Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2011 38; 286294

Review Article

Current challenges in successful rehabilitation with oral implants

A. WENNERBERG* & T. ALBREKTSSON

*Department of Prosthodontics, Faculty of Odontology, Malmo

University and Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Sweden

SUMMARY

Very high survival success rates have been reported for implant treatment, irrespective of the prosthetic type of reconstruction, be those full arcs, partial dentures, combined tooth implants or single crowns. However, survival success is commonly reported in simple Cumulative Survival Success Rate (CSR) tables only that may overestimate the true clinical outcome; furthermore, future challenges to clinical success may originate from too

rapid launching of untested novelties or recommendations to apply too bold clinical procedures, potential problems that are summarised in the present paper. KEYWORDS: oral implant treatment, clinical results, challenges, review Accepted for publication 19 September 2010

Introduction
Treating edentulous or partially dentate patients with implants is today a most common option to restore lost function with respect to chewing capability and aesthetics. Clinical long-term investigations (>5 years of follow-up) report very favourable survival rates at the implant as well as the prosthetic level for xed complete dentures, xed partial dentures, overdentures or single crown restorations.

Complete xed dentures (CFD)

CFD was the only treatment option recommended in the infancy of modern implantology, because it was deemed the best solution for totally edentulous patients during the rst decades of osseointegration. Today, there exist numbers of publications demonstrating a very good clinical outcome with CFDs after >5 years of follow-up. An overview of relevant literature reports implant survival to be in the rate of 87100% after 5 years or more of follow-up, where the lower gures were mostly related to maxillary dentures. The corresponding prosthesis survival rate was in the range of
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93100%. The marginal bone resorption varied between 02 and 05 mm after 5-year follow-up (16). The referred studies all used turned implants, i.e. a minimally rough surface with an average height deviation of about 07 lm. Today, most implants have a moderately rough surface, in the range of 12 lm in height deviation. The benets of moderately rough surfaces will be discussed later in this paper. Even if the follow-up period is substantially prolonged from 5 years to 1520 years, clinical results remain very good with an implant survival rate of 8799% and prostheses survival of 84100% (710). The mean marginal bone resorption in these long-term follow-up studies amounted to approximately 2 mm, with an annual resorption of 005 mm after year 1 (8, 9). Again, the implants in these long-term studies were without exception turned, Branemark titanium screws. The reported complications were dominated by fracture of resins, hyperplasia and mucositis (37). As judged from the literature, CFDs supported by implants will provide a good and predictable long-term clinical result. New types of supraconstructions, the use of titanium instead of gold (1) or milling instead of casting (11), have actually been proven to result in an
doi: 10.1111/j.1365-2842.2010.02170.x

CHALLENGES IN ORAL IMPLANT TREATMENT

improved t and not in a challenge towards the treatment outcome. favourable results. The marginal bone resorption was reported to be small 0212 mm after 5 years (2326). Resin fractures and prosthesis screw loosening were the dominating complications after 5 years of follow-up in the aforementioned studies.

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Overdentures (OD) The Implant Survival rate demonstrates a huge variation, 7297% after 57 years in function, with significantly better results in the mandible compared with the maxillae. The prosthesis survival rate varies too, 78100% again with the lower gures representing the clinical outcome with ODs in the upper jaw (1216). The mean marginal bone resorption was in general small, 0608 mm, (12, 15, 16). The survival of the implants and the ODs was seemingly better after 1015 years; however, implant survival is 8697% and OD survival is 9193% gures from the latter studies limited to ODs in the mandible (1719). Still the marginal bone resorption was reported to be very low, 1 mm after the 1 year and thereafter 005 mm per year (17). The OD treatment necessitated frequent revisits to the dental clinic for adjustment of the prosthesis, change of attachment, activation of attachment and relining. Although regular revisits were necessary, a majority of the treated patients were satised or very satised with this treatment option (16, 20). In a systematic overview, Bryant et al. (21) included 46 studies with a follow-up time of 5 years. This study conrmed the previously cited studies with an implant survival of 7184% and a prosthesis survival of 7887% in the maxilla, corresponding values in the mandible were 83100% and 100%, respectively. The marginal bone resorption was reported to be 0512 mm in the maxilla and 0211 in the mandible. Stanford (22) stressed the importance of information to patients before treatment about the necessity for annual visits to the dental clinic for prosthesis check-up and adjustments. The cited literature related to treatment with ODs is mainly using turned implants, but there are TPS (Titanium Plasma Sprayed) surfaces included too.

Fixed partial dentures supported by tooth and implant A systematic review revealed a survival rate of the construction of more than 95% after 5 years, but the gure was signicantly lower after 10 years of followup (78%) (27, 28).

Single crown (SC) Implant supported single crowns have been demonstrated to provide with a high predictability for very good clinical results in several systematic reviews. (2831). The implant survival rate varied between 96 and 97% and the survival of the prosthetic construction was between 87 and 97% after 5 years. There seems to be a difference depending on the material; ceramic crowns had a survival rate of 8797%, while ceramics fused to metals achieved somewhat higher survival rates of 9597%. The marginal bone resorption exceeded 2 mm for 56% of the implants (30). Often reported complications were loss of retention, loosening of abutment screws and fractures of veneer. In a systematic review by Pjetursson and Lang (28), the 10-year survival of implants was still high (89%).

Challenges to maintain a high predictability with implant treatment

Even though an impressive amount of publications report a very favourable clinical outcome with the use of implants in various treatment options, future challenges may be substantial. The majority of the previously cited papers refer to results achieved by specialised surgeons and or prosthodontists and are commonly reported in so-called simple Cumulative Survival Success Rate (CSR) data with bone level reports only that may hide some clear clinical problems. Today, implant treatment is performed by general practitioners with varying degree of experience. A clear knowledge about surgical techniques, optimal implant position, loading conditions, and peri-implant tissues and how to maintain a healthy condition are, but a few,

Fixed partial dentures (FPD) The implant survival rate was reported to be high for this therapy in the range of 9297%. More recent publications have presented improved gures. The prosthesis survival rate differed between 86 and 100%, again with older publications demonstrating less
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examples of clinical skills that may be crucial for the clinical outcome in the future. high levels of implant fracture with increasing time (39). The same risk, if theoretical as we do not know the precise acceptable levels of loading for the material, may affect zirconia that is known to have decreased fracture toughness and strength after prolonged exposure to water vapour at temperatures above 30 degrees centigrades, referred to as low temperature degradation by Chevalier and Gremillard (40).

Possible challenges related to materials

Technical problems may be exemplied by new materials introduced in the implant treatment concept; Ceramic single crowns were reported to have a decreased survival rate compared with metal ceramic crowns as already stated (30). For FPDs ceramic, fractures have been reported to occur in 32% after only 1 year in function (32). The increased use of ceramics may therefore be a problem if the material or material preparation cannot meet with functional demands, and this includes implants made from Zirconia (33). However, ceramic implant abutments seem to function equally well as metal abutments after 5-year follow-up (34). Cobalt-chrome is widely used as a material for the supra-constructions; a direct contact between titanium and Co-Cr is commonly established. Because the oral environment is highly corrosive, this metal contact may increase the corrosion process. Furthermore, laser welding has been demonstrated to frequently result in porosities and microcracks, which may enhance the risk for corrosion (35). Although Co-Cr is a frequently used material, very few studies have been published to verify good clinical results over a long period. Co-Cr may have biological complications such as toxicity and hypersensitivity, if particles ions are released owing to corrosion. A large device such as a Co-Cr knee prosthesis has demonstrated to increase the blood concentration of chromium 5 years post-operatively (36). Although dental implants are much smaller and thus the corrosion products less abundant, this may be of interest because about 13% of the general population is allergic to cobalt and chromium, and the chromium allergy is known to increase (37). Another clear challenge to good science is changing from c.p. titanium to zirconia as implant material that has been suggested by some commercial companies. Zirconia needs surface roughening for proper osseointegration, a procedure that inevitably will lower its strength. Clinical short-term data (1 year) have presented results in the range of 9398% success (33, 38), The main drawback with zirconia is that it may duplicate problems with other ceramics such as aluminium oxide that was found resulting in adequate short-term clinical results but showed unacceptably

Possible challenges related to new surfaces

Still the huge majority of long-term clinical studies of 5 years or more have been related to Branemark implants, i.e. a turned, minimally rough surface (Fig. 1). A considerably rougher surface, the TPS (Titanium Plasma Sprayed), has been shown to result in increased bone resorption when compared with the turned surface (4144) and with a sandblasted and acid etched (SLA) surface (45). Plasma sprayed surfaces have since almost disappeared from the market because of less good clinical results than modern, moderately rough surfaces. We will continue by presenting an overview of clinical results of oral implants but for practical reasons limit this overview to the four largest companies, today allegedly Nobel Biocare, Straumann, Astra Tech and Biomet 3i in that order. In 1992, the rst moderately rough surface was introduced into the market, TiOBlast (Astra Tech AB). The TiOBlast design has today been positively documented for 1012 years (46, 47), it represents the longest followed-up implant system with the exception

Fig. 1. A minimally rough surface. A turned surface, with an average height deviation about 06 lm.
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CHALLENGES IN ORAL IMPLANT TREATMENT

of turned implant surfaces. Today, most of the implant companies have followed suit and introduced their own moderately rough surface modication with the alleged purpose to enhance implant incorporation in bone (Fig. 2). Nobel Biocare introduced TiUnite around 2000, this surface has now been positively documented with good results and maintained bone heights for 5 years (4850). It is interesting to observe that clinical long-term results seem very similar to those of older, turned implants when implants are placed under normal conditions (51), whereas clinical results from other comparative studies between turned and modern implants support the modern versions if implants were placed under challenging conditions (5254). The newer Nobel Active implant with the same surface has been positively documented for a shorter time of 2 years (55). The Straumann SLA implant has likewise been positively documented for 5 years (56). SLActive implants were launched more recently and have now a limited clinical follow-up of 1 year (57) Astra Techs OsseoSpeed implant has been positively documented for a full of 3 years in one clinical study (58) and, if in an abstract form only, for 5 years by Steveling et al. (59). Biomet 3 I Osseotite implants have been supported by clinical data for 5 years (60), whereas the newer Nanotite implants have positive clinical documentation limited to 1 year (61). All in all, it seems like modern, moderately rough implants present as good as or better clinical results compared with older Branemark surfaces when simple comparisons are made at similar times. There is really no reason to believe that patient selection differs in old days compared to modern times, if a difference, modern implants are more commonly placed under more challenging conditions than were older implants. The experimental ndings reporting unstoppable bone resorption around some moderately rough surfaces achieved from so-called ligature studies (62) seem to have little or no clinical correlates at least over a follow-up period of 510 years. However, whether all or some of these modern surfaces will result in bone resorption that will jeopardise the implant treatment after more than 10 years is yet not known. So far, the few existing clinical studies demonstrate no such indication. A comparison after 12 year between Branemark turned implants and Astra Techs TiOBlast demonstrated no difference with respect to marginal bone level, pocket depth, bleeding on probing or plaque accumulation (47). The latest surface modication technique used on commercial implants is to apply nanometre structures on the surface either as a coat or as a result of reconstruction of the supercial oxide layer with the aim to promote early event during the healing phase, i.e. recruit appropriate proteins for further cell adhesion and calcium phosphate deposition (63). Whether these small particles will prove to support clinical function remains unknown.

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Possible challenges and promises related to new designs

Microthreads around the coronal part of oral implants represent an original Astra tech innovation that today has been copied by many implant manufacturers. Microthreads have been demonstrated to maintain bone levels in many clinical studies of Astra Tech implants (64, 65). So-called platform-switched restorations, i.e. a change from the same diameter of the implant as the prosthetic components to a smaller diameter of the latter, have in some clinical studies demonstrated a better bone preservation for a short time of follow-up, 12 years (66, 67) and for 5 years (68). Other studies have failed to demonstrate any difference (69). If this change in design may cause clinical problems after a long time of follow-up is so far unknown. The theoretical mechanisms behind platform switching are neither known do such designs prevent or minimise the alleged disadvantage of microbiological leakages or do they simply present an improved loading situation?

Fig. 2. A moderately rough surface. A blasted and etched surface with an average height deviation close to 15 lm, a structure that is dominating on commercial implants of today.
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Naturally, it must be pointed out that new implants with whatever optimised design and surface properties can never compensate for a badly planned and performed clinical treatment and a poor maintenance of oral hygiene. It is possible that clinical errors represent the major reason for implant failure today (70, 71). the organisers, may those have been periodontists or prosthodontists, i.e. there is anything but a true consensus on the real reason for marginal bone loss. Overloading theories have been criticised by periodontists based on the fact that mainly non-physiological loads have been applied to prove the point, whereas the main periodontal evidence presented for peri-implantitis; ligature studies, no doubt can be claimed to be very far away from any clinical reality. Hence, there is no surprise that periodontists have presented widely varying gures for the proportion of implant patients suffering from the alleged disease, from about 6% (75) to 12% at the implant level (76) to some 70 at the patient level (77). In a recent publication by Koldsland et al. (78), it was concluded that peri-implant inammation was a common clinical observation that may occur with or without bone loss. In contrast, many prosthodontists, biomechanists, oral surgeons and biomaterials researchers interpret the reality very differently, and here gures for periimplantitis have been reported in the 02% range (7981), whereas evidence for bone loss owing to adverse loading has been claimed for interfaces experiencing microstrains of <50100 or more than 3000 (82), with probable if not proven clinical consequences (83). However, irrespective of the origin of the researchers it seems like everyone is agreed that marginal bone loss does not seem to threaten longterm implant survival with the exception of some particular cases. Periodontists have explained this by referring to that peri-implantitis may be a dormant disease like perio-dontitis, whereas prosthodontists are satised by re-adjusting bridges and thereby claim to be able to stop potentially harmful adverse loading of the implants. Like many other controversial issues, the correct explanation for observed marginal bone loss around oral implants may be a third alternative; the healing adaptation theory (84). This theory claims that marginal bone loss and implant failure depend on similar mechanisms, with only the magnitude of the trauma deciding whether an implant may fail or remain in the bone but with marginal bone loss. The healing adaptation theory includes one or more commonly a combination of several of the following examples (Fig. 3), all known to cause problems in the clinical situation and not only experimentally: i) poor surgical techniques (70, 71), ii) poor host beds owing to genetical disorders, drug abuse, disease or previous
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Possible challenges related to new operational techniques

Computer-aided implant surgery has been introduced with the purpose to insert implants more precisely and optimally with respect to the planned prosthetic construction. The technique requires nancial investments, and the clinical outcome may be challenged, especially if computer-guided treatment is used together with apless surgery and immediate loading. Systematic reviews concerning the clinical outcome using computer-guided techniques report a high implant survival, 91100% after 15 years, but a large number of techniques related to surgical and prosthodontic problems occurred (72, 73). Komiyama et al. (74) found a substantial marginal bone resorption and other complications when the aforementioned technique was used when compared with conventional operation technique. Although the patient number was rather small (29 jaws were treated) and the follow-up period was short (1 year), some concern with these recent techniques appears logical. Probably, the evolution moves in the direction of different computer-guided treatment options, but some improvements seem to be needed for a safe and predictable patient caretaking. However, even if signicantly improved, computerised programmes can never be a substitute for a lack of anatomical knowledge and surgical skill.

Possible challenges related to marginal bone loss

Over the last few years, a number of reports, mainly originating from the periodontal discipline, have been reported on marginal bone resorption and found this to depend on a disease entity termed peri-implantitis. At the same time, a growing body of mainly prosthodontic researchers has interpreted the same marginal bone loss to depend on another entity such as overloading of implants. Both prosthodontics and periodontist have arranged consensus conferences over the years, consensus conferences that have supported the opinion of

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part of the problem behind marginal bone loss; other factors are much more common. Having said this, if ongoing marginal bone loss does occur, implant micromovements may ensue that in turn develop what may be termed as secondary peri-implantitis. This secondary problem may, of course, need clinical treatment. According to the present authors, to focus on periimplantitis as the primary problem around osseointegrated implants is as misconceived as focusing on overloading; such approaches will lead to incorrect precautions and the treatment of symptoms rather than the actual reason for problems relating to marginal bone loss.

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1.Poor surgical techniques kill cells needed for repair

2. Host bed disturbances due to gene c disorders, disease, drugs or previous irradia on

4. Smoking and allergies or similar condi ons disturb bone cells and/or their vascular supply

3. Too much strain for bone cell adjustment due to implant mist or prosthodon c errors

The compromised Healing/adap on theory

Fig. 3. The compromised healing adaptation theory (84). It states that the outcome of an implantation procedure depends on the combined action of several subfactors. If e.g. surgery is poor, the patient has a poor bone bed and smokes copiously and the prosthodontist manufactures a bridge causing bone strain, the summed effect of these factors may lead to implant failure, if the summed trauma is less severe in magnitude instead marginal bone resorption may follow. This theory is much more generally applicable to the true clinical situation than are hypotheses of isolated peri-implantitis or overloading, the alleged reasons for marginal bone loss in many experimental papers, however of poorly proven clinical relevance.

Conclusion
Despite several challenges, implant treatment, in general, continues to be a predictable and safe treatment option for edentate and partially dentate patients. Modern moderately rough implants seem to outperform older turned xtures at least when implants are placed under challenging situations. In some contrast to this positive statement is the lack of any attempts to clinically document new surfaces or designs before they are commercialised. This uncritical marketing of novel implants may prove fatal in the short- and long-term perspective in cases where new, untested handling of implants is advocated such as in the case of Nobel Direct or when new materials are tooted such as zirconia implants without realising that they may prove too brittle in the long run. In addition, we lack a lot of information on preferable solutions in common situations such as comparison between tooth supported vs. implant supported xed bridges.

irradiation (37, 85, 86), iii) Too much strain from implant mist, bone cell adjustment or prosthodontic errors (82, 83, 87) or iv) Smoking, allergies or similar conditions that disturb bone cells or their vascular supply (37, 88). Good clinical examples of healing adaptation theory sequelae include poor surgery that was found to either cause implant failure or unacceptable bone loss clinically (70), data supported by Bryant (71) who also found evidence for failure bone loss being coupled to the initial prosthodontist who took care of the patient. Other clinical evidence for healing adaptation theory dates back to experience from the Nobel Direct implant that displayed either implant failure or 3 mm or more of bone loss in about one-third of cases at about 18 months of follow-up (8992). In all probability problems were attributed to a combination of grinding down the implant in situ with direct loading of it, a clear example of the healing adaptation theory. Interestingly, in those cases where these clinical interventions recommended by the company were avoided, good clinical results followed for the same implant (89). The healing adaptation theory sees adverse loading or peri-implantitis to be, at best,
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Acknowledgments
Grants have been received from Hjalmar Svensson Research Foundation, Sylvans Foundation and Swedish Research Council.

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Correspondence: Ann Wennerberg, Faculty of Odontology, Malmo University, 205 06 Malmo, Sweden. E-mail: ann.wennerberg@mah.se

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