Ignace Naert George Koutsikakis Joke Duyck Marc Quirynen Reinhilde Jacobs Daniel van Steenberghe

Biologic outcome of implant-supported restorations in the treatment of partial edentulism

Part 1: A longitudinal clinical evaluation

Authors afliations Ignace Naert, George Koutsikakis, Joke Duyck, Department of Prosthetic Dentistry. Marc Quirynen, Reinhilde Jacobs, Daniel van Steenberghe, Department of Periodontology, School of Dentistry, Oral Pathology and Maxillofacial Surgery, Faculty of Medicine, Catholic University Leuven, Belgium. Correspondence to: Prof. I. E. Naert Department of Prosthetic Dentistry School of Dentistry, Oral Pathology and Maxillofacial Surgery Kapucijnenvoer, 7 B-3000 Leuven Belgium Fax: 32 16 33 23 09 e-mail: Ignace.Naert/med.kuleuven.ac.be

Key words: dental implants, implant survival, implant-tooth connection, partial edentulism, posterior implants Abstract: The purpose of this study was to predict the outcome of implant restorations in the treatment of partial edentulism, taking into account implant interdependency and the effect of several confounding variables. Between December 1982 and June 1998, 1956 Brnemark systemA implants (1212 and 744 in the maxilla and mandible, respectively, 846 distal to rst premolars) were installed in 660 patients (248 males) at the Department of Periodontology of the University Hospitals of the Catholic University of Leuven. Of the 810 restorations installed at the Department of Prosthetic Dentistry of the same hospital, 235 were single crowns, 166 were supported by implants and teeth and 409 were free-standing xed partial prostheses. An additional 87 restorations was placed in private dental ofces and were not included. The patients were followed from implant installation until June 1999. The estimated cumulative survival rates were 91.4% for all implants and 95.8% for all restorations over a period of 16 years. Estimated cumulative survival rates from loading for implant-tooth connected and free-standing implants were, respectively, 93.6% and 97.2%. Neither jaw site nor implant position (anteriorposterior) had any signicant effect on the outcome. Short implant length, high number of implants per patient, low number of implants per prosthesis, implants loaded by acrylic-veneered restorations and implants combined with bone grafting present a higher risk hazard for implant failure. The idea of not splinting the implants in a xed partial prosthesis is promising but needs replication before accepting it.

Date:

Accepted 30 August 2001

To cite this article:

Naert I, Koutsikakis G, Duyck J, Quirynen M, Jacobs R, van Steenberghe D. Biologic outcome of implantsupported restorations in the treatment of partial edentulism Clin. Oral Impl. Res, 13, 2002; 381389 Copyright C Blackwell Munksgaard 2002 ISSN 0905-7161

Since the incidence of full edentulism is declining in the industrialised part of the world and partial edentulism prevails (Weintraub & Burt 1985; Meskin & Brown 1988), the application of partial implantsupported restorations has attained a valuable place in the therapeutic armamentarium (van Steenberghe 1989). Indeed, psychological benets and tooth structure maintenance are among the advantages of implant-supported prostheses use. Especially in Kennedy classes 1 and 2, where traditional xed cantilevered prostheses present increased biologic and technical problems (Hmmerle et al. 2000), and

where removable partial dentures are usually disregarded by patients, the installation of some oral implants can be benecial. However, evidence of the long-term serviceability of implant-based therapy in partially edentulous patients should be provided before accepting it as a safe alternative for traditional prosthodontic treatment. Indeed, only one 10-year study appears in the literature reporting favourable results based on life table analysis from placement, and taking into account implant interdependency (Lekholm et al. 1999). The use of subsequent single im-

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plant crowns to restore multiple tooth loss instead of using xed partial prostheses has been reported in a limited way for two different implant types (Buser et al. 1997; Naert et al. 2000). On the other hand, a metaanalytic approach did not manage to pool implants used in single crowns with those applied in xed partial prostheses to derive valid information on the predictability of these two therapeutic alternatives (Lindh et al. 1998). The present investigation based on a consecutive large series of implants installed in one clinical centre, taking into account an assortment of parameters as mentioned by Bryant (1998) and Esposito et al. (1998a), using proper updated statistics, will further clarify the aforementioned issues. The aim of this study is to investigate the long-term predictability of implant-supported prosthetic restorations in the treatment of partial edentulism and to compare single crowns with xed partial prostheses. In Part 2 (Naert et al. 2002b), the marginal bone level estimations are reported.

Table 1. Distribution of 1956 implants according to tooth position and jaw Maxilla: Total 1212 (anterior* 856, posterior **356)
18 1 17 3 16 39 15 136 14 193 13 88 12 75 11 88 21 77 22 77 23 79 24 178 25 122 26 50 27 3 28 3

Mandible: Total 744 (anterior *254, posterior **490) 48 1 47 30 46 98 6 *In between rst premolars, total 1110. ** Distal to rst premolars, total 846. 45 11 44 78 43 21 42 16 42 15 31 18 32 17 33 13 34 76 35 11 3 36 10 4 37 28 38

Table 2. Distribution of implants according to length and tread prole

Implant length No implants Thread prole No implants 6 7 Standard 827 7 1103 Self-tapping 524 8 19 Mk-II 540 8.5 39 5 mm 52 10 719 Conical 13 11.5 8 12 7 13 15 18 20 2 537 454 54

Surgical procedures

Material and methods

Patients

A two-stage surgical intervention was performed according to a standard protocol (Adell et al. 1985). Surgical stents of different congurations (Naert et al. 1988) were mostly used to optimise the alignment of the implants. After a mean healing period of 5 and 6.8months for maxilla and mandible, respectively, abutments were connected.
Prosthetic procedures

Equal and simultaneous contact for implant restorations and teeth was ensured at maximal intercuspation. During excursions, interference was avoided on restorations supported by implants only. When this was not achievable, equally distributed contacts on teeth and implants were aimed at.
Clinical evaluation

All partially edentulous patients treated with Brnemark systemA implants (Nobel Biocare, Gteborg, Sweden) between December 1982 and June 1998, at the Department of Periodontology and at the Department of Prosthetic Dentistry of the University Hospitals of the Catholic University Leuven, were included in this study. The study comprises 660 patients (248 males) aged between 15 and 83years (mean 50.5). In all, 1956 (270 intended to support single crowns and 1686 to serve for xed partial prostheses), were placed in maxilla and mandible in anterior and posterior sites. Table1 depicts the distribution of implants related to tooth position and jaw, while Table2 summarises the implant length and thread prole. A total of 121 implants had a bone dehiscence at the time of their installation. In 170 implant sites a membrane and/or an autologous bone or xenon graft (Bio-OssA, Geistlich, Switzerland) was applied to close the dehiscence, to ll the voids between implants and extraction sockets, or to supply enough bone volume to harbour implants.

Prosthetic restorations were fabricated according to the conventional protocol (Zarb & Jansson 1985). A total of 810 xed prostheses (235 single crowns and 575 xed partial prostheses) were placed at the Department of Prosthetic Dentistry. An additional 87 prostheses were installed in private dental ofces. These prostheses were not included in the analysis because there was not enough follow-up data available. To obtain optimal healing of the soft tissues, 381 temporary restorations were used, lasting 4.2months on average. Afterwards, the nal abutments were connected and the nal prostheses were placed (673 ceramic- and 137 acrylic-veneered). From the xed partial prostheses, 166 were supported by implants and teeth (comprising 398 implants), called implant-tooth connected, while 409 were supported by implants only (1022 implants), called freestanding. Table3 summarises xed partial prostheses, implants and failures in freestanding and implant-tooth connected prostheses.

After installation of the restorations, patients were recalled (bi)annually. The observation time from implant installation until the last control reached up to 16.5years (mean 5.5) (Fig.1). The rigidity of the implant-bone continuum at abutment connection and at prosthesis installation was systematically recorded from 1988 on, by means of the PeriotestA device (Siemens AG, Bensheim, Germany). Before this date, tapping the abutments back and forth between two instrument handles was used to check implant stability. When a radiolucency was evidenced or supposed to be present, the xed partial prosthesis was removed to again individually check the implant stability. Implant success criteria were: O an individual implant was immobile when tested clinically (PTV 8 in the
Table 3. Fixed partial prostheses, implants and failures (between brackets) in free-standing and tooth-connected prostheses Prostheses Implants
Free-standing Implant-tooth connected 409 (15) 166 (11) 1022 (30) 398 (34)

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Fig.1. Observation period from implant installation till last control and percentage of implants corresponding to each time period.

rst year and PTV 5 in the following years); O a radiograph did not demonstrate any evidence of peri-implant radiolucency; O an implant showed no signs or symptoms of irreversible pain or infection; O the implant did not fracture. A restoration was considered an absolute failure when it could not remain in function as a consequence of implant loss, without adding supplementary implants (Naert et al. 1992). The follow-up ended in June 1999. Seventy-three patients had been evaluated earlier than 1.5years from the completion of the study. These patients were taken into account until their last visit. Table4 summarises the drop out of patients, implants and prostheses.
Statistics

A shared frailty model (Hougaard 2000) was used to model the lifetimes of the implants and prostheses. The shared frailty model is a Cox proportional hazards model with a patient-specic random effect added to. The term shared is used because all implants of one patient share the same common risk. The patient-specic random effect is called a frailty. Addition of this random effect in the model allows the de-

pendency between implants of the same patient to be taken into account. One analysis considers the start of the implant lifetime at installation. In a second analysis, the lifetime of an implant starts at rst loading. Consequently, the lifetime of the prosthesis starts at rst loading. The exact time of implant failure is generally not known. It usually happens in an interval between visits (interval censored) or after the last time the patient was seen (right-censored). Only for implants failing at abutment connection, is the exact failure time known. For implants failing before or after abutment connection, the date of last control would be an over-estimation of the failure time. Therefore as failure time, the time point halfway between the previous and the last control is chosen. This reasoning has also been applied for the calculation of the failure times for the prostheses. A multiple version of the Cox regression is used to take into account the inuence of possible confounding variables. A nal model for the survival of the implants and prostheses has been obtained after simplifying the shared frailty model in each step by removal of the redundant terms in the model. To assess the non-inferiority of single vs. partial free-standing implants and prostheses, a one-sided 95% condence interval has been constructed for the hazard ratio, comparing the hazard rates in the respective groups. Based upon the Cox regression, survival curves are constructed for the levels of specic variables (e.g. jaw site). It means that the resulting survival curves are for two average implants (one in the maxillary and one in the mandibular site) with average values for the other variables in the shared frailty model, but withthe variable jaw-site entered as a stratication factor (q6'S-Plus 2000 Guide to Statistics 1999). Due to the exploratory characteristics of the study, no corrections are made for multiple testing.

Table 5. Number of patients with their number of implants and failures Implant Failures 1
12 10 13 8 8 10 6 0 0 0 0 0 1 0 68 4 1 2 7 2 0 1 0 1 0 0 0 0 18 2 1 0 0 1 0 1 0 1 0 0 0 6 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1

frequency 0
1 2 3 4 5 6 7 8 9 10 11 13 15 16 Total 168 141 107 69 31 27 11 5 4 1 1 1 0 0 566

3 4 6 Patients
180 155 123 80 46 39 18 7 5 2 2 1 1 1 660

Results
Implants

Table5 presents a distribution of the number of implants per patient and the occurrence of failures, while Table6 depicts the life table according to Cutler & Ederer (1958). There is no signicant difference in hazard rate between implants intended to support single crowns and those intended to be splinted by means of a xed partial prosthesis (P0.82). The estimated hazard rate for implants supporting xed partial prostheses equals 1.09 times the hazard rate of implants supporting single crowns, with [0.5; 2.40] as 95% condence interval and no signicant difference. There is no signicant difference in hazard rate between the mandible (estimated cumulative survival rate from 9.0years on: 93.3%) and the maxilla (estimated cumulative survival rate from 10.0years on: 89.9%) (P0.065). The estimated hazard rate in the mandible equals 0.66 times the hazard rate in the maxilla, with [0.42; 1.03] as 95% condence interval. For both jaws the estimated cumulative survival rate is 91.4% from 10.0years till 16.6years, which is the largest censoring time (Fig.2).

Table 4. Patients, implants and prostheses dropout Patients

Deceased Other reasons* Total
*

Implants
31 (1.6%) 173 (8.8%) 204 (10.4%)

Prostheses
14 (1.6%) 88 (10.4%) 102 (12%)

6 (0.9%) 67 (10.1%) 73 (11%)

Seven unable to come, eight had moved abroad, 13 had moved to unknown address, 36 did not respond at all, 3 were unwilling to come.

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Table 6. Life table analysis of all implants Period

Before abutment connection At abutment connection 06 months 612 months 1218 months 1824 months 22.5 years 2.53 years 33.5 years 3.54 years 44.5 years 4.55 years 55.5 years 5.56 years 66.5 years 6.57 years 77.5 years 7.58 years 88.5 years 8.59 years 99.5 years 9.510 years 1010.5 years 10.511 years 1111.5 years 11.512 years 1212.5 years 12.513 years 1313.5 years 13.514 years 14.515 years 1515.5 years 15.516 years 16 years

Implants at Implants Censored Failed Survival rate Cumulative start of period at risk within period survival rate
1956 1920 1878 1785 1651 1553 1423 1316 1212 1138 1050 949 871 807 739 635 560 503 462 404 354 300 259 192 154 126 67 34 27 21 16 9 4 1 1953.5 1920.0 1849.5 1721.0 1606.0 1490.0 1372.0 1265.0 1175.0 1096.0 1000.0 912.5 839.5 774.0 688.0 597.5 532.0 482.5 434.0 379.5 327.0 279.5 225.5 173.0 140.0 96.5 50.5 30.5 24.0 18.5 12.5 6.5 2.5 0.5 5 21 57 128 90 126 102 102 74 84 100 73 63 66 102 75 56 41 56 49 54 41 67 38 28 59 33 7 6 5 7 5 3 1 31 21 36 6 8 4 5 2 0 4 1 5 1 2 2 0 1 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 98.4 98.9 98.1 99.7 99.5 99.7 99.6 99.8 100.0 99.6 99.9 99.5 99.9 99.7 99.7 100.0 99.8 100.0 99.5 99.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 98.4 97.3 95.4 95.0 94.5 94.3 93.9 93.7 93.7 93.4 93.3 92.7 92.6 92.3 92.1 92.1 91.9 91.9 91.4 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1 91.1

Fig.2. Estimation of survival function of all implants in maxilla and mandible together based on a shared frailty Cox proportional hazard model. Some values of the estimated survival function are the following:

Years
3 months 6 months 1 years 2 years 3 years 5 years Last event Last event Largest censoring time

Estimated survival
0.990 0.979 0.961 0.950 0.943 0.936 0.914 10.03 years 16.56 years

SE
0.002 0.003 0.005 0.006 0.007 0.007 0.010

The estimated hazard rate for implants at the posterior site equals 0.96 times the hazard rate of implants at the anterior site (P0.85), with [0.6; 1.52] as 95% condence interval. The effect of jaw-site is also not signicantly different in the posterior compared to the anterior site (P0.31). The estimated hazard rate for free-standing implants (estimated cumulative survival rate from 7.3years on: 97.2%) equals 0.45 times the hazard rate of tooth-connected implants (estimated cumulative survival rate from 8.6years on: 93.6%) (P 0.03), with [0.22; 0.92] as 95% condence interval (Fig.3). The estimated hazard rate is 4.2 times higher if a membrane and/or a graft is used (P 0.001), with [1.8; 9.6] as 95% condence interval. The shorter the implant length, the higher the hazard rate (P 0.001). Decreasing the implant length by 1mm increases the hazard rate 0.16 times with [0.07; 0.26] as 95% condence interval (Fig.4), although a linear approach can be questioned from a clinical point of view.

The higher the number of implants a patient has, the higher the hazard rate (P 0.005). Increasing the number of implants by one, increases the hazard rate 0.14 times with [0.04; 0.24] as 95% condence interval. There is no signicant effect of gender, age at implant installation or thread prole.
Prostheses

Table7 depicts the life table of prostheses. There is no signicant difference in hazard rate between single, free-standing and tooth-implant connected prostheses (P 0.99). The estimated hazard rate in the mandible equals 0.77 times the hazard rate in the maxilla, with [0.36; 1.63] as 95% condence interval and no signicant difference between both jaws (P0.49). The effect of jaw site is not signicantly different between single, free-standing and toothimplant connected prostheses (P0.38). The estimated survival rate of all prostheses is 95.8% from 8.6 to 15.7years,

which is the last censoring time (Fig.5)Table7. Table8 summarises the number of patients with their number of prostheses and failures. The hazard rate of a prosthesis of a patient with a specic number of prostheses is on average 1.45 times higher than the hazard rate of a prosthesis of a patient with one prosthesis less (P0.002) with [1.14; 1.85] as 95% condence interval. Table9 summarises the number of prostheses with their number of implants and failures. The hazard rate of a prosthesis with a specic number of implants is on average 1.75 times higher than a prosthesis with one implant more, with [1.15; 2.67] as 95% condence interval. The lower the number of implants in a prosthesis, the higher the hazard rate (P0.01). There is a signicant difference in hazard rate as a function of the used prosthesis material (P 0.0001). The estimated hazard rate for acrylic- or composite-veneered prostheses is 4.84 times the hazard rate for ceramic-veneered prostheses, with [2.37; 9.90] as 95% condence interval.
Subsequent single implant restorations vs. freestanding xed partial prostheses

The non-inferiority analysis gave as esti-

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Fig.3. Estimation of implant survival function in free-standing and tooth-implant connected prostheses, based on a shared frailty Cox proportional hazard model. Some values of the estimated survival function are the following:

Discussion
All partially edentulous patients who could benet from implant-supported restorations and who were judged to be able to undergo surgery were enrolled in the present study, thereby providing a representative sample of the population at large (van Steenberghe 1997). It is indeed a policy of the two departments involved, which often function as last resort reference centres, to accept any patient regardless of local or systemic conditions, as long as his oral rehabilitation can benet from the use of oral implants. Ten implants were left sleeping. One of those was installed as a rescue implant in case one of the other implants should fail. Two implants could not be used because the adjacent implants were lost and the patient refused the installation of supplementary implants. Seven could not be used due to malpositioning. These seven could be counted as failures according to Smith & Zarb (1989), but were not counted for any further analysis in this study. The clinical manifestation of intimate bone apposition is the absence of mobility of the individual implant (Albrektsson & Isidor 1994). This can only be tested in case of non-connected implants or after removal of the prosthesis. Removing the partial prosthesis to check the implant mobility on a routine base, however, would be a burden for the patient. That is why this study is reporting survival rates, at least for implants supporting xed partial prostheses. Although life table analyses as described earlier by Babbush et al. (1986) and in an improved version by Buser et al. (1997) have their own value, they are rather descriptive as they do not take into account implant interdependency (Hermann et al. 1999) and do not correct for possible confounding variables. Predicted estimations of survival functions in this study were therefore based on a shared frailty Cox proportional hazard model. Estimated cumulative survival rates of implants after 10years, counted from implant installation, were 89.9% for the maxilla and 93.3% after 9years for the mandible (91.4% after 10years for both together). The results remained stable until the last censored time of 16.6years. Considering cumulative survival rates counting from implant loading, reveals even better results (97.2% from 7.26years on for free-standing

Free-standing Years
3 months 6 months 1 years 2 years 3 years 5 years Last event Last event

Connected SE
0.002 0.002 0.002 0.004 0.005 0.006 0.007

Estimated
0.996 0.998 0.994 0.986 0.983 0.978 0.972 7.26 years

Estimated
0.985 0.980 0.977 0.975 0.973 0.956 0.936 8.64 years

SE
0.006 0.007 0.008 0.008 0.009 0.012 0.017

mated hazard rate for single implants 2.17 times the hazard rate of free-standing implants, with [0.67; 7.10] as 95% condence interval, but without a signicant difference between the hazard rates (P0.20). However, the upper limit of the one-sided 95% condence interval for the hazard

ratio 2.17 equals 5.87. The non-inferiority analysis of single vs. free-standing partial prostheses, on the other hand, gave a hazard ratio of 0.79 with [0.22; 2.87] as 95% condence interval, with no signicant difference (P0.72). The upper limit of the one-sided 95% condence interval is 2.33.

Fig.4. Estimation of survival function of implants with different lengths based on a shared frailty Cox proportional hazard model. Some values of the estimated survival function are the following:

Years

10 mm Estimated survival
0.970 0.948 0.867 0.845 0.839 0.826 0.037 0.941 0.815 6.73 14.32 years

SE

1013 mm Estimated survival

0.991 0.981 0.966 0.956 0.948 0.910 10.03 16.56 years

SE

15 mm Estimated survival
0.988 0.978 0.966 0.954 0.949 0.946 4.11 16.56 years

SE

3 months 6 months 1 years 2 years 3 years 5 years Last event Last event Largest censoring time

0.013 0.018 0.030 0.031 0.031 0.008 0.040

0.003 0.004 0.006 0.007 0.008 0.013

0.005 0.006 0.008 0.010 0.011 0.011

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Table 7. Life table analysis of all prostheses Period

06 months 612 months 1218 months 1824 months 22.5 years 2.53 years 33.5 years 3.54 years 44.5 years 4.55 years 55.5 years 5.56 years 66.5 years 6.57 years 77.5 years 7.58 years 88.5 years 8.59 years 99.5 years 9.510 years 1010.5 years 10.511 years 1111.5 years 11.512 years 1212.5 years 12.513 years 1313.5 years 13.514 years 14.515 years 1515.5 years 15.516 years

Prostheses at start of period

810 753 697 644 593 545 502 464 431 387 358 326 289 251 218 196 171 150 126 110 91 67 55 40 18 11 8 7 6 2 1

Prostheses at risk
784.0 727.0 672.5 620.5 570.0 523.5 483.5 448.5 409.5 374.5 342.0 308.5 270.0 234.5 207.5 184.0 160.5 138.5 118.0 100.5 79.0 61.0 47.5 29.0 14.5 9.5 7.5 6.5 4.0 1.5 0.5

Censored
52 52 49 47 46 43 37 31 43 25 32 35 38 33 21 24 21 23 16 19 24 12 15 22 7 3 1 1 4 1 1

Failed
5 4 4 4 2 0 1 2 1 4 0 2 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

Survival rate within period

99.4 99.4 99.4 99.4 99.6 100.0 99.8 99.6 99.8 98.9 100.0 99.4 100.0 100.0 99.5 99.5 100.0 99.3 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Cumulative survival rate

99.4 98.8 98.2 97.6 97.2 97.2 97.0 96.6 96.3 95.3 95.3 94.6 94.6 94.6 94.1 93.6 93.6 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9 92.9

Fig.5. Estimation of survival function of single, freestanding, and implant-tooth connected xed partial prostheses together, based on standard Cox proportional hazards model. Some values of the estimated survival function are the following:

Years
3 months 6 months 1 years 2 years 3 years 5 years Last event Last event Largest censoring time

Estimated survival
0.997 0.995 0.991 0.983 0.981 0.969 0.958 8.64 15.72

SE
0.002 0.002 0.003 0.005 0.005 0.008 0.011

implants). These results are comparable with those reported in other studies (Quirynen et al. 1992a; Lekholm et al. 1994; Wyatt & Zarb 1998; Lekholm et al. 1999), but contradict with those of Hultin et al. (2000). In the study by Hultin et al. (2000), implant-tooth connected restorations are not considered. It is, however, relevant to include implant-tooth connected prostheses as there is a signicant difference of the estimated cumulative survival rate (counted from loading) between free-standing (97.2% from 7.3years on) and connected (93.6% from 8.6years on) implants. This is in line with results reported earlier by Naert et al. (2001), partly referring to the same patient material. On the other hand, the present results contradict those of Gunne et al. (1999) who found lower implant survival rates (88%, counted from implant installation) but with no difference for the two groups. The presently reported high survival rates also apply to posterior implants, since no signicant differences with anterior implants were found either in the maxilla or in the mandible. This complies with the 89% cumulative survival rate reported by

Parein et al. (1997) who investigated retrospectively posterior implants over 6years. Age at implant installation, gender and jaw site have no signicant effect on survival rates. Thread prole also did not lead to a different outcome, which is in disagreement with Quirynen et al. (1992b) who reported higher failure rate for standard implants compared to self-tapping for the same implant system. The implant length has a signicant effect on the hazard rate. For implants shorter than 10mm, the survival rate decreases to 81.5%. Fifty-two implants (2.7%) failed before or at abutment connection, meaning that osseointegration was not achieved. This matches the 2% early failures reported by Esposito et al. (1998b). Implant failures were mainly of biologic origin, since 115 implants did not acquire or lost osseointegration, whereas only 17 fractured. A high absolute cumulative survival rate of 95.8% at 8.64years was predicted for the prostheses counted from rst loading and remained stable until the latest censoring time of 15.72years. Forty-three prostheses could not be installed at all because of early implant failures. Veneering material fracture, discoloration, gold screw-abutment screw loosening or fracture, even two metal framework fractures, occlusal disturbances and cement dissolution, were noted among the observed technical complications. Their estimation was beyond the scope of this study. Persistent occurrence of such complications, however, might imply local overloading of some implants, which may consequently jeopardise the implant prognosis (Rangert et al. 1997). The higher the number of implants per patient and the lower the number of implants per prosthesis, the higher the risk. Note that this number is cumulative since implant reinstallations may have been done. Prostheses with one, two to three and more than three implants presented survival rates of 91.2%, 97.0% and 97.6%, respectively. There is no specic explanation for the fact that acrylic-veneered prostheses had a survival rate of 86.3% vs. 95.1% for the ceramic ones, except that the acrylic-veneered prostheses were installed during the learning curve of this centre (19821988). Because of implant failure, 27 patients underwent supplementary implant installations, 22 of whom obtained a successful

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Table 8. Number of prostheses/patient with survived and failed prostheses No. of prostheses /patient
1 2 3 4 5 6 7

No. of patients with successful prostheses

401 105 24 7 1 2 1

No. of patients with failed prostheses

9 7 12 4 0 0 0

Total no. of patients

410 112 36 11 1 2 1

taient des prothe `ses partielles xe es. De plus 87 et 409 e taient place dans des cabinets dentaires es restaurations e s te tude. Les prive et nont pas e incluses dans cette e ` te patients ont e suivis a partir du placement implantaire ` s jusqua juin 1999. Les taux de survie cumulatifs estime taient de 91,4 % pour tous les implants et de 95,8% e riode de 16 anpour toutes les restaurations sur une pe es. Les taux de survie cumultatifs estime depuis la s ne s mise en charge pour les implants-dents connecte et pour taient respectivement de 93,6 et les implants libres e choire ni la position de lim97,2%. Ni le site de la ma rieur ou poste rieur) navait deffet signicatif plant (ante `s ` sur le succe a long terme. Une petite longueur de limplant, un grand nombre dimplants par patient, peu dim`se, s plants par prothe des implants charge avec des restaus rations acrylique-veneer et des implants combine avec sentaient un risque plus e leve un greffon osseux pre chec. Lide de ne pas joindre les implants dans une e de `se e cessite une prothe partielle xe est prometteur mais ne tude avant le de t dune conclusion nale. po nouvelle e

Table 9. Number of prostheses with their survived and failed implants No. of implants per prosthesis
1 2 3 4 5 6 Total

No. of prostheses without implant failures

274 254 183 43 15 9 778

No. of prostheses with implant failures

14 12 4 2 0 0 32

Total no. of prostheses

289 266 187 45 15 9 810

Zusammenfassung
Das Ziel dieser Studie war es, die Langzeitprognose von implantatgetragenen Rekonstruktionen bei der Behandlung von Teilbezahnungen vorauszusagen. Dabei wurde insbesondere die gegenseitige Beeinussung der Implantate und der Einuss einiger verschiedenen Variablen beurteilt. Zwischen Dezember 1982 und Juni 1998 wurden auf der Abteilung fr Parodontologie des Universittsspitals der katholischen Universitt Leuven bei 660 Patienten (248 davon mnnlich) total 1956 Implantate nach dem Brnemark-System (1212 im Ober-und 744 im Unterkiefer, 846 distaler als der erste Prmolar) gesetzt. Von den 810 auf der Abteilung fr Prothetik desselben Spitals eingesetzten Rekonstruktionen waren 235 Einzelkronen, 166 gemischt getragene und 409 rein implantatgetragene Brken. Zustzlich gelangten 87 der Implantate in der Privatpraxis zur Rekonstruktion und wurden in der Studie nicht eingeschlossen. Die Patienten wurden ab dem Tag der Implantation bis zum Juni 1999 nachuntersucht. Die geschtzte kumulative berlebensrate fr 16 Jahre betrug fr alle Implantate 91.4% und fr die Gesamtzahl der Rekonstruktionen 95.8%. Die geschtzte kumulative berlebensrate ab dem Tag der Belastung gerechnet betrug fr gemischt getragene Rekonstruktionen 93.6% und fr rein implantatgetragene 97.2%. Weder die Kieferseite, noch die Implantatlokalisation (vorne oder hinten) hatte einen signikanten Einuss auf das Ergebnis. Kurze Implantate, eine hohe Anzahl Implantate am selben Patienten, geringe Anzahl Implantate pro Brcke, Implantate mit einer kunststoffverblendeten Rekonstruktion und Implantate in Verbindung mit einer Knochenaugmentation zeigten ein grsseres Risiko fr Implantatmisserfolge. Die Idee, Implantate bei einer Brcke nicht zu verblocken ist ein vielversprechender Ansatz, der aber vor der Anerkennung eine Besttigung braucht.

restoration. Twenty-one patients with failed implants could still be rehabilitated with modied implant prostheses. For 33 patients where implant failures led to prosthesis failures or inability of prosthesis installation, a further surgery was impossible without grafting, or this treatment proposal was rejected by the patient. Patients with failed single tooth restorations were never retreated by means of oral implants, but an alternative solution was offered. In 37 subsequent single tooth implant restorations used to restore edentulous spaces of two, three and four missing teeth in 13, 1 and 2 patients, respectively, only one implant failed. This raised the issue of whether this modality could replace the traditional xed partial implant prostheses. This was conrmed by the lack of signicant difference between single vs. partial (free-standing) implants and prostheses. The estimated upper limit of 5.87 of the implants, however, questioned the method. Further research is needed to investigate the performance of single implant restorations to treat multiple missing teeth.

and posterior sites. It seems promising that in partial edentulism, single tooth implant restorations can be used instead of xed partial prostheses, although this needs further investigation. The survival rate increases as the number of implants supporting a xed restoration increases. Patients with more implants, on the other hand, have an increased failure risk. Free-standing restorations present higher survival rates compared to implant-tooth connected restorations. Implants shorter than 10-mm present a higher risk. Thread prole, age or gender at implant installation do not seem to inuence the outcome. Acknowledgements: R Jacobs is postdoctoral researcher of the F.W.O.-Flanders. J.Duyrick in postdoctoral researcher of the Research Council of K. U. Leuven.

sume Re
tude a e de pre te dire le succe de restau`s Le but de cette e dente partiels s rations implantaires lors du traitement de pendance des implants et en tenant compte de linterde cembre de linuence de plusieurs variables. Entre de 1982 et juin 1998, 1 956 implants ad modum Brnemark (respectivement 1 212 dans le maxillaire et 744 dans la `res pre molaires) ont mandibule, 846 en distal des premie te re pare inse s chez 660 patients (248 hommes) dans le de tement de Parodontologie des hopitaux universitaires de luniversite catholique de Leuven. Des 810 restaurations es partement de Me decine dentaire prothe place dans le de taient des couronnes isome hopital , 235 e tique du me es, taient supporte par des implants et des dents, es le 166 e

Conclusions
Fixed restorations in partially edentulous patients have a high predictability when Brnemark system implants are used. This applies in both jaws, and in both anterior

Resumen
El proposito de este estudio fue predecir el resultado de restauraciones de implantes en el tratamiento de edentulismo parcial, tomando en cuenta la interdependencia de los implantes y el efecto de varias variables confusas.En-

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Naert et al . Clinical evaluation of implant-xed partial restorations

tre diciembre de 1982 y junio de 1988, se instalaron 1956 implantes del sistema Brnemark
A

(1212 y 744 en el

maxilar superior e inferior respectivamente, 846 distal a los primeros premolares)en 660 pacientes (248 hombres) en el Departamento de Periodoncia del Hospital Universi tario de la Universidad Catolica de Leuven. De las 810 restauraciones instaladas en el Departamento de Odonto tica del mismo hospital, 235 fueron coronas loga Proste unitarias, 166 estaban soportadas por implantes y dientes y 409 fueron protesis parciales jas libres. Un numero adicional de 87 restauraciones se colocaron en consultas dentales privadas y no se incluyeron en el estudio. Los pacientes se siguieron desde la colocacion del estudio hasta junio de 1999. Las tasas acumuladas de supervivencia estimadas fueron de 91.4% para todos los implantes y 95.8% para todas las

restauraciones a lo largo de un periodo de 16 anos. Las tasas acumuladas de supervivencia estimadas para carga sobre conexiones diente-implante y para implantosoportadas unicamente fueron de 93.6% y 97.2% respectiva mente. Ni el lugar de implante en la boca ni la posicion del implante (anterior o posterior) tuvieron efectos signicativos en el resultado. La menor longitud de los implantes, un alto numero de implantes por paciente, bajo numero de implantes por protesis, implantes cargados por restauraciones de acrlico e implantes combinados con in jertos oseos presentaron un mayor riesgo de fracaso implantario. La idea de no ferulizar los implantes en una protesis par cial es prometedora pero necesita replicacion antes de ser aceptada.

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