Periodontology 2000, Vol. 73, 2017, 7–21 © 2016 John Wiley & Sons A/S.

ley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Modern implant dentistry based

In the past 50 years, implant dentistry has evolved high-profile team members such as Tomas Albrek-
from an experimental treatment to a highly pre- tsson, Ragnar Adell, Ulf Lekholm and Torsten Jemt;
dictable option to replace missing teeth with implant- whereas Andr e Schroeder established, in 1980 in
supported prostheses. It is a treatment modality Switzerland, the International Team for Implantol-
widely used in daily practice for fully and partially ogy, which has become, in the intervening 35 years,
edentulous patients because modern implant therapy the world’s largest association in implant dentistry,
offers not only significant functional and biologic with more than 15,000 members and fellows in
advantages for many patients when compared with approximately 100 countries worldwide. Initially, the
conventional fixed or removable prostheses, but also research teams in Sweden and Switzerland did not
yields excellent long-term results, as documented by know about each other as they published their early
numerous 10-year studies with success and survival studies only in local journals in their respective coun-
rates above 95% (46, 80, 89, 98). This breakthrough in tries and they worked independently of each other.
oral rehabilitation was initiated 50 years ago by the
discovery that implants made of commercially pure
titanium could achieve anchorage in the bone with 1965 to 1985: the scientific quest
direct bone-to-implant contact. The most important for osseointegration and its clinical
pioneer of modern implant dentistry was Professor P. I. application
Br
anemark from the University of Gothenburg
(Sweden) who performed the first preclinical and Until the mid-1980s, only basic surgical guidelines
clinical studies in the 1960s (33). Later, he termed this had been established for the predictable achievement
phenomenon osseointegration (32), which is today a of osseointegration. These guidelines included a low-
widely accepted term. In the late 1960s, the second trauma surgical technique for implant bed prepara-
pioneer, Professor Andre  Schroeder from the Univer- tion to avoid overheating of the bone during prepara-
sity of Bern (Switzerland), started to examine the tis- tion, implant insertion with sufficient primary
sue integration of various implant materials, and his stability and a healing period of 3–6 months without
group was the first to document direct bone-to- functional loading (3, 32, 179). Both research teams
implant contact for titanium implants in nondecalci- agreed on these basic principles of implant surgery.
fied histologic sections (177). A few years later, he also However, there were differences concerning two
reported as the first one about the soft tissue reac- other important aspects – the healing modality and
tions to titanium implants (179). Both pioneers were the implant surface. The Br
anemark team used tita-
leading a team that performed numerous preclinical nium screw-type implants with a machined surface,
and clinical studies to establish the scientific basis for which was rather smooth, whereas the Schroeder
modern implant dentistry. The group in Sweden International Team for Implantology used tita-
became known as the Br
anemark team, with nium implants of various shapes with a titanium

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plasma-sprayed surface, which was quite rough and Implantology in the 1970s were further developed
microporous. In addition, Br
anemark required sub- into two-piece implants to offer more prosthetic flexi-
merged healing of the implant, whereas Schroeder bility with various abutments (193) but keeping the
favored nonsubmerged, transmucosal healing basic concept of a tissue-level implant for a nonsub-
because the prototype implants tested were all made merged healing modality in healed sites (55). This
as one-piece implants with the abutment being an evolution meant that, by the end of the 1980s, the
integral part of the implant. Both aspects caused, in leading implant systems offered mainly two-piece
the 1990s, heated debates at professional congresses. titanium screw-type implants with either a machined
Both research teams worked closely with an indus- or a rough titanium plasma-sprayed surface.
trial partner because they needed the expertise of
proper development and engineering, precise manu-
facturing, marketing and sales. It is remarkable that 1985 to 2000: major progress in the
these initial partners have, in the last 30 years, devel- field of implant dentistry
oped into the most famous brands and successful
companies in implant dentistry, namely Nobel Bio- The next phase in implantology started in the mid-
care (initially called Nobelpharma) and Straumann. 1980s, when implant therapy expanded into partially
Both are examples of an impressive success story, edentulous patients. The first clinical publications
achieved through translational medical research, appeared around 1990 and were encouraging in
input of science-focused clinicians worldwide and terms of implant-related outcomes (53, 54, 147, 174,
professional entrepreneurship during the past 197). Since then, partially edentulous patients have
50 years. become the dominant patient group, and in some
In the initial phase of clinical testing, Br

anemark competence centers, they currently represent more
used titanium implants primarily in edentulous jaws than 90% of all implant patients (24, 36). Conse-
to support fixed dental prostheses with the goal to quently, the growing demand to replace lost teeth by
improve chewing comfort and the quality of life for not only functional but also esthetically pleasing
these patients. The clinical results up to 15 years of implant-supported restorations became an important
follow up were very promising, in particular in the challenge. Industry answered by producing a larger
edentulous mandible (1, 32). The International Team number of prosthetic implant components, such as
for Implantology used the prototype implants with a angulated abutments, and esthetic single-tooth and
titanium plasma-sprayed surface, not only in fully cementable abutments. Clinical research was pushed
edentulous mandibles but also in partially edentulous to improve the condition of soft and hard tissues. This
patients with shortened dental arches and single esthetically driven demand was answered by the
tooth gaps (136, 145, 178). development of bone-augmentation procedures to
During this developing phase in the 1970s and overcome local bone deficiencies in potential implant
1980s, other implant materials or prototype implants sites. The best-documented surgical techniques for
were clinically tested. A prominent implant in Ger- bone augmentation were guided bone regeneration
many was the ceramic Tuebingen implant made of utilizing barrier membranes and sinus floor elevation
aluminum oxide (181). Another prominent German (2). The guided bone-regeneration technique was ini-
implant system was the titanium, nonthreaded IMZ tiated with preclinical studies around 1990 (51, 75, 76,
implant system with a titanium plasma-sprayed sur- 172). In the same period, the first case reports
face (15, 131). The American Core-Vent implant sys- and short-term clinical studies were published to
tem utilized a titanium aluminum vanadium alloy document various applications of the guided bone
(158, 165) and was quite prominent on the market. regeneration technique in patients (17, 40, 74, 128,
In the second half of the 1980s, there was a marked 143, 159). During the 1990s, surgical modifications
shift in the dental implant market to the use of com- were implemented to improve the predictability of
mercially pure titanium as the implant material of the guided bone regeneration technique and to
choice (187–189), and the threaded solid screw-type reduce the risk of complications. This included
implant became the preferred implant shape. This improved incision techniques, the utilization of fixa-
evolution was induced by a famous and highly cited tion devices to stabilize the membranes and the
paper by Albrektsson et al. (7), which reviewed the application of bone grafts to support the membranes
efficacy of dental implant systems available at that (43, 128). Later, the utilization of resorbable barrier
time. In addition, the one-piece prototype implants membranes became increasingly more popular, in
first used by Schroeder’s International Team for particular noncrosslinked collagen membranes, as

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they were able to reduce the number of surgical inter- follow up (28, 67, 190). This early loading has become
ventions and the rate of complications (103, 110, 112, a well-documented loading protocol for partially
214). The sinus floor elevation technique was first edentulous patients, indicating a clear reduction of
introduced during the 1980s (30, 195) with the lateral healing periods compared with the original healing
window technique. In the 1990s, a second technique periods proposed by Br
anemark and Schroeder in the
was presented, which is often called the osteotome 1970s (204). In the same decade, the immediate load-
technique using a transalveolar approach (191). In ing protocol became well documented, especially for
1996, the first sinus consensus conference was held fully edentulous patients. The protocol was first
by the Academy of Osseointegration, presenting tested with implant-retained overdentures in the
acceptable clinical results (115). edentulous mandible (14, 146) and was later intro-
In the 1990s, a paradigm shift took place in the field duced for fixed implant-supported prostheses (167,
of implant surface technology. As mentioned above, 175, 176). The reduction in healing period was an
the first 20 years of the implant market was domi- important development to increase the attractiveness
nated by two surfaces: the rather smooth machined of implant therapy and was primarily facilitated by
surface; and the rough, microporous titanium these improved microrough implant surfaces. Cur-
plasma-sprayed surface. This new development was rently, the clinical outcome for immediate loading in
initiated by a preclinical study at the University of fully edentulous mandibles and maxillae is compara-
Bern by Buser et al. (52). They examined the influ- ble with that for conventional delayed loading (79).
ence of surface characteristics on bone apposition to The authors reported a failure rate of 0–3.3% for the
five different titanium surfaces. The best bone appo- edentulous mandible and a failure rate of up to 7.2%
sition among titanium surfaces was found for a sur- for the maxilla. In the early 1990s, another debate
face produced with sandblasting using a large grit raised the question of whether an implant must be
and an acid-etching technique. A hydroxyapatite sur- submerged or not during healing in order to achieve
face showed the highest bone-to-implant contact val- osseointegration with high predictability. Successful
ues but also yielded significant signs of resorption. tissue integration of nonsubmerged titanium
Therefore, the hydroxyapatite surface was not the implants with a titanium plasma-sprayed surface was
first choice and its clinical application is currently not demonstrated in preclinical and clinical studies (39,
recommended. The sandblasted and acid-etched sur- 48, 54, 202, 203). When this was confirmed in clinical
face, which was moderately rough or microrough, studies using Br
anemark-type implants (18, 19, 88),
also showed significantly increased removal torque this debate came to an end around the Millennium
values when compared with implant surfaces classi- change (95). Since then, there is agreement that both
fied as smooth or rough (49, 50). Similar findings were healing modalities can be applied in daily practice
found by other groups for surfaces with various sand- depending on the clinical situation. When possible, a
blasting techniques alone, both in histomorphomet- nonsubmerged healing modality is utilized, which is
ric and in removal torque value studies (207–209), advantageous for the patient because it eliminates
and for implant surfaces produced by a dual-acid surgical intervention and reduces cost and morbidity.
technique in removal torque value studies (132, 133). On the other hand, additional bone or soft-tissue
At this time also the original Brånemark implants regenerative procedures, or certain risk patients, may
became available with a moderately rough, micro- benefit from a submerged healing period without
porous surface produced by anodic oxidation (141), functional load.
and was marketed as the TiUnite surface. Preclinical Another attempt to ease implant therapy for the
studies have shown a markedly stronger bone patient involved efforts to reduce the time between
response to TiUnite surfaces than to machined con- tooth extraction and implant placement. The concept
trol surfaces (213). These preclinical studies triggered of immediate implant placement was first utilized in
heated debates in the late 1990s but also initiated Germany (181) and was then adopted around 1990
studies of these new titanium surfaces, which are (17, 143, 159). The 1990s was the trial-and-error phase
most often called microrough or moderately rough of immediate implant placement, with numerous
surfaces. Currently, the microrough implant surfaces short- and mid-term studies primarily presenting sur-
of various brands are accepted as the surfaces of first vival data (13, 16, 31, 96, 100, 135, 140, 210). The topic
choice (37, 206). Two of these new microrough sur- of implant placement postextraction has been
faces were intensively tested in an early loading pro- debated at all major implant congresses ever since
tocol after 6–8 weeks of healing up to 5 years of and is discussed below in more detail.

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2000 to 2010: the fine-tuning phase This was confirmed in some clinical studies and sys-
tematic reviews (12, 44, 111); however, a recent ran-
in implant dentistry
domized controlled trial shows that platform
switching is only effective when the mucosal thick-
After the change of the Millennium, 15 years of major
ness allows establishment of a biologic width (198). In
developments and significant progress came to an
the prosthetic field, the development of zirconia
end, in particular in the surgical field, and a new
abutments had a major impact (8, 97, 160, 166, 168).
phase started with several fine-tuning efforts. The
In addition, the importance of implant esthetics has
dental research community tried to improve implant
also been underscored with the development of
therapy further with the goal to optimize the so-called
esthetic parameters to judge esthetic outcomes (21,
primary and secondary objectives of implant ther-
91). The whole spectrum of implant esthetics is criti-
apy (38).
cally reviewed in this volume of Periodontology 2000
The primary objectives of implant therapy are two-
and is discussed in the paper by Cosyn et al. (72).
fold: first, to achieve successful treatment outcomes
Treatment protocols were also improved in the
from a functional, esthetic and phonetic point of view
field of postextraction implant placement, originally
with high predictability and good long-term stability;
triggered by clinical and preclinical studies examining
and, second, to have a low risk of complications dur-
postextraction ridge alterations (10, 11, 180). These
ing healing and during the follow-up period. These
studies provided the basis for a much better under-
aspects are most important for patients because they
standing of the tissue biology in postextraction sites.
want to know what long-term prognosis they can
An update of these aspects are comprehensively pro-
expect and what risks are involved with different
vided in this volume of Periodontology 2000, with a
treatment proposals. Treatment outcomes are pri-
review paper by Chappuis et al. (56) including the
marily measured by assessment of implant survival
aspects of socket grafting and ridge-preservation
and success rates but also increasingly according to
techniques. The expanded knowledge about these
patient-centered outcomes (78).
biologically driven ridge alterations and the severe
The secondary objectives of implant therapy
vertical bone resorption observed in postextraction
include the fewest possible number of surgical inter-
sites with a thin-wall phenotype in the anterior
ventions, low pain and morbidity during healing,
maxilla of patients (59) has helped to increase our
short healing periods, short overall treatment time
understanding of the various causes of esthetic com-
and acceptable good-effectiveness. These objectives
plications with severe mid-facial recession of the
are also very important for patients but they are
mucosa in immediate implants (60, 63). Since 2003,
clearly of lower priority when compared with the pri-
this topic has been debated and analyzed at three
mary objectives. In the past 16 years, significant pro-
consecutive International Team for Implantology
gress has been achieved with these fine-tuning
consensus conferences where the classification of
efforts, although the steps of progress were clearly
treatment options was defined, risk factors for muco-
smaller and incremental and related to the ethically
sal recessions at immediate implants were identified
guided strive for minimal risks for patients.
and selection criteria for the potential treatment
Significant progress was achieved in relation to
options with immediate, early or late implant place-
esthetics. This became a topic of increasing interest
ment were described (61–63, 65, 102, 155). A recent,
in the mid-1990s (20) and came to the forefront after
5-year study demonstrated that around single, imme-
the Millennium change at every implant conference
diately restored implants, the mid-facial recession,
offered by national or international associations. Sev-
the mid-facial contour and the alveolar process defi-
eral improvements in implant components or surgi-
ciency deteriorate over time, and close to 50% of the
cal and prosthetic protocols were presented, such as
cases showed esthetic issues despite treatment by
a better understanding of the correct three-dimen-
experienced clinicians (71). This emphasizes the
sional implant positioning in relation to the esthetic
importance of proper case selection and risk assess-
outcomes (47, 94, 99). Another attempt was made
ment, and underscores the importance of proper
with improved manufacturing of titanium implants
long-term documentation of at least 5 years before a
using the concept of platform switching (144). This
clinical protocol can be objectively judged. This
concept has been adopted by most of the major
important topic, in particuar in esthetic sites, is dis-
implant manufacturers because it was claimed that
cussed in the review paper by Buser et al. (41) in this
this implant design would be more effective at main-
volume of Periodontology 2000.
taining peri-implant bone levels in the crestal area.

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To compensate for postextraction bone resorption, (182). The main concern with dental computed
bone augmentation must be performed in the major- tomography was radiation exposure in patients,
ity of esthetic implant sites, in particular on the facial which prevented its widespread application in daily
aspect (47, 99). In sites with minor bone deficiencies, practice (87). Thus, rather conservative guidelines
the use of a connective tissue graft can be used as an were given for the utilization of dental computed
alternative to increase the buccal soft tissues (70). tomography in implant patients by a European Asso-
This localized bone augmentation is performed using ciation of Osseointegration workshop (105). The new
the guided bone-regeneration technique, which was cone-beam computed tomography technology
further fine-tuned after the Millenium change. offered improvements over dental computed tomog-
Besides the change to resorbable collagen mem- raphy, not only concerning image quality but also
branes (104), preclinical research started to focus on concerning radiation exposure (27, 101, 148, 149). The
bone grafts and bone subsititutes for guided bone- technological progress of cone-beam computed
regeneration procedures. These bone fillers not only tomography and the much reduced radiation expo-
mechanically support barrier membranes to reduce sure have led to considerably wider application of this
the risk of membrane collapse during healing, they technology in daily practice (23) and less conservative
also have biologic properties, such as osteogenic guidelines have been formulated by the European
potential to activate new bone formation, and a high Association for Osseointegration (106). Up-to-date
or a low substitution rate, which will influence the information on cone-beam computed tomography is
stability of the augmented bone over time (45, 116– offered in the review paper by Bornstein et al. (26).
118, 121). A bovine bone filler demonstrated a low- The advent of cone-beam computed tomography
substitution rate and is widely used, not only for con- was also an important basis for the progress in digital
tour augmentation in early implant placement (42, implant dentistry, which has influenced both surgical
69) but also for internal augmentation in immediate and prosthetic aspects of implant dentistry. In the
implant placement (64, 70). A similar discussion on surgical field, increasingly sophisticated surgical
bone grafts and bone substitutes also took place for stents were created, which could be used for com-
sinus floor elevation. For this bone augmentation puter-assisted implant surgery. These computer-
technique, numerous combinations have been exam- assisted implant surgical techniques were often rec-
ined and used in patients, including autografts alone, ommended for a flapless surgical approach (34, 90).
allografts alone, xenografts alone or combinations of In the prosthetic field, the first steps toward com-
thereof, which is often called a composite graft (35, puter-aided design and computer-assisted manufac-
120). A recent preclinical study confirmed previous turing were made. In 2008, these initial developments
results of bone filler research for guided bone regen- were critically scrutinized at the 4th International
eration and demonstrated that autografts increased Team for Implantology Consensus Conference. A sys-
the bone-to-implant contact at 12 weeks of healing tematic review in the surgical field reported accept-
and that a bovine-derived low-substitution filler able precision of computer-assisted implant surgery
showed much better volume stability when compared but only short-term data were available (129). The
with allografts (122, 124). The combination with auto- status concerning computer-aided design and com-
grafts does not improve the long-term results of puter-assisted manufacturing procedures was less
implants (123) but it helps to reduce the healing per- positive. A systematic review in the prosthetic field
iod (137). It was also recommended to perform sinus concluded that clinical studies on the use of com-
floor elevation without any application of bone fillers puter-aided design and computer-assisted manufac-
in well-selected patients (150). An update on sinus turing techniques were too preliminary and
floor elevation procedures with different treatment underpowered to provide meaningful conclusions
approaches, the respective selection criteria and regarding the performance of abutments/frameworks
long-term data are provided in a narrative review by designed using these manufacturing procedures
Lundgren et al. (151). (130).
Another important field of improvement was In this decade, the technique of resonance fre-
achieved in the area of preoperative radiographic quency analysis was extensively examined in clinical
examination using the new three-dimensional cone- studies. Originally developed in the mid-1990s by
beam computed tomography technology, which was Meredith et al. (153), the resonance frequency analy-
first described in the late 1990s (156). This technology sis technique was significantly improved in 2004 and
quickly replaced the dental computed tomography 2009, and hence has provided clinicians with an
that was used in implant dentistry during the 1990s objective diagnostic tool to assess implant stability at

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any stage during implant therapy and follow up. The lack of consensus regarding which types of clinical
resonance frequency is measured using a transducer and radiographic parameters should be used to
and is translated into an implant stability quotient define peri-implantitis. The paper by Coli et al. (68)
value on a scale of up to 100 implant stability quo- critically appraises the literature discussing the topic
tients. The implant stability quotient value reflects of peri-implantitis and revisited some papers in the
the micro-mobility of the implant (164), which in turn context of diagnostic methodology and disease
is determined by factors such as bone density, surgi- thresholds. It is obvious that the high prevalence of
cal technique, implant design and healing time (184). peri-implantitis reported by some authors is related
A predetermined implant stability quotient 60 and 70 to a scientific flaw that holds a certain risk of damage
has been used as criterion for using immediate or to the reputation of implant dentistry but also may
early loading protocols in several studies (25, 137, lead to overtreatment of a ‘so-called disease’. On the
162, 163). Although numerous studies have shown the other hand, peri-implantitis may be a real clinical
clinical value of the resonance frequency analysis challenge that, of course, needs attention whenever
technique to provide relevant information on the diagnosed properly. In this context, the paper by De
state of implant integration, no consensus guidelines Bruyn et al. (77) points to patient risk factors for peri-
have yet been presented on how to use the resonance implantitis, such as smoking and periodontal disease,
frequency analysis technique in daily practice. in this volume of Periodontology 2000. In smokers
In the field of biology, there was a hype in the early with a history of periodontal disease, implant treat-
2000s to use platelet-rich plasma, which was triggered ment seems to be prone to additional bone loss, as
by a publication of Marx et al. (152) for bone grafting confirmed in a recent 9-year follow-up study (201).
with maxillofacial surgery. It has been speculated that Since the days of the founding fathers, the choice
the stimulating effect of platelet-rich plasma was a between predominantly screw-retained or cement-
result of the accumulation of autogenous platelets, retained prosthetic restorations has been a matter of
providing a high concentration of platelet growth fac- debate. The quest for improved esthetic outcomes
tors with a well-documented impact on bone regen- and the practicality of digitally designed abutments
eration (161, 186). A large number of platelet-rich have guided clinicians more toward cementable
plasma centrifuges were sold, pushed by the market- options. On the other hand, recent suggestions that
ing efforts of the companies involved. A few years cement remnants may induce peri-implantitis (211)
later, this hype ended abruptly when preclinical and counteract this evolution. The paper by Wittneben
clinical studies could not provide evidence that plate- et al. (212), in this volume of Periodontology 2000,
let-rich plasma was, in fact, able to accelerate reviews the recent literature in this respect. It pro-
osseointegration (119, 196, 205). vides clinical guidelines for choosing the retention
system appropriate for the patient on an individual
basis and takes feasibility and complication risks into
2010 and beyond: current trends account.
and open questions The cause of crestal bone loss is another unan-
swered question and is heavily debated. It is mainly
Compared with the era of introduction of dental accepted that crestal bone loss at dental implants
implants in clinical practice half a century ago, during the first year of loading is an inevitable phe-
implant survival is now highly predictable. Several nomenon and is generally looked upon as an adaptive
clinical papers reporting on 10-year clinical outcomes response to surgical trauma and loading (1). The
with contemporary modern surface-modified amount of bone loss may differ according to the
implants revealed an implant survival rate of more implant design and the location of the implant abut-
than 95% and that less than 5% of implants are diag- ment interface (108, 109), but most types of implant
nosed with purulent infection or peri-implantitis (4). show similar and minimal annual bone loss there-
Similar results were reported by a few studies with up after, based on average values (126, 142). However, if
to 23 years of follow up (57, 83, 199). Despite the making a frequency distribution of the bone loss in a
favorable clinical results, peri-implantitis has become patient population, some implants will show more
one of the largest controversies in recent years. bone loss than others and a few implants will even
Suggestions by professional boards of periodontists show continuous loss of bone over time. It is, of
that the incidence of biologic complications, and course, important to be able to identify implants
more specifically of peri-implantitis, may be up to showing continuous bone loss as a result of the risk
50%, has shaken the dental community. There is a for poor esthetics, discomfort and failure. Long-term

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studies on modern implant designs have shown that D’haese et al. (73). It is still unknown as to how fast,
implant failure per se is rare, often being below 5%, and to what extent, these digital techniques will
and that the primary reason for implant failure is usu- achieve widespread application in private offices.
ally other than continuous marginal bone loss (4, 82). Another trend is that implant patients have become
The reasons for marginal bone loss are not fully increasingly older since the arrival of the large birth
understood and are currently a matter of debate (4, cohorts of the so-called baby-boomer generation in
6). Some authors look upon marginal bone loss as a dental practices in the western world. Consequently,
biofilm-mediated process that is similar to periodon- the therapeutic strategies need to be adapted for
titis and have suggested the use of periodontal elderly patients considering the special characteristics
indices to diagnose peri-implantitis (139). Other of this age group, especially medical risk factors, func-
authors look at osseointegration as a balanced for- tional impairment and the possible onset of depen-
eign-body reaction. Therefore, it has been suggested dency and frailty (157). In implant surgery, it is
that marginal bone loss may also be influenced by important to minimize the morbidity for elderly
factors modulating the immunologic balance, such patients. All these medical, surgical and prosthetic
as implant hardware, patient characteristics (includ- aspects have been scrutinized in the review paper by
ing medication) and nonoptimal surgery and pros- Schimmel et al. (173).
thetics. These potential causes are discussed in the In the past 10 years, ceramic implants seem to be
two review papers by Albrektsson et al. (5) and making a comeback, after their first clinical applica-
Bosshardt et al. (29), the latter also providing a histo- tions in the 1960s and 1970s. The first attempts to
logic update on osseointegration of titanium and introduce aluminum oxide implants (169, 181) were
zirconia implants. not successful because at the end of the 1980s, com-
A strong trend in implant dentistry is the increasing mercially pure titanium implants became the mate-
utilization of digital technology, particularly in the rial of choice in implant dentistry. The new trend in
prosthetic field. The impressive progress with treat- ceramic implants is based on zirconium dioxide (also
ment planning software and with computer-aided known as zirconia) implants and successful preclini-
design and computer-assisted manufacturing tech- cal testing (58, 92, 93, 170). A recent systematic review
nology by the MedTech industry has simplified and on clinical short-term studies with zirconia implants
improved the workflow of digital implant therapy and documents the potential of this interesting material
fixed prosthetic dentistry. Making a digital impression (107). It seems as if the current preclinical and clinical
by using an intra-oral scanner may help to overcome documentation of zirconia implants are comparable
errors that occur during conventional impression tak- with those of commercially pure titanium implants
ing and pouring of stone models because the virtual with modern microrough surfaces first reported
model used by the computer-aided design software is approximately 15 years ago. The current status and
created almost immediately using the data of the potential advantages of zirconia implants are criti-
intra-oral scanner. Computer-guided milling further cally reviewed by Cionca et al. (66). It is as yet
completes the procedure in a cost-beneficial way. unknown whether it is possible for zirconia implants
Although many studies demonstrate a significant to become a valid alternative implant material to
improvement in the accuracy of computer-aided commercially pure titanium. Such a development
design and computer-assisted manufacturing com- would require information from long-term studies,
pared with conventional cast frameworks, much similar to the existing data available for commercially
depends on the workflow from an impression proce- pure titanium with microrough surfaces, and further
dure to the technical implementation during manu- progress of implant companies in the manufacturing
facturing of the prosthesis (200). The state of the art of two-piece zirconia implants allowing the place-
of digital implant dentistry was analyzed at the 5th ment of screw-retained prostheses.
International Team for Implantology Consensus Con- In recent years, the use of platelet-rich concen-
ference in 2013 in two systematic reviews, demon- trates has again gained momentum in the dental field
strating clear progress since 2008 (130, 194). In the as an autologous source of growth factors. Not only
present volume of Periodontology 2000, further pro- platelet-rich plasma, but also platelet-rich fibrin and
gress since then, and the currently feasible digital variations thereof (leukocyte-platelet-rich fibrin, fib-
workflow and technical pros and cons, are reviewed rin-platelet-rich fibrin, etc.) have been examined by
by Joda et al. (127). In the surgical field, the current various groups in vitro (22, 84, 85, 171, 185). However,
state of the art is critically reviewed in the paper by very little clinical documentation is currently avail-

13
Buser et al.

16000757, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/prd.12185 by CAPES, Wiley Online Library on [11/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
able, and clear evidence for any beneficial effects on the necessary skill and experience level for daily prac-
bone formation in postextraction or in peri-implant tice with implant surgery, as highlighted in a recent
sites are still lacking (9, 81, 113, 192). The next few review (134). A workshop on dental education clearly
years will show if this interesting technique of platelet suggests that the clinical education and training in
concentration will live up to its expections and pro- implant surgery should be based on postgraduate
duce a clinical breakthrough in the daily practice of programs (86). However, there are no hard facts to
implant surgery. sustain the suggestion that inexperienced and insuffi-
One increasing complication around osseointe- ciently educated or trained colleagues will cause an
grated implants in function is the development of increasing rate of implant complications or failures.
peri-implant mucosal recessions. Despite the fact Facts to document this potential fear are absent as
that, in most cases, mucosal recessions do not signifi- this group seldom publishes in scientific journals, as
cantly influence long-term implant maintenance, is the case for academic specialists. For instance,
their presence can affect the esthetic outcome and excellent 10-year results of numerous clinical studies
patient satisfaction. Several factors, such as the thick- were obtained by university-based groups with signif-
ness of hard and soft tissues surrounding the osseoin- icant clinical experience (4). However, a number of
tegrated implant, incorrect implant positioning (60) studies support the assumption that an increased fail-
and/or the quality of prosthetic reconstructions, ure rate may be expected when surgery is performed
appear to play a role in the etiology of mucosal reces- by less-experienced surgeons (125, 138, 154). Apart
sions. Owing to the increase in the number of from experience, factors such as skills and judgement
implants placed worldwide, it can be anticipated that also seem to affect the clinical outcome of implant
in the near future, the occurrence of mucosal reces- surgery (114). Another observation – that esthetic fail-
sions will also increase. The paper of Sculean et al. ures are most often caused by an implant malposition
(183) in the current volume of Periodontology 2000 – supports such a theory (60) as these complications
critically appraises the literature regarding recession are iatrogenic in nature. The future will show if this
coverage. At present, the treatment possibilities for observation of increased complication and failure
the coverage of peri-implant soft-tissue recessions are rates can be confirmed. Such a trend would have the
very limited and it is indicated that only shallow peri- potential to harm the reputation of implant therapy
implant mucosal recessions (e.g. up to 2 mm) may be as a first-choice treatment modality in dental
successfuly treated by certain surgical techniques, medicine.
including the use of subepithelial connective tissue
graft or guided bone regeneration; no data support
the possibility of covering deep and large peri-
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