Torsten Jemt

Association between Marginal Bone Loss around Osseointegrated Mandibular Implants and Smoking Habits: A 10-year Follow-up Study

While many factors are conceivable, occlusal loading and plaque-induced inflammation are frequently stated as the most important ones negatively affecting the prognosis of oral implants. Currently, little is known about the relative importance of such factors. The aim of this study was to analyze the influence of smoking and other possibly relevant factors on bone loss around mandibular implants. The participants were 45 edentulous patients, 21 smokers and 24 non-smokers, who were followed for a 10-year period after treatment with a fixed implant-supported prosthesis in the mandible. The peri-implant bone level was measured on intraoral radiographs, information about smoking habits was based on a careful interview, and oral hygiene was evaluated from clinical registration of plaque accumulation. Besides standard statistical methods, multiple linear regression models were constructed for estimation of the relative influence of some factors on peri-implant bone loss. The long-term results of the implant treatment were good, and only three implants (1%) were lost. The mean marginal bone loss around the mandibular implants was very small, about 1 mm for the entire 10-year period. It was greater in smokers than in non-smokers and correlated to the amount of cigarette consumption. Smokers with poor oral hygiene showed greater marginal bone loss around the mandibular implants than those with good oral hygiene. Oral hygiene did not significantly affect bone loss in non-smokers. Multivariate analyses showed that smoking was the most important factor among those analyzed for association with peri-implant bone loss. The separate models for smokers and non-smokers revealed that oral hygiene had a greater impact on peri-implant bone loss among smokers than among non-smokers. This study showed that smoking was the most important factor affecting the rate of peri-implant bone loss, and that oral hygiene also had an influence, especially in smokers, while other factors, e.g., those associated with occlusal loading, were of minor importance. These results indicate that smoking habits should be included in analyses of implant survival and peri-implant bone loss.

A 3-year follow-up study on single implant treatment

The purpose of this study was to investigate restorative and postinsertion problems in patients provided with single implant supported restorations. Fifty consecutive single implant patients were reviewed over a period of 3 years following placement of artificial crowns. One (1.4%) of the 70 inserted implants was lost during the follow-up period, which gives a cumulative success rate of 98.5%. The most frequent complication was loosening of the single tooth abutment screw. This problem was associated with fistulas during the first year of clinical service. A more severe complication was that three adjacent teeth had to be endodontically treated due to accidental devitalization from surgical trauma during implant insertion. The mean marginal bone level adjacent to the implants was reduced 0.5 mm from crown insertion to the third annual review.

Is marginal bone loss around oral implants the result of a provoked foreign body reaction

BACKGROUND When a foreign body is placed in bone or soft tissue, an inflammatory reaction inevitably develops. Hence, osseointegration is but a foreign body response to the implant, which according to classic pathology is a chronic inflammatory response and characterized by bone embedding/separation of the implant from the body. PURPOSE The aim of this paper is to suggest an alternative way of looking at the reason for marginal bone loss as a complication to treatment rather than a disease process. MATERIALS AND METHODS The present paper is authored as a narrative review contribution. RESULTS The implant-enveloping bone has sparse blood circulation and is lacking proper innervation in clear contrast to natural teeth that are anchored in bone by a periodontal ligament rich in blood vessels and nerves. Fortunately, a balanced, steady state situation of the inevitable foreign body response will be established for the great majority of implants, seen as maintained osseointegration with no or only very little marginal bone loss. Marginal bone resorption around the implant is the result of different tissue reactions coupled to the foreign body response and is not primarily related to biofilm-mediated infectious processes as in the pathogenesis of periodontitis around teeth. This means that initial marginal bone resorption around implants represents a reaction to treatment and is not at all a disease process. There is clear evidence that the initial foreign body response to the implant can be sustained and aggravated by various factors related to implant hardware, patient characteristics, surgical and/or prosthodontic mishaps, which may lead to significant marginal bone loss and possibly to implant failure. Admittedly, once severe marginal bone loss has developed, a secondary biofilm-mediated infection may follow as a complication to the already established bone loss. CONCLUSIONS The present authors regard researchers seeing marginal bone loss as a periodontitis-like disease to be on the wrong track; the onset of marginal bone loss around oral implants depends in reality on a dis-balanced foreign body response.

CNC‐Milled Titanium Frameworks Supported by Implants in the Edentulous Jaw: A 10‐Year Comparative Clinical Study

BACKGROUND No long-term clinical studies covering more than 5 years are available on Computer Numeric Controlled (CNC) milled titanium frameworks. AIM To evaluate and compare the clinical and radiographic performance of implant-supported prostheses provided with CNC titanium frameworks in the edentulous jaw with prostheses with cast gold-alloy frameworks during the first 10 years of function. MATERIAL AND METHODS Altogether, 126 edentulous patients were by random provided with 67 prostheses with titanium frameworks (test) in 23 maxillas and 44 mandibles, and with 62 prostheses with gold-alloy castings (control) in 31 maxillas and 31 mandibles. Clinical and radiographic 10-year data were collected for the groups and statistically compared on patient level. RESULTS The 10-year prosthesis and implant cumulative survival rate was 95.6% compared with 98.3%, and 95.0% compared with 97.9% for test and control groups, respectively (p > .05). No implants were lost after 5 years of follow-up. Smokers lost more implants than nonsmokers after 5 years of follow-up (p < .01). Mean marginal bone loss in the test group was 0.7 mm (SD 0.61) and 0.7 mm (SD 0.85) in the maxilla and mandible, with similar pattern in the control group (p > .05), respectively. One prosthesis was lost in each group due to loss of implants, and one prosthesis failed due to framework fracture in the test group. Two metal fractures were registered in each group. More appointments of maintenance were needed for the prostheses in the maxilla compared with those in the mandible (p < .001). CONCLUSION The frequency of complications was low with similar clinical and radiological performance for both groups during 10 years. CNC-milled titanium frameworks are a viable alternative to gold-alloy castings for restoring patients with implant-supported prostheses in the edentulous jaw.

Marginal Bone Loss at Implants: A Retrospective, Long‐Term Follow‐Up of Turned Brånemark System® Implants

BACKGROUND Lately, presence of progressive bone loss around oral implants has been discussed. PURPOSE The aim of this study was to report in a large patient group with different prosthetic restorations marginal bone level and its change as measured in radiographs obtained from prosthesis insertion up to a maximum 20 years in service. Further, it also aimed to study the impact of gender, age, jaw, prosthetic restoration, and calendar year of surgery. MATERIALS AND METHODS Out of 1,716 patients recorded for clinical examination during 1999, 1,346 patients (78.4%) could be identified. A total of 640 patients (3,462 originally installed Brånemark System implants, Nobel Biocare, Göteborg, Sweden) with a follow-up of >or=5 years were included in the study, while patients with continuous overdentures and augmentation procedures were not. Distance between the fixture/abutment junction (FAJ) and the marginal bone level was recorded. RESULTS The number of implants with a mean bone level of >or=3 mm below FAJ increased from 2.8% at prosthesis insertion to 5.6% at year 1, and 10.8% after 5 years. Corresponding values after 10, 15, and 20 years were 15.2, 17.2, and 23.5%, respectively. Implant-based bone loss was as a mean 0.8 mm (SD 0.8) after 5 years, followed by only minor average changes. Mean bone loss on patient level followed a similar pattern. Disregarding follow-up time, altogether 183 implants (107 patients) showed a bone loss >or=3 mm from prosthesis insertion to last examination. Significantly larger bone loss was found the older the patient was at surgery and for lower jaw implants. CONCLUSIONS Marginal bone support at Brånemark implants was with few exceptions stable over years.

Rehabilitation of Edentulous Mandibles by Means of Five TiUnite™ Implants After One‐Stage Surgery: A 1‐Year Retrospective Study of 90 Patients

BACKGROUND Recently, the present team reported the 1-year data of one-stage surgery and mainly early loading performed in edentulous mandibles using 750 turned Brånemark System implants in 152 patients. PURPOSE The aim of the present investigation was to retrospectively evaluate the 1-year results of the same treatment technique, using Brånemark System implants with an oxidized surface (TiUnite, Nobel Biocare AB, Göteborg, Sweden). The outcome was compared with that of the former study (control) on turned implants. MATERIALS AND METHODS The present study involved 90 individuals with 450 TiUnite implants of mainly the Brånemark System Mark III design, placed in edentulous mandibles and using one-stage surgery. The prosthetic procedure was commenced as a mean 8 days after the surgical intervention. Intraoral radiographs were obtained at prosthesis insertion and at the 1-year annual checkup. Failure rates of test and control groups were compared by means of the chi-square test. RESULTS No implants were found to be mobile up to and including the first annual checkup, resulting in an implant cumulative survival rate (CSR) of 100%. The corresponding CSR for the control group was 97.5%, and this difference in implant survival was statistically significant when analyzed with the chi-square test (p < .001). A statistically significant difference was also demonstrated (p < .01) when conducting the same statistical analysis on the patient level. The mean marginal bone resorption during the first year of function was 0.49 mm (SD 0.56), and the corresponding figures for the control study were 0.39 mm (SD 0.46). The central TiUnite implant, that is, the one placed in or in close relation to the symphyseal region showed significantly more bone loss (p < .05) than the corresponding central turned implant of the control study. Distally positioned test implants demonstrated less marginal bone loss than the corresponding central one. CONCLUSIONS The outcome of 450 TiUnite implants placed in 90 patients with edentulous mandibles, of which 380 implants in 76 patients were followed for 1 year, showed an implant CSR of 100%. The figure was significantly different from the control study result of 97.5% on turned surface implants. The levels of marginal bone were close to identical for test and control implants at the 1-year checkup.

Early Laser-Welded Titanium Frameworks Supported by Implants in the Edentulous Mandible: A 15-Year Comparative Follow-Up Study

BACKGROUND Comparative long-term knowledge of different framework materials in the edentulous implant patient is not available for 15 years of follow-up. PURPOSE To report and compare a 15-year retrospective data on implant-supported prostheses in the edentulous mandible provided with laser-welded titanium frameworks (test) and gold alloy frameworks (control). MATERIALS AND METHODS Altogether, 155 patients were consecutively treated with abutment-level prostheses with two early generations of fixed laser-welded titanium frameworks (titanium group). Fifty-three selected patients with gold alloy castings formed the control group. Clinical and radiographic 15-year data were collected and compared for the groups. RESULTS All patients who were followed up for 15 years (n = 72) still had a fixed prosthesis in the mandible at the termination of the study. The 15-year original prosthesis cumulative survival rate (CSR) was 89.2 and 100% for titanium and control frameworks (p = .057), respectively (overall CSR 91.7%). The overall 15-year implant CSR was 98.7%. The average 15-year bone loss was 0.59 mm (SD 0.56) and 0.98 mm (SD 0.64) for the test and control groups (p = .027), respectively. Few (1.3%) implants had >3.1-mm accumulated bone loss after 15 years. The most common complications for titanium frameworks were resin or veneer fractures and soft tissue inflammation. Fractures of the titanium metal frame were observed in 15.5% of the patients. More patients had framework fractures in the earliest titanium group (Ti-1 group) compared to the gold alloy group (p = .034). Loose and fractured implant screw components were few (2.4%). CONCLUSION Predictable overall long-term results could be maintained with the present treatment modality. Fractures of the metal frames and remade prostheses were more common in the test group, and the gold alloy frameworks had a tendency to work better when compared with welded titanium frameworks during 15 years. However, on the average, more bone loss was observed for implants supporting gold alloy frameworks.

Statements from the Estepona Consensus Meeting on Peri-implantitis

† The great majority of well-documented oralimplants show very good long-term clinical results.† A limited amount of crestal bone loss (CBL) ormarginal bone loss may be a biologic response toimplant placement.† CBL may occur for reasons other than infection.† CBL may occur around implants and can have along-termimpactontheoutcomeof thoseimplants.† Some implants can demonstrate substantial boneloss, but a steady state may be reached and nofurther clinically significant bone loss observed.† There is an adaptive change of the crestal bone levelafter placement and restoration.† Peri-implantitis is an unsuitable term to describe allCBL.† The term peri-implantitis is here defined as aninfection with suppuration associated with clini-cally significant progressing CBL after the adaptivephase.† In contrast, peri-implant mucositis is defined asinflammation of the peri-implant mucosa withoutdiscernibly progressing CBL.† Bone remodeling including CBL is influenced byinflammation.† Implant-, clinician-, and patient-related factors aswell as foreign body reactions may contribute toCBL. Implant factors: material, surface properties,and design (e.g., ease of plaque removal); clinicianfactors: surgical and prosthodontic experience,skills, and ethics; patient factors: systemic diseaseand medication, oral disease (e.g., untreated orrefractory periodontal disease, local infections),behavior (e.g., patient compliance with oral hygieneand maintenance, smoking), and site-related factors(e.g., bone volume and density, soft tissue quality);and foreign body reactions (e.g., corrosion by-products, excess cement in soft tissues).† A radiograph does not give an absolutely accuratepicture of the bone-implant contact or the crestalbone situation. However, the periapical radiographis an important clinical tool to be used at im-plant placement, implant loading, and repeatedlythereafter.† Radiographs taken longitudinally may assist the cli-nician to monitor changes in crestal bone levels.† Peri-implant examinations that include bleedingon probing and probing depths do not by

Clinical experience of TiUnite implants: a 5-year cross-sectional, retrospective follow-up study.

BACKGROUND Little is known of the long-term clinical and radiographic performance of moderately rough surface implants. PURPOSE The aim of the present retrospective investigation was to study two pioneer cohorts of patients, that is, the first patients to receive Brånemark System implants with a moderately rough surface (TiUnite, Nobel Biocare AB, Göteborg, Sweden) at the present clinic. TiUnite implants were inserted either in compromised bone sites in a mixed-mouth concept together with turned implants or used solely. Patients were followed up over a period of 5 years with regard to implant survival and the marginal bone response. MATERIALS AND METHODS Patients who received both implant types (mixed group) comprised 41 subjects, and the second group (TiUnite group) comprised 70 subjects. A total of 110 turned and 68 TiUnite implants were placed in the mixed group, and 212 TiUnite implants in the TiUnite group. Follow-up radiographs were obtained at prosthesis placement and at the 1- and 5-year check-ups, and examined by independent observers. RESULTS One turned (0.9%) and two TiUnite (2.9%) implants failed in the mixed group, and three implants (1.6%) failed in the TiUnite group, indicating no significant differences between surfaces or groups (p < .05). The mean marginal bone loss at 5 years was 0.6 mm to 0.8 mm, also indicating no significant differences for the two implant types tested in the mixed group. CONCLUSIONS Cumulative survival rates for the two implant surfaces were favorable at 5 years, and the marginal bone loss was low and similar for both implant surfaces.

Statements from the Estepona Consensus Meeting on Peri-implantitis, February 2–4, 2012

† The great majority of well-documented oralimplants show very good long-term clinical results.† A limited amount of crestal bone loss (CBL) ormarginal bone loss may be a biologic response toimplant placement.† CBL may occur for reasons other than infection.† CBL may occur around implants and can have along-termimpactontheoutcomeof thoseimplants.† Some implants can demonstrate substantial boneloss, but a steady state may be reached and nofurther clinically significant bone loss observed.† There is an adaptive change of the crestal bone levelafter placement and restoration.† Peri-implantitis is an unsuitable term to describe allCBL.† The term peri-implantitis is here defined as aninfection with suppuration associated with clini-cally significant progressing CBL after the adaptivephase.† In contrast, peri-implant mucositis is defined asinflammation of the peri-implant mucosa withoutdiscernibly progressing CBL.† Bone remodeling including CBL is influenced byinflammation.† Implant-, clinician-, and patient-related factors aswell as foreign body reactions may contribute toCBL. Implant factors: material, surface properties,and design (e.g., ease of plaque removal); clinicianfactors: surgical and prosthodontic experience,skills, and ethics; patient factors: systemic diseaseand medication, oral disease (e.g., untreated orrefractory periodontal disease, local infections),behavior (e.g., patient compliance with oral hygieneand maintenance, smoking), and site-related factors(e.g., bone volume and density, soft tissue quality);and foreign body reactions (e.g., corrosion by-products, excess cement in soft tissues).† A radiograph does not give an absolutely accuratepicture of the bone-implant contact or the crestalbone situation. However, the periapical radiographis an important clinical tool to be used at im-plant placement, implant loading, and repeatedlythereafter.† Radiographs taken longitudinally may assist the cli-nician to monitor changes in crestal bone levels.† Peri-implant examinations that include bleedingon probing and probing depths do not by