2013) (8.33%) article on magnesium phosphate cement (MPC), one (Vayron et al., 2013) (8.33%) article on tricalcium silicate-based cement (TSBC), one (Smeets et al., 2010) (8.33%) article on PMMA-ABC, and one article (Seong et al., 2011) (8.33%) on specially developed dental implant bone cement (DIBC).

Calcium phosphate cement

Mode of use of calcium phosphate cement

Out of the eight studies which discussed CPC, two (Zou et al., 2012, and Wang et al., 2010) (25%) studies describe CPC/BMSC (bone marrow stromal cells) composite, two (Winge et al., 2011, and Arisan et al., 2010) (25%) articles describe the use of injectable CaP cement (ICAP), and one article (Baier et al., 2013) (12.5%) describes the addition of strontium bioactive mineral to CPC, whereas others (E. M Ooms et al., 2003; Seung-Yun Shin et al., 2014; and Lin Dan-Jae et al., 2011) (37.5%) debate on various CPCs.

Additives to calcium phosphate cement

Three (Zou et al., 2012; Wang et al., 2010; and Baier et al., 2013) (36, 5%) studies out of the eight studies describe the incorporation of growth factors and bioactive minerals to CPCs. Two articles (Wang et al., 2010, and Seung-Yun Shin et al., 2014) describe the repair of circumferential bone defect around dental implants.

Resorbable versus nonresorbable bone cement

Out of the total five (ABC, CPC, MPC, DIBC, and TSBC) different types of cements described in this review, two cements (ABC and DIBC) are nonresorbable and three (CPC, MPC, and TSBC) are resorbable.

In two of the studies (Zou et al., 2012, and Lin Dan-Jae et al., 2011), autologous bone has been compared with CPC.

Type of procedure

Eight articles (Zou et al., 2012; Wang et al., 2010; Vayron et al., 2013; Smeets et al., 2010; Seung-Yun Shin et al., 2014; Seong et al., 2011; Shelke et al., 2013; and Arisan et al., 2010) (66.66%) out of the 12 describe bone cements and their potential use with benefits and limitation in oral cavity (oral and maxillofacial surgeries), whereas other three (E. M Ooms et al., 2003; Lin Dan-Jae et al., 2011; Winge et al., 2011; and Baier et al. 2013) (33.33%) articles discuss bone cements and their potential implications in orthopedic surgery.

Effect of bone cements

Out of the above 12 articles reviewed, eight articles (Zou et al., 2012; E. M Ooms et al., 2003; Wang et al., 2010; Seung-Yun Shin et al., 2014; Seong et al., 2011; Shelke et al., 2013; Lin Dan-Jae et al., 2011; and Baier et al., 2013) (66.66%) support the use of bone cements in increasing the primary and/or secondary stability of dental implants along with better quality and/or quantity of bone around dental implants, one article (Arisan et al., 2010) (8.33%) did not show any significant benefit for the use of bone cement, and the remaining three (Vayron et al., 2013; Smeets et al., 2010; and Winge et al., 2011) (25%) articles were inconclusive.

Assessment of outcome measures

Of the 12 studies assessed for the use of bone cements in the oral cavity, three (Zou et al., 2012; Shelke et al., 2013; and Lin Dan-Jae et al., 2011) (25%) studies measured the bone-to-implant contact (BIC), two (Seong et al., 2011, and Arisan et al., 2010) (16.66%) studies described bone–cement–implant–interface, one (Wang et al., 2010) (8.33%) study evaluated the mineral apposition rate (MAR), one (Smeets et al., 2010) (8.33%) study emphasized about increase in bond strength, and one (Seung-Yun Shin et al., 2014) (8.33%) study assessed the implant stability quotient (ISQ). The remaining articles describe the cortical bone response and fatigue stresses and assess the osseointegration and biomechanical effects of bone cements (E. M Ooms et al., 2003; Baier et al., 2013; Vayron et al., 2013; and Winge et al., 2011).


   Discussion Top


Various bone cements are available in the market; among them, PMMA-based ABCs and CaP-based CPC are the two most commonly used cements. Eight out of 12[3],[45],[12],[57],[58],[59],[60],[61] articles support the use of bone cement in stabilizing the implant in extraction sockets, improving primary or secondary stability, and forming better quality of bone around the dental implants after maxillary sinus lifts. Out of the eight articles which support the hypothesis, none of them have discussed the use of ABC even though it is the most popular bone cement in orthopedic surgery. ABC is used for anchorage of implants in orthopedic surgeries (i.e., total knee arthroplasty, total hip replacement) and bone defect filling because of its favorable properties such as bio-inertness, simple handling, significant mechanical strength, and economical.[62] The major reason for the limited application of ABC in the oral environment can be attributed to its nonbiodegradability, tissue necrosis resulting from the exothermic setting reaction, monomer toxicity, lack of bonding (except for mechanical interlocking), degradation of fragments causing irritation and inflammation, and leakage of monomer.[63]

Out of the eight articles which found results supporting the use of bone cements, six articles used CaP-based CPC. The major reasons for CPCs' wide uses in oral environment are their unique combination of osteoconductivity, bioactivity (capacity to directly bond to bone, thus establishing a uniquely strong interface), biodegradability, injectability, nonexothermic setting, moldability, and negligible shrinkage.[62] In addition, CaPs do not cause an antigenic response in the body and can be easily customized to its intended application.[64] Two articles[65],[66] out of the eight articles which used CPC in the review did not show results favoring bone cements, and both the studies have used ICAP. This could be attributed to the relatively low flexural strength of bone cement used and very dense recipient bone area used in one of the studies,[65] whereas the other study[66] using injectable CaP cement found no significant radiological or biomechanical difference between avascularized corticocancellous bone, vascularized corticocancellous bone, and avascular cortical bone groups. However, their results were favoring the use of CaP bone cement to mechanically stabilize the cortical bone fragments and as a possible alternative to autologous bone grafting. Other major limitation of injectable CaP cement could be the “washout” effect experienced in the area with excessive blood flow.[67]

Out of the two studies[3],[59] describing the repair of circumferential bone defects around dental implants one[59] used bioengineered CPC composite whereas the other study[3] used CPC. Shin et al.[3] showed that the use of CPC grafting improves the initial stability of an implant with insufficient cortical bone. The ISQ values increased drastically after the use of CPC, as the depth of defect increased, suggesting its clinical use to rescue implants placed in maxillary posterior jaw locations with poor bone quality and iatrogenic oversized osteotomy. Another study by Lin et al.[59] also confirms the hypothesis for the use of CPC to reinforce the implant fixation process and facilitate early osseointegration than the autograft. Histological evaluation of CPC has found it to be biocompatible, osteoconductive, as well as osteotransductive in contrast to PMMA-ABC, which becomes surrounded by a fibrous encapsulation.

On the other side, CPC lacks sufficient osteoinductivity (i.e., does not have the capability to form a new bone in nonskeletal intramuscular or subcutaneous sites), and a mixture of growth factors can alter the osteoinductive properties of CaP materials, hence promoting bone repair and formation.[68],[69],[70] It is widely accepted that in the regeneration of lost bone and periodontal tissues, growth factors play a vital role in the complex cascade of tissue regeneration process.[71] To overcome this problem, two studies[58],[59] out of six studies which support the hypothesis for the use of bone cements have used BMSC as an osteogenic growth factor. The second study[59] additionally uses bone morphogenic protein-2 (BMP-2) (potent osteoinductive activity) and fibroblast growth factor (bFGF) (potent mitogen for fibroblasts and other mesoderm-derived cells) to overcome the shortcomings of any one single factor. Both these studies suggest that CPC could be an acceptable alternative carrier for biocompatible, artificial cell-seeded constructs. Addition of BMP-2 and bFGF shows a synergistic effect because of which they show best results compared to BMSC + CPC together which gave better results than CPC alone or autologous bone. Addition of various bioactive ions, such as magnesium, strontium, magnesium, copper, zinc, and fluoride, may further promote the biological performance of CPCs by improving bone metabolism.[72] Addition of strontium to CPC has shown to improve local bone formation in a study by Baier et al.,[60] which improves the fixation ability of CPC grafting material in osteoporotic bone.

The major advantage of CaP-based bone cements is its handling properties in comparison to particulate bone substitutes/graft materials which are widely used in market. Majority of the published research on grafting material in oral implantology focuses on the use of granular structure with no cohesive potential. The major limitation of the use of granules is that it needs to be stabilized with membranes or grafted in sites with no biomechanical stresses. Stresses may induce micromovements between the particles and induce ingrowth of connective tissue (which may explain the substandard success rate of guided bone regeneration technique), whereas CPC can be directly grafted and once set, does not require membrane to stabilize the cement.

Appropriate CaPs with suitable geometry, architecture, and distinctive porosity may stimulate the development of HA layer at the bone–implant junction, which leads to the formation of matrix by attracting protein, to which cells attach, multiply, and differentiate and later biomineralize or develop into new bone.[21],[73],[74] This ability of CPCs to form new bone has led to diverse applications, varying from graftings to coatings, in implantology.[21],[74],[68],[69],[70],[73],[74],[75],[76],[77],[78],[79],[80],[81]

Two cements out of the total five different cements included in this review, which support the hypothesis, are MPC and DIBC. MPC is also a biodegradable bone cement. MPC may act as bioactive bone cement due to the release of magnesium ions, which improve the activity of osteoblasts. Sehlke et al.[45] tried stabilizing dental implant in large molar site using magnesium-based bone cement such as OsteoCrete (Bone Solutions Inc., Colleyville, Texas, USA) which helps clinically in reducing an additional surgical procedure and the time needed prior to final restoration. One of the most significant observations made during the study was that cement surface, when exposed to oral environment, became discolored and began to soften and diffuse because of consistent exposure to bacterial contaminants and saliva. MPC used in this study had a nonporous surface compared to CPC, which prohibited the ingrowth of new vasculature and bone and arrested the perfusion of blood through the cement. A similar study by Lew et al., 2010, reported the use of HA cement (HAC, BoneSource Howmedica Leibinger, Inc., Dallas, TX, USA – similar to CaP cement) to support the dental implant in large extraction molar site.[64] The study concluded that HAC could be effective in the oral environment for small defects (<25 mm[2]), such as jumping gap filler for dental implants or extraction, site where conserving alveolar ridge height is important.

DIBC is a special cement developed by The University of Minnesota Bio-Engineering Lab, which is nonresorbable, biocompatible, fast setting, and can be loaded.[12] It reportedly stays inert in situ. DIBC can be used to stabilize implant that can withstand occlusal forces, and its advantages are that it does not require any additional bone removal or replacement. In addition, DIBC can be used to treat failing dental implants that show signs of infection from peri-implantitis along with advanced bone loss[12] [Figure 3].
Figure 3: Periapical radiographs of a maxillary left canine implant placed in a 62-year-old woman who developed peri-implantitis. (left to right) October 2005. October 2008. September 2009. November 2009. Overloading might have initiated bone loss around the initially healthy canine implant. As bone loss progressed and the pocket depth increased, bacterial infection (peri-implantitis) worsened along with suppuration. However, currently, the prognosis of the implant with canine is poor and the patient was informed of the future loss of the implant and adjacent maxillary left lateral incisor

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Secondary implant stability improved considerably after the use of DIBC. However, the mechanical properties plateaued at 1 week for bone–cement–implant interfaces with minimal changes over the successive 12 weeks, whereas the bone–implant interface improved progressively. Histologic examination and scanning electron microscope (SEM) showed that cement had established tight mechanical interlocking, hence making an adhesive failure between implant and cement and cement and bony trabeculae very difficult. In comparison to CPC, which is resorbable, DIBC is a nonresorbable material. This property of DIBC can be used to a benefit, by using it to rescue hopelessly mobile implants in posterior maxillae of elderly or medically compromised patien, however, long-term results need to be further investigated.

Last group of cements, which have been described in this review, are TSBCs such as Biodentine[82],[83] that have been used in restorative and endodontic procedures for the replacement of dentinal tissue[84] in clinical practice, which could be potentially used as bone substitutes for dental implants. The mechanical properties of Biodentine have been well established,[85],[86] along with its bioactive properties[87],[88],[82],[83] and biocompatibility.[89],[90] Biodentine requires only 9–12 min of manipulation, making its clinical use relatively easy.[86] Furthermore, TSBCs are suitable to be used as bone substitute materials because of their adhesive properties with calcified tissues of teeth.[91] These increase with time because of their chemical composition.[92] Apart from these properties, bone substitutes must also have fatigue behavior in order to reduce the mechanical stresses produced by dental implants. Vayron et al.[74] had described in an experimental setup, the use of Biodentine as a bone substitute material for implant stabilization. An ultrasonic device was used to supervise the changes of the ultrasonic response of a dental implant embedded in Biodentine and administered to mechanical fatigue, which was found to be effective. However, no supporting evidence has been found for the use of TSBCs for stabilizing implants.

Various parameters assessed to evaluate the outcome measures for the use of bone cements are BIC, MAR, ISQ, bone–cement–implant interface, the bond strength, the cortical bone response, fatigue stresses, which assessed the osseointegration and biomechanical effects of bone cements. Of these parameters, the ones which clearly help define the significance for the use of bone cements are increase in ISQ, better MAR, and good BIC similar to good bone–cement–implant interface. Of the above-mentioned parameters, the one which is of clinical significance is increase in ISQ value showing improvement in the stability of implants, whereas the others require histological and microscopic evaluation and are important from research point of view.

One of the major limitations of this study in terms of its generalizability is that all the studies included are in vitro studies, which represent a relatively poor quality of evidence as the behavior of human teeth inside a functioning oral cavity within a unique specialized periodontium is different from the behavior of teeth under standardized in vitro experimental conditions (Al Ansary et al., 2009).[93] Furthermore, the studies considered were animal trials or in vitro studies, which represent the low level of evidence.

Due to the lack of controlled trials in humans or in vivo studies, it is difficult to extrapolate these results in the clinical scenario. In addition, a considerable variation was seen among the studies in terms of outcome measures or variables considered, methodology in terms of assessment of properties, and also the type of cements used in various studies. Owing to this heterogeneity, meta-analyses could not be done.

The limitations of this review are that articles from nonindexed journals could not be included. Other online databases apart from PubMed such as Medline, Cochrane, and Google Scholar have not been searched. Articles which were not available online have not been included in this review, which could have yielded more relevant studies. Few significant articles could have been overlooked as hand search of bibliographies and references of the most recent articles and publications could not be done. The study would have yielded in more comprehensive search results and better data to compare if the time frame could have been extended from 1995 to 2015 along with more search terms with specific cements used in oral implantology, for example, CPC and oral implantology, acrylic bone cement, and oral implantology. The study would have gained weightage if multiple reviewers could be involved, thus catering to inter-examiner variability or agreement.


   Conclusion Top


Bone cements can be used to increase the primary and/or secondary stability of dental implants in oral cavity. However, out of the available bone cements, CaP-based CPC seems to be the most appropriate choice for clinical application because of its similar composition to bone. ABC is neither biodegradable nor osteoconductive. This severely limits its application in the field of oral implantology. On the other hand, CaP-based biomaterials such as CPC due to their high osteconductivity and self-hardening and suitable mechanical properties have the potential to be used as an alternative to regular bone substitutes/grafts. In addition, they can be used as scaffolds in tissue engineering for bone regeneration. Bone cements have the potential to completely replace autografts (no need for secondary surgical site) and also reduce the risk of eliciting an immune response and the potential risk of transmissible diseases as in allograft or xenograft.[58] However, despite extensive research in the field over the past years, these efforts have been considerably unfocused, limiting the clinical application of CaP-based biomaterials.[94] The clinical application of CPCs for dental and intraoral applications has been particularly sparse. To enable optimal clinical use of bone cements in implant dentistry, the material characteristics and requirements for a specific clinical use (e.g., grafting or coating) should be first evaluated and well understood. Development of “ready-to-use” CPCs and optimizing their drug delivery along with bioactive molecules is also equally important. Nonetheless, the use of CPC should be limited to appropriate/indicated clinical applications only.[96]

Considering the advances in the past years, CPC and its analogs certainly have the potential to replace the currently available autograft materials in implant dentistry.

Bone cements can be considered a viable option for bone grafting and regeneration of bone. Furthermore, bone cements may be relatively economical compared to allografts and xenografts, owing to complex manufacturing and sterilization protocols involved in their fabrication. A review of various bone cements and literature supports the use of bone cements to fix the implant with bone and load them relatively faster, thus reducing patient discomfort and treatment time. However, further prospective clinical trials involving human subjects is needed to establish its clinical effectiveness.

Recommendations

  • Recommendations for clinical research are as follows:


    1. Identifying the most suitable bone cement from commercially available bone cements with desirable biomechanical properties similar to alveolar bone
    2. In vitro testing of their mechanical and dissolution properties in oral environment
    3. Animal trials followed by clinical trials for the use of bone cements in stabilizing dental implants in large extraction site and direct sinus lift with immediate loading
    4. Long-term follow-up of bone cements including human participants
    5. Comparing regular grafting material with CPC bone cements in split-mouth design in direct sinus lift procedure


  • Recommendations for clinical use


    1. Use CPC to stabilize dental implant in immediate extraction case and load them immediately in the posterior molar area


Summary

Bone cements have the potential to provide mechanical stability to dental implants during the healing phase while the natural bone is formed around implants. This may be due to active or passive absorption, thus reducing the need for an additional surgery and healing time. Among the commercially available bone cements, CaP-based CPCs seem to be most suitable cements for clinical application in implant dentistry. Use of bone cements, if supported with suitable evidence, would reduce the risk of transmissible disease (in comparison to allograft and xenograft), improve patient comfort (avoid secondary surgery for autograft), reduce treatment cost, reduce treatment time, and might act as local drug delivery system. However, prospective controlled trials in human subjects need to be conducted in order to establish its clinical effectiveness. Research based on similar objective parameters will be needed for drawing definitive conclusions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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