Smoking cessation before implant placement

Discussion

The role of smoking in the development of MRONJ has been established as one of the risk factors (Bedogni et al. 2024; Ruggiero et al. 2022). In this review, the relationship between smoking and MRONJ was reported in a limited manner, with few studies directly mentioning the impact of smoking. Although specific data on smoking were scarce in the analyzed studies, the medical literature suggests that smoking can lead to complications in oral surgeries and can impair both bone and soft tissue healing, contributing to implant failure and peri‐implantitis, potentially increasing the risk of developing MRONJ (Bedogni et al. 2024; Landi et al. 2024; Ruggiero et al. 2022). Evaluating risk factors for dental implants, Chen et al. (2013) concluded that individuals who smoke are more likely to experience dental implant failure (Chen et al. 2013). On the other hand, Kim et al. (2020) reported that smoking was not a significant factor in their study (Kim et al. 2020). Aljohani et al. (2017), when evaluating the relationship between smoking and MRONJ, found that only 5.5% of the patients were smokers, which did not stand out as a relevant risk factor (Aljohani et al. 2017). Therefore, despite the limited discussion of smoking in the articles reviewed, smoking is considered an additional risk factor for patients undergoing antiresorptive therapy and dental implant procedures.

MRONJ Risk Related to Dental Implants in Osteoporosis Treated With Denosumab: A Systematic Review. © 2026 The Author(s). Oral Diseases published by John Wiley & Sons Ltd. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Discussion

Tobacco and smoking reduce leukocyte activity, which is responsible for low chemotactic migration rate, low motility levels, and low phagocytic activity. This causes a decrease in infection resistance and delays in wound healing [33]. In addition, smoking has been associated with lower calcium absorption. One possible mechanism by which cigarette smoking may affect osteointegration is decreased blood flow as a result of increased peripheral resistance and inhibition of platelet aggregation. Tobacco use directly affects osteoblast function and its toxic by-products delay wound healing. It also inhibits cell proliferation [34]. Literature data show that the survival rate of dental implants is lower in smokers [35]. In a systematic review-meta-analysis published by Strietzel et al. in 2007, it was concluded that the risk of biological complications is significantly increased among smokers, an important risk factor for dental implant treatment and accompanying augmentation procedures [36]. Our present study supports these findings. There is a significant difference in survival rates between the smoking population and the non-smoking population. While the survival rate is 87.7% in the smoking population (7 failed implants), a 98.5% success rate (1 failed implant) is observed in the non-smoker population. Of the total 8 failed implants, 7 were among the smokers, 4 of these 7 failed implants were in Group 3 patients, 2 were in Group 2 patients, and 1 were in Group 1 patients. Especially in groups where the surgical procedure is complex, smoking seriously affects survival rates. As an additional data, male patients were observed statistically significantly higher among the smoking population.

Retrospective analysis of dental implants immediately placed in extraction sockets with periapical pathology: immediate implant placement in infected areas. © The Author(s) 2023. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

The effect of implant characteristics (diameter / length), smoking and age on immediate implantation success

Of the 124 implants placed in 69 patients included in the study, 116 (95.55%) were successful, while 8 (4.45%) were unsuccessful. The mean diameter of the unsuccessful implants was lower than the successful ones, but no statistically significant relationship was observed (p = 0.0953). No statistically significant relationship was observed between the success of the implants and their height (p = 0.276). While the mean number of daily cigarette smoking was 16.88 ± 12,229 in unsuccessful immediate implants, this number was 7.07 ± 9.647 in successful patients. A statistically significant relationship was observed between success and the number of daily cigarettes (p = 0.007). No significant relationship was found between age and success (p = 0.345) (Table 2).

Retrospective analysis of dental implants immediately placed in extraction sockets with periapical pathology: immediate implant placement in infected areas. © The Author(s) 2023. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Secondary Endpoints

At the implant level, the LASSO‐regularized logistic regression model identified several variables as significantly associated with an increased risk of implant failure (Table 1). In both the total cohort and the IR subgroup, the most prominent predictors were implantation in the neomandible, smaller implant diameter (< 4.2 mm) and diabetes mellitus. These variables consistently demonstrated high and statistically significant coefficients, indicating a robust association with elevated failure risk. Furthermore, active smoking and implant placement in the maxilla were also significantly associated with a higher likelihood of failure (Figures 4 and 5). Other variables, including age > 65 years, gender, cardiovascular disease, thyroid dysfunction, alcohol consumption, and smoking history (former or never smokers), were not significantly associated with implant failure. Conversely, anticoagulant use and hypertensive disease exhibited statistically significant negative coefficients.

Dental Implants in Medically Compromised Patients Undergoing or After Receiving Anti‐Resorptive or Radiotherapy: Retrospective Clinical and Radiographic Data. © 2025 The Author(s). Clinical Oral Implants Research published by John Wiley & Sons Ltd. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Discussion

Risk factors for late implant failure can be categorized into 3 groups. Group 1 includes risk factors related to patient history. Group 2 includes the clinical parameters. Group 3 includes the technical factors [23]. The risk factors related to patients are the history of periodontitis, bruxism, radiotherapy, and early implant loss. Clinical risk factors are bone type 4 and posterior location. Smoking more than 10 cigarettes per day is the dominant risk for implant failure and in the presence of buccal dehiscence and/or infection, adds more risk [24]. Technical risk factors include low initial stability, > 1 implant placement during the surgery, and using the conus-type connection for implant-supported overdenture. In our study, ASA I and II patients were included for the immediate implant placement as both categories of patients bear similar risks for implant failure [25]. The systematic conditions that can affect the osseointegration of dental implants such as diabetes, cardiovascular disease, hypertension, and osteoporosis were excluded from our study [17]. Hence, the patient’s medical history had no bearing on the failure or success of the implant. Similarly, in this study, we choose fresh extraction sockets for the implant placement because the structure of sockets has slightly changed with age but it is not the same as the healed site that has a wide range of bone density variations.

Clinical outcomes of 3–5 years follow-up of immediate implant placement in posterior teeth: a prospective study. © The Author(s) 2024. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

2. Materials and Methods

Before enrolment, extraction sites were both clinically and radiologically evaluated by performing a 3D Cone Beam examination with a 4 × 4 cm FOV (Hyperion X9pro, Myray, Cefla, Imola, Italy). The reasons for extraction included crown and/or root fracture, endodontic treatment failure, and untreatable caries. Patients with acute periodontal or periapical infections were not included. The systemic exclusion criteria were the existence of metabolic bone disease, current pregnancy, history of radiotherapy or chemotherapy for malignancy in the past 5 years, history of autoimmune disease, and drug consumption that could interfere with implant therapy. Patients who smoked more than 10 cigarettes per day were also excluded, and those who smoked 10 or fewer cigarettes per day were requested to stop smoking for 2 weeks before and after surgery. A comprehensive periodontal examination and professional oral hygiene with scaling and root planing was performed on all patients when needed. Instructions for personal care were delivered to ensure a healthy periodontal environment.

Clinical and Radiological Evaluation of a Fully Tapered Implant Design Following Immediate Placement with Immediate Provisionalization in the Esthetic Area: A Prospective Case Series Study. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).