Peter Rammelsberg Effect of prosthetic restoration on

Justo Lorenzo-Bermejo
Stefanie Kappel
implant survival and success

Authors’ affiliations: Key words: clinical research, clinical trials, prosthodontics, statistics
Peter Rammelsberg, Stefanie Kappel, Department
of Prosthodontics, University Hospital Heidelberg,
Heidelberg, Germany Abstract
Justo Lorenzo-Bermejo, Institute for Biometry and Purpose: The objective of this work was to evaluate the effect of prosthetic restoration on the
Informatics, University Hospital Heidelberg,
survival of implants and on the incidence of implant-related complications.
Heidelberg, Germany
Material and methods: From a prospectively documented clinical study, 1569 implants placed in
Corresponding author: 630 patients (mean age 59.56 years) were evaluated. Selection criteria were a conventional loading
Peter Rammelsberg
Department of Prosthodontics, University Hospital
protocol, prosthetic restoration with at least one follow-up, and a minimum observation period of
Heidelberg, Im Neuenheimer Feld 400, D-60120 9 months. Implants that failed before prosthetic restoration were excluded. The sample included
Heidelberg, Germany 1345 tissue-level implants and 104 bone-level implants (Straumann), and 120 Replace implants
Tel.: 00496221566032
Fax: 00496221565371 (Nobel Biocare). The observation period ranged between 9 months and 11 years after prosthetic
e-mail: peter_rammelsberg@med.uni-heidelberg.de restoration (mean 4.0 years; SD 2.5). The implants were restored with single crowns (n = 557), fixed
dental prostheses (n = 594), or removable dental prostheses (RDP) (n = 418). In the RDP group, 356
implants were restored with telescoping crowns, 22 with bar units 24 with bar joints, and 16 with
locator attachments. The incidence of implant-related complications and failures was analyzed by
use of Kaplan–Meier survival curves. Cox regression analysis was used to identify possible risk
factors.
Results: Twenty-seven failures (1.8%; loosened or removed implants) were observed after
prosthetic restoration; the incidence of failure was 3% for implants placed in males and 1% for
implants placed in females. Other factors had no effect on the incidence of failure. Peri-implantitis
(n = 29) and marginal bone loss >2 mm without acute inflammation (n = 6) also resulted in a 4%
incidence of severe implant-related complications (62 of 1569; success 96%). Cox regression analysis
revealed combined tooth–implant-supported restorations as a significant risk-reducing factor for
severe implant-related complications (hazard ratio, HR = 0.34; P = 0.04). There was, furthermore, a
tendency toward a greater incidence of complications for implants restored with RDPs than for
single crowns (P = 0.08). Other factors, for example location (anterior/posterior, maxilla/mandible),
age, sex, or implant placement combined with bone augmentation, had no significant effect on
the incidence of implant-related complications (P values ranging between 0.16 and 0.94).
Conclusions: The type of support has a small but significant effect on implant prognosis. For
detailed analysis of the effects of loading by different types of prosthetic restoration, larger
sample sizes are required.

Replacing missing teeth by use of dental
implants has become a reliable treatment
option for support of single crowns (SCs) and
fixed dental prostheses (FDPs). A recent
review revealed further improvement of high
5-year survival from 93.5% in early studies to
97.1% for studies published after 2000 (Pje-
tursson et al. 2014). In a recent long-term
study, Wittneben et al. 2014; calculated sur-
vival of 95.5% for implant-supported single
crowns and FDPs after 10 years. A possible
Date:
Accepted 14 August 2016 reason for the increase in survival might be
that early clinical studies included a substan-
To cite this article:
Rammelsberg P, Lorenzo-Bermejo J, Kappel S. Effect of tial proportion of implants with machined sur-
prosthetic restoration on implant survival and success.
faces. Exclusion of implants with machined
Clin. Oral Impl. Res. 00, 2016, 1–7
doi: 10.1111/clr.12974 surfaces increased mean 5-year survival for
implants restored with FDPs from 95.6% to
97.2% (calculated in a meta-analysis by Pje-
tursson et al. 2012). In a recent review, Jimbo
& Albrektsson (2015) reported that long-term
survival of maxillary implants with a moder-
ately rough surface was significantly better
than for minimally rough implants.
For removable dental prostheses (RDPs), a
variety of attachments (bar joints, rigid bar
units, ball attachments, telescoping double
crowns) have been recommended for reten-
tion and/or support of RDPs on implants
(Gotfredsen et al. 2008). Survival of implants
up to 100% has been reported in well-docu-
mented clinical studies (Krennmair et al.
2012; Zou et al. 2013).

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Rammelsberg et al
Prosthetic restoration and implant prognosis
To estimate implant survival, early studies
and reviews focused on implant failure
whereas recent reviews have included addi-
tional complications in their analysis to esti-
mate implant success. Implant success has
been defined on the basis of a variety of crite-
ria, making comparison difficult. Strict crite-
ria with a focus on long-term osseous
integration of the implants, proposed by
Albrektsson et al. 1986; have been most fre-
quently used in the last decade (Moraschini
et al. 2015). On the basis of these criteria,
success has been defined on the basis of the
absence of implant mobility and radiographic
signs of peri-implant radiolucency, maximum
annual bone loss of 0.2 mm in the implant’s
first year, and the absence of such persistent
signs and symptoms such as pain, infection,
and violation of nerves (Albrektsson et al.
1986).
As a result of these additional criteria,
measured success is lower than survival. In a
recent review of long-term survival and long-
term success (Moraschini et al. 2015) which
included only clinical studies with minimum
observation periods of 10 years, mean sur-
vival of the implants after a mean follow-up
time of 13.4 years was 94.6% whereas mean
success was 89.7% (mean follow-up time
15.7 years).
Another important aspect revealed by that
review was that approximately 70% of the
failures occurred after prosthetic restoration
and loading (Moraschini et al. 2015). A popu-
lation-based Swedish study of 2367 implants
placed in 567 patients with an observation
period of 9 years confirmed this observation
(Derks et al. 2015). Early implant loss
occurred for 1.4% of the implants, compared
with 2% late failures after prosthetic restora-
tion. With increasing observation periods,
late failures contribute increasingly to overall
failure and complications.
In the past, the prognosis of the implants
was predominantly analyzed separately for
different types of prosthetic restoration. As a
consequence, numerous reviews and meta-
analyses are available for implants used to
support single crowns or FDPs. A review
from 2007 (Pjetursson et al. 2007) was one of
the first to report systematic analysis of the
10-year survival of fixed implant-supported
restorations. Recent reviews on implant prog-
noses included only small numbers of studies
on implant-supported or implant-retained
RDPs. Studies focusing on a variety of attach-
ments in a comparable clinical situation are,
however, available for limited sample sizes
only. The variety of attachments, the number
of implants, and the possibility of combining
2 | Clin. Oral Impl. Res. 0, 2016 / 1–7
implants and natural teeth within one RDP
increase the number of confounding
variables.
In a review from 2008 (Pjetursson & Lang
2008), survival of implant-supported and
combined tooth and implant-supported FDPs
was similar after 5 years, but survival after
10 years was lower for exclusively implant-
supported FDPs. Recent clinical studies of
FDPs reported a tendency toward greater suc-
cess for combined tooth and implant-sup-
ported restorations (Schwarz et al. 2012) and
improved implant prognosis of combined
tooth and implant-supported RDPs (Ram-
melsberg et al. 2014).
Although loading of the implants with the
prosthetic restorations is an important aspect
of consensus recommendations on the num-
ber of implants required for different restora-
tions (Gotfredsen et al. 2008), clinical studies
of the effect of the restoration on implant
prognosis have rarely been conducted.
Although different survival has been reported
for a variety of prosthetic restorations, the
effect of the type of prosthetic restoration on
implant success has not been investigated for
a homogenous sample including a variety of
fixed and removable prosthetic restorations
supported by implants.
The objective of this clinical study was,
therefore, to evaluate the effect of prosthetic
restoration on survival and on the incidence
of implant-related complications.
Material and methods
In a prospectively documented clinical study,
2258 implants had been placed from 2002 to
2014. By March 2014, 1909 of these implants
had been restored with different prosthetic
restorations. Only implants with a conven-
tional loading protocol were included. As a
consequence, five implants combined with
immediate implant placement or immediate
loading were excluded. Because recalls for
344 implants had not been documented until
Table 1. Data and selection procedure for the final set of results used for statistical analysis
Implants placed between 2002 and 2013
No baseline data on prosthetic restoration
Reasons
Early implant failure
Delayed restoration
Restoration elsewhere
No restoration
Passed away
Other
Immediate implantation and/or restoration
Prosthetic restoration from 2002 to March 2014
No follow-up data until December 2014
Implants with at least 9 months of loading by final prosthetic restorations
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
the time point of evaluation, the final sample
size was 1569 implants with a minimum of
9 months in service for the prosthetic
restoration (Table 1). The study was approved
by the local university ethic study committee
(registration number 027/2005).
The final study population comprised 306
men and 324 women with a mean age of
59.56 years; 1569 implants were placed from
2002 to 2013 (Fig. 1). Selection criteria were a
conventional loading protocol, prosthetic
restoration with at least one follow-up, and a
minimum observation period of 9 months
after prosthetic restoration. Implants that
failed before prosthetic restoration were
excluded (Table 1).
The implants used were 1345 tissue-level
implants and 104 bone-level implants from
Straumann (Waldenburg, Switzerland), and
120 Replace implants (Nobel Biocare, Zurich,
Switzerland) (Table 2). The length of most of
the implants ranged from 8 to 12 mm; only
15 implants were longer than 12 mm. The
diameter was predominantly 4.1 mm (range
3.3–5 mm). Eight-hundred and fifty-six were
tissue-level implants with the dimensions
4.1 mm 9 10 mm.
Most (n = 1202) of the implants were
placed in posterior quadrants, with only 367
in the anterior region; 890 implants were
located in the maxilla and 679 in the mand-
ible. Simultaneous bone augmentation,
including bone spreading, bone splitting,
guided bone regeneration, and internal sinus
floor elevation, was performed for 1033
implants whereas 536 implants were placed
in native bone.
The implants were restored with single
crowns (n = 557), FDPs (n = 594), or RDPs
(n = 418). In the RDP group, the attachments
used were telescopic for 356 implants, bar
units (rigid U-shaped bar without spacer) for
22 implants, bar joints (ovoid bars with
spacer) for 24 implants, and stud attachments
(locator, Zest Anchors, Escondido, CA, USA)
for 16 implants (Table 3). A total of 1.306
2258
344
38
45
16
18
2
225
5
1909
340
1569
 Rammelsberg et al
Prosthetic restoration and implant prognosis

Age of patients in years without acute inflammation (n = 6) resulted

90 in 28 failures and accounted for 62 severe
implant-related complications, resulting in
80 an incidence of severe implant-related com-
70
plications of 4%, and success of 96% for the
complete sample (Table 5).
60 In contrast with survival, implant success
was similar for men and women (Fig. 3).
50
After 5 years, the probability of success was
40 around 95% for both men and women when
the survival curves demonstrated multiple
30
crossings. Kaplan–Meier analyses of the vari-
20 able location, whether mandibular or maxil-
lary or anterior or posterior quadrant, also
10
resulted in success curves with multiple
Male Female crossings. The probability of success ranged
between 94% and 96% after 5 years (Figs. 4
Fig. 1. Variation of age of 306 male and 324 female patients.
and 5).
A substantial proportion of the implants
implants were used for exclusively implant- Implant-related complications and failures (17%) were used in combination with natural
supported restorations, whereas 263 implants were studied visually by use of Kaplan–Meier teeth to support RPDs and FDPs. After
were restored with FDPs and RDPs in combi- curves. Cox regression analysis was used to 5 years, Kaplan–Meier success curves
nation with natural teeth (Table 4). identify prognostic factors. Possible within- revealed a probability of success of 95% for
The observation period for the implants patient correlation of failure and complica- exclusively implant-supported restorations
ranged from 9 months to 11 years after pros- tion times was taken into account by use of compared to more than 96% for implants
thetic restoration (mean 4.0 years; SD 2.5). a shared frailty model considering the patient restored with FDPs and RDPs with combined
as a random effect. Statistical analysis was tooth–implant support (Fig. 6). A tendency
Table 2. Implant characteristics conducted by use of SAS V9.3 (SAS Institute toward greater implant success was also
No. of Inc., Cary, NC, USA). found for single crowns compared with RDPs
Characteristic implants and FDPs. After 5 years, success for implants
Implant type restored with single crowns was 97%
Straumann tissue level 1345
Results
Straumann bone level 104
Nobel Biocare Replace 120 Twenty-seven failures (1.8% loosened or
Location
removed implants) were observed after pros- Table 5. Distribution of failures and severe
Posterior 1202
thetic restoration; the incidence of failure complications
Anterior 367
Maxilla 890 after 5 years was 3% for implants placed in Failures Implant loosening 1
Mandible 679 Removal 26
males compared to 1% for females (Fig. 2). Severe Peri-implantitis 29
Simultaneous bone augmentation
For further analysis of implant success, fail- complications Bone loss without signs 6
With 1033
Without 536 ures and severe complications were analyzed of acute infection
Severe 62
together. A combination of peri-implantitis
complications + failures
(n = 29) and marginal bone loss >2 mm

Table 3. Prosthodontic characteristics

Implant survival
No. of % of
1,0
Restoration implants implants Male
Single crown 557 35.5 Female
Male-censored
FDP 594 37.9 0,9 Female-censored
RDP 418 26.6
Telescopic 356 22.7
Cum. Survival

Bar unit 22 1.4 0,8

Bar joint 24 1.5
Stud attachment 16 1.0
0,7

0,6
Table 4. Support of the restorations
No. of % of
Support implants implants 0,5

Exclusively implant 1306 83.2% 0 1 2 3 4 5 6 7 8 9 10

Tooth and implant 263 16.8% Observation period in years
combined
Fig. 2. Kaplan–Meier survival curves for implants placed in males and females.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2016 / 1–7
Rammelsberg et al
Prosthetic restoration and implant prognosis

Implant success compared with 95.5% for FDPs and 93% for
1,0 RDPs (Fig. 7).
Male
Female
Statistical evaluation of possible risk fac-
Nale censored tors was restricted to Cox regression analysis
0,9 Female censored
using a shared frailty model considering the
patient as a random effect. This procedure
0,8 was selected to avoid the bias of clustering
effects by multiple implants placed in one
0,7 patient. Cox regression analysis revealed no
effect on failure of gender, age, and location
(maxilla or mandible, anterior or posterior; P
0,6
values ranging between 0.16 and 0.94;
Table 6). Placement of implants in combina-
0,5 tion with simultaneous augmentation proce-
dures was not a risk factor after prosthetic
0 1 2 3 4 5 6 7 8 9 10
Observation period in years restoration (P = 0.43). Fewer implant-related
complications were observed for implants
Fig. 3. Kaplan–Meier curves for success of implants placed in males and females. used for combined tooth–implant support of
the restoration than for solely implant-sup-
ported restorations (hazard ratio (HR) 0.34;
Implant success
P = 0.04). Multivariate analysis considering
Location multiple implants for a patient as a random
1,0
Maxilla effect also resulted in a marginal P value
Mandible
Maxilla-censored
(0.08) for type of restoration combined with
0,9 Mandible- an HR of 1.8 for RDPs.
censored

0,8
Discussion
0,7
Prospectively documented implants placed
and restored in a single center were selected
0,6 for this study. Variations of implant place-
ment and prosthetic restoration procedures
were therefore reduced compared with multi-
0,5
center studies and survival analysis per-
0 1 2 3 4 5 6 7 8 9 10 formed on the basis of reviews. Any
Observation period in years
confounding effect of implant dimensions
Fig. 4. Success of maxillary and mandibular implants. Kaplan–Meier curves represent implant survival without
was minimized, because implants of length
implant-related complications. and diameter less than 8 and 3.3 mm, respec-
tively, were not included. In a previous study
by Derks et al. 2015 and in reviews by Pje-
tursson et al. 2012 and Jimbo & Albrektsson
Implant success
2015, negative effects of smooth or machined
1,0 Location surfaces on implant prognosis were revealed.
Anterior In our work, this factor, with possible con-
Posterior
Anterior-censored
founding effects, was eliminated, because
0,9 Posterior- implants with machined surfaces were not
censored
included. The representativeness of data from
0,8 a single center is, however, limited.
Implants included were all those restored
with a conventional loading protocol (mand-
0,7
ible >3 months, maxilla >6 months after
implant placement) and with a minimum
0,6 loading time of 9 months. Hence, negative
effects of immediate loading on implant prog-
0,5 nosis, highlighted in the review of Sanz-San-
chez et al. 2015, were avoided.
0 1 2 3 4 5 6 7 8 9 10
Observation period in years Survival of the implants was high (>98%),
at the high end of that reported in previous
Fig. 5. Success of anterior and posterior implants. reviews. One reason for this positive

4 | Clin. Oral Impl. Res. 0, 2016 / 1–7 © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Rammelsberg et al
Prosthetic restoration and implant prognosis

Implant success success to 96% for the complete sample. The

1,0 Support residual sample size of 1569 implants in
Implant
Combined (tooth-
combination with 62 implant-related
implant) complications was sufficient for considera-
0,9 Implant-censored
Combined- tion of several risk factors in multivariate
censored
analysis.
0,8 Focusing on implant survival, the distribu-
tion of 28 failures within this study revealed
0,7 a risk of implant failure of 3% for men com-
pared to 1% for women aftet 5 years. This
difference disappeared if all implant-related
0,6
complications were considered, because the
higher incidence of failure for men was com-
0,5 pensated by the higher proportion of females
0 1 2 3 4 5 6 7 8 9 10
with peri-implantitis. Age had no significant
Observation period in years effect on implant success. These findings are
in agreement with the analysis of Noda et al.
Fig. 6. Kaplan–Meier success curves for implants restored with implant-supported and combined tooth–implant- (2015).
supported restorations.
Recent reviews have revealed negative
effects of smoking on implant survival
Implant success (Moraschini & Barboza 2015), if late and early
1,0 Restoration failures were combined, and on marginal
Single Crown
FDP bone loss (Clementini et al. 2014; Moraschini
0,9
RDP et al. 2015). Other clinical studies revealed
Crown-censored
FDP-censored smoking and periodontitis as risk factors for
RDP-censored early failures occurring before prosthetic
0,8
restoration (Derks et al. 2015; Noda et al.
2015). These variables had no significant
0,7 effect on late failures occurring after pros-
thetic restoration of the implants, however.
In our study, 38 early failures were excluded,
0,6
because of the focus on the effects of pros-
thetic restoration on implant success; the
0,5 ratio of early-to-late failures was comparable
0 1 2 3 4 5 6 7 8 9 with that in the studies by Derks et al.
Observation period in years (2015), Noda et al. (2015), and Moraschini
et al. (2015).
Fig. 7. Success of implants restored with single crowns, FDPs, and RDPs. Noda et al. (2015) previously identified pos-
terior location and maxilla as significant risk
Table 6. Cox regression analysis of risk factors for implant success factors for late failures. In contrast, in our
No. of study, location had no significant effect on
Variable Level Implants Complications P value HR 95% CI implant success after prosthetic restoration.
Age Cont. 1569 62 0.16 0.98 0.96 1.01 One-third of the implants were placed in
Sex Male 796 34 0.94 Ref. native bone whereas two-thirds were placed
Female 773 28 0.98 0.59 1.62 in simultaneously augmented sites. Simulta-
Location Maxilla 890 39 0.75 Ref.
Mandible 679 23 0.92 0.55 1.62 neous bone augmentation had no significant
Anterior 367 17 0.53 1.20 0.69 2.10 effect on implant success. This seems to be
Posterior 1202 45 Ref. in contrast with a previous study in which
Augmentation Without 536 18 0.43 0.80 0.46 1.39
more complex augmentation procedures sig-
With 1033 44 Ref.
Support Implant 1306 58 0.04 Ref. nificantly reduced implant prognosis com-
Combined tooth–implant 263 4 0.34 0.12 0.95 pared with implants placed in native bone
Restoration type Single crown 557 16 0.08 Ref. (Rammelsberg et al. 2012). In that study,
FDP 594 20 1.04 0.54 2.00
RDP 418 26 1.83 0.98 3.42
early complications predominantly affected
success. In our study, however, only implants
after a conventional loading protocol and a
outcome might be the use of predominantly types of implant. The high survival must also minimum loading time of 9 months were
tissue-level implants. In an analysis of 2367 be considered in relation to a mean observa- included. As a consequence, 38 early failures
implants after 9 years, Derks et al. 2015 tion period of 4 years (maximum 11 years). were excluded because of the primary focus
revealed favorable survival of tissue-level Consideration of failures and of severe on prosthetic restoration as a possible risk
implants (Straumann) compared with other implant-related complications reduced factor.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5 | Clin. Oral Impl. Res. 0, 2016 / 1–7
Rammelsberg et al
Prosthetic restoration and implant prognosis
A recent review (Sanz-Sanchez et al. 2015)
on the effectiveness of lateral bone augmen-
tation revealed high success of the implants,
from 91% to 100% after 1–5 years, as a sec-
ondary outcome. A review by Clementini
et al. (2012) found 5-year implant success
greater than 90% in sites augmented by use
of the techniques of horizontal and vertical
bone regeneration. In their analysis of risk
factors for 721 implants, Noda et al. (2015)
found a slightly increased odds ratio for risk
of early failures, and a reduced risk of late
failures, for implants placed in augmented
sites; these differences were far from signifi-
cant, however. Bone augmentation proce-
dures seem to affect short-term prognosis,
but the effect decreases for long-term com-
plications occurring after prosthetic restora-
tion.
As already mentioned, in this study, risk
factor analysis was restricted to late failures
and complications occurring after prosthetic
restoration. With regard to type of restora-
tion, a tendency toward a greater incidence of
complications was observed for implants
restored with RDPs rather than for fixed
restorations (SCs and FDPs). Several reviews
of prognosis of fixed restorations have
recently been published. A review based on
63 clinical studies revealed different 5-year
survival for single crowns (96.4%), exclu-
sively implant-supported FDPs (94.5%), and
tooth and implant-connected FDPs (91.3%)
(Muddugangadhar et al. 2015). Compared
with SCs, survival of FDPs was significantly
lower. Survival of the restoration did not
depend exclusively on the prognosis of the
implants, however. In a review on FDPs,
Pjetursson et al. (2012) calculated implant
survival of 95.6% after 5 years and 93.1%
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success of RDPs compared with SCs and
FDPs. Further investigations of implant prog-
nosis with focus on aspects of loading are
needed, however.
An early review (Pjetursson et al. 2007)
revealed 10-year survival of exclusively
implant-supported FDPs was greater than
that for combined tooth–implant-supported
FDPs, although the difference was based on
small sample sizes. A recent meta-analysis
(Muddugangadhar et al. 2015) with a focus on
the prognosis of different implant-supported
fixed restorations revealed different survival
for implant-supported FDPs (94.53%) and
tooth–implant-supported FDPs (91.27%) after
5 years. Survival data for the restorations
were not identical with those for survival of
the implants, however. In contrast, our study
revealed a small but significant positive
effect of combined tooth–implant support on
implant success (HR 0.34). This effect was
based on the total sample, including SCs,
FDPs, and RDPs, but not on exclusive evalu-
ation of FDPs. An explanation might be more
physiological force control by the periodontal
receptors of natural teeth during mastication.
Conclusions
Within the limitations of this clinical study,
the following conclusions can be drawn:
• Combined tooth–implant support of pros-
thetic restorations has a small positive but
significant effect on implant prognosis.
• For detailed analysis of critical implant
loading by different types of prosthetic
restoration, larger sample sizes are
required.
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