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Systematic Review
Dental Implants
V. Moraschini E. dS. Porto Barboza: Success of dental implants in smokers and nonsmokers: a systematic review and meta-analysis. Int. J. Oral Maxillofac. Surg. 2015;
xxx: xxxxxx. # 2015 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.
Abstract. The purpose of this review was to test the null hypothesis of no difference in
marginal bone loss and implant failure rates between smokers and non-smokers
with respect to the follow-up period. An extensive electronic search was performed
in PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials
to identify relevant articles published up to February 2015. The eligibility criteria
included randomized and non-randomized clinical studies. After an exhaustive
selection process, 15 articles were included. The meta-analysis was expressed in
terms of the odds ratio (OR) or standardized mean difference (SMD) with a
confidence interval (CI) of 95%. There was a statistically significant difference in
marginal bone loss favouring the non-smoking group (SMD 0.49, 95% CI 0.07
0.90; P = 0.02). An independent analysis revealed an increase in marginal bone loss
in the maxilla of smokers, compared to the mandible (SMD 0.40, 95% CI 0.240.55;
P < 0.00001). A statistically significant difference in implant failure in favour of
the non-smoking group was also observed (OR 1.96, 95% CI 1.682.30;
P < 0.00001). However, the subgroup analysis for follow-up time revealed no
significant increase in implant failure proportional to the increase in follow-up time
(P = 0.26).
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
neutrophils, and decreasing immunoglobulin production and functioning of lymphocytes.9,10 There is still no consensus on
the number of cigarettes smoked and the
relationship with implant failure, however
heavy smokers may exhibit a higher incidence.6
Some longitudinal studies have reported
a higher rate of implant failure in smoking
patients.1115 However, these failures are
subject to many factors, such as a history
of periodontitis, hormonal or metabolic
diseases that affect bone turnover, diseases that favour infection, characteristics
of the implant used (shape and surface
treatment), and prosthetic factors, such
as the loading protocol and type of occlusion. It is rather difficult to interpret the
data and reduce the bias, as all of these
factors interact with each other.
The goal of this meta-analysis was to
compare marginal bone loss and the failure of implants during different follow-up
periods between smokers and non-smokers.
Objective
Search strategy
Quality assessment
Selection criteria
This review sought prospective and retrospective cohort studies, as well as randomized controlled trials (RCTs) that
compared the marginal bone loss and implant failure rates between smokers and
non-smokers. For this review, implant
failure was regarded as the absolute loss
of the implant. The exclusion criteria included animal studies, in vitro studies, and
case series, case reports, and reviews. In
addition, studies conducted on volunteers
with unbalanced metabolic diseases, or
with periodontal disease without prior
treatment, were excluded.
Screening process
Data extraction
No restriction
MEDLINE/PubMed, Web of Science, and Cochrane Central Register of Controlled Trials
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
Medline/PubMed
Records identified through
database searching
(n = 965)
Cochrane (CENTRAL)
Records identified through
database searching
(n = 85)
Included
Web of Science
Records identified through
database searching
(n = 240)
Records excluded
(n = 1261)
Full-text articles assessed for
eligibility (n = 29)
Eligibility
Screening
Identification
Fig. 1. Flow diagram (PRISMA format) of the screening and selection process.
Study characteristics
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
No. of
subjects
No. per
group
Retrospective
72
540
NR
Retrospective
Up to 108
Age range
Mean age
Gender
Implant brand
Surface
Implant
size (mm)
(diameter
length)
Smoking definition
No. of implants
1385
55.1
229 M/311 F
2194
Branemark
Machined
NR 7,
10, 13,
15, 18, 20
421
107 (G1)/
314 (G2)
1688
53.1
171 M/250 F
1366
Branemark, Friatec
Machined, rough
NR NR
Retrospective
41.6
60
16 (G1)/
44 (G2)
4184
64.6
27 M/33 F
228
NR
NR
NR NR
Prospective
36
>800
NR
3089
NR
NR
2887
NR
NR
NR NR
Prospective
18
461
72 (G1)/
389 (G2)
NR
NR
NR
Smoker consisted of
patients who smoked half
a pack or more cigarettes a
day
1183
Straumann
Rough
NR NR
Schwartz-Arad et al.
(2002)12
Prospective
36
261
89 (G1)/
172 (G2)
1867
48
NR
Non-smokers; mild
smokers (up to 10
cigarettes/day); heavy
smokers (>10 cigarettes/
day)
959
NR
NR
NR NR
Prospective
9.486.6
(mean 45.5)
161
59 (G1)/
102 (G2)
2389
57
NR
Non-smokers; mild
smokers (up to 10
cigarettes/day); heavy
smokers (>10 cigarettes/
day)
646
NR
NR
NR NR
Prospective
Up to 240
200
54 (G1)/
146 (G2)
1577
52.1
NR
1539
Branemark
Machined
NR NR
Sanchez-Perez et al.
(2007)22
Retrospective
60
66
40 (G1)/
26 (G2)
1571
43.4
NR
Non-smokers; light
smokers (<10 cigarettes/
day); moderate smokers
(1020 cigarettes/day);
heavy smokers (>20
cigarettes/day)
165
Biotech
Rough
NR NR
Authors (year)
Study design
Follow-up
time in
months
(mean or
range)
YIJOM-3245; No of Pages 11
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
Authors (year)
Study design
Follow-up
time in
months
(mean or
range)
No. of
subjects
No. per
group
Age range
Mean age
Gender
Smoking definition
No. of implants
Implant
size (mm)
(diameter
length)
Implant brand
Surface
Retrospective
130
1498
199 (G1)/
1299 (G2)
1492
49.7
637 M/861 F
4607
Branemark, Nobel
Biocare
Machined, rough
3.3, 3.75, 4,
5 7, 8.5, 10,
11.5, 13, 15,
18, 20
Retrospective
8
650
76 (G1)/
574 (G2)
1384
42.7
NR
1628
NR
NR
Retrospective
60
1727
549 (G1)/
1178 (G2)
1785
49.2
702 M/1025 F
5843
NR NR
Vandeweghe and De
Bruyn (2011)26
Retrospective
60
329
41 (G1)/
288 (G2)
1884
54
141 M/188 F
712
Southern Implants
Rough
Retrospective
24
300
65 (G1)/
235 (G2)
1782
56
114 M/186 F
1093
NR
NR
3.5, 4, 4.5, 5 8,
9, 11, 13, 15, 17
Retrospective
60
80
40 (G1)/
40 (G2)
NR
57.6
38 M/42 F
80
Branemark; Nobel
Biocare
Rough
NR
Healing period
for loading
(months)
Antibiotics/mouth
rinse (days)
Implant survival
rate (%)
Failed/placed
implants
Drop-outs
6 (maxilla)
3 (mandible)
NR
NR
88.7 (G1)
95.2 (G2)
44/390 (G1)
86/1804 (G2)
<0.001
NR
3 to 7
NR
NR
NR/366 (G1)
NR/1000 (G2)
NR
NR
NR
NR
NR
65.3 (G1)
82.7 (G2)
12/70 (G1)
11/158 (G2)
0.027
NR
NR
NR
91.1 (G1)
94 (G2)
85/959 (G1)
115/1928 (G2)
NR
NR
1 to 3
NR
NR
97 (G1)
98.3 (G2)
8/269 (G1)
15/914 (G2)
<0.05
NR
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
Table 2 (Continued )
Antibiotics/mouth
rinse (days)
Implant survival
rate (%)
Failed/placed
implants
Drop-outs
NR
7/NR
NR
96 (G1)
98 (G2)
15/380 (G1)
12/579 (G2)
<0.05
NR
NR
NR
NR
NR
NR/271 (G1)
NR/375 (G2)
NR
NR
6 (maxilla)
3 (mandible)
NR
NR
NR
NR/494 (G1)
NR/1045 (G2)
NR
NR
NR
NR
84.2 (G1)
98.6 (G2)
15/95 (G1)
1/70 (G2)
<0.001
NR
NR
NR
NR
91.2 (G1)
95.2 (G2)
NR
NR
23
NR
NR
NR
96.6 (G1)
97.1 (G2)
7/197 (G1)
43/1431 (G2)
0.5994
NR
0 to 9
5/14
NR
94.5 (G1)
97.1 (G2)
107/1961 (G1)
112/3882 (G2)
0.003
250
NR
NR
95.2 (G1)
98.8 (G2)
5/104 (G1)
7/608 (G2)
0.007
NR
NR
NR
96.7 (G1)
98.7 (G2)
8/244 (G1)
11/849 (G2)
0.025
3 to 4
NR
89.6 (G1)
96.9 (G2)
4/40 (G1)
1/40 (2)
<0.05
12
M, male; F, female; NR, not reported; SD, standard deviation; G1, smokers; G2, non-smokers.
Healing period
for loading
(months)
YIJOM-3245; No of Pages 11
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
Table 2 (Continued )
YIJOM-3245; No of Pages 11
A study can be awarded a maximum of one star for each item within the selection and outcome categories. A maximum of two stars can be given for comparability.
Two years of follow-up was chosen to be sufficient for the outcome survival to occur.
7/9
7/9
0
0
*
*
0
0
*
*
*
*
**
**
*
*
*
*
Total 9/9
0
0
*
0
0
0
0
0
0
*
0
*
0
*
*
*
*
0
*
*
*
*
*
0
*
*
*0
*0
*0
*0
*0
*0
*0
*0
**
*0
*0
*0
**
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
0
0
0
*
0
0
0
0
*
0
0
*
0
Ascertainment
of exposure
Representativeness
of the exposed
cohort
Selection of
external
control
Outcome of
interest not
present at start
*
*
*
*
*
*
*
*
*
*
*
*
*
Adequacy of
follow-up
of cohorts
Was follow-up
long enough
for outcomes
to occur?b
Assessment
of outcome
Outcome
Comparability
Comparability
of cohorts on
the basis of the
design or analysisa
Selection
Authors (year)
6/9
6/9
7/9
7/9
5/9
6/9
6/9
6/9
8/9
7/9
5/9
8/9
7/9
Publication bias
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
Fig. 3. Forest plot for the event marginal bone loss between the maxilla and mandible in smokers.
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
Fig. 5. Funnel plot for the studies reporting the outcome event implant failure rate.
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
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30.
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32.
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996
YIJOM-3245; No of Pages 11
33.
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35.
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41. Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines
for reporting parallel group randomised
trials. BMC Med 2010;8:18.
Address:
Vittorio Moraschini Filho
Department of Periodontology
School of Dentistry
Fluminense Federal University
Rua Mario dos Santos Braga
30
Centro
Niteroi
Rio de Janeiro
Cep. 24020-140
Brazil
E-mail: vittoriomf@terra.com.br
Please cite this article in press as: Moraschini V, Barboza ESP. Success of dental implants in smokers and non-smokers: a systematic
review and meta-analysis, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.08.996