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Retrospective Long-term Evaluation of Dental Implants in Totally and Partially Edentulous Patients. Part I: Survival and Marginal Bone Loss Anna Trullenque-Eriksson, DDS, PhD,* and Blanca Guisado-Moya, MD, PhD†
ral rehabilitation with dental osseointegrated implants is a frequently chosen treatment option, which is considered safe and predictable. Most studies give long-term survival figures of between 85% and 100% of the implants placed.1–28 Implant loss can take place before or after functional loading. However, a surviving implant does not necessarily imply the maintenance or reestablishment of the patient’s well-being. Implant survival merely implies that it has not been lost, and it does not specify its condition. Marginal bone loss can compromise the long-term results of implants. In addition, implant treatment is not without complications, which generate discomfort to the patient and whose treatment is time consuming and imply an additional cost. They can be divided into early or late depending on the time of occurrence and into biological or mechanical depending on their nature.16,29–31 It is interesting to gain knowledge of the long-term results of this treatment
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*Private Practice, Bury St Edmunds, United Kingdom; and †Professor of Oral Surgery, Department of Oral and Facial Medicine and Surgery, Faculty of Dentistry, Universidad Complutense de Madrid, Madrid, Spain.
Reprint requests and correspondence to: Blanca Guisado Moya, MD, PhD, Departamento de Medicina y Cirugía Bucofacial, Facultad de Odontología, Universidad Complutense de Madrid, Plaza Ramón y Cajal, 28013 Madrid, Spain, Phone: +34 91 394 19 68, E-mail: [email protected] ISSN 1056-6163/14/02306-732 Implant Dentistry Volume 23 Number 6 Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0000000000000171
Purpose: This retrospective longitudinal study aims to assess longterm outcomes of osseointegrated dental implants in partially and totally edentulous patients. Materials and Methods: Patients willing to sign the informed consent and attend a check-up were included. Implant failures were recorded, and marginal bone level and bone loss were evaluated on intraoral radiographs. Univariate and multivariate statistical analyses were conducted to determine the influence of various factors. Complications and patient satisfaction were recorded. Results: One hundred five patients who received 342 implants were included. Mean follow-up was 13.19 6 3.70 years. 9.4% of implants were lost, and 78.1% of patients retained all implants placed.
Mean marginal bone loss was 0.77 6 1.10 mm, being greater than 3 mm in 2.5% of analyzed implants. Factors with possible influence on implant survival and marginal bone loss were smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. 24.8% of patients remained free of complications. Patient satisfaction was high. Conclusions: In our sample, which included both totally and partially edentulous patients, longterm implant survival was more than 90% with a mean marginal bone loss of 0.77 mm and an implant survival at patient level of 78%; patient satisfaction was high despite the fact that complications were frequent. (Implant Dent 2014;23:732–737) Key Words: marginal bone levels, patient satisfaction, complications
alternative and factors that may influence them. It is also desirable to obtain information regarding the subjective assessment of the patients because, after all, our main purpose is their satisfaction and well-being. The aim of this study was to assess the long-term outcomes of osseointegrated dental implants placed in partially and totally edentulous patients. Part I of this study reports survival and marginal bone loss, as well as factors that may
have influenced these variables, complications, and patient satisfaction. Part II of this study will report on the presence of periimplant disease and factors that may have had an influence.
MATERIALS
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METHODS
This is a retrospective longitudinal study based on data collected through the patients’ medical and dental records, clinical and radiological examinations, and satisfaction questionnaires.
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Fig. 1. Types of implants placed. Implant brand, shape and surface are specified for all but Frialit implants where the specific implants are named. This chart shows that a variety of implants were placed. However, the size of the sample did not allow for a comparison between each specific implant design.
Patient Sample
Patients who had been rehabilitated through dental implants placed before or during year 2002 in the Magister of Oral Surgery and Implantology of the Faculty of Dentistry of the Complutense University of Madrid were contacted. As long as no important information regarding the implants was lacking, patients who agreed to sign the informed consent and attend an examination of their remaining implants were included in the study. Data were collected from their medical and dental records, including age, gender, drinking and smoking habits, systemic conditions, medication, checkup frequency, cause of original tooth loss, implant characteristics, information regarding implant placement and prosthetic rehabilitation, and complications. Implants placed to replace lost implants were not included. Patient Examination
During the clinical examination, implants and remaining teeth were evaluated (presence of plaque, probing depth, bleeding on probing and/or suppuration, gingival recession, mobility, and others). Presence of pain, anesthesia, or paresthesia was recorded. Intraoral radiographs were taken with help of a paralleling device (XCP, DENTSPLY Rinn, Elgin, Illinois). Radiographs taken at the time of abutment connection or, alternatively, prosthesis placement were considered as baseline.
After digitizing the radiographs, the marginal bone level was evaluated. Implant-abutment junction was used as the reference point in all implants except for Straumann implants (Basel, Switzerland) placed in posterior areas or that received overdentures, in which the coronal limit of the texturized part of the implant was used as reference. The same researcher (A.T.E.) made all the linear measurements of the vertical distance between the reference point and the most coronal bone-to-implant contact, rounding up to the nearest quarter of a millimeter, with help of an image analysis program (DBSWIN version 4.5, DÜRR DENTAL, Bietigheim-Bissingen, Germany). Measurements were calibrated with known lengths of the implant. Follow-up measurements were compared with the baseline measurement to determine modifications in marginal bone level. The patients also filled in a satisfaction questionnaire. Subjective evaluation of function, esthetics, phonetics, and ease of maintaining proper oral hygiene was evaluated by the patient through a visual analog scale.
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from the reference point and implants with a periimplant bone loss greater than 3 mm were also calculated; the former in all patients and the latter only in those with a valid baseline radiograph. Regarding the factors that could influence survival and changes in marginal bone level, the following variables were considered: age at implant placement, gender, smoking (heavy smoker ¼ more than 10 cigarettes per day), alcohol consumption (frequent drinker ¼ more than half a liter of wine per day or equivalent), diabetes, hypertension, diagnosed osteopenia or osteoporosis, bisphosphonate intake, thyroid dysfunction, hypercholesterolemia, chemotherapy and/or head and/or neck radiotherapy, anticoagulant intake, check-up frequency, history of periodontal disease (when the tooth that was replaced by an implant had been lost due to periodontal disease, periodontal pockets were present around remaining teeth or when the patient had been subject to periodontal treatment due to the situation of remaining teeth), implant shape (cylindrical or tapered), surface (minimally rough, moderately rough or rough),32,33 diameter, length and position, 1- or 2-stage surgery, need for regeneration techniques, prosthesis type, and follow-up time. The following statistical analyses were performed with Microsoft Excel and IBM SPSS 19.0 for Windows: • Descriptive statistics for quantitative and qualitative variables • Univariate: Pearson Chi-square test and Fisher exact test for qualitative variables • Multivariate: Logistic regression for the different qualitative variables. Results are given as mean 6 SD. Due to the high proportion of machined surface cylindrical Brånemark system implants, this group was also analyzed separately.
Data Analysis
Implant loss percentages were calculated with the implant and the patient as statistical units. The modification in marginal bone level was only evaluated in patients with a valid baseline radiograph. Percentages of implants with marginal bone level at more than 3 mm
RESULTS Sample Description
Three hundred four patients were identified, of which 105 were finally included in the study. Of the remainder,
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Table 1. Logistic RegressiondSurvival (Unit ¼ Implant) 95% CI for Exp(B)
Independent Variables Check-up frequency Maxilla/mandible Implant length Implant surface
Effect
B
#3 y/.3 y Mandible/maxilla Short/standard Short/long Min rough/mod rough
1.913 2.352 −2.167 −2.630 −1.741
Sig
Exp(B)
Min
Max Factors
0.000 6.774 2.769 16.570 0.000 10.504 2.845 38.776 0.000 0.114 0.035 0.375 0.000 0.072 0.018 0.287 0.004 0.175 0.054 0.565
Multivariate analysis (logistic regression) of the association of different factors with implant failure. The implant is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value. For example, when an implant is placed in the maxilla, there is an increased probability of implant failure, and the odds are multiplied by 10.5.
66.3% were not reachable, 24.6% did not want or were not able to attend the clinic, 7% failed to attend the appointment, and 2% had died. 35.2% of the included patients were male and 64.8% female. The average age at implant placement was 47.84 6 14.42 years (range, 16.02– 71.76 years). These patients had received 342 osseointegrated dental implants (Fig. 1). Regarding implant diameter, it was less than 3.75 mm in 22.2% and more than 4 mm in 19.3% of implants. 9.6% of implants were short (less than 10 mm in length), and 26.9% were long (more than 13 mm in length). The mean follow-up of those implants was 13.19 6 3.70 years (range, 8.46–24.37 years). 52.6% of implants were machined surface cylindrical
Brånemark system implants. A valid baseline radiograph was available for 78.4% of the implants. Implant Loss
9.4% of implants were lost. Of these, 53.1% were lost before prosthesis placement, 37.5% were lost after prosthesis placement, and 9.4% were “asleep.” 78.1% of patients retained all implants placed.
According to the univariate analyses, implant loss was significantly more frequent for implants placed in heavy smokers (P ¼ 0.041), frequent drinkers (P ¼ 0.031), patients who attended check-up every 3 or more years (P ¼ 0.002), short implants (P ¼ 0.016), implants placed in maxillae (P ¼ 0.004), and when the patient was rehabilitated with an overdenture (P ¼ 0.015). At patient level, those with osteopenia or osteoporosis presented implant failure more frequently (P ¼ 0.022). Presence of marginal bone loss greater than 3 mm was significantly more frequent for implants placed in heavy smokers (P ¼ 0.010) and short implants (P ¼ 0.012). Significant results from the multivariate analyses are summarized in Tables 1–3. Complications
Changes in Marginal Bone Level
The marginal bone level was on average 1.84 6 1.35 mm apical to the reference point. 16.1% of the analyzed implants had the bone level at more than 3 mm from the reference point at the final examination; these implants were placed in 26 patients. Regarding the marginal bone level modification, the average was a loss of
Complications were frequent, only 24.8% of patients had not reported any. 45.7% of patients had not suffered biological complications. The most frequent biological complications were periimplant disease (21%), followed by paresthesia (6.7%), gingival hyperplasia (5.7%), pain in the implant area (4.8%), and previous presence of periimplant disease without current disease (4.8%).
Table 2. Logistic RegressiondSurvival (Unit ¼ Patient) 95% CI for Exp(B) Independent Variables Osteopenia/osteoporosis Alcohol consumption
Effect
B
Sig
Exp(B)
Min
Max
Yes/no Yes/no
1.854 −1.226
0.007 0.042
6.388 0.293
1.651 0.090
24.723 0.954
Multivariate analysis (logistic regression) of the association of different factors with implant failure. The patient is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability, and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value.
Table 3. Logistic RegressiondMarginal Bone Loss .3 mm (Unit ¼ Implant) 95% CI for Exp(B) Independent Variables Implant length Smoking
Effect
B
Sig
Exp(B)
Min
Max
Short/standard Short/long Rest/heavy smokers
−2.578 −2.423 2.053
0.009 0.046 0.037
0.076 0.089 7.790
0.011 0.008 1.133
0.520 0.954 53.555
Multivariate analysis (logistic regression) of the association of different factors with the presence of marginal bone loss greater than 3 mm. The implant is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability, and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value.
IMPLANT DENTISTRY / VOLUME 23, NUMBER 6 2014 As for mechanical complications, 49.5% of patients had not reported any. The most frequent were screw loosening (21%), porcelain fractures (15.2%), prosthesis fractures (9.5%), loss of the screw-access hole restoration (7.6%), loss or change of retention element (4.8%). Two patients presented lateral radiolucency, and 2 others presented decreased bone density, all of them without clinical symptoms. Patient Satisfaction
The overall satisfaction with the treatment was equal to or greater than 8 of 10 for 79.4% of the patients and greater than 5 of 10 in 98% of patients. The mean values were 8.94 6 1.71 for function, 9.45 6 1.00 for phonetics, 8.63 6 1.98 for esthetics, and 8.21 6 2.07 for the ease of maintaining proper oral hygiene.
DISCUSSION In this retrospective longitudinal study, long-term results of implants were evaluated based on survival, changes in marginal bone levels, and the presence of periimplant disease (described in Part II). In this study, after a mean followup of 13 years, 9.4% of implants failed and 78.1% of patients retained all implants placed. Marginal bone loss was −0.77 6 1.10 mm, with 2.5% of implants exhibiting a bone loss of more than 3 mm. Patient satisfaction was high, despite the fact that complications were frequent. In the literature, survival figures after 10 years of follow-up generally exceed 90%.2,5,6,9,10,14,17,21–23,25,27,28 With a follow-up of more than 10 years, there is a greater variety of results between 83% and 99% of the implants.4,7,8,12,13,15,19,24,26,34 Other studies have also provided information on survival at patient level. In the study by Roos-Jansåker et al,13 1057 implants placed in 218 patients were retrospectively analyzed after 9 to 14 years follow-up. 89.9% of patients kept all implants placed. In the retrospective study of Simonis et al,19 131 implants in 55 patients were reviewed after up to 16 years. 78.2% of patients retained all implants placed.
In the retrospective study of Dierens et al,24 patients who had received implants 16 to 22 years earlier were contacted. 10.2% of the patients had lost 1 or more implants. Mertens et al26 followed 94 implants for an average of 11.26 years, having retained all of the implants 14 of 15 patients (93.3%). Mean bone loss of 1 mm or less has been reported by Lekholm et al12 and Dierens et al24 after 20 and 16 to 22 years, respectively. Other authors have found greater bone loss. Astrand et al15 informed of a bone loss of 1.72 mm after 20 to 24 years. Simonis et al19 reported a bone loss of 2.2 6 3.4 mm mesially and 2.3 6 3.4 mm distally with a follow-up of 10 to 16 years. Other studies have found bone loss greater than 3 mm in between 1% and 13% of implants after 10 or more years of follow-up.6,11,15,18,25,28 According to our results, it seems that certain factors may have an influence on long-term results of implants such as smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. Smoking was associated both with higher percentages of implant loss and marginal bone loss greater than 3 mm. As in this study, several authors have found a significantly higher implant loss19,20,26,35–37 and increased bone loss27,38–47 in smokers. The 2012 study by Örtorp and Jemt27 showed greater bone loss in smokers during the first year of follow-up, but this difference was not maintained in subsequent years. However, other studies only showed a nonsignificant trend or nonsignificant differences.3,8,10,13,48 Implant loss was more frequent in patients diagnosed with osteopenia or osteoporosis. Preclinical studies in animals suggest that there would be a negative influence of osteoporosis on the bone-to-implant contact. It seems that there is an association between osteoporosis and bone density around teeth and dental implants, and this could be associated with an increased risk of implant failure or reduced load carrying capacity in the long term.49 However, in the 2006 revision by Mombelli and Cionca,50 heterogeneous data were found
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regarding implant failures in patients with osteoporosis, with low evidence of association. There was a significantly greater implant loss and presence of marginal bone loss greater than 3 mm when the implant was short. Several authors have also found a significantly greater loss of short implants.2,4,7,35,51–55 Conflicting data can be found in the literature regarding the relation between marginal bone loss and implant length. Although Chung et al45 found a higher annual bone loss in short than in long implants, in the study by Ormianer and Palti,56 bone loss was more frequent in long than in short implants. Other authors found no significant differences.57–59 In this study, implant loss was more common in the maxilla than in the mandible and more specifically, in order, in the posterior and anterior maxilla, followed by the posterior and anterior mandible. Several authors have reported a greater loss of implants in the maxilla than in the mandible.2,13,52,54,59,60 There was a greater loss of implants in cases rehabilitated with overdentures. Other authors have also reported higher implant failure for overdentures.29,30,54 This is possibly due to the fact that this treatment option is usually chosen in critical cases where enough fixtures for another type of rehabilitation cannot be placed, such as those with extreme bone resorption and poor bone quality.29,61 Study Limitations
The design of this study entails a number of limitations. Also, only one third of the identified patients could be included in this study. Of those not included, more than half could not be contacted, and many found it difficult to attend the clinic due to the travel distance and limited opening hours. Although other studies have included data collected through telephone interviews to assess long-term results20,24,38,62 and none of the excluded patients who were reachable informed of implant loss, this information was not included in the analysis. This study can only suggest a possible influence of different factors; cause-effect relationships can only be established with long-term randomized clinical trials.
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CONCLUSIONS 1. Implant survival was 90.6% of the implants after a follow-up of 8.5 to 24 years. 78.1% of patients retained all the implants. 2. Bone level at the final examination was on average 1.84 6 1.35 mm apical to the reference point and mean marginal bone modification was −0.77 6 1.10 mm. 16.1% of the implants had bone level more than 3 mm from the reference point, and 2.5% of implants with valid baseline radiograph showed bone loss greater than 3 mm. 3. It seems that certain factors may have an influence on long-term results of implants such as smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. 4. Complications were frequent: only 24.8% of patients remained free of complications. 5. Patient satisfaction with treatment was high. In summary, in our sample,which included both totally and partially edentulous patients, long-term implant survival was more than 90% with a mean marginal bone loss of 0.77 mm and an implant survival at patient level of 78%; patient satisfaction was high despite the fact that complications were frequent.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
ACKNOWLEDGMENTS The authors would like to thank Pedro Cuesta and Santiago Cano for their invaluable help with the statistical analysis.
REFERENCES 1. Brånemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad
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modum Brånemark in full edentulism. Clin Oral Implants Res. 1995;6:227–231. 2. Lekholm U, Gunne J, Henry P, et al. Survival of the Brånemark implant in partially edentulous jaws: A 10-year prospective multicenter study. Int J Oral Maxillofac Implants. 1999;14:639–645. 3. Brocard D, Barthet P, Baysse E, et al. A multicenter report on 1,022 consecutively placed ITI implants: A 7-year longitudinal study. Int J Oral Maxillofac Implants. 2000;15:691–700. 4. Bryant SR. Oral Implant Outcomes Predicted by Age- and Site-specific Aspects of Bone Condition (master’s thesis). Toronto: Department of Prosthodontics, University of Toronto, 2001. 5. Ferrigno N, Laureti M, Fanali S, et al. A long-term follow-up study of non-submerged ITI implants in the treatment of totally edentulous jaws. Part I: Ten-year life table analysis of a prospective multicenter study with 1286 implants. Clin Oral Implants Res. 2002;13:260–273. 6. Leonhardt A, Gröndahl K, Bergström C, et al. Long-term follow-up of osseointegrated titanium implants using clinical, radiographic and microbiological parameters. Clin Oral Implants Res. 2002;13:127– 132. 7. Naert I, Koutsikakis G, Duyck J, et al. Biologic outcome of implant-supported restorations in the treatment of partial edentulism. Part I: A longitudinal clinical evaluation. Clin Oral Implants Res. 2002; 13:381–389. 8. Attard NJ, Zarb GA. Long-term treatment outcomes in edentulous patients with implant-fixed prostheses: The Toronto study. Int J Prosthodont. 2004; 17:417–424. 9. Pjetursson BE, Tan K, Lang NP, et al. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 2004;15:625–642. 10. Rasmusson L, Roos J, Bystedt H. A 10-year follow-up study of titanium dioxide-blasted implants. Clin Implant Dent Relat Res. 2005;7:36–42. 11. Jemt T, Johansson J. Implant treatment in the edentulous maxillae: A 15-year follow-up study on 76 consecutive patients provided with fixed prostheses. Clin Implant Dent Relat Res. 2006;8:61– 69. 12. Lekholm U, Gröndahl K, Jemt T. Outcome of oral implant treatment in partially edentulous jaws followed 20 years in clinical function. Clin Implant Dent Relat Res. 2006;8:178–186. 13. Roos-Jansåker AM, Lindahl C, Renvert H, et al. Nine- to fourteen-year follow-up of implant treatment. Part I: Implant
loss and associations to various factors. J Clin Periodontol. 2006;33:283–289. 14. Visser A, Meijer HJ, Raghoebar GM, et al. Implant-retained mandibular overdentures versus conventional dentures: 10 years of care and aftercare. Int J Prosthodont. 2006;19:271–278. 15. Astrand P, Ahlqvist J, Gunne J, et al. Implant treatment of patients with edentulous jaws: A 20-year follow-up. Clin Implant Dent Relat Res. 2008;10:207– 217. 16. Jung RE, Pjetursson BE, Glauser R, et al. A systematic review of the 5-year survival and complication rates of implantsupported single crowns. Clin Oral Implants Res. 2008;19:119–130. 17. Lambert FE, Weber HP, Susarla SM, et al. Descriptive analysis of implant and prosthodontic survival rates with fixed implant-supported rehabilitations in the edentulous maxilla. J Periodontol. 2009; 80:1220–1230. 18. Pikner SS, Gröndahl K, Jemt T, et al. Marginal bone loss at implants: A retrospective, long-term follow-up of turned Brånemark system implants. Clin Implant Dent Relat Res. 2009;11:11–23. 19. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: A 10-16-year follow-up of non-submerged dental implants. Clin Oral Implants Res. 2010;21:772–777. 20. Vercruyssen M, Marcelis K, Coucke W, et al. Long-term, retrospective evaluation (implant and patient-centered outcome) of the two-implants-supported overdenture in the mandible. Part 1: Survival rate. Clin Oral Implants Res. 2010;21: 357–365. 21. Ueda T, Kremer U, Katsoulis J, et al. Long-term results of mandibular implants supporting an overdenture: Implant survival, failures, and crestal bone level changes. Int J Oral Maxillofac Implants. 2011;26:365–372. 22. Buser D, Janner SF, Wittneben JG, et al. 10-Year survival and success rates of 511 titanium implants with a sandblasted and acid-etched surface: A retrospective study in 303 partially edentulous patients. Clin Implant Dent Relat Res. 2012;14:839– 851. 23. Degidi M, Nardi D, Piattelli A. 10year follow-up of immediately loaded implants with TiUnite porous anodized surface. Clin Implant Dent Relat Res. 2012;14:828– 838. 24. Dierens M, Vandeweghe S, Kisch J, et al. Long-term follow-up of turned single implants placed in periodontally healthy patients after 16-22 years: Radiographic and peri-implant outcome. Clin Oral Implants Res. 2012;23:197–204. 25. Fischer K, Stenberg T. Prospective 10-year cohort study based on a random-
IMPLANT DENTISTRY / VOLUME 23, NUMBER 6 2014 ized controlled trial (RCT) on implant-supported full-arch maxillary prostheses. Part 1: Sandblasted and acid-etched implants and mucosal tissue. Clin Implant Dent Relat Res. 2012;14:808–815. 26. Mertens C, Steveling HG, Stucke K, et al. Fixed implant-retained rehabilitation of the edentulous maxilla: 11-year results of a prospective study. Clin Implant Dent Relat Res. 2012;14:816–827. 27. Örtorp A, Jemt T. CNC-Milled titanium frameworks supported by implants in the edentulous jaw: A 10-year comparative clinical study. Clin Implant Dent Relat Res. 2012;14:88–99. 28. Östman PO, Hellman M, Sennerby L. Ten years later. Results from a prospective single-center clinical study on 121 oxidized (TiUnite™) Brånemark implants in 46 patients. Clin Implant Dent Relat Res. 2012;14:852–860. 29. Esposito M, Hirsch JM, Lekholm U, et al. Biological factors contributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. Eur J Oral Sci. 1998;106:527–551. 30. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2002;29(suppl 3):197– 212. 31. Lang NP, Berglundh T, HeitzMayfield LJ, et al. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants. 2004;19(suppl):150–154. 32. Albrektsson T, Wennerberg A. Oral implant surfaces: Part 1dReview focusing on topographic and chemical properties of different surfaces and in vivo responses to them. Int J Prosthodont. 2004;17:536– 543. 33. Albrektsson T, Wennerberg A. Oral implant surfaces: Part 2dReview focusing on clinical knowledge of different surfaces. Int J Prosthodont. 2004;17:544–564. 34. Merickse-Stern R, Aerni D, Geering AH, et al. Long-term evaluation of non-submerged hollow cylinder implants. Clinical and radiographic results. Clin Oral Implants Res. 2001;12:252–259. 35. Baelum V, Ellegaard B. Implant survival in periodontally compromised patients. J Periodontol. 2004;75:1404–1412. 36. Strietzel FP, Reichart PA, Kale A, et al. Smoking interferes with the prognosis of dental implant treatment: A systematic review and meta-analysis. J Clin Periodontol. 2007;34:523–544. 37. Koldsland OC, Scheie AA, Aass AM. Prevalence of implant loss and
the influence of associated factors. J Periodontol. 2009;80:1069–1075. 38. Vercruyssen M, Quirynen M. Longterm, retrospective evaluation (implant and patient-centered outcome) of the twoimplant-supported overdenture in the mandible. Part 2: Marginal bone loss. Clin Oral Implants Res. 2010;21:466–472. 39. Lindquist LW, Carlsson GE, Jemt T. Association between marginal bone loss around osseointegrated mandibular implants and smoking habits: A 10-year follow-up study. J Dent Res. 1997;76:1667– 1674. 40. Haas R, Haimböck W, Mailath G, et al. The relationship of smoking on periimplant tissue: A retrospective study. J Prosthet Dent. 1996;76:592–596. 41. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study of mandibular fixed prostheses supported by osseointegrated implants. Clinical results and marginal bone loss. Clin Oral Implants Res. 1996;7:329–336. 42. Gruica B, Wang HY, Lang NP, et al. Impact of IL-1 genotype and smoking status on the prognosis of osseointegrated implants. Clin Oral Implants Res. 2004;15: 393–400. 43. Karoussis IK, Müller S, Salvi GE, et al. Association between periodontal and peri-implant conditions: A 10-year prospective study. Clin Oral Implants Res. 2004;15:1–7. 44. Galindo-Moreno P, Fauri M, AvilaOrtiz G, et al. Influence of alcohol and tobacco habits on peri-implant marginal bone loss: A prospective study. Clin Oral Implants Res. 2005;16:579–586. 45. Chung DM, Oh TJ, Lee J, et al. Factors affecting late implant bone loss: A retrospective analysis. Int J Oral Maxillofac Implants. 2007;22:117–126. 46. Fransson C, Wennström J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss. Clin Oral Implants Res. 2008;19:142– 147. 47. Stoker G, van Waas R, Wismeijer D. Long-term outcomes of three types of implant-supported mandibular overdentures in smokers. Clin Oral Implants Res. 2012;23:925–929. 48. García-Bellosta S, Bravo M, Subirá C, et al. Retrospective study of the longterm survival of 980 implants placed in a periodontal practice. Int J Oral Maxillofac Implants. 2010;25:613–619. 49. Giannobile WV, Ríos HF, Lang NP. El hueso como tejido. In: Lindhe J, Lang NP, Karring T, eds. Periodontología clínica e implantología odontológica. 5th Ed. Buenos Aires: Médica Panamericana, 2009: 86–98.
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50. Mombelli A, Cionca N. Systemic diseases affecting osseointegration therapy. Clin Oral Implants Res. 2006;17(suppl 2):97–103. 51. Ellegaard B, Baelum V, KølsenPetersen J. Non-grafted sinus implants in periodontally compromised patients: A time-to-event analysis. Clin Oral Implants Res. 2006;17:156–164. 52. Snauwaert K, Duyck J, van Steenberghe D, et al. Time dependent failure rate and marginal bone loss of implant supported prostheses: A 15-year followup study. Clin Oral Investig. 2000;4:13–20. 53. Artzi Z, Carmeli G, Kozlovsky A. A distinguishable observation between survival and success rate outcome of hydroxyapatite-coated implants in 5-10 years in function. Clin Oral Implants Res. 2006;17:85–93. 54. Herrmann I, Lekholm U, Holm S, et al. Evaluation of patient and implant characteristics as potential prognostic factors for oral implant failures. Int J Oral Maxillofac Implants. 2005;20:220–230. 55. Renouard F, Nisand D. Impact of implant length and diameter on survival rates. Clin Oral Implants Res. 2006;17 (suppl 2):35–51. 56. Ormianer Z, Palti A. Retrospective clinical evaluation of tapered screw-vent implants: Results after up to eight years of clinical function. J Oral Implantol. 2008;34:150–160. 57. Lops D, Bressan E, Pisoni G, et al. Short implants in partially edentulous maxillae and mandibles: A 10 to 20 years retrospective evaluation. Int J Dent. 2012; 2012:351793. 58. Naert I, Koutsikakis G, Quirynen M, et al. Biologic outcome of implant-supported restorations in the treatment of partial edentulism. Part 2: A longitudinal radiographic study. Clin Oral Implants Res. 2002;13:390–395. 59. Mertens C, Steveling HG. Implantsupported fixed prostheses in the edentulous maxilla: 8-year prospective results. Clin Oral Implants Res. 2011;22:464–472. 60. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997;8:161–172. 61. Engquist B, Bergendal T, Kallus T, et al. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implants. 1988;3:129–134. 62. Gotfredsen KA. 10-year prospective study of single tooth implants placed in the anterior maxilla. Clin Implant Dent Relat Res. 2012;14:80–87.
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Retrospective Long-term Evaluation of Dental Implants in Totally and Partially Edentulous Patients. Part I: Survival and Marginal Bone Loss Anna Trullenque-Eriksson, DDS, PhD,* and Blanca Guisado-Moya, MD, PhD†
ral rehabilitation with dental osseointegrated implants is a frequently chosen treatment option, which is considered safe and predictable. Most studies give long-term survival figures of between 85% and 100% of the implants placed.1–28 Implant loss can take place before or after functional loading. However, a surviving implant does not necessarily imply the maintenance or reestablishment of the patient’s well-being. Implant survival merely implies that it has not been lost, and it does not specify its condition. Marginal bone loss can compromise the long-term results of implants. In addition, implant treatment is not without complications, which generate discomfort to the patient and whose treatment is time consuming and imply an additional cost. They can be divided into early or late depending on the time of occurrence and into biological or mechanical depending on their nature.16,29–31 It is interesting to gain knowledge of the long-term results of this treatment
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*Private Practice, Bury St Edmunds, United Kingdom; and †Professor of Oral Surgery, Department of Oral and Facial Medicine and Surgery, Faculty of Dentistry, Universidad Complutense de Madrid, Madrid, Spain.
Reprint requests and correspondence to: Blanca Guisado Moya, MD, PhD, Departamento de Medicina y Cirugía Bucofacial, Facultad de Odontología, Universidad Complutense de Madrid, Plaza Ramón y Cajal, 28013 Madrid, Spain, Phone: +34 91 394 19 68, E-mail: [email protected] ISSN 1056-6163/14/02306-732 Implant Dentistry Volume 23 Number 6 Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0000000000000171
Purpose: This retrospective longitudinal study aims to assess longterm outcomes of osseointegrated dental implants in partially and totally edentulous patients. Materials and Methods: Patients willing to sign the informed consent and attend a check-up were included. Implant failures were recorded, and marginal bone level and bone loss were evaluated on intraoral radiographs. Univariate and multivariate statistical analyses were conducted to determine the influence of various factors. Complications and patient satisfaction were recorded. Results: One hundred five patients who received 342 implants were included. Mean follow-up was 13.19 6 3.70 years. 9.4% of implants were lost, and 78.1% of patients retained all implants placed.
Mean marginal bone loss was 0.77 6 1.10 mm, being greater than 3 mm in 2.5% of analyzed implants. Factors with possible influence on implant survival and marginal bone loss were smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. 24.8% of patients remained free of complications. Patient satisfaction was high. Conclusions: In our sample, which included both totally and partially edentulous patients, longterm implant survival was more than 90% with a mean marginal bone loss of 0.77 mm and an implant survival at patient level of 78%; patient satisfaction was high despite the fact that complications were frequent. (Implant Dent 2014;23:732–737) Key Words: marginal bone levels, patient satisfaction, complications
alternative and factors that may influence them. It is also desirable to obtain information regarding the subjective assessment of the patients because, after all, our main purpose is their satisfaction and well-being. The aim of this study was to assess the long-term outcomes of osseointegrated dental implants placed in partially and totally edentulous patients. Part I of this study reports survival and marginal bone loss, as well as factors that may
have influenced these variables, complications, and patient satisfaction. Part II of this study will report on the presence of periimplant disease and factors that may have had an influence.
MATERIALS
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METHODS
This is a retrospective longitudinal study based on data collected through the patients’ medical and dental records, clinical and radiological examinations, and satisfaction questionnaires.
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Fig. 1. Types of implants placed. Implant brand, shape and surface are specified for all but Frialit implants where the specific implants are named. This chart shows that a variety of implants were placed. However, the size of the sample did not allow for a comparison between each specific implant design.
Patient Sample
Patients who had been rehabilitated through dental implants placed before or during year 2002 in the Magister of Oral Surgery and Implantology of the Faculty of Dentistry of the Complutense University of Madrid were contacted. As long as no important information regarding the implants was lacking, patients who agreed to sign the informed consent and attend an examination of their remaining implants were included in the study. Data were collected from their medical and dental records, including age, gender, drinking and smoking habits, systemic conditions, medication, checkup frequency, cause of original tooth loss, implant characteristics, information regarding implant placement and prosthetic rehabilitation, and complications. Implants placed to replace lost implants were not included. Patient Examination
During the clinical examination, implants and remaining teeth were evaluated (presence of plaque, probing depth, bleeding on probing and/or suppuration, gingival recession, mobility, and others). Presence of pain, anesthesia, or paresthesia was recorded. Intraoral radiographs were taken with help of a paralleling device (XCP, DENTSPLY Rinn, Elgin, Illinois). Radiographs taken at the time of abutment connection or, alternatively, prosthesis placement were considered as baseline.
After digitizing the radiographs, the marginal bone level was evaluated. Implant-abutment junction was used as the reference point in all implants except for Straumann implants (Basel, Switzerland) placed in posterior areas or that received overdentures, in which the coronal limit of the texturized part of the implant was used as reference. The same researcher (A.T.E.) made all the linear measurements of the vertical distance between the reference point and the most coronal bone-to-implant contact, rounding up to the nearest quarter of a millimeter, with help of an image analysis program (DBSWIN version 4.5, DÜRR DENTAL, Bietigheim-Bissingen, Germany). Measurements were calibrated with known lengths of the implant. Follow-up measurements were compared with the baseline measurement to determine modifications in marginal bone level. The patients also filled in a satisfaction questionnaire. Subjective evaluation of function, esthetics, phonetics, and ease of maintaining proper oral hygiene was evaluated by the patient through a visual analog scale.
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from the reference point and implants with a periimplant bone loss greater than 3 mm were also calculated; the former in all patients and the latter only in those with a valid baseline radiograph. Regarding the factors that could influence survival and changes in marginal bone level, the following variables were considered: age at implant placement, gender, smoking (heavy smoker ¼ more than 10 cigarettes per day), alcohol consumption (frequent drinker ¼ more than half a liter of wine per day or equivalent), diabetes, hypertension, diagnosed osteopenia or osteoporosis, bisphosphonate intake, thyroid dysfunction, hypercholesterolemia, chemotherapy and/or head and/or neck radiotherapy, anticoagulant intake, check-up frequency, history of periodontal disease (when the tooth that was replaced by an implant had been lost due to periodontal disease, periodontal pockets were present around remaining teeth or when the patient had been subject to periodontal treatment due to the situation of remaining teeth), implant shape (cylindrical or tapered), surface (minimally rough, moderately rough or rough),32,33 diameter, length and position, 1- or 2-stage surgery, need for regeneration techniques, prosthesis type, and follow-up time. The following statistical analyses were performed with Microsoft Excel and IBM SPSS 19.0 for Windows: • Descriptive statistics for quantitative and qualitative variables • Univariate: Pearson Chi-square test and Fisher exact test for qualitative variables • Multivariate: Logistic regression for the different qualitative variables. Results are given as mean 6 SD. Due to the high proportion of machined surface cylindrical Brånemark system implants, this group was also analyzed separately.
Data Analysis
Implant loss percentages were calculated with the implant and the patient as statistical units. The modification in marginal bone level was only evaluated in patients with a valid baseline radiograph. Percentages of implants with marginal bone level at more than 3 mm
RESULTS Sample Description
Three hundred four patients were identified, of which 105 were finally included in the study. Of the remainder,
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Table 1. Logistic RegressiondSurvival (Unit ¼ Implant) 95% CI for Exp(B)
Independent Variables Check-up frequency Maxilla/mandible Implant length Implant surface
Effect
B
#3 y/.3 y Mandible/maxilla Short/standard Short/long Min rough/mod rough
1.913 2.352 −2.167 −2.630 −1.741
Sig
Exp(B)
Min
Max Factors
0.000 6.774 2.769 16.570 0.000 10.504 2.845 38.776 0.000 0.114 0.035 0.375 0.000 0.072 0.018 0.287 0.004 0.175 0.054 0.565
Multivariate analysis (logistic regression) of the association of different factors with implant failure. The implant is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value. For example, when an implant is placed in the maxilla, there is an increased probability of implant failure, and the odds are multiplied by 10.5.
66.3% were not reachable, 24.6% did not want or were not able to attend the clinic, 7% failed to attend the appointment, and 2% had died. 35.2% of the included patients were male and 64.8% female. The average age at implant placement was 47.84 6 14.42 years (range, 16.02– 71.76 years). These patients had received 342 osseointegrated dental implants (Fig. 1). Regarding implant diameter, it was less than 3.75 mm in 22.2% and more than 4 mm in 19.3% of implants. 9.6% of implants were short (less than 10 mm in length), and 26.9% were long (more than 13 mm in length). The mean follow-up of those implants was 13.19 6 3.70 years (range, 8.46–24.37 years). 52.6% of implants were machined surface cylindrical
Brånemark system implants. A valid baseline radiograph was available for 78.4% of the implants. Implant Loss
9.4% of implants were lost. Of these, 53.1% were lost before prosthesis placement, 37.5% were lost after prosthesis placement, and 9.4% were “asleep.” 78.1% of patients retained all implants placed.
According to the univariate analyses, implant loss was significantly more frequent for implants placed in heavy smokers (P ¼ 0.041), frequent drinkers (P ¼ 0.031), patients who attended check-up every 3 or more years (P ¼ 0.002), short implants (P ¼ 0.016), implants placed in maxillae (P ¼ 0.004), and when the patient was rehabilitated with an overdenture (P ¼ 0.015). At patient level, those with osteopenia or osteoporosis presented implant failure more frequently (P ¼ 0.022). Presence of marginal bone loss greater than 3 mm was significantly more frequent for implants placed in heavy smokers (P ¼ 0.010) and short implants (P ¼ 0.012). Significant results from the multivariate analyses are summarized in Tables 1–3. Complications
Changes in Marginal Bone Level
The marginal bone level was on average 1.84 6 1.35 mm apical to the reference point. 16.1% of the analyzed implants had the bone level at more than 3 mm from the reference point at the final examination; these implants were placed in 26 patients. Regarding the marginal bone level modification, the average was a loss of
Complications were frequent, only 24.8% of patients had not reported any. 45.7% of patients had not suffered biological complications. The most frequent biological complications were periimplant disease (21%), followed by paresthesia (6.7%), gingival hyperplasia (5.7%), pain in the implant area (4.8%), and previous presence of periimplant disease without current disease (4.8%).
Table 2. Logistic RegressiondSurvival (Unit ¼ Patient) 95% CI for Exp(B) Independent Variables Osteopenia/osteoporosis Alcohol consumption
Effect
B
Sig
Exp(B)
Min
Max
Yes/no Yes/no
1.854 −1.226
0.007 0.042
6.388 0.293
1.651 0.090
24.723 0.954
Multivariate analysis (logistic regression) of the association of different factors with implant failure. The patient is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability, and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value.
Table 3. Logistic RegressiondMarginal Bone Loss .3 mm (Unit ¼ Implant) 95% CI for Exp(B) Independent Variables Implant length Smoking
Effect
B
Sig
Exp(B)
Min
Max
Short/standard Short/long Rest/heavy smokers
−2.578 −2.423 2.053
0.009 0.046 0.037
0.076 0.089 7.790
0.011 0.008 1.133
0.520 0.954 53.555
Multivariate analysis (logistic regression) of the association of different factors with the presence of marginal bone loss greater than 3 mm. The implant is used as analysis unit. When the value of the coefficient B is positive, it implies an increase of the probability, and a negative value implies a decrease of the probability; Exp(B) informs how many times the odds are multiplied when a given independent variable has a certain value.
IMPLANT DENTISTRY / VOLUME 23, NUMBER 6 2014 As for mechanical complications, 49.5% of patients had not reported any. The most frequent were screw loosening (21%), porcelain fractures (15.2%), prosthesis fractures (9.5%), loss of the screw-access hole restoration (7.6%), loss or change of retention element (4.8%). Two patients presented lateral radiolucency, and 2 others presented decreased bone density, all of them without clinical symptoms. Patient Satisfaction
The overall satisfaction with the treatment was equal to or greater than 8 of 10 for 79.4% of the patients and greater than 5 of 10 in 98% of patients. The mean values were 8.94 6 1.71 for function, 9.45 6 1.00 for phonetics, 8.63 6 1.98 for esthetics, and 8.21 6 2.07 for the ease of maintaining proper oral hygiene.
DISCUSSION In this retrospective longitudinal study, long-term results of implants were evaluated based on survival, changes in marginal bone levels, and the presence of periimplant disease (described in Part II). In this study, after a mean followup of 13 years, 9.4% of implants failed and 78.1% of patients retained all implants placed. Marginal bone loss was −0.77 6 1.10 mm, with 2.5% of implants exhibiting a bone loss of more than 3 mm. Patient satisfaction was high, despite the fact that complications were frequent. In the literature, survival figures after 10 years of follow-up generally exceed 90%.2,5,6,9,10,14,17,21–23,25,27,28 With a follow-up of more than 10 years, there is a greater variety of results between 83% and 99% of the implants.4,7,8,12,13,15,19,24,26,34 Other studies have also provided information on survival at patient level. In the study by Roos-Jansåker et al,13 1057 implants placed in 218 patients were retrospectively analyzed after 9 to 14 years follow-up. 89.9% of patients kept all implants placed. In the retrospective study of Simonis et al,19 131 implants in 55 patients were reviewed after up to 16 years. 78.2% of patients retained all implants placed.
In the retrospective study of Dierens et al,24 patients who had received implants 16 to 22 years earlier were contacted. 10.2% of the patients had lost 1 or more implants. Mertens et al26 followed 94 implants for an average of 11.26 years, having retained all of the implants 14 of 15 patients (93.3%). Mean bone loss of 1 mm or less has been reported by Lekholm et al12 and Dierens et al24 after 20 and 16 to 22 years, respectively. Other authors have found greater bone loss. Astrand et al15 informed of a bone loss of 1.72 mm after 20 to 24 years. Simonis et al19 reported a bone loss of 2.2 6 3.4 mm mesially and 2.3 6 3.4 mm distally with a follow-up of 10 to 16 years. Other studies have found bone loss greater than 3 mm in between 1% and 13% of implants after 10 or more years of follow-up.6,11,15,18,25,28 According to our results, it seems that certain factors may have an influence on long-term results of implants such as smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. Smoking was associated both with higher percentages of implant loss and marginal bone loss greater than 3 mm. As in this study, several authors have found a significantly higher implant loss19,20,26,35–37 and increased bone loss27,38–47 in smokers. The 2012 study by Örtorp and Jemt27 showed greater bone loss in smokers during the first year of follow-up, but this difference was not maintained in subsequent years. However, other studies only showed a nonsignificant trend or nonsignificant differences.3,8,10,13,48 Implant loss was more frequent in patients diagnosed with osteopenia or osteoporosis. Preclinical studies in animals suggest that there would be a negative influence of osteoporosis on the bone-to-implant contact. It seems that there is an association between osteoporosis and bone density around teeth and dental implants, and this could be associated with an increased risk of implant failure or reduced load carrying capacity in the long term.49 However, in the 2006 revision by Mombelli and Cionca,50 heterogeneous data were found
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regarding implant failures in patients with osteoporosis, with low evidence of association. There was a significantly greater implant loss and presence of marginal bone loss greater than 3 mm when the implant was short. Several authors have also found a significantly greater loss of short implants.2,4,7,35,51–55 Conflicting data can be found in the literature regarding the relation between marginal bone loss and implant length. Although Chung et al45 found a higher annual bone loss in short than in long implants, in the study by Ormianer and Palti,56 bone loss was more frequent in long than in short implants. Other authors found no significant differences.57–59 In this study, implant loss was more common in the maxilla than in the mandible and more specifically, in order, in the posterior and anterior maxilla, followed by the posterior and anterior mandible. Several authors have reported a greater loss of implants in the maxilla than in the mandible.2,13,52,54,59,60 There was a greater loss of implants in cases rehabilitated with overdentures. Other authors have also reported higher implant failure for overdentures.29,30,54 This is possibly due to the fact that this treatment option is usually chosen in critical cases where enough fixtures for another type of rehabilitation cannot be placed, such as those with extreme bone resorption and poor bone quality.29,61 Study Limitations
The design of this study entails a number of limitations. Also, only one third of the identified patients could be included in this study. Of those not included, more than half could not be contacted, and many found it difficult to attend the clinic due to the travel distance and limited opening hours. Although other studies have included data collected through telephone interviews to assess long-term results20,24,38,62 and none of the excluded patients who were reachable informed of implant loss, this information was not included in the analysis. This study can only suggest a possible influence of different factors; cause-effect relationships can only be established with long-term randomized clinical trials.
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CONCLUSIONS 1. Implant survival was 90.6% of the implants after a follow-up of 8.5 to 24 years. 78.1% of patients retained all the implants. 2. Bone level at the final examination was on average 1.84 6 1.35 mm apical to the reference point and mean marginal bone modification was −0.77 6 1.10 mm. 16.1% of the implants had bone level more than 3 mm from the reference point, and 2.5% of implants with valid baseline radiograph showed bone loss greater than 3 mm. 3. It seems that certain factors may have an influence on long-term results of implants such as smoking, osteopenia or osteoporosis, check-up frequency, implant surface, length and position, and type of prosthesis. 4. Complications were frequent: only 24.8% of patients remained free of complications. 5. Patient satisfaction with treatment was high. In summary, in our sample,which included both totally and partially edentulous patients, long-term implant survival was more than 90% with a mean marginal bone loss of 0.77 mm and an implant survival at patient level of 78%; patient satisfaction was high despite the fact that complications were frequent.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
ACKNOWLEDGMENTS The authors would like to thank Pedro Cuesta and Santiago Cano for their invaluable help with the statistical analysis.
REFERENCES 1. Brånemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad
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modum Brånemark in full edentulism. Clin Oral Implants Res. 1995;6:227–231. 2. Lekholm U, Gunne J, Henry P, et al. Survival of the Brånemark implant in partially edentulous jaws: A 10-year prospective multicenter study. Int J Oral Maxillofac Implants. 1999;14:639–645. 3. Brocard D, Barthet P, Baysse E, et al. A multicenter report on 1,022 consecutively placed ITI implants: A 7-year longitudinal study. Int J Oral Maxillofac Implants. 2000;15:691–700. 4. Bryant SR. Oral Implant Outcomes Predicted by Age- and Site-specific Aspects of Bone Condition (master’s thesis). Toronto: Department of Prosthodontics, University of Toronto, 2001. 5. Ferrigno N, Laureti M, Fanali S, et al. A long-term follow-up study of non-submerged ITI implants in the treatment of totally edentulous jaws. Part I: Ten-year life table analysis of a prospective multicenter study with 1286 implants. Clin Oral Implants Res. 2002;13:260–273. 6. Leonhardt A, Gröndahl K, Bergström C, et al. Long-term follow-up of osseointegrated titanium implants using clinical, radiographic and microbiological parameters. Clin Oral Implants Res. 2002;13:127– 132. 7. Naert I, Koutsikakis G, Duyck J, et al. Biologic outcome of implant-supported restorations in the treatment of partial edentulism. Part I: A longitudinal clinical evaluation. Clin Oral Implants Res. 2002; 13:381–389. 8. Attard NJ, Zarb GA. Long-term treatment outcomes in edentulous patients with implant-fixed prostheses: The Toronto study. Int J Prosthodont. 2004; 17:417–424. 9. Pjetursson BE, Tan K, Lang NP, et al. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 2004;15:625–642. 10. Rasmusson L, Roos J, Bystedt H. A 10-year follow-up study of titanium dioxide-blasted implants. Clin Implant Dent Relat Res. 2005;7:36–42. 11. Jemt T, Johansson J. Implant treatment in the edentulous maxillae: A 15-year follow-up study on 76 consecutive patients provided with fixed prostheses. Clin Implant Dent Relat Res. 2006;8:61– 69. 12. Lekholm U, Gröndahl K, Jemt T. Outcome of oral implant treatment in partially edentulous jaws followed 20 years in clinical function. Clin Implant Dent Relat Res. 2006;8:178–186. 13. Roos-Jansåker AM, Lindahl C, Renvert H, et al. Nine- to fourteen-year follow-up of implant treatment. Part I: Implant
loss and associations to various factors. J Clin Periodontol. 2006;33:283–289. 14. Visser A, Meijer HJ, Raghoebar GM, et al. Implant-retained mandibular overdentures versus conventional dentures: 10 years of care and aftercare. Int J Prosthodont. 2006;19:271–278. 15. Astrand P, Ahlqvist J, Gunne J, et al. Implant treatment of patients with edentulous jaws: A 20-year follow-up. Clin Implant Dent Relat Res. 2008;10:207– 217. 16. Jung RE, Pjetursson BE, Glauser R, et al. A systematic review of the 5-year survival and complication rates of implantsupported single crowns. Clin Oral Implants Res. 2008;19:119–130. 17. Lambert FE, Weber HP, Susarla SM, et al. Descriptive analysis of implant and prosthodontic survival rates with fixed implant-supported rehabilitations in the edentulous maxilla. J Periodontol. 2009; 80:1220–1230. 18. Pikner SS, Gröndahl K, Jemt T, et al. Marginal bone loss at implants: A retrospective, long-term follow-up of turned Brånemark system implants. Clin Implant Dent Relat Res. 2009;11:11–23. 19. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: A 10-16-year follow-up of non-submerged dental implants. Clin Oral Implants Res. 2010;21:772–777. 20. Vercruyssen M, Marcelis K, Coucke W, et al. Long-term, retrospective evaluation (implant and patient-centered outcome) of the two-implants-supported overdenture in the mandible. Part 1: Survival rate. Clin Oral Implants Res. 2010;21: 357–365. 21. Ueda T, Kremer U, Katsoulis J, et al. Long-term results of mandibular implants supporting an overdenture: Implant survival, failures, and crestal bone level changes. Int J Oral Maxillofac Implants. 2011;26:365–372. 22. Buser D, Janner SF, Wittneben JG, et al. 10-Year survival and success rates of 511 titanium implants with a sandblasted and acid-etched surface: A retrospective study in 303 partially edentulous patients. Clin Implant Dent Relat Res. 2012;14:839– 851. 23. Degidi M, Nardi D, Piattelli A. 10year follow-up of immediately loaded implants with TiUnite porous anodized surface. Clin Implant Dent Relat Res. 2012;14:828– 838. 24. Dierens M, Vandeweghe S, Kisch J, et al. Long-term follow-up of turned single implants placed in periodontally healthy patients after 16-22 years: Radiographic and peri-implant outcome. Clin Oral Implants Res. 2012;23:197–204. 25. Fischer K, Stenberg T. Prospective 10-year cohort study based on a random-
IMPLANT DENTISTRY / VOLUME 23, NUMBER 6 2014 ized controlled trial (RCT) on implant-supported full-arch maxillary prostheses. Part 1: Sandblasted and acid-etched implants and mucosal tissue. Clin Implant Dent Relat Res. 2012;14:808–815. 26. Mertens C, Steveling HG, Stucke K, et al. Fixed implant-retained rehabilitation of the edentulous maxilla: 11-year results of a prospective study. Clin Implant Dent Relat Res. 2012;14:816–827. 27. Örtorp A, Jemt T. CNC-Milled titanium frameworks supported by implants in the edentulous jaw: A 10-year comparative clinical study. Clin Implant Dent Relat Res. 2012;14:88–99. 28. Östman PO, Hellman M, Sennerby L. Ten years later. Results from a prospective single-center clinical study on 121 oxidized (TiUnite™) Brånemark implants in 46 patients. Clin Implant Dent Relat Res. 2012;14:852–860. 29. Esposito M, Hirsch JM, Lekholm U, et al. Biological factors contributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. Eur J Oral Sci. 1998;106:527–551. 30. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2002;29(suppl 3):197– 212. 31. Lang NP, Berglundh T, HeitzMayfield LJ, et al. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants. 2004;19(suppl):150–154. 32. Albrektsson T, Wennerberg A. Oral implant surfaces: Part 1dReview focusing on topographic and chemical properties of different surfaces and in vivo responses to them. Int J Prosthodont. 2004;17:536– 543. 33. Albrektsson T, Wennerberg A. Oral implant surfaces: Part 2dReview focusing on clinical knowledge of different surfaces. Int J Prosthodont. 2004;17:544–564. 34. Merickse-Stern R, Aerni D, Geering AH, et al. Long-term evaluation of non-submerged hollow cylinder implants. Clinical and radiographic results. Clin Oral Implants Res. 2001;12:252–259. 35. Baelum V, Ellegaard B. Implant survival in periodontally compromised patients. J Periodontol. 2004;75:1404–1412. 36. Strietzel FP, Reichart PA, Kale A, et al. Smoking interferes with the prognosis of dental implant treatment: A systematic review and meta-analysis. J Clin Periodontol. 2007;34:523–544. 37. Koldsland OC, Scheie AA, Aass AM. Prevalence of implant loss and
the influence of associated factors. J Periodontol. 2009;80:1069–1075. 38. Vercruyssen M, Quirynen M. Longterm, retrospective evaluation (implant and patient-centered outcome) of the twoimplant-supported overdenture in the mandible. Part 2: Marginal bone loss. Clin Oral Implants Res. 2010;21:466–472. 39. Lindquist LW, Carlsson GE, Jemt T. Association between marginal bone loss around osseointegrated mandibular implants and smoking habits: A 10-year follow-up study. J Dent Res. 1997;76:1667– 1674. 40. Haas R, Haimböck W, Mailath G, et al. The relationship of smoking on periimplant tissue: A retrospective study. J Prosthet Dent. 1996;76:592–596. 41. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study of mandibular fixed prostheses supported by osseointegrated implants. Clinical results and marginal bone loss. Clin Oral Implants Res. 1996;7:329–336. 42. Gruica B, Wang HY, Lang NP, et al. Impact of IL-1 genotype and smoking status on the prognosis of osseointegrated implants. Clin Oral Implants Res. 2004;15: 393–400. 43. Karoussis IK, Müller S, Salvi GE, et al. Association between periodontal and peri-implant conditions: A 10-year prospective study. Clin Oral Implants Res. 2004;15:1–7. 44. Galindo-Moreno P, Fauri M, AvilaOrtiz G, et al. Influence of alcohol and tobacco habits on peri-implant marginal bone loss: A prospective study. Clin Oral Implants Res. 2005;16:579–586. 45. Chung DM, Oh TJ, Lee J, et al. Factors affecting late implant bone loss: A retrospective analysis. Int J Oral Maxillofac Implants. 2007;22:117–126. 46. Fransson C, Wennström J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss. Clin Oral Implants Res. 2008;19:142– 147. 47. Stoker G, van Waas R, Wismeijer D. Long-term outcomes of three types of implant-supported mandibular overdentures in smokers. Clin Oral Implants Res. 2012;23:925–929. 48. García-Bellosta S, Bravo M, Subirá C, et al. Retrospective study of the longterm survival of 980 implants placed in a periodontal practice. Int J Oral Maxillofac Implants. 2010;25:613–619. 49. Giannobile WV, Ríos HF, Lang NP. El hueso como tejido. In: Lindhe J, Lang NP, Karring T, eds. Periodontología clínica e implantología odontológica. 5th Ed. Buenos Aires: Médica Panamericana, 2009: 86–98.
737
50. Mombelli A, Cionca N. Systemic diseases affecting osseointegration therapy. Clin Oral Implants Res. 2006;17(suppl 2):97–103. 51. Ellegaard B, Baelum V, KølsenPetersen J. Non-grafted sinus implants in periodontally compromised patients: A time-to-event analysis. Clin Oral Implants Res. 2006;17:156–164. 52. Snauwaert K, Duyck J, van Steenberghe D, et al. Time dependent failure rate and marginal bone loss of implant supported prostheses: A 15-year followup study. Clin Oral Investig. 2000;4:13–20. 53. Artzi Z, Carmeli G, Kozlovsky A. A distinguishable observation between survival and success rate outcome of hydroxyapatite-coated implants in 5-10 years in function. Clin Oral Implants Res. 2006;17:85–93. 54. Herrmann I, Lekholm U, Holm S, et al. Evaluation of patient and implant characteristics as potential prognostic factors for oral implant failures. Int J Oral Maxillofac Implants. 2005;20:220–230. 55. Renouard F, Nisand D. Impact of implant length and diameter on survival rates. Clin Oral Implants Res. 2006;17 (suppl 2):35–51. 56. Ormianer Z, Palti A. Retrospective clinical evaluation of tapered screw-vent implants: Results after up to eight years of clinical function. J Oral Implantol. 2008;34:150–160. 57. Lops D, Bressan E, Pisoni G, et al. Short implants in partially edentulous maxillae and mandibles: A 10 to 20 years retrospective evaluation. Int J Dent. 2012; 2012:351793. 58. Naert I, Koutsikakis G, Quirynen M, et al. Biologic outcome of implant-supported restorations in the treatment of partial edentulism. Part 2: A longitudinal radiographic study. Clin Oral Implants Res. 2002;13:390–395. 59. Mertens C, Steveling HG. Implantsupported fixed prostheses in the edentulous maxilla: 8-year prospective results. Clin Oral Implants Res. 2011;22:464–472. 60. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997;8:161–172. 61. Engquist B, Bergendal T, Kallus T, et al. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implants. 1988;3:129–134. 62. Gotfredsen KA. 10-year prospective study of single tooth implants placed in the anterior maxilla. Clin Implant Dent Relat Res. 2012;14:80–87.
