Chapter 87 Results of Implant Treatment










C H A P T E R 8 7
Results of Implant
Treatment
Perry R. Klokkevold
CHAPTER OUTLINE
Defining Implant Outcomes
Factors That Influence Implant Outcomes
Aesthetic Results and Patient Satisfaction
Conclusions
The landmark Göteborg study and the replica study at the
University of Toronto supported expectations for the success and
predictability of root-form dental implants. The study, conducted
over a 15-year period at the University of Göteborg, Sweden, by P.I.
Bränemark and coworkers, began in 1965 and concluded in 1980.
The results, which were reported in several articles, defined the
concept of osseointegration, described protocols for success, and
shared clinical experiences.
The most significant article from the study, published in 1981,
was on osseointegrated implants in the treatment of the edentulous
4618

jaw.
2
The Göteborg study included 2768 root-form implants placed
into 410 edentulous jaws in 371 consecutive patients. The data were
most often reported in subsets according to the three study phases
(i.e., initial, developmental, and routine). Cases treated in the
routine period with standardized procedures and an observation
time of 5 to 9 years were thought to reflect the potential of the
method and were the basis of data reported in that historic
publication. The subset consisted of 895 implants placed in 130
jaws. The implant survival rate was 81% in the maxilla and 91% in
mandible. The prosthesis survival (i.e., continuous stability) rate
was 89% in the maxilla and 100% in the mandible.
The replica study, which was conducted at the University of
Toronto, demonstrated that comparable results could be
predictably achieved using the same implant design and treatment
protocols.
5,7880
Together, these studies demonstrated that implant
survival of 81% or more and prosthesis survival of 89% or more
could be expected in the edentulous patient.
In the decades since the landmark discovery of osseointegration
and the documentation of its clinical effectiveness, clinicians have
had tremendous success in replacing missing teeth with endosseous
root-form dental implants in both partially edentulous and
edentulous patients.
1,48
Despite the high level of success and long-
term predictability, a 100% success rate cannot be achieved.
Complications and implant failures do occur.
2,12
Some implants fail
to achieve osseointegration; some achieve osseointegration but lose
bone progressively over time, leading to failure; and other implants
rapidly lose bone and fail in a short time. Some implants achieve
and maintain osseointegration but fail because they do not meet the
aesthetic expectations of the patient or clinician.
The reporting of implant success varies widely in the literature,
which makes defining an absolute implant success rate impractical.
This chapter considers implant treatment results in light of the
factors that influence implant survival and success. The intent is to
outline important aspects that need to be considered in evaluating
implant outcomes and offer guidelines for understanding published
results.
4619

Defining Implant Outcomes
Implant outcomes are reported in a variety of ways in the literature.
Various levels of implant success and failure are described in case
reports, case series, retrospective studies, controlled studies, and
prospective studies. The type of study and method of reporting are
decided by the authors and often influenced by the data collected
and the study objectives. Each type of study or report has
recognized limitations, but because of tremendous variation that
exists in the ways individual investigators measure, interpret, and
report implant outcomes, differences in the results from one study
to another may not be obvious.
Some implant outcomes are reported as the presence or absence
of the implant at the time of the last examination, regardless of
whether the implant was functional, suffered from bone loss, or had
other problems. This type of assessment is a measure of implant
survival and should not be confused with implant success. In
contrast to such an overly simplified assessment, some investigators
report implant outcomes using specific criteria to determine
implant success.
Implant success is defined by specific criteria used to evaluate the
condition and function of the implant. Criteria for implant success
have been proposed in the literature but have not been used
consistently. The problem is that a universally accepted definition
of implant success has not been established. In the classic definition,
Albrektsson and colleagues
3
defined success as an implant with no
pain, no mobility, no radiolucent peri-implant areas, and less than
0.2 mm of bone loss annually after the first year of loading.
3
Bone
loss in the first year was recognized, but it was not defined or
quantified as part of the success criteria until later in a separate
definition by Roos and associates.
61
The challenge in comparing reported data between studies is that
investigators use different criteria for success in their work. As a
result, it is difficult or impossible to make comparisons between
studies, and drawing conclusions about implant success or failure
from data reported in different studies is tenuous.
Success rates are dramatically affected by variations in the criteria
used to define them. In strict terms, if implant success is considered
4620

to be an outcome without adverse effects or problems, the
treatment would be performed as planned, implants would remain
stable and functioning without problems, peri-implant tissues
would be stable and healthy, and the patient and treating clinician
would be pleased with the outcome (Fig. 87.1). Use of strict criteria
would produce implant success rates lower than those determined
using less stringent criteria.
FIG. 87.1 Clinical implant success was demonstrated
when a single implant was placed in the mandible to
replace the lower second premolar (as planned). The
implant osseointegrated, and function was successfully
restored. The patient and clinicians were pleased with
the outcome. (A) Photograph of the dentition in
occlusion (from the left side). (B) Close-up photograph
of the dentition in occlusion. The mandibular second
premolar is an implant-supported crown. (C) Occlusal
view of an implant-supported crown in the second
premolar position. Replacement of the mandibular
second premolar with an implant is a conservative
treatment, obviating the need to prepare adjacent
4621

teeth. (D) Periapical radiograph of the posterior
mandibular teeth and implant in the second premolar
position. Bone support is good, and bone loss is
minimal and consistent with expectations for this
implant design.
Table 87.1 illustrates the powerful effect that small changes in
success criteria have on reported success rates. The data
demonstrate that changing the criteria of success to include a
probing pocket depth (PPD) of 5 mm or less to 6 mm or less
changed the implant success rates from 52.4% to 62% and from
79.1% to 81.3% for patients with and without a history of
periodontitis, respectively.
42
This also shows that implant survival
is quite different from implant success.
TABLE 87.1
Effect of Slight Modifications of Implant Success Criteria on
Successful Outcomes
a
Group
PPD ≤5 mm, No
BOP, BL <0.2
mm/yr (%)
PPD ≤6 mm, No
BOP, BL <0.2
mm/yr (%)
PPD ≤5
mm, No
BOP (%)
PPD ≤6
mm, No
BOP (%)
Implant
Survival
(%)
Group
A
52.4 62 71.4 81 90.5
Group
B
79.1 81.3 94.5 96.7 96.5
a
The initial success criteria at 10 years were set as a PPD ≤5 mm, no BOP, and BL
<0.2 mm annually. The implant success rates for group A (i.e., patients with a history
of periodontitis) and group B (i.e., patients with periodontal health) using these initial
criteria are listed in the first column. Notice how dramatically the success rates
change when the criteria used to define success are modified to include PPD ≤6 mm
(i.e., second column). The next two columns show the success rates for each group
using PPD ≤5 mm and ≤6 mm when the criteria are modified to omit bone loss as a
determinant. The last column shows the implant survival rate for each group, which
demonstrates that the survival rate is different than the success rate.
PPD, Probing pocket depth; BOP, bleeding on probing; BL, bone loss.
Data from Karoussis IK, Salvi GE, Heitz-Mayfield LJ, et al: Long-term implant
prognosis in patients with and without a history of chronic periodontitis: a 10-year
prospective cohort study of the ITI Dental Implant System. Clin Oral Implant Res
14:329–339, 2003.
4622

Key Fact
Implant success is defined by specific criteria used to evaluate the
condition and function of the implant. Criteria for implant success
have been proposed in the literature but not used consistently.
Depending on the criteria used, the rates of implant success
reported in studies can vary substantially.
Implant survival is defined as an implant that remains in place at
the time of evaluation, regardless of untoward signs and symptoms
or a history of problems. Extant implants that are healthy and
functioning under an implant-retained restoration are different
from those that are suffering from peri-implant bone loss or those
that are not connected to a restoration and not functioning (Fig.
87.2), but these operational differences do not affect calculations of
implant survival. Implants that are osseointegrated but not
functional are referred to as sleepers and should not be considered
successful merely because they are present and osseointegrated.
FIG. 87.2 Panoramic radiograph shows an implant
placed in the position of a missing maxillary right
central incisor. The implant appears to be placed in a
nonrestorable position. It is osseointegrated and could
technically be counted as a surviving implant, but it
must be considered a failure because it does not meet
the intended goal and function has not been restored.
4623

Implant survival and implant success are different outcome
measures. Consider the dramatic difference between survival and
success rates for implants reported in a systematic review (21
studies included) of implants supporting fixed partial dentures.
59
The 5-year implant survival rate was 95.4%, whereas the overall 5-
year success rate (individual implant success rates were not
calculated), defined as free of complications, was only 61.3%.
59
In a 10-year retrospective study of 397 fixed implant
reconstructions in 300 patients, the observed mechanical
complication rate was 24.7%.
77
The most frequent complication was
ceramic chipping (20.31%), followed by occlusal screw loosening
(2.57%) and loss of retention (2.06%).
77
Although relatively
uncommon, occlusal screw loosening can result in a subgingival
gap at the implant–abutment junction that retains plaque and
stimulates an inflammatory reaction in the soft and hard tissues,
leading to bone loss around the implant. Although surviving, these
implants would fail to meet optimal success criteria.
Defining implant results in absolute terms is difficult and
confusing. Implant survival, which typically is reported in studies,
can overestimate good implant outcomes. Implant success, which is
less often reported, could offer a better measure if specific success
criteria were universally defined, accepted, and used. Implant
success is difficult or impossible to compare across studies because
of differences in evaluation criteria used by investigators. Implant
success in a single study or series of studies using the same success
criteria is meaningful only in the context of that study or series.
Currently, the usefulness of implant success rates from different
studies is limited. Implant survival is important but is only an
indicator of surviving implants and does not reveal whether they
are functioning or had problems associated with them over time.
The incidence of peri-implant problems is more significant than
once thought. A systematic review of the literature evaluating the
prevalence of peri-implant disease reported that peri-implant
mucositis and peri-implantitis occurred in 19% to 65% and 1% to
47% of cases, respectively.
22
Factors That Influence Implant
4624

Outcomes
Many issues influence implant outcomes, including available bone,
implant design, placement and loading protocols, and host-related
factors.
Anatomic Location
Osseointegration depends on the availability of an adequate
quantity and quality of bone at the implant site. Areas with
abundant bone volume in the desired location are better than those
with deficient bone volume. Areas with good bone density provide
more predictable outcomes than those with poor bone density.
The bone classification system described by Lekholm and Zarb
49
defines bone with different levels of support for implants and the
likely impact on survival and success. The quality of bone support
is greatly influenced by the anatomic location, and implant
outcomes are sometimes categorized according to location. Extreme
examples are the anterior mandible and the posterior maxilla. The
anterior mandible typically consists of dense cortical bone, which
offers great support and high bone-to-implant contact, whereas the
posterior maxilla is often limited in volume because of alveolar
resorption and sinus pneumatization and typically consists of a
loose, trabecular structure and a thin cortical bone shell.
Implants placed in the posterior maxilla are less well supported
compared with implants placed in the anterior mandible. Jaffin and
Berman
36
demonstrated the significance of bone quality on implant
survival in a report of 1054 Bränemark implants. Ninety percent of
the implants were placed in type I, II, or III bone, with a failure rate
of only 3%. Of the 10% that were placed in type IV bone, 35%
failed.
36
Excluding those placed in the mandible, 23 (44%) of 52
implants placed in type IV bone in the maxilla failed, for a dismal
survival rate of 56%. The study authors concluded that bone quality
was the single greatest determinant of implant loss.
Anatomic location has a significant effect on implant outcome,
particularly for the posterior maxilla. The implants used in the
study by Jaffin and Berman
36
had machined surfaces, and current
implants with altered microtopography are thought to perform
4625

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C H A P T E R 8 7Results of ImplantTreatmentPerry R. KlokkevoldCHAPTER OUTLINEDefining Implant OutcomesFactors That Influence Implant OutcomesAesthetic Results and Patient SatisfactionConclusionsThe landmark Göteborg study and the replica study at theUniversity of Toronto supported expectations for the success andpredictability of root-form dental implants. The study, conductedover a 15-year period at the University of Göteborg, Sweden, by P.I.Bränemark and coworkers, began in 1965 and concluded in 1980.The results, which were reported in several articles, defined theconcept of osseointegration, described protocols for success, andshared clinical experiences.The most significant article from the study, published in 1981,was on osseointegrated implants in the treatment of the edentulous4618 jaw.2 The Göteborg study included 2768 root-form implants placedinto 410 edentulous jaws in 371 consecutive patients. The data weremost often reported in subsets according to the three study phases(i.e., initial, developmental, and routine). Cases treated in theroutine period with standardized procedures and an observationtime of 5 to 9 years were thought to reflect the potential of themethod and were the basis of data reported in that historicpublication. The subset consisted of 895 implants placed in 130jaws. The implant survival rate was 81% in the maxilla and 91% inmandible. The prosthesis survival (i.e., continuous stability) ratewas 89% in the maxilla and 100% in the mandible.The replica study, which was conducted at the University ofToronto, demonstrated that comparable results could bepredictably achieved using the same implant design and treatmentprotocols.5,78–80 Together, these studies demonstrated that implantsurvival of 81% or more and prosthesis survival of 89% or morecould be expected in the edentulous patient.In the decades since the landmark discovery of osseointegrationand the documentation of its clinical effectiveness, clinicians havehad tremendous success in replacing missing teeth with endosseousroot-form dental implants in both partially edentulous andedentulous patients.1,48 Despite the high level of success and long-term predictability, a 100% success rate cannot be achieved.Complications and implant failures do occur.2,12 Some implants failto achieve osseointegration; some achieve osseointegration but losebone progressively over time, leading to failure; and other implantsrapidly lose bone and fail in a short time. Some implants achieveand maintain osseointegration but fail because they do not meet theaesthetic expectations of the patient or clinician.The reporting of implant success varies widely in the literature,which makes defining an absolute implant success rate impractical.This chapter considers implant treatment results in light of thefactors that influence implant survival and success. The intent is tooutline important aspects that need to be considered in evaluatingimplant outcomes and offer guidelines for understanding publishedresults.4619 Defining Implant OutcomesImplant outcomes are reported in a variety of ways in the literature.Various levels of implant success and failure are described in casereports, case series, retrospective studies, controlled studies, andprospective studies. The type of study and method of reporting aredecided by the authors and often influenced by the data collectedand the study objectives. Each type of study or report hasrecognized limitations, but because of tremendous variation thatexists in the ways individual investigators measure, interpret, andreport implant outcomes, differences in the results from one studyto another may not be obvious.Some implant outcomes are reported as the presence or absenceof the implant at the time of the last examination, regardless ofwhether the implant was functional, suffered from bone loss, or hadother problems. This type of assessment is a measure of implantsurvival and should not be confused with implant success. Incontrast to such an overly simplified assessment, some investigatorsreport implant outcomes using specific criteria to determineimplant success.Implant success is defined by specific criteria used to evaluate thecondition and function of the implant. Criteria for implant successhave been proposed in the literature but have not been usedconsistently. The problem is that a universally accepted definitionof implant success has not been established. In the classic definition,Albrektsson and colleagues3 defined success as an implant with nopain, no mobility, no radiolucent peri-implant areas, and less than0.2 mm of bone loss annually after the first year of loading.3 Boneloss in the first year was recognized, but it was not defined orquantified as part of the success criteria until later in a separatedefinition by Roos and associates.61The challenge in comparing reported data between studies is thatinvestigators use different criteria for success in their work. As aresult, it is difficult or impossible to make comparisons betweenstudies, and drawing conclusions about implant success or failurefrom data reported in different studies is tenuous.Success rates are dramatically affected by variations in the criteriaused to define them. In strict terms, if implant success is considered4620 to be an outcome without adverse effects or problems, thetreatment would be performed as planned, implants would remainstable and functioning without problems, peri-implant tissueswould be stable and healthy, and the patient and treating clinicianwould be pleased with the outcome (Fig. 87.1). Use of strict criteriawould produce implant success rates lower than those determinedusing less stringent criteria.FIG. 87.1 Clinical implant success was demonstratedwhen a single implant was placed in the mandible toreplace the lower second premolar (as planned). Theimplant osseointegrated, and function was successfullyrestored. The patient and clinicians were pleased withthe outcome. (A) Photograph of the dentition inocclusion (from the left side). (B) Close-up photographof the dentition in occlusion. The mandibular secondpremolar is an implant-supported crown. (C) Occlusalview of an implant-supported crown in the secondpremolar position. Replacement of the mandibularsecond premolar with an implant is a conservativetreatment, obviating the need to prepare adjacent4621 teeth. (D) Periapical radiograph of the posteriormandibular teeth and implant in the second premolarposition. Bone support is good, and bone loss isminimal and consistent with expectations for thisimplant design.Table 87.1 illustrates the powerful effect that small changes insuccess criteria have on reported success rates. The datademonstrate that changing the criteria of success to include aprobing pocket depth (PPD) of 5 mm or less to 6 mm or lesschanged the implant success rates from 52.4% to 62% and from79.1% to 81.3% for patients with and without a history ofperiodontitis, respectively.42 This also shows that implant survivalis quite different from implant success.TABLE 87.1Effect of Slight Modifications of Implant Success Criteria onSuccessful OutcomesaGroupPPD ≤5 mm, NoBOP, BL <0.2mm/yr (%)PPD ≤6 mm, NoBOP, BL <0.2mm/yr (%)PPD ≤5mm, NoBOP (%)PPD ≤6mm, NoBOP (%)ImplantSurvival(%)GroupA52.4 62 71.4 81 90.5GroupB79.1 81.3 94.5 96.7 96.5aThe initial success criteria at 10 years were set as a PPD ≤5 mm, no BOP, and BL<0.2 mm annually. The implant success rates for group A (i.e., patients with a historyof periodontitis) and group B (i.e., patients with periodontal health) using these initialcriteria are listed in the first column. Notice how dramatically the success rateschange when the criteria used to define success are modified to include PPD ≤6 mm(i.e., second column). The next two columns show the success rates for each groupusing PPD ≤5 mm and ≤6 mm when the criteria are modified to omit bone loss as adeterminant. The last column shows the implant survival rate for each group, whichdemonstrates that the survival rate is different than the success rate.PPD, Probing pocket depth; BOP, bleeding on probing; BL, bone loss.Data from Karoussis IK, Salvi GE, Heitz-Mayfield LJ, et al: Long-term implantprognosis in patients with and without a history of chronic periodontitis: a 10-yearprospective cohort study of the ITI Dental Implant System. Clin Oral Implant Res14:329–339, 2003. 4622 Key FactImplant success is defined by specific criteria used to evaluate thecondition and function of the implant. Criteria for implant successhave been proposed in the literature but not used consistently.Depending on the criteria used, the rates of implant successreported in studies can vary substantially.Implant survival is defined as an implant that remains in place atthe time of evaluation, regardless of untoward signs and symptomsor a history of problems. Extant implants that are healthy andfunctioning under an implant-retained restoration are differentfrom those that are suffering from peri-implant bone loss or thosethat are not connected to a restoration and not functioning (Fig.87.2), but these operational differences do not affect calculations ofimplant survival. Implants that are osseointegrated but notfunctional are referred to as sleepers and should not be consideredsuccessful merely because they are present and osseointegrated.FIG. 87.2 Panoramic radiograph shows an implantplaced in the position of a missing maxillary rightcentral incisor. The implant appears to be placed in anonrestorable position. It is osseointegrated and couldtechnically be counted as a surviving implant, but itmust be considered a failure because it does not meetthe intended goal and function has not been restored.4623 Implant survival and implant success are different outcomemeasures. Consider the dramatic difference between survival andsuccess rates for implants reported in a systematic review (21studies included) of implants supporting fixed partial dentures.59The 5-year implant survival rate was 95.4%, whereas the overall 5-year success rate (individual implant success rates were notcalculated), defined as free of complications, was only 61.3%.59In a 10-year retrospective study of 397 fixed implantreconstructions in 300 patients, the observed mechanicalcomplication rate was 24.7%.77 The most frequent complication wasceramic chipping (20.31%), followed by occlusal screw loosening(2.57%) and loss of retention (2.06%).77 Although relativelyuncommon, occlusal screw loosening can result in a subgingivalgap at the implant–abutment junction that retains plaque andstimulates an inflammatory reaction in the soft and hard tissues,leading to bone loss around the implant. Although surviving, theseimplants would fail to meet optimal success criteria.Defining implant results in absolute terms is difficult andconfusing. Implant survival, which typically is reported in studies,can overestimate good implant outcomes. Implant success, which isless often reported, could offer a better measure if specific successcriteria were universally defined, accepted, and used. Implantsuccess is difficult or impossible to compare across studies becauseof differences in evaluation criteria used by investigators. Implantsuccess in a single study or series of studies using the same successcriteria is meaningful only in the context of that study or series.Currently, the usefulness of implant success rates from differentstudies is limited. Implant survival is important but is only anindicator of surviving implants and does not reveal whether theyare functioning or had problems associated with them over time.The incidence of peri-implant problems is more significant thanonce thought. A systematic review of the literature evaluating theprevalence of peri-implant disease reported that peri-implantmucositis and peri-implantitis occurred in 19% to 65% and 1% to47% of cases, respectively.22Factors That Influence Implant4624 OutcomesMany issues influence implant outcomes, including available bone,implant design, placement and loading protocols, and host-relatedfactors.Anatomic LocationOsseointegration depends on the availability of an adequatequantity and quality of bone at the implant site. Areas withabundant bone volume in the desired location are better than thosewith deficient bone volume. Areas with good bone density providemore predictable outcomes than those with poor bone density.The bone classification system described by Lekholm and Zarb49defines bone with different levels of support for implants and thelikely impact on survival and success. The quality of bone supportis greatly influenced by the anatomic location, and implantoutcomes are sometimes categorized according to location. Extremeexamples are the anterior mandible and the posterior maxilla. Theanterior mandible typically consists of dense cortical bone, whichoffers great support and high bone-to-implant contact, whereas theposterior maxilla is often limited in volume because of alveolarresorption and sinus pneumatization and typically consists of aloose, trabecular structure and a thin cortical bone shell.Implants placed in the posterior maxilla are less well supportedcompared with implants placed in the anterior mandible. Jaffin andBerman36 demonstrated the significance of bone quality on implantsurvival in a report of 1054 Bränemark implants. Ninety percent ofthe implants were placed in type I, II, or III bone, with a failure rateof only 3%. Of the 10% that were placed in type IV bone, 35%failed.36 Excluding those placed in the mandible, 23 (44%) of 52implants placed in type IV bone in the maxilla failed, for a dismalsurvival rate of 56%. The study authors concluded that bone qualitywas the single greatest determinant of implant loss.Anatomic location has a significant effect on implant outcome,particularly for the posterior maxilla. The implants used in thestudy by Jaffin and Berman36 had machined surfaces, and currentimplants with altered microtopography are thought to perform4625 better in the posterior maxilla due to increased bone-to-implantcontact. When all 1054 implants (placed in all types of bone) areconsidered together, the combined implant survival rate (93.9%) inthe study is within or slightly higher than the reported range in theGöteborg study (done with similar implants).Implant DesignImplant design influences outcome. Hundreds of companiesmanufacture and market dental implants worldwide, and thenumber continues to grow. Implant dimensions, geometries, andsurface characteristics vary tremendously and continue to evolve asinnovation and research findings pave the way for changes that arethought to improve outcomes. Very few implant designs have beenstudied. They instead rely on being clinically similar to researchedand approved designs without additional studies or documentationto support their effectiveness. In most cases, it is impossible toappreciate the effect of a particular implant design features onoutcomes. Nonetheless, novel implant designs are being used, andoutcomes are being reported in studies that evaluate other aspectsof treatment that are not specific to the design, which makescomparisons and assessments more confusing and unreliable.The studies that have documented the success of dental implantsbased on design characteristics have shaped current standards forselection and use. For example, many clinicians adhere to thepremise that longer implants, threaded implants, and rough-surfaced implants are better than shorter, unthreaded, and smoothdesigns. As changes in design and use have evolved over time,some beliefs have been disproved, and continued advances andresearch will undoubtedly refute other firmly held beliefs.Clinicians would like to know whether one implant designperforms better than the rest, but it is almost impossible todetermine which design characteristics are important, because thereare many variables to consider and implants are successful most ofthe time. Given the generally high rate of success, it appears thatsubtle differences in implant design are probably not significant formost patients and situations.24,28 However, in patients withinadequate sites or challenging circumstances, certain implant4626 designs may perform better than others. An example is the effect ofimplant surface characteristics. Implants with altered surfacemicrotopography (i.e., acid-etched or blasted) enhance the bone-to-implant interface44,45 and can improve outcomes, especially incompromised sites.71,72 Lower success rates have been associatedwith smooth-surface (i.e., machined) implants.37,60,64Implant length is another consideration. Many studies havesupported the dogma that longer is better for implant success,65,66but later studies have challenged it.31 Another important feature isthe macro-thread design of implants. Clinical research52 evaluatingthe stability (assessed by resonance frequency analysis) of a novelimplant designed with a wide thread depth and increased pitchfound that it did not cause the typical decrease in stability in theearly postoperative healing period. This finding may have animpact on early and immediate loading protocols. Key FactMany features influence outcomes, including available bone,implant design, placement and loading protocols, and host-relatedfactors. Defining implant results in absolute terms can be difficultand confusing.Placement and Loading ProtocolsThe traditional placement protocol required a healed edentulousridge into which implants were placed and allowed toosseointegrate for a period without occlusal loading (see Chapter78). The nonloading period after implant placement wasempirically determined to be 3 to 4 months in the mandible and 6months in the maxilla.10 A strongly held belief was that earlyloading would lead to higher failure rates.11In contrast to the early standards, some current protocolsadvocate dramatically different approaches, including implantplacement immediately after tooth extraction and implant occlusalloading immediately or shortly after placement. Each of theseapproaches has distinct advantages, but they are accompanied bychallenges that have the potential to adversely affect outcomes.4627 Immediate Implant PlacementThe immediate implant placement protocol describes the procedurein which an implant is placed in an extraction socket after toothremoval and socket debridement. This procedure, described bySchulte and colleagues68 in 1978 and by Lazzara in 1989,47 has beenreported with survival rates equivalent to those of implants placedinto healed ridges.14,51 The advantages of immediate placementinclude decreased surgery, cost, and healing time.69 Immediateimplant placement introduces an additional risk of complications,including poor implant position, compromised aesthetic outcome,and implant failure (see Chapter 85). Despite the increased risk, ahigh long-term (1- to 16-year) survival rate of 96% has beenreported for implants immediately placed into extraction sockets.74Immediate Occlusal LoadingBränemark established the concept of the osseointegrated dentalimplant as a predictable treatment modality for the edentulouspatient on the empirically based requirement that the implantremain submerged and unloaded for a healing period of 3 to 6months.10 This original protocol, requiring the implant to remainstress free, was based on the concern that premature loading wouldcause micromotion of the dental implant, leading to fibrousencapsulation and implant failure. However, studies have shownthis assumption to be incorrect, demonstrating that immediatelyloaded implants can achieve success rates (>90%) similar to thosefor conventionally loaded dental implants.15,19,29,33,40 The long-termpredictability of immediately loaded implants requires strictsurgical and prosthodontic protocols.7Bone AugmentationA common problem encountered in implant dentistry is insufficientbone quantity to allow implant placement. Deficiencies in alveolarbone result from developmental defects, periodontal disease, toothloss, or trauma.6,13,67 For most cases with alveolar ridge resorption,bone regenerative procedures are required to correct the defectsbefore or simultaneously with implant placement (see Chapters 79and 80). The question is whether implants placed in sites that are4628 reconstructed with bone augmentation procedures can achieve thesame survival and success rates as implants placed in native bonesites.The results of implants and bone augmentation proceduresreported in the literature have been assessed by expert clinicians inseveral workshops.16,30,34,35 One systematic review of the literature(2003 Workshop on Contemporary Science in Clinical Periodontics),including 13 studies (i.e., guided bone regeneration) with 1741patients and 5 studies (i.e., distraction osteogenesis) with 92patients, found that survival rates of dental implants in augmentedbone achieved a high level of predictability that was similar to thatfor implants placed in natural (nongrafted) bone.30Another systematic review of the literature (2008 ConsensusReport of the Sixth European Workshop on Periodontology73)pointed out that bone augmentation procedures can fail and thatimplants placed in these areas do not enjoy the high long-termsurvival rates of dental implants placed in pristine sites.73 The 2003systematic review did not include an assessment of whether boneaugmentation procedures failed; it intentionally focused onimplants placed in sites that were successfully treated with boneaugmentation. More research is needed to determine the long-termperformance of dental implants placed in augmented bone and theclinical benefits of bone augmentation with respect to alternativetreatments (e.g., use of short implants).Risk FactorsMost patients enjoy similar rates of survival and success withdental implants. Only a few patients experience implant failure.In addition to the factors previously discussed, host-relatedfactors can adversely affect healing, osseointegration, andmaintenance of dental implants. Smoking, diabetes, andperiodontitis have been identified as risk factors that can adverselyaffect implant outcomes. In a systematic review of the literature,Klokkevold and Han43 evaluated the influence of smoking, diabetes,and periodontal disease on outcomes and found that smoking hasan adverse effect on implant survival and success, with the effectsbeing more pronounced in areas of loose trabecular bone (e.g.,4629 posterior maxilla).The review also suggested that type 2 diabetes had an adverseeffect on implant survival rates, but the limited number of includedstudies did not permit a definitive conclusion.43 The review didconclude that although patients with a history of treatedperiodontitis did not show a decrease in implant survival, they didexperience more complications and lower success rates, especiallywhen the implants were followed over longer periods (10+ years).43SmokingAbove all other risk factors, smoking has a significant negativeimpact on implant survival and success. In a study of 2194implants, Bain and Moy reported a significantly greater rate offailure among smokers (11.28%) than nonsmokers (4.76%).8 DeBruyn and Colleart reported an early failure rate of 9% amongsmokers compared with 1% among nonsmokers.18 Two otherstudies, one of 10 years25 and the other with follow-up assessmentof 6 months to 21 years,56 concluded that smoking was a definiterisk factor for implant survival.20,21DiabetesThe role of diabetes mellitus as a risk factor for implant outcomes isless clear. Although a metabolic disease such as diabetes wasexpected to have an adverse effect on bone healing75 and tissuesupport for implants, the research has not definitively determinedthat diabetes has a negative impact on implant survival or success.4Moy and coworkers56 reported a significantly lower success rate(68.7%) for patients with diabetes compared with the success rate(85.1%) for the entire study population (1140 patients with 4680implants); individual implant survival and success rates were notreported. However, the low success rate (i.e., high failure rate) maybe an overestimate of the actual implant failure rate for patientswith diabetes, because it counts the number of patients with failuresregardless of how many implants they had (i.e., implantssuccessfully inserted and maintained in these patients are notcounted). There were 48 patients with diabetes in the study, 4.2% ofthe 1140 total. Of these, 15 patients experienced implant failures.Conversely, in a systematic review of the literature (33 studies),4630 Javed and Romanos found that patients with good metaboliccontrol (i.e., glycated hemoglobin [HbA1c] levels in the normalrange) achieve success rates with osseointegrated implants that aresimilar to those for patients without diabetes.38 Dowell andcoworkers23 also found similar success for implants placed inpatients with controlled diabetes.PeriodontitisA limited number of studies have assessed the prognosis of implanttreatment in patients with a history of periodontitis.41 Most of thesestudies suggest that implants are equally successful in patients witha history of chronic periodontitis. Short-term studies demonstrate90% to 100% implant survival in patients with a history of chronicperiodontitis.53,55 Long-term studies report 90% to 97% implantsurvival rates for patients with a history of chronicperiodontitis.42,50,62,76 Short-term implant survival rates for patientstreated for aggressive periodontitis are 95% to 100%.53,54 One long-term study reported an 88.8% implant survival rate over 5 years forpatients treated for aggressive periodontitis.55Implant survival in patients with a history of periodontitisappears to be highly predictable. However, the lack of long-termstudies to support implant survival in patients treated foraggressive periodontitis leaves the prognosis for these patientsopen to question.41Long-term studies evaluating implant treatment in periodontallycompromised patients suggest that they may experience more peri-implant problems.42 When these patients are followed for extendedperiods, there appear to be more complications (i.e., peri-implantitis) associated with implants than in periodontally healthypatients. In a 10-year prospective study of patients with andwithout a history of chronic periodontitis, the rate of biologiccomplications (i.e., peri-implantitis) was higher for those with ahistory of chronic periodontitis (28.6%) than those with periodontalhealth (5.8%).42 This controlled study by Karoussis and coworkers42found a statistically significant difference in mean peri-implantbone loss between patients with a history of chronic periodontitisand patients who were periodontally healthy.Peri-implant problems may be attributed to a continuous increase4631 in the percentage of implants exhibiting probing pocket depths of 4mm or deeper over time.26 A systematic review of implantoutcomes in patients treated for periodontitis concluded that theseindividuals had a greater incidence of biologic complications andlower success and survival rates compared with periodontallyhealthy subjects.70 Key FactSmoking, diabetes, and periodontitis are risk factors that canadversely affect implant outcomes.Aesthetic Results and PatientSatisfactionThe ultimate goal of treatment is to achieve natural-appearing,optimally functioning, implant-supported tooth replacements.Proper tooth dimensions and contours, and ideal soft tissue supportare key factors for successful aesthetic outcomes.46 If crown form,dimension, and shape and gingival harmony around the implantsare not ideal, the patient may consider the implant restorationunacceptable, because the result does not represent a natural dentalprofile (Fig. 87.3). For some patients, such as those with severealveolar deficiency, an ideal aesthetic outcome may be impossiblebecause reconstructive surgical procedures are complex, requireextensive time, and remain unpredictable. For others, a less-than-ideal aesthetic outcome may be acceptable (see Chapter 81).4632 FIG. 87.3 Clinical photograph shows a maxillaryanterior fixed restoration supported by twomalpositioned implants in the central incisor positions.The patient was dissatisfied with the aestheticoutcome. The left implant was positioned between thecentral and lateral incisor and angled toward the facialsurface at a level above the gingival margin. A tooth-colored material was used to mask the exposedframework in the gingival area.Aesthetic problems and patient dissatisfaction happen whenresults are inferior to what was expected. Satisfaction with theaesthetic outcome of the implant prosthesis varies from patient topatient, depending on a number of factors. The risk for aestheticfailure is increased for patients with high aesthetic expectations.The risk is also higher when patients present with patient-relatedrisk factors such as a high smile line, thin periodontal soft tissues,and compromised bone support. Two recent systematic reviewsreported that the patient's perceptions and desires greatly influenceand determine how well he or she accepts the implant outcome.17,57Although infrequently reported, aesthetic success and patientsatisfaction need to be included when considering the results ofimplant therapy. Despite several proposed methods for evaluatingaesthetic results, reports of aesthetic parameters in the scientificliterature are scarce.9 A restorative index appraises the whiteaesthetics of the final restoration,39 a soft tissue or pink aestheticscore considers soft-tissue parameters,32 and an aesthetic index usesa combination of pink and white aesthetic scores, focusing on the4633 visible part of the implant restoration.8 These indices quantify theaesthetic result, providing an objective method of judging aestheticsuccess.In a survey of patient satisfaction, more than 90% of patientswere completely satisfied in terms of function and aesthetics.58 Aquestionnaire was given to 104 patients 5 to 15 years (mean, 10.2years) after implant placement to assess subjective perceptions oftreatment. Of these patients, 48% were treated with single implantcrowns and 52% were treated with fixed partial dentures. Thesurvival rate for all implants was 93%. Most patients had favorableresponses to the questions regarding function, aesthetics, hygiene,and cost. Table 87.2 lists the percentage of patients responding ashighly satisfied or satisfied for each category. Comparing chewingcomfort for teeth or implants, 72.1% perceived no difference, 17.3%felt more secure chewing on teeth, and 7.7% felt more securechewing on implants.TABLE 87.2Patient Satisfaction With Implant TreatmentImplant Experience Highly Satisfied or Satisfied (%)aFunction or chewing 97Phonetics 96Aesthetics 97Oral hygiene ease 93Complete fulfillment 92Would do treatment again 94Would recommend to friend or relative 89Reasonable or justified cost 87aPercentage of patients subjectively responding with highly satisfied or satisfied tosurvey questions about their implant experience. More than 90% respondedfavorably and thought implant treatment was a positive experience.Data from Pjetursson BE, Karoussis I, Burgin W, et al: Patients' satisfaction followingimplant therapy. A 10-year prospective cohort study. Clin Oral Implants Res 16:185–193, 2005.In another survey, patient satisfaction with implant-supportedprostheses in totally edentulous jaws was evaluated.63 Experiencewith an implant-supported prosthesis was assessed over a period of10 years, and 97% of the 135 patients reported overall satisfactionwith treatment. Chewing satisfaction was reported as good or verygood by all but one patient (99.3% positive response rate).4634 Improved lifestyle and greater self-confidence in public werereported by 75% and 82% of patients, respectively.A systematic review of the literature, which included allrandomized controlled trials published in English or French up toApril 2007 comparing conventional mandibular dentures andimplant overdentures in adult edentulous patients, identified eightpublications for meta-analysis.27 The study reported that patientswere more satisfied with implant overdentures than withconventional mandibular dentures. However, there was a lack ofevidence to show a patient's perception of the impact of mandibularimplant overdentures on general health. Clinical CorrelationAesthetic problems and dissatisfaction happen when results do notmatch a patient's expectations. Satisfaction with the aestheticoutcome of an implant prosthesis varies among patients. The riskof failure is greater among those with high aesthetic demands andrisk factors such as a high smile line, thin periodontal soft tissues,or compromised bone support.ConclusionsThe use of dental implants to replace missing teeth is highlypredictable, advantageous, and beneficial for patients. Because ofvariations in implant designs, study protocols, and populationsstudied, results are difficult to compare and an absolute definitionof implant success remains elusive. The results of implant treatmentare reported using a wide range of criteria from being present (i.e.,survival) to being functional without complications (i.e., success).It is challenging to compare the results of studies because thenumber of variables continues to change. Clinical research suggeststhat certain risk factors can decrease success rates for some patients.Understanding what is being reported in the literature helpspatients and clinicians appreciate implant treatment results. 4635 Case Scenario 86.1Patient:57-year-old maleChief Complaint:“My front tooth is loose. It bothers me, and I want an implant.”Background Information:The patient reports a history of trauma to his front teeth as a youngteenager. Both central incisors were fractured. Multiple restorationswere done over the years. Tooth #9 had root canal treatment and acrown. Later, it became infected and required an apicoectomy. It isnow loose and migrating.Current Findings:Tooth #9 has severe localized gingival recession. Tooth mobility isclass 2/3. It has drifted in a coronal and facial direction. There areno significant probing pocket depth measurements around tooth #9or the remaining dentition. The patient is healthy and has nosystemic illnesses.CASE-BASEDQUESTIONSOLUTION AND EXPLANATION1. Is it possible toreplace tooth #9 withan implant?A. Yes. Implantscansuccessfullyreplace failingteeth.B. No. There istoo muchgingivalrecession.C. No. Implantsare notsuccessful inthe anteriormaxilla.D. Maybe. Itdepends on thepatient'saestheticdemands.Answer: AExplanation: There will likely be a need for bone and soft tissueaugmentation. Implant placement in the anterior maxilla has beena successful option for replacement of a single tooth.4636 References1. Adell R, Eriksson B, Lekholm U, et al. Long-term follow-upstudy of osseointegrated implants in the treatment of totallyedentulous jaws. 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The longitudinal clinical effectivenessof osseointegrated dental implants: the Toronto Study. PartII: the prosthetic results. J Prosthet Dent. 1990;64:53–61.80. Zarb GA, Schmitt A. Osseointegration and the edentulouspredicament. The 10-year-old Toronto study. Br Dent J.1991;170:439–444.4644 PART 5Atlas ofPeriodontalDiseasesOUTLINEChapter 88 Atlas of Periodontal Diseases4645

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