Periodontology 2000, Vol.

66, 2014, 712

Printed in Singapore. All rights reserved

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Implant therapy: 40 years of

experience
MARC QUIRYNEN, DAVID HERRERA, WIM TEUGHELS & MARIANO SANZ

Dental implants placed under favorable conditions

in healthy patients have success rates of over 95%,
even after 15 years of follow up. In spite of this
excellent outcome, technical, biologic and esthetic
complications do occur (17, 27, 30, 31). Moreover,
the outcome can be less desirable if dental
implants are placed in patients affected with systemic diseases or other compromising conditions
(2, 4, 13, 22, 25). Metabolic disorders or immune
deciencies can, for example, give rise to surgical
complications and may also interfere with bone
apposition and/or remodeling at the implantbone
interface. Similarly, radiation therapy in the surgical
area may signicantly reduce cellularity and vascularity, and hence affect the healing of oral
implants. In compromised patients, implant-based
treatment may be a questionable choice. Medication, such as biphosphonates and/or anticoagulants, may also affect the outcome of implant
placement or increase the frequency of postoperative complications. The placement of dental
implants in such patients must adhere to strict
treatment protocols (19, 20).
The clinical protocol for the placement of dental
implants has changed signicantly over the past
40 years (Table 1). From the initial biocompatibilityoriented protocol, aiming at osseointegration and
long-term success, there has been an evolution
toward less stringent criteria for implant placement
in order to speed the healing process and
improve the esthetic results, although it is still
questionable whether patients will ultimately benet from these changes. The purpose of this volume
of Periodontology 2000 is to evaluate the new
developments in implantology, review their scientic evidence and analyze their indications, advantages and disadvantages. It is organized into 16
chapters
dealing
with
diagnostic
and
therapeutic concepts, from the use of current

three-dimensional radiographic techniques to

guided surgical implantation and enhanced surgical
protocols. The overall goal is to guide the clinician
in decision making around implant therapy and
to provide an understanding of the etiology and
therapy of peri-implant diseases.

Indication/treatment planning
Whereas initially only fully edentulous patients with
optimal jaw bone dimensions (width and height)
were the basic indication for implant therapy, now
nearly every edentulous space is considered as suitable for implant placement. In situations where
insufcient bone is available for implant therapy,
bone-augmentation techniques are routinely considmmerle (3) concluded that such
ered. Benic & Ha
techniques are highly predictable if the proper indications are respected and appropriate healing time
is allowed for bone regeneration. Another approach
is the use of the zygoma when the maxillary bone is
severely atrophic. As discussed by Aparicio et al. (1),
the zygomatic implant technique offers the possibility to treat highly complex situations with low morbidity. The bone height in the posterior maxilla is
often limited and a sinus lift procedure is recommended. Besides the conventional lateral window
technique, a less invasive transalveolar approach is
described by Pjetursson & Lang (26). As an alternative to surgical bone regeneration, various studies
have reported successful outcome with the use of
short implants in the mandible as well as in the
maxilla. Nisand & Renouard (24) discuss the indications and evidence-based efcacy of the use of
short and narrow implants. The esthetic outcome of
implant therapy is addressed by Merheb et al. (21)
and Thoma et al. (34). Merheb et al. (21) review
the optimal implant-placement within the bone

Quirynen et al.

Table 1. Changes to the original standard implant protocol of the 1970s to 1980s
Current changes to implant protocols
Original protocol (strict, biocompatibility = crucial)

Present protocol (less strict, speed and

esthetics = crucial)

Indication/planning
Primarily fully edentulous patients

All type of indications

Strict inclusion/exclusion criteria

Rare exclusion criteria

Minimal jaw bone width of 78 mm

Guided bone regeneration for horizontal augmentation

Minimal jaw bone height of 10 mm

Guided bone regeneration for vertical augmentation

Planning based on two-dimensional radiographs

Three-dimensional cone beam computed tomography

and virtual planning

Six to eight implants in edentulous jaw

Three to six implants in edentulous jaw

Anterior to the maxillary sinus

Sinus augmentation techniques

Timing
Four to 6 months of healing after tooth extraction

Immediate placement

Two-stage surgery

One-stage surgery

Submerged healing (36 months)

Nonsubmerged healing

No denture immediately after implant insertion

Immediate loading

Surgical protocol
Only specialists

General dentists

No surgical guides

Guided implant placement

Presurgical antibiotics

No standard antibiotic prophylaxis

Presurgical atropine to reduce saliva ow

No atropine

Low-speed placement + excessive cooling

Higher-speed placement, no cooling

Two surgical aspirators (operation area and mouth)

Single aspiration

Palatally/lingually pediculated ap

Crestal incision

Prosthetic protocol
Abutments not removed after the second surgery

Prosthesis on implant level

Titanium abutments

Different materials in mucosa

Implants interconnected

Free-standing implants

Screw retained

Cemented

Cast chromium cobalt/goldframework

Computer numeric controlled-milled titanium

framework

Occlusion in resin

Occlusion in porcelain/metal

Prosthesis design focused on cleansability

Prosthesis design focused on esthetics

Implant material/design
Minimally rough implants

Moderately rough implants

Commercially pure Grade I titanium implants

Grade IIIV titanium implants

External hex connection implant-abutment

Internal connection

Experience with implant surgery

Table 1. (Continued)
Current changes to implant protocols
Implants diameter: 3.5 mm and length: 10 mm

Short/narrow implants

No platform switch

Platform switch

Overall appreciation
Very strict protocol, biocompatibility = crucial

envelope to achieve acceptable long-term results,

and Thoma et al. (34) focus on the peri-implant soft
tissues and their impact on the esthetic outcome.
The treatment of the fully edentulous patient is discussed by Emami et al. (8), from the use of fullmouth xed rehabilitations to overdentures retained
by two to four implants. This latter treatment
option can offer excellent results with a satisfactory
costbenet ratio.

Implant treatment strategies

The original implant protocol was based on the placement of dental implants in healed ridges (at least
6 months after tooth extraction) and respecting an
extended healing time (of 36 months) in order to
obtain optimal osseointegration. The advent of
implants with a moderately rough surface has accelerated osseointegration and decreased the required
healing time (40, 41). This healing period may even be
reduced to a minimum, and immediate loading protocols have been used with a high degree of predictability under specic clinical conditions. These
indications, and the scientic evidence, are reviewed
by De Bruyn et al. (6).
Similarly, the placement of dental implants at the
time of tooth extraction has signicantly reduced
the treatment time and patient morbidity. This surgical protocol, however, can be associated with
esthetic complications as a result of remodeling of
the hard/soft tissue after tooth extraction (5, 7, 11,
28). Vignoletti & Sanz (38) review the incidence of
complications as well as the evidence-based outcomes of immediately placed implants. Implants
with rough surfaces have raised concerns about the
possible negative impact of enhanced biolm formation (29), even though studies have failed to
show signicant differences in bone loss or in the
incidence of peri-implant infections for implants
with minimally and moderately rough surfaces (16,
23, 35, 41).

Less strict protocol, speed and esthetics = crucial

Surgical protocol
The classical implant surgical protocol has changed signicantly over the years (Table 1). The focus
on maximal attention to sterility has diminished,
and even the need for systemic antibiotic cover is
questioned (9, 32). The introduction of threedimensional imaging has led to improvements in
preoperative diagnosis and implant surgery (12).
The complex anatomy of the jaws and the implications in implant surgery are discussed by Jacobs
et al. (14), and the use of cone beam computed
tomography for diagnosis/planning of dental
implant therapy is reviewed by Jacobs & Quirynen
(15). Guided surgery can improve the positioning
of implants, shorten the surgical time and reduce
postoperative complications. The advantages/disadvantages of guided implant surgery, either dynamic
or static, are reviewed respectively by Vercruyssen
et al. (36) and Vercruyssen et al. (37).

Peri-implant diseases
Two major infectious processes, designated apical
peri-implantitis and marginal peri-implant diseases,
may develop around successfully integrated dental
implants. Clinical studies have demonstrated that
apical peri-implantitis is strongly linked with periapical pathology around an extracted tooth at the
implant site (18). Temmerman et al. (33) discuss the
etiology, diagnosis and treatment of apical peri-implantitis. Marginal peri-implant diseases are dened
as inammatory processes of infectious origin of
the marginal peri-implant tissues. Similarly to periodontitis, marginal peri-impant diseases have a multifactorial etiology (Fig. 1). Two types of marginal
peri-implant diseases have been identied. Periimplant mucositis affects the peri-implant mucosa
without evidence of peri-implant crestal bone
loss, whereas peri-implantitis denotes inammation

Quirynen et al.

Genetics/Host (e.g. quality immune response)

Environment (e.g. periodontopathogens and beneficial bacteria)
Lifestyle (smoking, oral hygiene, diet and stress)
Hardware (sand-blasted and acid-etched implant/abutment,
connection, platform, etc.)
Procedure (guided bone regeneration, type of restoration,
cemented/screw, etc.)

Hard/Soft tissue (density, vascularization, thickness of mucosa,

etc.)

associated with bone loss. Whilst peri-implant mucositis has clinical and histopathological characteristics
similar to gingivitis, peri-implantitis exhibits distinct
characteristics in terms of rate of progression and
histopathology. Concerning treatment response,
peri-implant mucositis is reversible with appropriate
therapy, but the treatment of peri-implantitis is
unpredictable and suffers from the lack of an
evidence-based treatment protocol. Figuero et al.
(10) discuss the two marginal peri-implant diseases in
terms of etiopathogenesis, diagnosis and therapy.
The chronic inammation that denes periimplant diseases depends not only on the degree of
microbial accumulation and the composition of the
implant-associated biolm, but also on factors relating to the implant and the patient. Some of the
patient risk factors may be behaviourally based, and
therefore modiable, such as lack of oral hygiene and
smoking; however, other risk factors are not modiable, such as genetic susceptibility to infection and
systemic health status (e.g. diabetes).

Prosthetic protocol/materials
As shown in Table 1, changes have also occurred in
implant composition and macro-design, in implant
abutment connection and in restorative materials
and protocols. Although the new types of material
and therapy can inuence the outcome of implant
therapy, they are not dealt with in this volume of
Periodontology 2000.

Conclusions
Implant dentistry has changed signicantly during
the past 40 years. At the introduction of the osseointegration principle, implant placement and restoration were mostly carried out by specialists, but such

10

Fig. 1. Complexity of peri-implantitis, underlining the multicausality

model and the interaction among
different causal factors.

treatments are now increasingly being performed by

general dentists. A clear shift has also been seen in
the indications for implants, from xed full prostheses to overdentures, and later to partial bridges and
solitary implants. Implants were initially only placed
in healed extraction sites with convenient bone
parameters (bone height 10 mm and bone width
7 mm), and were loaded after a submerged healing
period, but these prerequisites have now been partly
abandoned. At the same time, patients have become
more demanding, with requests for faster treatment
and with clearly higher esthetic expectations.
Diagnostic improvements in implantology include
the introduction of computed tomography technology. The clinician suddenly obtained the ability to
examine the jaw anatomy in more detail. The identication of lingual foraminae, a double mental foramen, an undercut in the caninepremolar area of the
mandible, an extension of the alveolar canal to the
midline, sinus pathology, a widened naso-palatine
canal, an artery underneath the maxillary canine or in
the lateral wall of the sinus, and so forth, made treatment planning more difcult, but also reduced the
risk for neurovascular disturbance and/or serious
hemorrhage. A three-dimensional analysis of the jaw
bone and surrounding soft tissues has made guided
surgery possible. However, a review of the current literature indicates that the accuracy of the available
diagnostic techniques is not always perfect, and that
clear guidelines, as detailed in several chapters of this
volume, have to be carefully followed in order to prevent the malpositioning of implants (12).
Improvements in implant surface topography and
macro- and microdesign have facilitated the osseointegration process and paved the way for new concepts in implantology, such as short implants,
immediate loading and immediate placement (39).
However, immediate placement might not always be
as successful, from the esthetic point of view, as the
conventional approach to implant therapy, and

Experience with implant surgery

therefore should be carried out with appropriate caution. Guided bone regeneration is becoming an
accepted treatment option, either prior to, or simultaneously with, implant insertion. The use of resorbable
barrier membranes can simplify surgical procedures,
but requires careful attention to new guidelines, as
highlighted in this volume. It is now generally
accepted that horizontal bone augmentation is a predictable therapy, but this is not the case for vertical
augmentation. Current advances in implantology are
adversely affected by an unexpected high prevalence
of peri-implantitis. As no well-dened treatment is
currently available to arrest peri-implantitis, or to
regenerate bone lost to infection, the prevention of
peri-implantitis becomes even more important.
Finally, it is, of course, always important to keep
the patient at the center of any treatment planning
and to consider carefully his/her special wishes and
expectations. Not all patients need a xed restoration.
A simple overdenture can offer several advantages for
many patients, including a less demanding positioning of the implants, lower costs and simplicity of
maintenance.

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