Clinical evaluation of dental

implant treatment
Christoph H. F. Hammerle & Roland Glauser
During the past decades, implant therapy has devel-
oped into a successful treatment for partial and com-
plete edentulism. Based on the healing response of
bone leading to osseointegration, a desired type of
anchorage of the endosseous part of dental implants
can predictably be obtained. The nature of this bone-
to-implant relationship is obviously capable of sup-
porting the loads resulting from forces exerted onto
the implant-borne suprastructures.
In addition, under standard clinical conditions a
stable and competent soft tissue seal is established
during the phase of tissue integration at the part of
the implant penetrating the tissues and extending
into the oral cavity. This soft tissue seal comprises
an epithelial attachment and a connective tissue
adaptation to the neck portion of the implant. A
stable mechanical seal is thus provided by these tis-
sues along with their capacity to mount a competent
immunologic reaction to the microbial challenge
occurring at the marginal area of the implant.
An understanding of the factors crucial for obtain-
ing stable and lasting tissue integration of functional
implants has led to a therapeutic approach rendering
excellent long-term success. Many factors play
important roles in obtaining long-lasting implant
stability. These include factors related to the beha-
vior and systemic health of patients, to the health of
the implant recipient site, to the amount and quality
of the tissues at the recipient site, to the forces
exerted onto the implant and surrounding tissues,
to the implant system and type of implant chosen,
and to the skill of the therapists providing care
including surgical, prosthetic as well as maintenance
procedures.
During treatment planning, execution of therapy,
and maintenance of patients, the clinician is faced
with the challenge of making the right decisions for
rendering implant success to an individual patient.
In order to do so, the clinician has to be able to
obtain all pertinent information regarding the
patient history and to perform the necessary exam-
inations prior to implant therapy, during implant
therapy and also during the maintenance phase.
The aim of this chapter is to review the critical
parameters available to evaluate patients in need of
implant therapy and monitor implants on a long-
term basis.
Diagnostic procedures prior to
implant placement
Competent treatment planning is a key to long-term
success of implant therapy. Indications and contra-
indications must carefully be balanced and optional
treatments must be taken into the decision-making
process in each individual patient eligible for implant
therapy.
Systemic factors
Information derived from a thorough medical history
is mandatory as an initial step of treatment planning.
The aim of this history is to identify current and past
diseases, medications taken by the patient, and pre-
sent or past therapeutic interventions relevant to the
treatment with oral implants. In the case of systemic
conditions that may inuence implant therapy, con-
tacting the physician treating the patient for further
clarication is recommended.
Prerequisites for implant therapy include an
undisturbed wound healing capacity, the possibility
of mounting a competent host response to microbial
challenges, and the absence of bleeding disorders. In
addition, jaw growth should have been completed.
An exception to this rule is the placement of perma-
nent or temporary implants as elements of ancho-
rage for orthodontic therapy.
230
Periodontology 2000, Vol. 34, 2004, 230239 Copyright
#
Blackwell Munksgaard 2004
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
Systemic diseases including rheumatoid arthritis,
osteomalacia, or developmental disorders like osteo-
genesis imperfecta are considered high risk factors in
implant therapy. Whether or not and to what degree
osteoporosis is to be considered a risk factor is still
under debate (9, 22).
Patients severely immunocompromised as a result
of medications, systemic diseases, or irradiation
therapy are considered at risk for implant therapy
failure (50). However, when approved protocols are
followed in irradiated patients, e.g. regarding the
time span between termination of irradiation and
implant placement, survival rates similar to those
reported for implants placed in native, non-irra-
diated bone can be obtained (38).
Non-controlled severe diabetes, in particular insu-
lin-dependent diabetes (type I), is considered a risk
factor due to an impaired healing response and an
increased rate of implant loss. Once the diabetes is
under control, implants can successfully be used in
such patients.
Bleeding disorders pose a risk for oral surgical
interventions in general and implant placement in
particular. Necessary precautions need to be taken in
coordination with the responsible physician prior to
incorporation of implants.
The importance of genetic factors known to be
associated with the development and progression
periodontal disease in predicting higher risks for
implant failures remains to be elucidated.
Patient compliance
Certain aspects of patient behavior have been associa-
ted with increased risk for complications relative to
implant therapy. Lack of proper daily oral hygiene
measures has been associated with an increased
rate of peri-implant disease including the destruction
of bone supporting the implant (50). In addition,
heavy and long-standing cigarette smoking has
been demonstrated to lead to higher rates of early
failures and to adversely affect long-term prognosis
of implants (8, 23, 51).
Aspects of the stomatognathic system
A thorough intra- and extraoral examination is per-
formed to identify general and local factors that
might adversely affect long-term success of implants.
In this context, the soft tissues and the bone are
inspected for diseases by means of clinical, radio-
graphic and possibly histologic methods.
An association has been found in a number of
studies between loss of osseointegration of dental
implants and parafunctional activities such as brux-
ism (67, 70, 74). Although more data are needed, it
seems at present that bruxism is a risk factor for
maintaining osseointegration over time.
In cases of reduced salivary ow rate the protective
function of the components of the immune system in
saliva and the rinsing effect of the saliva are ham-
pered. This may pose a threat to the wound healing
after implant placement and to the long-term main-
tenance of the implants.
Untreated periodontal disease is also a risk factor
for loss of implants resulting from an increased
chance for contamination of the implant surfaces
with periodontopathogenic bacteria and subsequent
infection of the peri-implant tissues. Various studies
have shown an association between the microbial
ora developing on the implants and the ora on
the remaining dentition (62).
Pathologic changes of the soft tissues like erosive,
bullous or hyperkeratotic lesions are potential risk
factors and should be thoroughly examined and ade-
quately treated before implant therapy in the region
is conducted.
In addition, the prospective host bone has to be
examined to detect ongoing disease processes or
lesions resulting from previous diseases. Based on
the ndings, a decision can be taken as to whether
implant therapy is possible.
Finally, insufcient bone volume in orofacial and/
or mesiodistal directions at the prospective implant
site is considered to be a factor associated with com-
plications related to the peri-implant tissues or with
early implant loss. These conditions are evaluated
using periapical radiographs, orthopantomograms,
computer tomograms or combinations thereof. In
more simple cases involving only anterior sites, peri-
apical radiographs are sufcient. In more complex
cases, especially in the area of the inferior alveolar
nerve, mental foramen, and the maxillary sinus,
orthopantomograms or computer tomograms are
chosen.
Clinical inspection combined with measurements
of the thickness of the soft tissues further help to
estimate the available bone volume. The amount of
bone necessary for implant placement may vary
depending on the requirements of the specic
implant system recommended by the manufacturer.
Recommendations based on data from studies in the
literature are also important.
Subsequently, treatment planning is performed by
taking into consideration all of the factors mentioned
above. In addition, the planning phase for determin-
ing the best sites for implant placement is governed
Evaluation parameters for implants
231
by the prosthetic needs of the patient. Ideally, a sur-
gical stent based on a wax-up of the planned nal
reconstruction is used for guiding the placement of
the implants in the best location. This stent is applied
to simplify placing the implant in the correct location
regarding the implant axis, the implant position in
the orofacial as well as mesiodistal dimension, and
the implant sink depth.
Diagnostic procedures between
implant placement and initiation of
prosthesis fabrication
Evaluation during the phase of tissue
integration
During implant placement and immediately there-
after, various methods are available to judge the
quality of the clinical procedures. Measurements of
insertion torque as well as assessments of bone-
implant damping reactions (e.g. tapping, resonance
frequency analysis) are used to determine the initial
stability (i.e. primary stability) of the newly placed
implants. Radiographic analysis will make it possible
to judge the location of the implant within the bone
and with respect to the neighboring structures like
roots of adjacent teeth, sinuses, and nerve structures.
In the early period of clinical application of
endosseous osseointegrated implants, it was recom-
mended that primary stability following placement
could be assessed by tapping the implant with a
metallic instrument (1). Such a test is more of a
raw, qualitative character since a clear determination
of the resonance and damping characteristics of an
implant-bone-interface is simply not possible. The
availability of a clinically applicable, simple and
non-invasive test to assess implant stability is con-
sidered to be of major interest. Therefore, different
non-destructive techniques mainly based on vibra-
tion methods in the sonic or ultrasonic range have
been investigated to study implant integrity (25, 40,
42, 55). These methods can basically be divided into
transient or impact methods and steady-state or
swept-frequency techniques (54). The Periotest
1
is
an example of an impact technique, whereas the
resonance frequency analysis is a typical steady-
state, swept-frequency technique.
Periotest
1
The Periotest
1
(Gulden, Bensheim, Germany) is an
electronic device designed to perform quantitative
measurements of the damping characteristics of
the periodontium, thereby establishing a value for
tooth mobility (82). The mobility of a tooth is eval-
uated as a function of the contact time of a small
metal plug containing an accelerometer, which is
used to strike a tooth. In the search for a quantitative
method of assessing implant stability, a number of
studies have been performed using the Periotest
1
to
measure dental implants (21, 57, 60, 61, 69, 84, 85, 90,
93, 94). It has been shown experimentally that the
device also measures contact time when applied on
dental implants or abutments (43, 58). In an early
review of the literature, Periotest
1
values were
described that had been obtained for a number of
implant systems (69). For example, typical values
reported for ITI implants were 5 to 5, which repre-
sents a narrow range over the possible scale from 8
to 50. In a clinical assessment on the use of the
Periotest
1
device for a baseline mobility measure-
ment of craniofacial implants, a good interexaminer
reliability has been reported (24). But the authors
also listed a number of variables that inuence Peri-
otest
1
values: the vertical measuring point on the
abutment, the angulation of the handpiece relative
to the abutment, and the horizontal distance of the
handpiece to the abutment. The inuence of opera-
tor variability in the application was also reported in
other investigations (53, 58). Moreover, Periotest
1
measurements on a group of 2,212 osseointegrated
implants revealed that the range of the mean Peri-
otest
1
values was less than 2 units for implants
placed in dense or in soft bone (95). In conclusion,
lack of resolution, poor sensitivity, and susceptibility
to operator variables limit the use of the Periotest
1
device as a clinical diagnostic aid to measure implant
stability.
Resonance frequency analysis
A method based on a steady-state, swept-frequency
technique termed Resonance Frequency Analysis
(RFA) has been developed by Meredith and co-work-
ers. The method utilizes a small transducer, which is
screwed onto an implant or abutment (55). The
transducer is excited by a steady-state signal, and
its response is measured. The resonance frequency
value of an implant is a function of its stiffness in the
surrounding bone and the level of the marginal bone.
The overall stiffness of an implant placed in the reci-
pient bone is inuenced by the stiffness of 1) the
implant itself, 2) the implant-tissue interface, and
3) the surrounding bone. In vitro and in vivo inves-
tigations have revealed that the RFA technique is
232
Hammerle & Glauser
non-invasive, easy to use, and capable of eliciting
quantitative information on implant stability and
stiffness. Therefore, this technique has been widely
used to assess implant stability during healing and
bone formation (30, 31, 3335, 39, 56, 68, 7579, 83,
86, 87). Experimental and clinical studies have
demonstrated that a slight increase or decrease in
resonance frequency is related to mechanical stress
relaxation and bone remodeling following implant
placement (30, 31, 57). An increase in resonance
frequency values following implant placement has
been documented for implants placed in soft bone
conditions, where bone formation during healing is
obviously more pronounced as compared to dense
bone conditions (31). A pronounced decrease in
resonance frequency value is related to a major
decrease in stiffness at the bone-implant-interface,
which may be indicative of potential failure (56).
Soft tissue integration
In the case of transmucosal location of the implant or
the healing cap, additional evaluations are used to
assess the congruency between the margins of the
soft tissue aps and the implant structures pene-
trating these tissues. A tight adaptation of the soft
tissues is expected to enhance soft and hard tissue
integration of the implant during the early phases of
healing.
During healing, the health of the mucosal tissues
adjacent to the implant are regularly checked with
respect to adequate plaque control by chemical or
mechanical means and to the absence of loading
forces exerted onto the implant (e.g. via temporary
prosthesis). In addition, the patient is examined for
adverse reactions resulting from the surgical inter-
vention or appearing during the phase of healing.
In situations of a submerged mode of healing, fol-
low-up visits are only necessary for removal of the
sutures and for the examination regarding adverse
reactions.
Numerous animal and clinical studies in humans
have demonstrated that neither the transmucosal
nor the submerged mode of healing show signicant
advantages regarding tissue integration of implants
and their long-term prognosis (12, 28, 29, 37, 96).
Radiographs
Immediately following implant placement or shortly
thereafter, a periapical radiograph is taken to control
for correct placement of the implant regarding posi-
tion, sink depth, and angulation (14). In addition, this
radiograph is used as baseline documentation for the
analysis of subsequent bone level changes. Depend-
ing on the circumstances, this radiograph may also
have forensic meaning.
Healing times
Recommended healing times with a documented
scientic background sufcient for recommendation
for clinical practice range from 6 weeks (20, 80) to
12 months (32). The choice within this range is deter-
mined by local and by patient factors. Hence, in bone
quality of types IIII, implants with a sand-blasted
and acid-etched surface (SLA) that were loaded after
6 weeks have been shown to be highly successful (20)
and this clinical protocol can be as predictable as
traditional protocols with loading initiated only
3 months after implant placement (80). In contrast,
implants placed in bone of low density in osteoporo-
tic patients have been demonstrated to still be suc-
cessful provided that extended healing periods are
allowed before prosthetic loading is initiated (32).
To date, parameters are lacking that permit the
determination of the minimal healing time necessary
for the occurrence of sufcient bone integration to
allow functional implant loading. Measurements of
implant stability using RFA are presently being ana-
lyzed for their value in providing this information.
Ideally, an assessment obtained immediately after
implant placement should yield this kind of data.
In this case, further treatment planning could be
done at the end of the surgical session for implant
placement.
The possibilities for immediate loading and the
short- as well as the long-term outcomes of this
approach are being extensively investigated. Loading
of implants immediately following their placement
has been demonstrated to be possible while still
obtaining excellent long-term results when four or
more implants placed in the mandible are splinted in
one single reconstruction (6, 41, 48).
Diagnostic procedures following
incorporation of prosthetic
reconstructions
Peri-implant soft tissues
Various parameters are available to the clinician to
determine the state of the peri-implant tissues and
from which to draw the appropriate conclusions in
order to initiate the correct interceptive therapy.
233
Evaluation parameters for implants
Microbiota at implant sites
Similar to the situation with other hard, non-shed-
ding surfaces in uid systems, a biolm develops on
implant surfaces once they penetrate the mucosal
tissues and are exposed to the oral environment.
These microorganisms may lead to inammation of
the peri-implant tissues, eventually causing destruc-
tion of the implant-supporting structures.
It has been demonstrated in a large number of
studies that the microbiota associated with healthy
peri-implant soft tissues is similar to the microbiota
detected in sulci of healthy sites at teeth (62).
Furthermore, implant sites exhibiting diseased tis-
sues have been demonstrated to harbor a periodon-
topathogenic ora similar to the one found in
periodontal pockets of sites showing advanced peri-
odontitis.
Hence, the information derived from analysis of
the microbiota in conjunction with the interpretation
of the clinical ndings is used to make a decision as
to the need and the mode of therapy in cases of peri-
implant infections.
Mucosal inflammation
Various studies in animals and humans have demon-
strated that the development of increased amounts
of plaque will lead to peri-implant mucositis (11, 71,
98), much like the gingival inammation observed
around teeth under similar conditions (52).
It may be concluded that the occurrence of peri-
implant mucositis can in general be interpreted as
the result of increased amounts of plaque and as a
sign of an inammatory reaction within these tis-
sues. Therefore, the assessment of the status of the
mucosa around implants is of value when trying to
discern a healthy from a diseased site.
This peri-implant mucositis has been studied with
respect to the cellular and humoral defense mechan-
isms. Basically, the mechanisms leading from
healthy to inamed tissues and the sequence of
events occurring during this process are similar
within the peri-implant soft tissues and the period-
ontal tissues (49, 91, 92).
The Gingival Index originally developed for the
assessment of the degree of inammation of the
marginal periodontal tissues (52) has been adapted
for use at implants (63). This modied index
describes the same degrees of severity of the inam-
mation as the original Gingival Index and can be
used to monitor peri-implant mucosal inammation.
It has to be taken into consideration, however, that
it has not been demonstrated so far that peri-implant
mucositis, if left untreated, will develop into peri-
implantitis.
Peri-implant probing
Originally, the value of peri-implant probing in deter-
mining the status of the peri-implant tissues was
questioned. However, in recent years the usefulness
of the information derived from it has generally been
accepted (3, 13). Probing the peri-implant soft tissue
zone renders information regarding the:
level of the mucosal margin;
peri-implant probing depth;
level of the tissues in the peri-implant zone provid-
ing resistance to probing;
effects of probing regarding bleeding, exudation
and suppuration.
Various factors affect the reliability of probing at
teeth and implants. Probing at implants is affected by
the size of the probe tip, the probing force, the direc-
tion of probe insertion, the health of the peri-implant
tissues, the macroscopic form and surface structure
of the implant, and the presence and the design of
the suprastructure.
Probing around teeth is a very useful tool to gather
information regarding the health of the tissues and
various anatomic landmarks. However, one should
be careful in expecting the same information from
probing around implants (13). The anchorage of
teeth and implants in the jawbone are distinctly dif-
ferent. With respect to probing the peri-implant and
the periodontal tissues the most important differ-
ence relates to the supracrestal soft tissue zone.
Whereas teeth exhibit connective tissue bers insert-
ing into supracrestal root cementum, the connective
tissue bers at implants generally show an orienta-
tion parallel to the implant surface without evidence
of insertion. This is particularly important when dis-
cussing the meaning of probing, since the bers
around teeth represent a primary source of resis-
tance to probe penetration (5).
Probe penetration at implant sites is heavily
dependent upon the conditions of the peri-implant
tissues (26, 47). At healthy sites the probe tip stopped
at around the level of the most coronal aspect of the
connective tissue adhesion to the implant neck. At
inamed sites the probe consistently reached close
to or was in contact with the bone level.
The optimal force for probing at teeth has been
suggested to be 0.25 N (64, 65). Results from clinical
studies suggest that a change in probing force
level has a higher impact at implants compared
to teeth (66). Hence, the use of a standardized force
is of higher importance when interpreting the
234
Hammerle & Glauser
measurements obtained at implants compared to
teeth. Acceptable levels of reproducibility regarding
probing measurements in patients using three differ-
ent pressure-calibrated probes have been reported
(19).
Various studies have described the probing depths
at healthy implant sites to be around 3 mm (2, 16, 27,
60, 63). Microbiological studies have shown a clear
difference between the microbiota in shallow and in
deep peri-implant pockets (63, 73, 81). Deeper pock-
ets harbored signicantly higher proportions of per-
iodontopathogenic microorganisms.
Regarding probing at implants, clinical studies
have shown a correlation between the probing depth
and the level of the marginal peri-implant bone as
determined on radiographs (17, 72). These data sup-
port the conclusion that probing represents a non-
invasive method free from irradiation to estimate the
marginal bone level. It has further been described in
one of these clinical studies that the mean distance
from the probe tip to the bone level amounted to
1.7 mm (17).
Despite the important information derived from
peri-implant sulcus probing, various shortcomings
decrease its value compared to the one obtained
from probing at teeth:
the conguration of the implant or the suprastruc-
ture may hinder proper probing;
increased probing depths, in particular in esthetic
sites, can be difcult to interpret.
Bleeding on probing
It has been established that bleeding on probing is a
valuable parameter in assessing the health status of
periodontal tissues (4, 7). In particular, the absence
of bleeding on probing has been shown to be a pre-
dictor of periodontal stability (45). The size of the tip
of the probe as well as the probing force should be
standardized to obtain meaningful data (44, 46).
Studies comparing bleeding scores at teeth and
implants in the same mouth have reported that the
bleeding on probing frequencies are higher at
implants compared to teeth (13). However, the value
in assessing healthy or diseased sites using bleeding
on probing registered at the peri-implant sulcus or
the peri-implant pockets has not yet been deter-
mined.
In this context, studies including the health status
of the peri-implant tissue in their success criteria also
assessed the presence or absence of suppuration
from the peri-implant sulcus or pocket (17, 18). His-
tologic studies have shown an inltration with large
numbers of polymorphonuclear leukocytes in
acutely inamed peri-implant soft tissues indicating
the clinical diagnostic value of suppuration.
Level of the mucosal margin
It has been reported that recession of the marginal
soft tissues occurs following incorporation of recon-
structions (10). Whereas this recession primarily tak-
ing place during the rst 6 months has never been
shown to adversely affect long-term survival of
affected implants, such recession may cause esthetic
problems in anterior areas of the mouth.
Keratinized mucosa
The question of whether or not keratinized mucosa is
required for the long-term maintenance of peri-
implant tissue health is still under debate. Neverthe-
less, several clinical studies in humans revealed that
the absence of marginal keratinized tissue is compa-
tible with soft tissue health provided adequate levels
of plaque control are maintained (10, 59, 61, 97).
In one of these studies, a retrospective analysis of
171 implants in 39 patients was conducted in order
to analyze the inuence of the presence or absence of
masticatory mucosa at the implant neck on the pre-
sence of plaque and the health status of the marginal
tissues (97). The results failed to reveal an inuence
of the condition of masticatory mucosa or marginal
soft tissue mobility on the outcome variables of pla-
que and bleeding on probing.
In another study, a prospective analysis of 163
implants in 41 patients evaluated the occurrence
and degree of recession during the rst two years
of implant function (10). Lack of masticatory mucosa
and mobility of the peri-implant soft tissues were
poor predictors of soft tissue recession. The investi-
gators concluded that the recession, which primarily
occurred during the rst 6 months of function, was
due to a physiological soft tissue remodeling aimed
at establishing appropriate biological dimensions of
the soft tissues.
Assessment of implant stability
During loading
Following successful osseointegration, implant load-
ing leads to an effective load distribution at the bone-
implant interface. Therefore, it has been proposed
that osseointegration of screw-shaped titanium
implants may be tested clinically by the application
of a counterclockwise torque up to 20 Ncm (reverse
torque test) at second-stage surgery (88). While
osseointegrated implants will resist a reverse torque
235
Evaluation parameters for implants
at this level, osseointegration failure with brous
encapsulation will lead to an unscrewing. Based on
this all-or-none result, the reverse torque test is not
able to discriminate the degree of healing or bone
formation around an implant. Moreover, the method
has some destructive potential since the test relies on
the direct application of shear stresses at the bone
implant interface, which have been reported to
induce irreversible bone deformations (15).
Radiographic evaluation is the most widely used
chairside technique to assess the boneimplant
interface during healing and implant function. The
objective is to determine marginal bone levels as well
as peri-implant radiolucencies. In general, the radio-
graphic evaluation has inherent shortcomings due to
the two-dimensional projection and the limitation to
the interproximal interfaces, as well as due to dif-
culties with standardization. In a clinical study on the
accuracy and precision of diagnosing implant stabi-
lity using radiographs, it was concluded that the
probability of predicting clinical implant instability
from radiographic examination was low in popula-
tions with a low prevalence of implant instability
(89).
Resonance frequency analysis as a rapid, non-
invasive method has also being used as a means of
monitoring the changes in stability related to bone
formation and the dynamics of osseointegration (i.e.
establishing secondary stability) over time. Clinically,
the technique has been used to follow implants
placed in combination with a non-submerged heal-
ing, to document implants subjected to immediate
loading, or to monitor implants placed in demanding
bone conditions (33, 35, 79).
Conclusions
A thorough history coupled with an evaluation of
relevant systemic factors is mandatory prior to the
initiation of implant therapy in order to recognize
conditions that may adversely affect treatment
results.
In addition to evaluating the site of the planned
implantation, a comprehensive examination of the
stomatognathic system is highly recommended
depending on the complexity of the clinical case.
Between implant placement and the initiation of
prosthetic therapy the peri-implant mucosa should
be examined regarding proper soft tissue integration.
Clinical visual examination aided by the use of a
periodontal probe allows the relevant information
to be gathered.
The most valuable clinical parameters for the
assessment of the health status of the peri-implant
tissues are the presence or absence of mucosal
inammation, signs of infection, and probing depth.
Standardized radiographs taken at regular intervals
are presently the best means to assess the bone-
implant relationship over time.
Resonance frequency analysis appears to be a use-
ful tool for assessing implant stability during the
phase of tissue integration and during implant func-
tion. More data, however, are needed to determine
discriminative levels of stability regarding measure-
ments taken at single as well as at repeated time
points.
References
1. Adell R. Surgical procedures. In: Branemark PI, Zarb G,
Albrektsson T, ed. Osseointegration in clinical dentistry. Chi-
cago: Quintessence Publishing, 1985: 232.
2. Adell R, Lekholm U, Rockler B, Branemark P-I. A 15-year
study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981: 10: 387416.
3. Albrektsson T, Isidor F. Consensus report of session IV. Ittin-
gen, Switzerland: Quintessence Publishing, 1994: 365369.
4. Armitage GC. Periodontal diseases: diagnosis. Ann Period-
ontol 1996: 1: 37215.
5. Armitage GC, Svanberg GK, Loe H. Microscopic evaluation
of clinical measurements of connective tissue attachment
levels. J Clin Periodontol 1977: 4: 173190.
6. Babbush CA. Titanium plasma spray screw implant system
for reconstruction of the edentulous mandible. Dent Clin
North Am 1986: 30: 117131.
7. Badersten A, Nilveus R, Egelberg J. Scores of plaque, bleed-
ing, suppuration and probing depth to predict probing at-
tachment loss. 5 years of observation following nonsurgical
periodontal therapy. J Clin Periodontol 1990: 17: 102107.
8. Bain CA, Moy PK. The association between the failure of
dental implants and cigarette smoking. Int J Oral Maxillofac
Implants 1993: 8: 609615.
9. Baxter JC, Fattore L. Osteoporosis and osseointegration of
implants. J Prosthodont 1993: 2: 120125.
10. Bengazi F, Wennstrom JL, Lekholm U. Recession of the soft
tissue margin at oral implants. Clin Oral Implants Res 1996:
7: 303310.
11. Berglundh T, Lindhe J, Marinello C, Ericsson I, Liljenberg B.
Soft tissue reaction to de novo plaque formation on im-
plants and teeth. An experimental study in the dog. Clin
Oral Implants Res 1992: 3: 18.
12. Bernard J-P, Belser UC, Martinet J-P, Borgis SA. Osseo-
integration of Branemark fixtures using a single-step opera-
ting system. A preliminary prospective one-year study in
the edentulous mandible. Clin Oral Implants Res 1995: 6:
122129.
13. Bragger U, Burgin W, Hammerle CHF, Lang NP. Associa-
tions between clinical parameters assessed around implants
and teeth. Clin Oral Implants Res 1997: 8: 412421.
14. Bragger U, Hafeli U, Huber B, Hammerle CHF, Lang NP.
Evaluation of postsurgical crestal bone levels adjacent to
236
Hammerle & Glauser
non-submerged dental implants. Clin Oral Implants Res
1998: 9: 218224.
15. Branemark R. Biomechanical study of osseointegration.
Goteborg: University of Goteborg, 1996.
16. Buser D, Weber HP, Bragger U. The treatment of partially
edentulous patients with ITI hollow-screw implants: pre-
surgical evaluation and surgical procedures. Int J Oral Max-
illofac Implants 1990: 5: 165174.
17. Buser D, Weber HP, Lang NP. Tissue integration of non-
submerged implants. 1-year results of a prospective study
with 100 ITI hollow-cylinder and hollow-screw implants.
Clin Oral Implants Res 1990: 1: 3340.
18. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke
N, Hirt HP, Belser UC, Lang NP. Long-term evaluation of
non-submerged ITI implants. Part I: 8-year life table analy-
sis of a prospective multi-center study with 2359 implants.
Clin Oral Implants Res 1997: 8: 161172.
19. Christensen MM, Joss A, Lang NP. Reproducibility of auto-
mated periodontal probing around teeth and osseointe-
grated oral implants. Clin Oral Implants Res 1997: 8: 455
464.
20. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D,
Taylor TM, Bernhard J, Peters F, Simpson JP. The use of
reduced healing times on ITI
1
implants with a sandblasted
and acid-etched (SLA) surface: Early results from clinical
trials on ITI
1
SLA implants. Clin Oral Implants Res 2002:
13: 144153.
21. Cranin AN, DeGrado J, Kaufman M, Baraoidan M, DiGre-
gorio R, Batgitis G, Lee Z. Evaluation of the Periotest as a
diagnostic tool for dental implants. J Oral Implantol 1998:
24: 139146.
22. Dao TTT, Anderson JD, Zarb GA. Is osteoporosis a risk factor
for osseointegration of dental implants? Int J Oral Maxillo-
fac Implants 1993: 8: 137144.
23. De Bruyn H, Collaert B. The effect of smoking on early
implant failure. Clin Oral Implants Res 1994: 5: 260264.
24. Derhami K, Wolfaardt JF, Dent M, Faulkner G, Grace M.
Assessment of Periotest device in baseline mobility mea-
surements of craniofacial implants. Int J Oral Maxillofac
Implants 1995: 10: 221229.
25. Elias JJ, Brunski JB, Scarton HA. A dynamic modal testing
technqiue for noninvasive assessment of bone-dental im-
plant interfaces. Int J Oral Maxillofac Implants 1996: 11:
728734.
26. Ericsson I, Lindhe J. Probing depth at implants and teeth. J
Clin Periodontol 1993: 20: 623627.
27. Ericsson I, Lekholm U, Branemark P-I, Lindhe J, Glantz
P-O, Nyman S. A clinical evaluation of fixed-bridge resto-
rations supported by the combination of teeth and osseo-
integrated titanium implants. J Clin Periodontol 1986: 13:
307312.
28. Ericsson I, Randow K, Glantz P-O, Lindhe J, Nilner K. Clin-
ical and radiographical features of submerged and nonsub-
merged titanium implants. Clin Oral Implants Res 1994: 5:
185189.
29. Ericsson I, Persson LG, Berglundh T, Edlund T, Lindhe J.
The effect of antimicrobial therapy on periimplantitis le-
sions. An experimental study in the dog. Clin Oral Implants
Res 1996: 7: 320328.
30. Friberg B, Sennerby L, Linden B, Grondahl K, Lekholm U.
Stability measurements of one-stage Branemark implants
during healing in mandibles. A clinical resonance frequency
analysis study. Int J Oral Maxillofac Surg 1999: 28: 266272.
31. Friberg B, Sennerby L, Meredith N, Lekholm U. A compar-
ison between cutting torque and resonance frequency mea-
surements of maxillary implants. A 20-month clinical study.
Int J Oral Maxillofac Surg 1999: 28: 297303
32. Friberg B, Ekestubbe A, Mellstrom D, Sennerby L. Brane-
mark implants and osteoprorosis: a clinical exploratory
study. Clin Implant Dent Relat Res 2001: 3: 5056.
33. Glauser R, Meredith N. Diagnostische Moglichkeiten zur
Evaluation der Implantatstabilitat. Implantologie 2001: 9:
147160.
34. Glauser R, Portmann M, Ruhstaller P, Lundgren AK, Haem-
merle CHF, Gottlow J. Stability measurements of immedi-
ately loaded machined and oxidized implants in the
posterior maxilla. A comparative clinical study using
resonance frequency analysis. Appl Osseointegr Res 2001:
2: 2729.
35. Glauser R, Ree A, Lundgren AK, Gottlow J, Hammerle
CHF, Schaerer P. Immediate occlusal loading of Branemark
implants applied in various jawbone regions: a prospective,
1-year clinical study. Clin Implant Dent Relat Res 2001: 3:
204213.
36. Glauser R, Lundgren AK, Gottlow J, Sennerby L, Portmann
M, Ruhstaller P, Hammerle CHF. Immediate occlusal load-
ing of Branemark TiUnite implants placed predominantly in
soft bone: 1-year results of a prospective, clinical study. Clin
Implant Dent Relat Res 2004: 5: in press.
37. Gotfredsen K, Rostrup E, Hjorting-Hansen E, Stoltze K,
Budtz-Jorgensen E. Histological and histomorphometri-
cal evaluation of tissue reactions adjacent to endosteal
implants in monkeys. Clin Oral Implants Res 1991: 2:
3037.
38. Granstrom G, Tjellstrom A, Branemark PI, Fornander J.
Bone-anchored reconstruction of the irradiated head and
neck cancer patient. Otolaryngol Head Neck Surg 1993: 108:
334343.
39. Heo SJ, Sennerby L, Odersjo M, Granstrom G, Tjellstrom A,
Meredith N. Stability measurements of craniofacial im-
plants by means of resonance frequency analyis. A clinical
pilot study. J Laryngol Oto 1998: 112: 537542.
40. Huang H-M, Lee S-Y, Yeh C-Y, Lin C-T. Resonance fre-
quency assessment of dental implant stability with various
bone qualities: a numerical approach. Clin Oral Implants
Res 2002: 13: 6574.
41. Jaffin RA, Kumar A, Berman CL. Immediate loading of
implants in partially and fully edentulous jaws: a series of
27 case reports. J Periodontol 2000: 71: 833838.
42. Kaneko TM. Pulsed oscillation technique for assessing the
mechanical state of the dental implant-bone interface.
Biomaterials 1991: 12: 555560.
43. Kaneko TM. Relationship between stiffness of the dental
implant-bone system and the duration of the implant-tap-
ping rod contact. Med Eng Phys 1994: 16: 310315.
44. Karayiannis A, Lang NP, Joss A, Nyman S. Bleeding
on probing as it relates to probing pressure and gingi-
val health in patients with a reduced but healthy period-
ontium. A clinical study. J Clin Periodontol 1992: 19:
471475.
45. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on
probing. An indication of periodontal stability. J Clin Period-
ontol 1990: 17: 714721.
46. Lang NP, Nyman S, Senn C, Joss A. Bleeding on probing as
it relates to probing pressure and gingival health. J Clin
Periodontol 1991: 18: 257261.
237
Evaluation parameters for implants
47. Lang NP, Wetzel AC, Stich H, Caffesse RG. Histologic probe
penetration in healthy and inflamed peri-implant tissues.
Clin Oral Implants Res 1994: 5: 191201.
48. Ledermann PD. Stegprothetische Versorgung des zahnlosen
Unterkiefers mit Hilfe von plasmabeschichteten Titans-
chraubenimplantaten. Dtsch Zahnarztl Z 1979: 34: 907911.
49. Liljenberg B, Gualini F, Berglundh T, Tonetti M, Lindhe J.
Composition of plaque-associated lesions in the gingiva and
the peri-implant mucosa in partially edentulous subjects.
J Clin Periodontol 1997: 24: 119123.
50. Lindquist LW, Rockler B, Carlsson GE. Bone resorption
around fixtures in edentulous patients treated with mandib-
ular fixed tissue-integrated prostheses. J Prosthet Dent 1988:
59: 5963.
51. Lindquist LW, Carlsson GE, Jemt T. Association between
marginal bone loss around osseointegrated mandibular im-
plants and smoking habits: a 10-year follow-up study. J Dent
Res 1997: 76: 16671674.
52. Loe H, Silness J. Periodontal disease in pregnancy. I. Pre-
valence and severity. Acta Odontol Scand 1963: 21: 533551.
53. Manz MC, Morris HF, Ochi S. An evaluation of the Periotest
system. Part I: Examiner reliability and repeatability of read-
ings. Implant Dent 1992: 1: 142146.
54. Meredith N. A review of nondestructive test methods and
their application to measure the stability and osseointegra-
tion of bone anchored endosseous implants. Crit Rev
Biomed Eng 1998: 26: 275291.
55. Meredith N, Alleyne D, Cawley P. Quantitative determina-
tion of the stability of the implant-tissue interface using
resonance frequency analysis. Clin Oral Implants Res
1996: 7: 261267.
56. Meredith N, Book K, Friberg B, Jemt T, Sennerby L. Reso-
nance frequency measurements of implant stability in vivo.
A cross-sectional and longitudinal study of resonance fre-
quency measurements on implants in the edentulous and
partially dentate maxilla. Clin Oral Implants Res 1997: 8:
226233.
57. Meredith N, Shagaldi F, Alleyne D, Sennerby L, Cawley P.
The application of resonance frequency measurements to
study the stability of titaniumimplants during healing in the
rabbit tibia. Clin Oral Implants Res 1997: 8: 234243.
58. Meredith N, Friberg B, Aparicio C, Sennerby L. Relationship
between contact time measurements and PTV values when
using the Periotest to measure implant stability. Int
J Prosthodont 1998: 11: 269275.
59. Mericske-Stern R. Oral tactile sensibility recorded in over-
denture wearers with implants or natural roots: a compara-
tive study. Part 2. Int J Oral Maxillofac Implants 1994: 9:
6370.
60. Mericske-Stern R, Steinlin Schaffner T, Marti P, Geering AH.
Peri-implant mucosal aspects of ITI implants supporting
overdentures. A five-year longitudinal study. Clin Oral Im-
plants Res 1994: 5: 918.
61. Mericske-Stern R, Milani D, Mericske E, Olah A. Periotest
1
measurements and osseointegration of mandibular ITI im-
plants supporting overdentures. A one-year longitudinal
study. Clin Oral Implants Res 1995: 6: 7382.
62. Mombelli A. Microbiology and antimicrobial therapy of
peri-implantitis. Periodontol 2000 2002: 28: 177189.
63. Mombelli A, Van Oosten MAC, Schurch E, Lang NP. The
microbiota associated with successful or failing osseointe-
grated titanium implants. Oral Microbiol Immunol 1987: 2:
145151.
64. Mombelli A, Muhle T, Frigg R. Depth-force patterns of per-
iodontal probing. Attachment-gain in relation to probing
force. J Clin Periodontol 1992: 19: 295300.
65. Mombelli A, Muhle T, Bragger U. Probing force dependence
of attachment level measurement in the assesment of ef-
fects of surgical periodontal treatment with or without
NSAID. Acta Med Dent Helv 1996: 1: 3439.
66. Mombelli A, Muhle T, Bragger U, Lang NP, Burgin WB.
Comparison of periodontal and peri-implant probing by
depth-force pattern analysis. Clin Oral Implants Res 1997:
8: 448454.
67. Naert I, Quirynen M, van Steenberghe D, Darius P. A study
of 589 consecutive implants supporting complete fixed
prostheses. Part II: Prosthetic aspects. J Prosthet Dent
1992: 68: 949956.
68. O'Sullivan D, Sennerby L, Meredith N. Measurements com-
paring the initial stability of five designs of dental implants:
a human cadaver study. Clin Implant Dent Relat Res 2000: 2:
8592.
69. Olive J, Aparicio C. The Periotest method as a measure of
osseointegrated oral implant stability. Int J Oral Maxillofac
Implants 1990: 5: 390400.
70. Perel ML. Parafunctional habits, nightguards, and root form
implants. Implant Dent 1994: 3: 261263.
71. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman
SR, Lang NP. Experimentally induced peri-implant mucosi-
tis. Clin Oral Implants Res 1994: 5: 254259.
72. Quirynen M, Naert I, van Steenberghe D, Teerlinck J,
Dekeyser C, Theuniers G. Periodontal aspects of osseo-
integrated fixtures supporting an overdenture. A 4-year
retrospective study. J Clin Periodontol 1991: 18: 719728.
73. Rams TE, Link CC. Microbiology of failing dental implants
in humans: electron microscopic observations. J Oral
Implantol 1983: 11: 93100.
74. Rangert B, Krogh PHJ, Langer B, van Roekel N. Bending
overload and implant fracture: A retrospective clinical ana-
lysis. Int J Oral Maxillofac Implants 1995: 10: 326334.
75. Rasmusson L, Meredith N, Kahnberg KE, Sennerby L.
Stability assessments and histology of titanium implants
placed simultaneously with autogenous onlay bone in
the rabbit tibia. Int J Oral Maxillofac Surg 1998: 27:
229235.
76. Rasmusson L, Meredith N, Cho IH, Sennerby L. The influ-
ence of simultaneous versus delayed placement on the sta-
bility of titanium implants in onlay bone grafts. A histologic
and biomechanic study in the rabbit. Int J Oral Maxillofac
Surg 1999: 28: 224231.
77. Rasmusson L, Meredith N, Kahnberg K-E, Sennerby L.
Effects of barrier membranes on bone resorption and
implant stability in onlay bone grafts. An experimental
study. Clin Oral Implant Res 1999: 10: 267277.
78. Rasmusson L, Stegersjo G, Kahnberg KE, Sennerby L. Im-
plant stability measurements using resonance frequency
analysis in the grafted maxilla. A cross-sectional pilot study.
Clin Implant Dent Relat Res 1999: 1: 7074.
79. Rasmusson L, Kahnberg KE, Tan A. Effects of implant design
and surface on bone regeneration and implant stability: an
experimental study in the dog mandible. Clin Implant Dent
Relat Res 2001: 3: 28.
80. Roccuzzo M, Bunino M, Prioglio F, Bianchi SD. Early load-
ing of sandblasted and acid-etched (SLA) implants: a pro-
spective split-mouth comparative study. One-year results.
Clin Oral Implants Res 2001: 12: 572578.
238
Hammerle & Glauser
81. Sanz M, Newman MG, Nachnani S, Holt R, Stewart R, Flem-
mig T. Characterization of the subgingival microbial flora
around endosteal sapphire dental implants in partially
edentulous patients. Int J Oral Maxillofac Implants 1990:
5: 247253.
82. Schulte W, Lucas D, Muhlbratdt L, Scholz F, Bretschi J, Frei
D, Gudat II, Knig M, Markl M, Quante F, Schief D, Topkaya
A. Periotest - ein neues Verfahren und Gerat zur Messung
der Funktion des Parodontiums. Zahnarztl Mitt 1983:
12291240.
83. Sennerby L, Meredith N. Resonance frequency analysis:
measuring implant stability and osseointegration. Compend
Contin Educ Dent 1998: 19: 493498.
84. Simunek A, Vokurkova J, Kopecka D, Celko M, Mounajjed R,
Krulichova I, Skrabkova Z. Evaluation of stability of titanium
and hydroxyapatite-coated osseointegrated dental im-
plants: a pilot study. Clin Oral Implants Res 2002: 13: 7579.
85. van Steenberghe D, Tricio J, Naert I, Nys M. Damping char-
acteristics of bone-to-implant interfaces. A clinical study
with the Periotest
1
device. Clin Oral Implants Res 1995: 6:
3139.
86. Stenport VF, Olsson B, Morberg P, Tornell J, Johansson CB.
Systemically administered human growth hormone im-
proves initial implant stability: an experimental study in
the rabbit. Clin Implant Dent Relat Res 2001: 3: 135141.
87. Sul Y-T, Johansson CB, Jeong Y, Wennerberg A, Albrektsson
T. Resonance frequency and removal torque analysis of
implants with turned and anodized surface oxides. Clin Oral
Implants Res 2002: 13: 252259.
88. Sullivan DY, Sherwood RL, Collins TA, Krogh PHJ. The re-
verse-torque test: A clinical report. Int J Oral Maxillofac
Implants 1996: 11: 179185.
89. Sunden S, Grondahl K, Grondahl H-G. Accuracy and preci-
sion in the radiographic diagnosis of clinical instability in
Branemark dental implants. Clin Oral Implants Res 1995: 6:
220226.
90. Teerlinck J, Quirynen M, Darius P, van Steenberghe D.
Periotest
1
: an objective clinical diagnosis of bone apposi-
tion toward implants. Int J Oral Maxillofac Implants 1991: 6:
5561.
91. Tonetti M, Imboden M, Gerber L, Lang NP. Compartmen-
talization of inflammatory cell phenotypes in normal gingi-
va and peri-implant keratinized mucosa. J Clin Periodontol
1995: 22: 735742.
92. Tonetti MS, Schmid J, Hammerle CH, Lang NP. Intraepithe-
lial antigen-presenting cells in the keratinized mucosa
around teeth and osseointegrated implants. Clin Oral Im-
plants Res 1993: 4: 177186.
93. Tricio J, Laohapand P, van Steenberghe D, Quirynen M,
Naert I. Mechanical state assessment of the implant-bone
continuum: a better understanding of the Periotest method.
Int J Oral Maxillofac Implants 1995: 10: 4349.
94. Tricio J, van Steenberghe D, Rosenberg D, Duchateau L.
Implant stability related to insertion torque force and
bone density: An in vitro study. J Prosthet Dent 1995: 74:
608612.
95. Truhlar RS, Lauciello F, Morris HF, Shigeru O. The influence
of bone quality on Periotest values of endosseous dental
implants at stage II surgery. J Oral Maxillofac Surg 1997:
55: 5561.
96. Weber HP, Buser D, Donath K, Fiorellini JP, Doppolapudi V,
Paquette DW, Williams RC. Comparison of healed tissues
adjacent to submerged and non-submerged unloaded tita-
nium dental implants. A histometric study in beagle dogs.
Clin Oral Implants Res 1996: 7: 1119.
97. Wennstrom JL, Bengazi F, Lekholm U. The influence of the
masticatory mucosa on the peri-implant soft tissue condi-
tion. Clin Oral Implants Res 1994: 5: 18.
98. Zitzmann N, Scharer P, Marinello CP, Schupbach P, Ber-
glundh T. Alveolar ridge augmentation with Bio-Oss: a his-
tologic study in humans. Int J Periodontics Restorative Dent
2001: 21: 288295.
239
Evaluation parameters for implants