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ORALIMPLANTOLOGYEUROPEAN JOURNAL OFOfficial publication of the British Society of Oral Implantology (BSOI),the Italian Society of Oral Surgery and Implantology (SICOI),the Danish Society for Oral Implantology (DSOI),the German Association of Oral Implantology (DGI),the Spanish Society of Implantology (SEI),and the British Academy of Implant & Restorative Dentistry (BAIRD)Patient centered management andoptimal number of implants in thetreatment of edentulismA consensus conferenceUniversity of Mainz, Germany27th and 28th March 2014EJOIVOLUME 7 / SUPPLEMENT 2SUMMER 2014

S86 nEDITORIALEditorialThis supplemental issue of EJOI is dedicated to theFoundation for Oral Rehabilitation (FOR) consensus conference, ‘Patient centered managementand optimal number of implants in the treatmentof edentulism’, which was held on the 27th and28th March, 2014. Scientific associations and otherorganisations using EJOI as their official publication are welcome to publish the outcome of theirconsensus conferences or working groups in thejournal.It is the policy of EJOI that these publications willnot be peer reviewed as they are normally. Consequently, readers are encouraged to critically evaluatethe findings presented, as they would with all scientific publications. Guidance on how to develop critical skills for research, analysis and the evaluation ofscientific publications (an important mission of EJOI)can be found in the ‘educational articles’1-4 and onthe EQUATOR (Enhancing the QUAlity and Transparency Of health Research) website (http://www.equatornetwork.org/). The EQUATOR Network isaimed at helping authors properly report their healthresearch studies. After selecting the ‘Resource Centre’, please click on the ‘Library for health researchEur J Oral Implantol 2014;7(Suppl2):S86reporting’ and you will access a comprehensive list ofreporting guidelines, organised by study type. Morespecifically, to evaluate systematic reviews pleasego to the PRISMA transparency guidelines (http://www.prisma-statement.org/).The results of consensus conferences or working groups can be interpreted differently, dependingon people’s perspectives and circumstances. Pleaseconsider the conclusions presented carefully. Theyare the opinions of the review authors, and are notnecessarily shared by EJOI editors.We would like to thank all contributors to thepresent supplement for their efforts.Marco Esposito and Michele Nieri1. Worthington HV, Esposito M, Nieri M, Glenny AM. What isa systematic review? Eur J Oral Implantol 2008;1:235–238.2. Glenny AM, Nieri M, Worthington H, Espostio M. Theimportance of the study design: from the case report tothe randomised controlled clinical trial. Eur J Oral Implantol2008;1:317–321.3. Nieri M, Glenny AM, Worthington H, Esposito M. How tointerpret meta-analyses of randomised clinical trials. Eur JOral Implantol 2009;2:61–66.4. Glenny AM, Worthington HV, Esposito M, Nieri M. Whatare clinical guidelines? Eur J Oral Implantol 2009;2:145–148.

GUEST EDITORIALn S87Guest editorialOral rehabilitation of complete edentulism by meansof implants is, and has been for decades, a predictable treatment option. It provides an improved quality of life, clearly superior to what can be achieved bymucosally retained dentures. But when the questionis raised of how many implants one needs to properlydeal with the rehabilitation of edentulous patients,opinions are sometimes country-specific, while science should be borderless.The Foundation for Oral Rehabilitation (F O R)took up the challenge. Being a global network ofexperts and clinicians it always refers to scientificallysound and well-proven data, which are universallyaccepted. A number of reputed researchers and clinicians were selected to tackle the question of thenumber of implants needed, in a thoroughly scientific manner. Their selection was based on expertise, number of publications and their citation indexrelated to this theme. Each one received a specificsubject to critically review in the literature, and ifdata were sufficiently available to provide a metaanalysis. After exchanging their manuscripts, theexperts met during 2 days at the University of Mainz.Travel and hotel expenses were taken care of byF O R, but no other compensation was provided.For any elective surgery, the patient should beinvolved in opting among the wide range of treatment alternatives. All participants chose the patientcentred viewpoint as a starting point. For a removable overdenture, one can choose whether to haveit on 2 or 4 implants in the mandible and 4 or moreimplants in the maxilla. Fixed prostheses are generally placed on 5 or 6 implants and sometimes evenmore in the maxilla.When only a limited jawbone volume remains,it can be necessary to consider bone augmentationprocedures to (optimally) place a sufficient numberof implants to support a fixed dental prosthesis witha long-term predictable outcome. The key questionis whether a more limited number of implants, thanthe classical 5 to 6 and more, suffice. A more limitednumber of implants could avoid the invasiveness ofbone augmentation/grafting procedures. A reviewof the literature (Nkenke and Neukam) underlinedthat, as an intraoral donor site for autologous bonegrafting, the mandibular ascending ramus is preferable. The symphyseal area leads to the highest(incidence of) morbidities. The posterior iliac crestis a good alternative but implies mostly general anaesthesia.Another meta-analysis (Al-Nawas and Schiegnitz) proved that the survival rate of oral implantsplaced in conjunction with augmentation proceduresis as good with bone substitute material as with autologous bone grafts. Nevertheless, the bone augmentation procedure by itself is more invasive andmore prone to postoperative pain and discomfortthan the straightforward (flapless) placement ofimplants. Thus, if the treatment is patient-centred,avoiding bone augmentation should be considered.Patient satisfaction with graftless solutions is indeedvery high and patients’ preference to minimally invasive implant surgery well established (Pommer andWatzek).The key question then becomes what should bethe minimal/optimal number of implants to insure areliable long-term outcome for the (fixed) prostheticrehabilitation. Two decades ago (Brånemark et al1),it was shown in a large-scale retrospective study thatthe 10-year survival in edentulous patients of fixeddental prostheses on either 4 or on 6 implants wasnot significantly different. The tradition to insert atleast 5 to 6 implants in edentulous jaws thus becamequestionable. Since very high survival rates are presEur J Oral Implantol 2014;7(Suppl2):S87–S88Wilfried Wagner,Prof Dr DrUniversity Medical Centerof the Johannes GutenbergUniversity Mainz, Mainz,GermanyDaniel vanSteenberghe,MD, PhD, Drhc,HFRCS (Irl)em. Professor, Facultyof Medicine, CatholicUniversity Leuven, Belgium

S88 nGUEST EDITORIALThe group of experts from left to right: Drs Gerry Raghoebar, Bernhard Pommer, Claudia Dellavia, John Brunski, WilfriedWagner, Daniel van Steenberghe, Emeka Nkenke, Massimo Del Fabbro, Bilal Al-Nawas, Regina Mericske-Stern, Georg Watzek.ently reached by implants with moderately roughsurfaces, the concept of inserting supplementaryimplants just to avoid a revision surgery should oneimplant fail became more or less obsolete.Furthermore, biomechanical calculations provethat with 4 implants to support a complete crossarch fixed reconstruction, strains in the bone or atthe bone-implant interface remain within the saferange (Brunski). Tilted implants, to insure a properanterior-posterior spread, can even be subject tolower forces than axial ones (Del Fabbro and Ceresoli). Furthermore, the marginal bone level aroundtilted implants does not significantly differ from thataround axial implants. The latter offers the possibility to achieve a good anterior-posterior spread withfew implants.Functional aspects of implant-supported rehabilitations have been investigated by different methodologies. The number of implants supporting theprostheses does not appear as a relevant factor inthe functional qualities (Dellavia et al).When segmentation of the fixed cross-archframework is necessary, more than 4 implants areneeded (Mericske-Stern and Worni), which raisesthe treatment cost and can render a bone augmentation procedure indispensable. One may wonder whyCAD-CAM technologies, which do reach the necessary precision of fit, are not used in these instancesto keep the treatment less invasive.We both feel privileged to coordinate this firstF O R consensus conference. The multidisciplinaryinteractions favoured cross-fertilisation but nevertheless led to an iteratively written consensus document, which was unanimously approved.The conclusions of this workshop should lead clinicians to also consider, for the benefit of their edentulous patients, less invasive procedures. Establishedscientific data, which should always prevail on traditions, do indeed prove that for complete edentulism,unless specific aesthetic and/or functional demandsare pressing, 4 implants only can already provide apredictable anchorage for fixed prostheses.Wilfried Wagnerwilfried.wagner@unimedizin-mainz.deDaniel van rs of the Consensus meeting1. Brånemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad modumBrånemark in full edentulism. Clin Oral Implants Ress1995;6:227–231.Eur J Oral Implantol 2014;7(Suppl2):S87–S88

CONTENTSn S89European Journal of Oral ImplantologySupplement 2, Summer 2014ContentsEDITORIALMarco EspositoS86Guest editorialWilfried Wagner, Daniel van SteenbergheS87review articlePatients’ preferences towards minimally invasive treatment alternativesfor implant rehabilitation of edentulous jawsBernhard Pommer, Georg Mailath-Pokorny, Robert Haas, Dieter Busenlechner,Rudolf Fürhauser, Georg Watzekclinical articleBiomechanical aspects of the optimal number of implants to carry a cross-archfull restorationJohn B. BrunskiS91S111review articleSOptimal number of oral implants for fixed reconstructions: A review of the literature S133Regina Mericske-Stern, Andreas WorniFunctional jaw muscle assessment in patients with a full fixed prosthesis ona limited number of implants: A review of the literatureClaudia Dellavia, Riccardo Rosati, Massimo Del Fabbro, Gaia PellegriniS155clinical articleThe fate of marginal bone around axial vs. tilted implants: A systematic reviewMassimo Del Fabbro, Valentina CeresoliS171review articleA systematic review of implant-supported overdentures in the edentulous maxilla,compared to the mandible: How many implants?S191Gerry M. Raghoebar, Henny J.A. Meijer, Wim Slot, James J.R. Huddleston Slater,Arjan Vissinkclinical articleAutogenous bone harvesting and grafting in advanced jaw resorption:Morbidity, resorption and implant survivalEmeka Nkenke, Friedrich W. Neukamreview articleAugmentation procedures using bone substitute materials or autogenous bone –a systematic review and meta-analysisBilal Al-Nawas, Eik Schiegnitzconsensus statementsPatient-centred rehabilitation of edentulism with an optimal number of implantsS203S219S235Eur J Oral Implantol 2014;7(Suppl2):S89