Periodontology 2000, Vol. 47, 2008, 914 Printed in Singapore.

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2008 The Author. Journal compilation 2008 Blackwell Munksgaard

PERIODONTOLOGY 2000

Dental implants: matters of course and controversies

LARS SENNERBY

Dental implants or dentures?

The introduction of osseointegrated implants is one of the most signicant breakthroughs in clinical dentistry. Independently of each other, the pioneers nemark and Schroeder and their research groups Bra established so-called standard protocols for implantsupported prostheses in edentulous patients based on a trial-and-error approach (5, 10, 28). The clinical outcome of these protocols has been reported in numerous publications (1, 2, 13). However, is this a strictly scientically proven treatment modality for the replacement of missing teeth? In an article published in the British Journal of Medicine, Smith & Pell concluded that The perception that parachutes are a successful intervention is based largely on anecdotal evidence (32). In a meta-analysis of the literature on parachuting they could not nd any randomized controlled trials with a control group of volunteers jumping from an aircraft without a parachute. On the other hand, they found case reports describing the survival of people, wearing either no parachute or a nonfunctional parachute, who had fallen out of planes, as well as reports of people who had died despite using a parachute. Their article wanted, of course, to point out some of the weaknesses of the strict use of evidence-based medicine for clinical recommendations. With regard to dental implants, few or even no randomized controlled trials comparing implant-supported bridges and dentures have been published, and, from a strict scientic point of view, the effectiveness of dental implants has not yet been proven. However, the seemingly logical conclusion that their use cannot be recommended based on the lack of randomized controlled trials seems to be somewhat extreme in light of the long and good clinical experiences with osseointegrated implants. According to Smith & Pell, the effectiveness of an intervention has to be judged relative to noninter-

vention. They are indeed correct and the effectiveness of osseointegrated implants is undisputed when going from a situation of total or partial edentulism with ill-tting dentures to a situation with xed implant-supported bridges. Observational studies evaluating patients before and after treatment with dental implants have demonstrated great advantages with regard to function, esthetics and psycho-social factors (9, 17). The large bulk of clinical follow-up studies generally show that implants, with some exceptions, are successful on most indications if the established standard protocols are followed (2, 13). Rightfully, it seems to be the opinion of the dental profession that osseointegrated implants is the rst choice for replacing one or several missing teeth, in spite of the lack of randomized controlled trials. However, it is not clear which type of implants and clinical techniques are superior to others and whether teeth should be extracted or not to make room for implants. Moreover, what is the long-term response to the surviving implants with regard to the health of the marginal bone and soft tissues (19)? These are some of the controversies and topics that will be discussed in this special issue on dental implants.

Old vs. new implant techniques and components

Essentially, the same type of implants and strict protocols were used during the rst 30 years of osseointegration, which means that these factors were well controlled in clinical studies. The inuence of other factors, such as jaw, age, bone quality and health, could be evaluated and risk factors have been identied in retrospective analyses of the literature (29, 34). Based on this information, patient selection and surgical techniques could be improved without

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altering the components (15). Moreover, when 5-year and 10-year data were reported, the implant designs were still commercially available and used in patients. When the mechanisms behind osseointegration became better understood and when good long-term function had been proven, it was absolutely necessary to improve and simplify the clinical techniques involved. To take one example, the nemark standard abutment to change from the Bra the EsthetiCone was a signicant and unquestionable improvement as was the development of single tooth abutments (20, 33). Improvement of the surgical technique by introducing self-tapping implants has also been positive as has the introduction of narrow and wide implants based on the original implant design. At present, the situation is completely different and change is the only thing constant within implant dentistry. It is not uncommon that when a 3-year or a 5-year study is published, the implant component is already old and abandoned (7). Controlled clinical studies are necessary when evaluating new clinical techniques and novel implant components before their introduction to the market. How can we otherwise justify changing from one clinical technique component that works well to another? There is always a risk that the new undocumented component technique performs worse than the old one, which, in the end, will affect the patient. One recent example is the introduction of one-piece implants with a rough titanium surface against the mucosa, which was claimed to minimize bone resorption and to result in soft tissue integration (12). Some authors reported poorer clinical outcomes with this concept as extensive bone resorption was seen (4, 25, 30). The concept of soft tissue integration had not been heard of before and in fact it was well known that epithelial cells are rugophobic (i.e. they cannot attach to a rough surface) (11) and thus form a poor soft tissue barrier to the oral cavity, which may explain the reported extensive bone resorption. Again, very few controlled studies have been published and this is best explained by the lack of incentives. Controlled clinical studies are costly and resource-demanding and few noncommercial bodies or universities can afford to fund such studies. If funded by a company, the same company runs the risk that the product tested or new clinical technique promoted will not win against the previously used method or implemented strategy. In contrast to a pharmaceutical drug, the introduction of which requires years of clinical research, dental implants are devices and can in principle be registered and sold without any clinical documentation of

that very product. This means that dentists, who may have been seduced by skillful marketing, will take a risk and will be responsible in the event of complications. In the worst case, the result will be an unhappy patient who suffers from sequels related to an unproven component procedure. The doctor has, of course, the opportunity to wave a red ag and report the complications. However, if the product has been approved by a regulatory body, the risk of withdrawal from the market is negligible unless the documentation of complications is extensive or if patients die. Moreover, in view of the legaleconomic risks for the lonely clinician, not many doctors even consider protesting. One way to avoid the release of undocumented products is to apply stricter rules for new products. It seems reasonable to suggest that data from clinical studies on the product should be presented, preferably from independent clinics, before approval can be considered. The performance of approved implant components can be monitored by establishing databases where implant placements and failures complications can be reported. However, do we want more rules and restrictions? A better way would be for the industry to work in symbiosis with clinicians and researchers with the best for the patient in focus, rather than implementing ideas that make attractive marketing campaigns but are questionable from a scientic point of view. As suggested by Albrektsson et al. (5), It may be that the companies are motivated to form specic Scientic Advisory Boards if the governmental agencies in Europe and the USA decide to strengthen their demands on the marketing of oral implants. These devices are, after all, placed in humans and they are not necessarily without harm to patients if unsuitable designs and or placement strategies continue to be recommended. The implant manufacturers are important sources of nancial support for research and give inventors and researchers the opportunity to explore their ideas because few other bodies, such as national research councils and universities, support this kind of work. The incentive for the companies is of course to develop new products and to use the results from scientic work for marketing purposes in order to be as protable as expected by their shareholders. This mode of operation is not completely without risks and there may be a problem when interpreting results from experimental studies and extrapolating to the clinical situation. Are the parameters used in a study clinically relevant? One good example is implant surface modication, and it is a welldocumented fact that a slight increase of surface

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Dental implants: matters of course and controversies

roughness results in more and earlier boneimplant contacts as well as a higher resistance to removal torque forces (3). It is then easy to believe that such a surface would perform much better in the clinical situation than an implant with an as-machined surface. To the knowledge of the present author, the few randomized controlled trials available have not been able to demonstrate this, which was also the conclusion of a meta-analysis (14). So the main question is, will the patients notice a difference? Having said this, this author believes that surface modication results in better clinical outcomes in biologically challenging situations such as bone augmentation and immediate loading. The few randomized controlled trials comparing implant surfaces have used two-stage procedures in patients with good bone conditions. When evaluating the literature on implant treatment in more challenging situations, such as soft bone, immediate loading and bone grafting, it seems as if moderately rough implants perform better. However, randomized controlled trials are needed to prove this point scientically. The problem is that control implants with a machined surface are no longer commercially available because the general opinion is that surface-modied implants are better. At present, the third generation of implant surfaces is already a clinical and commercial reality, often based on nanotechnology. Although some of the experimental research is convincing, using parameters such as boneimplant contacts and removal torque (3), the inuence on the clinical outcomes is unknown. However, the new surfaces on well-documented implant designs are probably not hazardous for the patients and may result in a faster integration, which theoretically would allow for shorter healing periods prior to loading.

well documented and meticulous protocols and rather ceremonious clinical procedures were used in an attempt to avoid all imaginable complications. In essence, dental implants did not really compete with conventional prosthetic techniques but served as a solution for the hopeless cases. Currently, long-term clinical studies have shown that the use of osseointegrated implants results in highly predictable outcomes, and few risk factors for implant failure have been identied. The increased condence in osseointegration has widened the indications and positioned implants as the rst choice of treatment for partially edentulous patients and for single tooth gaps. Suddenly, treatment planning is much more complicated and often involves the decision to extract teeth which in fact may be treatable using conventional techniques to make room for implants. Can extractions on prosthetic indications be justied from a practical, economic and prognostic point of view, or should we look upon this as an amputation of a healthy limb? It is apparent from the literature that this is a controversial topic which is currently under debate (22).

Surgical and prosthetic aspects of osseointegration

The aim of implant surgery is to provide a longlasting anchorage in the best possible positions for a functionally and esthetically optimal prosthetic device. For many reasons this may be difcult to achieve and experience is needed to know when measures have to be taken as a result of deviations from this ultimate goal. It is generally believed that primary stability is one determinant of osseointegration because increased failure rates have been seen in soft bone densities. Therefore, the surgical technique should aim to reach as high a primary stability as possible (15). One way to assess implant stability is by resonance frequency analysis measurements, which may be helpful for the clinician, as reviewed by Sennerby & Meredith (31). Primary stability can be inuenced by placing the implant in as much cortical bone as possible, by reducing the diameter of the osteotomy related to the implant diameter (by using thinner drills and or wider implants) or by using tapered implant designs (15). Placement of implants immediately after extraction is not uncommon, but is challenging because, in the case of a large socket, part of the implant will show exposed surfaces that will need to be covered with bone during healing. Moreover, because less of the

To extract or not to extract

During the rst 20 years of osseointegration, only totally edentulous patients who could not cope with a removable denture were treated with implants. At this time, decision making regarding type of treatment and patient selection was simple as rather strict criteria were utilized. For instance, treatment with a xed bridge required a bone volume sufcient to house at least ve 10-mm-long implants. Moreover, implants were only placed in healed sites and loaded after an initial healing period of 36 months. Teeth were extracted if pathosis or fracture prevented conventional treatment and were seldom removed on prosthetic indications. Implant treatment was not

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implant surface is engaged with bone than if placed in a healed site, it is possible that the primary stability will be low. However, if it is possible to achieve good results using this technique, there are benets for the patients in terms of the shorter treatment time. Some authors claim that immediate implant placement will counteract resorption following extraction. However, available data are not conclusive and the method is still controversial. The clinical techniques for optimal placement of implant in extraction sockets, the effect on bone resorption and the clinical outcomes are discussed by Becker & Goldstein (8). The secondary stability depends on the bone tissue response during healing, and stability seems to increase with time for implants with low primary stability. If a certain degree of primary stability is achieved, it seems that the changes of stability as a result of healing are less marked. This means that such implants may be candidates for immediate early loading protocols. stman (26) In this volume of Periodontology 2000, O reviews the literature on immediate early loading and presents a protocol that is based on implant stability. It seems to be the general opinion that surface-modied implants are preferred because of their rapid integration.

Treatment of the no-bone patient

Bone atrophy is commonly seen after loss of teeth, which makes it difcult to achieve good esthetics with implant-supported prosthesis. This is commonly seen in patients where one or two central incisors have been lost as a result of trauma. The treatment strategies in these patients are discussed by Palacci & Nowzari in this volume of Periodontology 2000 (27). Bone resorption may also be so extensive that the facial morphology of the patient is altered. Correction, for instance, of a retrograde maxilla requires extensive surgery and the use of autogenous bone grafts (23). Various techniques have been described, including onlay and inlay bone grafts and interpositional bone grafting in conjunction with a Le Fort I osteotomy. Dental implants have been placed in conjunction with bone grafting or after initial healing of the bone grafts. According to Lundgren et al. (23), delayed placement of implants is preferred as a result of the fact that the bone graft has had time for revascularization and will respond to implant surgery as normal bone. Favorable experiences with surface-modied implants have made it possible to reduce implant healing time and may even allow for immediate function in grafted bone.

If the available bone height in an area intended for implant placement is less than the shortest implant, a bone augmentation procedure is often considered. Moreover, it is generally anticipated that short implants are more prone to failure than longer implants, which is one further argument for a bone augmentation procedure in order to place long implants. This is especially common in the posterior maxilla where autogenous bone and bone substitutes are used for augmentation of the maxillary oor prior to, or in conjunction with, implant placement. Numerous techniques and grafting materials are available, as reviewed by Hallman & Thor (16). The use of endogenous platelet-rich plasma is one technique that has been evaluated. This is a biological technique employed to boost the incorporation of autogenous bone grafts using the patients own growth factors, which are found in the concentrate of trombocytes. The literature is not conclusive however, and little, if any, advantage with platelet-rich plasma has been demonstrated with regard to implant integration in maxillary sinus oor augmentation situations. However, platelet-rich plasma may serve as a glue for facilitating the handling of particulated bone grafts (16). The use of allogeneic, xenogeneic or alloplastic bone substitutes are also potentially attractive because no donor sites for autogenous bone grafts are needed. Apparently, good clinical outcomes can be obtained for maxillary sinus oor augmentation. In this volume of Periodontology 2000, Lundgren et al. (24) report on the experiences of a new technique for bone formation in the maxillary sinus without the use of any grafts. Using this technique, the sinus membrane is elevated and tented with surface modied implants and the space secluded with a replaceable bone window at the lateral aspect of the sinus wall. Predictable bone formation is shown from clinical radiographic examinations as well as from experimental studies in primates. Their results indicate an impressive healing capacity of the maxillary sinus, which may explain the generally good results obtained from various sinus lift procedures. From a historical point of view, it is correct that 7 nemark type implants with a machined surmm Bra face show higher failure rates than longer implants. However, retrospective analysis of more recent follow-up data points to no or only small differences between short implants and long implants (15). This may be related to improvements of surgical technique, where achievement of rm primary stability is strived for, and may also be explained by a positive bone response to the new modied implant surfaces.

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Dental implants: matters of course and controversies

One alternative to bone augmentation is thus to use short implants (15). Moreover, by using a bone safari technique (i.e. searching for bone using a thin spiral drill), long implants can be placed tilted (6, 15). Originally, nonaxial implants were regarded as biomechanically compromised; however, more recent understanding shows that as long as the head of the implant is under the occlusal plane, the position of the integrated implant body is not important. Comparative clinical studies have reported similar and sometimes better outcomes with tilted compared with axially placed implants (6).The ultimate version of this concept is the use of zygomatic implants, as reviewed by Aparicio & Hatano in this volume of Periodontology 2000 (6). This implant was originally developed for the treatment of maxillectomized patients where no other options for rehabilitation with xed epistheses and prostheses were at hand. Over the years, the technique has been developed to be used in patients with severe atrophy of the maxilla. A typical patient is treated with two zygomatic implants bilaterally and two to four implants in the pre-maxilla. According to Aparicio & Hatano, good clinical outcomes have been reported (6).

A look into the future

Although critical of the too rapid introduction of new products to the marketplace, the present author is indeed in favor of the development of new materials, concepts and techniques in order to improve different aspects of implant dentistry in the future. The rst generation of implant designs and surfaces, and clinical techniques, were probably not optimal, although it has been difcult to prove that the implants of today perform better clinically, as previously discussed. There are several other materials that are as biocompatible as titanium. Zirconium, niobium and hafnium are examples of other metals that integrate well with bone. Moreover, stainless steel (medical grade) and alloyed titanium, which have been used in orthopedic implants, are well tolerated by tissues. Concerns have been raised about the leakage of potentially toxic aluminum and vanadium ions from the alloyed titanium as a result of corrosion, which may have negative effects on bone healing. However, these concerns are not shared by all researchers in the eld and titanium alloys are used for dental implant components. Apart from corrosion, another drawback with metals is their grayish color, which may pose an esthetic problem in instances of thin lining mucosa or retraction. Ceramics is one group of

materials that is interesting in this respect as a result of their mechanical properties, tooth-like color and good biocompatibility. Aluminum oxide and zirconia abutments are already in clinical use, and ceramic implants made from zirconia are commercially available according to a review by Kohal et al. in this volume of Periodontology 2000 (21). Although promising short-term results are reported with ceramic implants, Kohal et al. does not currently recommend their clinical use. However, the research work continues. A most interesting topic in bone healing and implant integration research is the use of growth factors. These are powerful proteins that can initiate bone formation in soft tissue and bone tissues and it can be speculated that they may be used to improve bone healing and implant integration. However, although the possible clinical applications are numerous, their use is not completely without difculties and researchers have tried to nd clinical uses for bone growth factors since the discovery of bone morphogenetic proteins by Urist in 1965. Dosage, timing and the method of administration are some of the topics that have been addressed in various research projects. In order to become a viable commercial product, acquisition cost is also an issue. The history, problems, ndings from ongoing research projects and possible future use of bone growth factors are discussed by Huang et al. (18), who foresee that the ability to predictably induce osteogenesis through the use of bone morphogenetic protein technologies is not far from a clinical reality and will have a profound effect on clinical practice.

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