Monica Wahlstrom

Gun-Britt Sagulin
Leif E. Jansson

Authors affiliations:
Monica Wahlstrom, Gun-Britt Sagulin, Department
of Prosthetics at Kista-Skanstull, Public Dental
Health, Stockholm, Sweden
Leif E. Jansson, Department of Periodontology at
Kista-Skanstull, Public Dental Health, Stockholm,
Sweden

Clinical follow-up of unilateral, fixed

dental prosthesis on maxillary implants

Key words: functional disturbances, periodontology, prosthodontics, soft tissueimplant

interactions
Abstract
Aims/Background: The aims of the present study were to evaluate (1) the success rate of
unilateral maxillary fixed dental prosthesis (FDPs) on implants in patients at a periodontal

Corresponding author:
Monica Wahlstrom
Folktandvarden Skanstull
Gotgatan 100
118 62 Stockholm
Sweden
Tel.: 46 8 12316400
Fax: 46 8 6446271
e-mail: monica.wahlstrom@ftv.sll.se

clinic referred for periodontal treatment, (2) the prevalence of varying mechanical and
biological complications and (3) effects of potential risk factors on the success rate.
Material and methods: Fifty consecutive patients were invited to participate in a follow-up.
The patients had received FDPs on implants between November 2000 and December 2003
after treatment to achieve optimal peridontal health, and the FDPs had been in function for
at least 3 years. A questionnaire was sent to the patients before the follow-up examination.
Forty-six patients with 116 implants were examined. The follow-up comprised clinical and
radiographic examinations and evaluations of treatment outcome.
Results: Before implant treatment, 13% of the teeth were extracted; of these, 80% were
extracted due to periodontal disease. No implants had been lost before implant loading.
One implant in one patient fractured after 3 years of functional loading and three implants
in another patient after 6.5 years. The most frequent mechanical complications were veneer
fractures and loose bridge screws. Patients with peri-implant mucositis had significantly
more bleeding on probing around teeth and implants. Patients with peri-implantitis at the
follow-up had more deep periodontal pockets around their remaining teeth compared
with individuals without peri-implantitis, but these differences were not significant.
Smokers had significantly fewer teeth, more periodontal pockets  4 mm and a tendency
towards greater marginal bone loss at the follow-up, compared with non-smokers.
Conclusion: In the short term, overloading and bruxism seem more hazardous for implant
treatment, compared with a history of periodontitis.

Date:
Accepted 11 February 2010
To cite this article:
Wahlstrom M, Sagulin G-B, Jansson LE. Clinical followup of unilateral, fixed dental prosthesis on maxillary
implants
Clin. Oral Impl. Res. 21, 2010; 12941300.
doi: 10.1111/j.1600-0501.2010.01948.x

1294

Many longitudinal studies describe the use

of dental implants for prosthetic rehabilitation of partially dentate patients (Pjetursson et al. 2004). The survival rates of FDPs
on implants are generally high (Schou
2008). But implant survival also includes
implants with extensive bone loss and
implants without the use of a supraconstruction. Biological and mechanical complications occur, and there is some
evidence that patients with a history of

periodontal disease may be more prone to

peri-implantitis (Schou 2006). Hence, the
success rate of implant therapy, namely,
that the implant is in function and causes
no complications (Albrektsson et al. 1986;
Smith & Zarb 1989), may be a more
pertinent variable to study.
To implement implant therapy successfully, we have to minimize risk factors.
Some well-known risk factors for implant
therapy include tobacco use (Bain 2003),

c 2010 John Wiley & Sons A/S

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis

insulin-dependent diabetes, and difficulties

in maintaining proper oral hygiene caused by
the design or a bridge of patients (Esposito et
al. 1998; Serino & Strom 2009). In addition,
a history of periodontitis has been proposed
to be a possible risk factor. Roos-Jansaker
(2007) reported that implant loss is significantly correlated with periodontitis, and
peri-implant lesions are usually found after
1014 years of fixed dental prosthesis (FDP)
function. In another study (De Boever et al.
2009), the incidences of peri-implantitis and
implant loss in individuals with generalized
aggressive periodontitis were found to be
more frequent compared with periodontally
healthy individuals. No reports claim with
certainty that individuals with periodontitis,
which is associated with tooth loss, are more
susceptible to implant complications than
individuals without periodontitis. Only a
few studies specify the causes of tooth loss
before implant placement. The association
between bruxism (tooth grinding and clenching) and implant failure has been studied in
several clinical studies but randomized-controlled studies are lacking to support a causal
relationship between overload and implant
failure (Lobbezoo et al. 2004; Hobkirk &
Wiscott 2006; Lobbezoo et al. 2006).
The aims of the present study were to
evaluate (1) the success rate of unilateral
maxillary FDPs on implants in patients at a
periodontal clinic referred for periodontal
treatment, (2) the prevalence of varying
mechanical and biological complications
and (3) the effects of potential risk factors
on the success rate.

Material and methods

Subjects

This retrospective study followed up consecutive patients referred to the Departments

of Periodontal and Prosthetic Dentistry,
Public Dental Service, Skanstull, Stockholm, for periodontal or prosthetic treatment. The inclusion criteria were as follows:
 Treatment with implant-supported
FDPs positioned unilaterally in the maxilla on two or more implants between
November 2000 and December 2003.
 Natural teeth present on the contralateral side of the maxilla.
 FDPs in function for at least 3 years.
Fifty patients met the inclusion criteria.
Three patients had died, and one patient

c 2010 John Wiley & Sons A/S

could not be found. The final study group

comprised 46 patients with 116 implants
(13 men and 33 women). The mean patient
age at the time of prosthetic treatment was
59 years (range 3684). The mean time
between prosthetic loading of the FDPs
and the clinical and radiographic examinations at the follow-up was about 5 years
(median 58 months; mean 61.3 months;
range 4084).
A letter sent to patients home addresses
explained the study and invited participation. Enclosed with the letter was a questionnaire containing subjective questions
about health, satisfaction with FDP esthetics, chewing ability, oral hygiene, and
recall visits with dental hygienists. Patients were asked to fill out the questionnaire before the follow-up.

pending on the degree of marginal bone of

most remaining teeth:

Implant treatment






Before implant treatment, all patients (if

needed) were periodontally treated to
achieve periodontal health. Periodontists
and dental hygienists cooperated in an
attempt to motivate all smokers to quit.
Patients who achieved satisfactory periodontal conditions qualified for implant
treatment. In most instances, periodontists
at the Department of Periodontal Dentistry, Public Dental Service, Skanstull,
Stockholm, performed implant surgery.
Oral surgeons at two hospitals in Stockholm installed a few implants.
After a minimum of 3 months of submerged implant healing, surgical abutments were fitted. Shortly thereafter, the
FDPs were placed as per the manufacturers
instructions on either (1) Cresco CtC ins
serts (Cresco Ti precision method ; Cresco
Ti Systems Sa`rl; Lausanne, Switzerland) or
s
(2) ASTRA Tech (Molndal, Sweden) abutments. Between November 2000 and
December 2003, two dentists at the
Department of Prosthetic Dentistry, Public Dental Service, Skanstull, Stockholm,
provided prosthetic treatment. All patients
were instructed to maintain proper hygiene
of their FDPs and the remaining teeth.
Dental hygienists at the periodontal clinic
provided supportive treatment for all patients with a history of periodontitis.
Study variables

A periodontist determined the marginal

bone level on radiographs. The patients
were then divided into three groups de-





Mean bone loss o1/3 of the root

length.
Mean bone loss 1/3 and o2/3 of the
root length.
Mean bone loss 2/3 of the root
length.

Clinical variables determined before

periodontal and prosthetic treatment,
such as probing pocket depth (PPD) and
bleeding on probing (BOP), were extracted
from patients dental records. The same
periodontist determined periodontal variables at the follow-up.
These variables were extracted from dental records, patient questionnaires, and
clinical examinations at the follow-up:
















Age.
Gender.
Medical history and medications.
Questions about the function of the
FDP.
FDPs time in function.
Smoking habits: non-smoker, former
smoker, current smoker.
Number of remaining teeth before
treatment and at the follow-up.
Reasons for tooth extractions.
Temporomandibular disorders: occurrence of subjective and objective symptoms, parafunctions and interferences,
occlusal wear, and use of interocclusal
appliance.
Bone augmentation.
Number of implants.
Implant sites.
Implant system.
Design of prosthetic construction:
material in the supraconstruction
(Table 1), cemented or screw-retained
FDP, type of abutments, number of
bridge units and cantilevers (Table 2).
BOP.
PPD at four sites per tooth and implant
using a periodontal measuring probe
(CP-12, Hu-Friedy, Chicago, IL, USA).

Table 1. Frequency distribution of bridge

material in the fixed dental prosthesis
Material

Titanium/sinfony
Gold/porcelain
Titanium/porcelain
Wirobond/porcelain

1
34
1
10

1295 |

Clin. Oral Impl. Res. 21, 2010 / 12941300

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis




With light force, the probe was vertically inserted into the pocket between
the mucosa and the implant.
Peri-implant mucositis, defined by
BOP, PPDo4 mm, and without loss
of marginal bone around the implant.
Peri-implantitis, defined by the color
and shape of peri-implant mucosa,
bleeding or pus on probing, PPD 
4 mm, and marginal bone loss mesial
and distal of the fixtures 42 mm clearly
visible on radiographs, compared with
baseline radiographs made at the first
follow-up visit, in most cases 1 year
after prosthetic loading
Implant loss.
Mechanical complication of the supraconstruction and/or the implant during
functional loading.
Difficulties in maintaining proper oral
hygiene caused by the design of the
bridge or patients motoric disability.
Maintenance program for oral health.

Statistics

The Statistical Package for the Social

Sciences (SPSS, version 4.0 for the PC;
SPSS Inc., Chicago, IL, USA) was used to
analyze the data. In all analyses, the statistical computational unit was at the subject level. The KruskalWallis test
investigated between-group differences
based on investigated variables. The
w2-test was used to investigate the correlations between mucositis/peri-implantits
and smoking history. Results were considered statistically significant at Po0.05.

Before implant treatment, 13% of the teeth

were extracted; of these, 80% were extracted due to periodontal disease. Fiftysix percent of the patients had a mean bone
loss of o1/3 of the root length, while the
Table 2. The frequency distribution at the
subject level of number of implants, bridge
units, and cantilever segments
Number of
implants
Number of
bridge units
Number of
cantilever
segments

1296 |

38

1 2

26

16 4

13

23 6

5 6

3 1

Clin. Oral Impl. Res. 21, 2010 / 12941300

and were not correlated with the presence

of mucositis, peri-implantitis, or implant
loss. Most patients (80%) visited a dental
hygienist at least once a year, and 54%
visited a dental hygienist more than once a
year. During the follow-up period, two
patients received FDPs on the contralateral
side in the maxilla due to extractions for
periodontal reasons.
The relative frequency distributions of
answers to anamnestic variables in the
questionnaires that patients filled in before
the follow-up are presented in Table 3. No
patient regretted choosing implant treatment. All but one patient were satisfied
with the esthetic result of their FDPs. The
dissatisfied patient (with the esthetics)
complained because the titanium abutment
was exposed buccally on one implant.

Biological complications

At the follow-up, five patients stated that

they were smokers and 26 stated that they
were former smokers. The means for periodontal variables in teeth associated with a

%
100
90
80
70
60
50
40
30
20
10
0

Baseline
Follow-up

0-9

10-19

20-29

30

100
90
80
70
60
50
40
30
20
10
0

0-9

10-19

20-29

30

Number of periodontal
pockets 6 mm

Number of periodontal
pockets 4 mm
Fig. 1. Distribution of probing pocket
4 mm at baseline and at the follow-up.

Results

Variable

mean marginal bone loss of the remaining

teeth in 15% of the patients was 2/3 of
the root length. Thus, 29% of the individuals had a mean bone loss between 1/3
and 2/3 of the root length. Figs 1 and 2
illustrate the distributions of PPD  4
mm and 6 mm at baseline and at the
follow-up.
The frequency distributions at the
patient level of the bridge material in
the supraconstructions are presented in
Table 1. Gold/porcelain was the most frequent material and was used in 74% of the
s
cases. The Astra Tech System was used
for 111 implants in 44 patients. The Nobel
s
Biocare AB (Goteborg, Sweden) system
was used for five implants in two patients.
Twenty-eight of the 46 FDPs supraconstructions were made of components in the
s
Astra Tech System and 18 of components
s
in the Cresco Ti precision method
(Cresco Ti Systems Sa`rl).
Table 2 displays the number of implants,
bridge units, and cantilever segments. Bone
augmentation techniques before implant
treatment were used in 50% of the cases

depths

Fig. 2. Distribution of probing pocket

6 mm at baseline and at the follow-up.

depths

Table 3. The relative frequency distribution (%) of answers to anamnesis variables on the
questionnaire
Variable

Yes (%)

No (%)

Smoker
Former smoker
Takes snuff
Subjective symptoms of temporomandibular disorders
Bruxism
Frequent headache
Use of interocclusal appliance
Bleeding around implants
Satisfied with implants
Chewing habits were changed
Subjective symptoms caused by the implants
Satisfied with the esthetics of the implants
Subjective feeling of difference between implants and teeth
Regretted the choice of implant treatment

11
57
7
13
31
9
28
35
89
13
20
98
13
0

89
43
93
87
69
91
72
65
11
87
80
2
87
100


c 2010 John Wiley & Sons A/S

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis

Table 4. Median values (range) for periodontal variables associated with smoking history
Smoking history

Number of teeth Number of tooth sites

at follow-up
with periodontal
pockets 4 mm

Number of tooth sites Number of

with periodontal
bleeding tooth
pockets 6 mm
sites at probing

Percentage (SD) of subjects

with a marginal bone loss
41/3 of root length

Smokers
Former smokers
Non-smokers

5
26
15

20 (1429)
17 (824)
23 (1628)

4 (323)
0 (03)
0 (01)

40 (54.8)
53.8 (50.8)
26.7 (45.8)

smoking history are presented in Table 4.

Former smokers had significantly fewer
teeth, more periodontal pockets 4 mm
at the follow-up, and a tendency (P 0.06)
towards more marginal bone loss compared
with non-smokers. Smokers had significantly (Po0.01) more tooth sites with
periodontal pockets 6 mm at the follow-up compared with non-smokers and
former smokers. Table 5 displays the
frequency distributions of subjects with
peri-implant mucositis and peri-implantitis associated with a smoking history.
Smoking was not significantly correlated
with the presence of peri-implant mucositis and peri-implantitis (P40.05).
Peri-implant mucositis was diagnosed in
10 patients (Table 5). These 10 patients
had significantly more bleeding tooth sites
and periodontal pockets 4 mm and
6 mm during probing around the teeth,
compared with patients without peri-implant mucositis (P 0.05, Table 6). Two
patients had peri-implantitis during functional loading and more periodontal pockets and bleeding tooth sites compared with
patients without peri-implantitis: one patient with peri-implantitis had a mean
marginal bone loss 1/3 of the root
length; the other had a mean marginal
bone loss 2/3.
Mechanical complications

No early implant failure was documented.

Two patients had lost four implants due to
implant fracture. In one of these patients,
all three implants fractured 6.5 years after
functional loading, in a four-unit FDP
without a cantilever, but involved the
canine. The patient used a soft interocclusal appliance. In the other patient, the
posterior implant of two implants fractured
after 3 years. The construction had one
distal cantilever, and the patient did not
use a stabilization splint.
One patient with peri-implant mucositis
and bruxism diagnoses had one fractured
abutment after 6 years and 8 months of

c 2010 John Wiley & Sons A/S

4 (049)
3.5 (023)
1 (04)

2 (037)
3 (034)
2 (044)

Table 5. Frequency distributions of subjects with peri-implant mucositis and peri-implantitis associated with smoking history
Smoking history

Number of patients
with mucositis

Number of patients
with peri-implantitis

Smokers
Former smokers
Non-smokers
Total

5
26
15
46

3
5
2
10

1
1
0
2

loading. The abutment was exchanged, and

the FDP is still in function. No significant
differences in mechanical complications
were found between the two systems of
supraconstruction fabrication on Astra
s
Tech implants: Astra abutments or the
s
Cresco Ti precision method . Ten of the 46
suprastructures had lost their screw retention during functional loading and had to be
reset.
Veneer fractures were recorded in nine
out of 46 FDPs. Six of those nine FDPs
were made of gold and porcelain and two
were made of wirobond and porcelain; this
difference was not significant. The only
suprastructure made of titanium and porcelain showed a veneer chipping fracture.
The frequencies of veneer fractures were
not significantly correlated with use of
occlusal appliance or bruxism.
The survival rate of the FDPs was 94%
(three out of 46 FDPs were lost). Two of
those three patients received new implants
and new FDPs, but the new implants are
not included in the results. One individual
lost the suprastructure due to loosening of
bridge screws. The implants resulted in no
complications, although the supraconstruction could not be examined at the
follow-up; this patient was mentally disabled at the time of examination.
Twenty-one out of 46 patients had
neither biological nor mechanical complications in their FDPs during functional
loading. Thus, the success rate for the
patients was 46%. Biological complications were observed in 11 patients (24%)
and one or several mechanical complica-

tions of varying severities in 14 patients

(30%). Four of these patients (9%) had
biological and mechanical complications
during functional loading.

Discussion
The present study consisted of 46 patients
and the analyses were performed at the
patient level. Thus, the material consisted
of a limited number of data and the analyses were performed using non-parametric
tests as these tests have the advantage of
not requiring the assumption of normality
or the assumption of homogeneity of variance. The multiple comparisons between
different groups may result in mass significance, which means an increased risk of
rejecting a correct hypothesis.
Consensus statements and recommendations (Lang et al. 2004) regarding implant
survival and complications for implantsupported FDPs in an ordinary population
noted that the cumulative survival rate of
FDPs that are supported by oral implants
was 95% after 5 years in function and
86.7% after 10 years in function. In our
limited material, the survival rate of FDPs
was 93.5% after 37 years in function.
Most studies are based on the FDP survival
rate from treatment in the mandible and
the maxilla, while our study only reports
results from maxillary treatment. Jemt &
Lekholm (1995) observed a lower FDP
survival rate in the maxilla.
The Pjetursson et al. (2004) review of
four studies on the effects of FDPs on

1297 |

Clin. Oral Impl. Res. 21, 2010 / 12941300

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis

Table 6. Median values (range) for periodontal variables associated with the presence of peri-implant mucositis, peri-implantitis, and
implant loss
Diagnosis

Peri-implant mucositis


Peri-implantitis


Implant loss (due to fracture)

Number of
bleeding sites
at probing

Percentage (SD) of
subjects with a
marginal bone loss
 1/3 of root length

Number of
teeth at
follow-up

Number of
periodontal
pockets
 4 mm

10
36

19.5 (1326)
20 (829)

3.5 (049)
1 (013)

2 (023)
0 (03)

8.5 (044)
1.5 (021)

30 (48.3)
47.2 (50.6)

2
44

17.5 (1619)
20 (829)

26.5 (449)
1.5 (023)

10.5 (023)
0 (03)

22 (737)
2 (044)

100 (-)
40.9 (49.7)

2
44

17.5 (1619)
20 (829)

2 (04)
1.5 (049)

0 (00)
0 (023)

15.5 (724)
2 (044)

100 (-)
40.9 (48.2)

implants found an implant success rate of

61% after 5 years. Thus, 39% of the
patients had some type of complication in
the first 5 years of loading. The success
rate in our material was 46%, which
means that we had more complications
than these studies reported. The more
recent Pjetursson et al. (2007) review of
nine cohort studies found that the criteria
for reporting biological and mechanical
complications varied between the studies.
In this study, we observed a rather low
incidence of biological complications, such
as increased PPDs and BOP, infections of
peri-implant mucosa, and remaining teeth
at the follow-up, although many patients
had a history of periodontitis. This might
be due to (1) the oral hygiene information
and instructions that all patients received
before treatment with implants and (2)
supportive periodontal therapy afterward.
The follow-up period is relatively short,
sometimes only slightly 43 years (range
4084 months). Several studies point out
that peri-implant mucositis and peri-implantitis are common clinical findings in
periodontally compromised patients who
had their FDPs in function for 5 or more
years (Hardt et al. 2002; Karoussis et al.
2003; Roos-Jansaker et al. 2006a, 2006b,
2006c).
In a review of nine studies of patient
groups that received periodontal treatment
and groups that did not have periodontitis,
Ong et al. (2008) found that peri-implantitis was about seven times as common in
treated periodontitis patient groups. Overall, the non-periodontitis patients demonstrated better outcomes than patients with
periodontitis. The studies varied in their
reporting of periodontal treatment, quality
of supportive periodontal therapy, and con-

1298 |

Number of
periodontal
pockets
 6 mm

Clin. Oral Impl. Res. 21, 2010 / 12941300

founders such as smoking history and outcome criteria.

Nevertheless, several studies indicate that
patients treated for periodontitis more often
develop complications around implants
than non-periodontitis patients. Evidence
is stronger for implant survival than implant
success. But Shou (2006) reviewed two
studies on the treatment outcome of implant therapy in (1) patients who lost teeth
due to periodontitis and (2) patients who had
teeth extracted for other reasons. Although
they found no significant differences associated with the survival rates of implants
after 5 and 10 years, significantly more
patients were affected by peri-implantitis
with increased bone loss around the implants in patients treated for periodontitis.
The 10-year longitudinal Karoussis et al.
(2007) study found significant differences in
the implant survival and success rate between patients with a history of chronic
periodontitis and periodontally healthy individuals. By installing oral implants into a
partially dentate dentition, ecological conditions of the oral cavity, which influence
biofilm formation on implants, vary from
the totally edentulous individual (Mombelli
et al. 1995). Residual pockets may represent niches for infection on implants; consequently, the importance of periodontal
treatment of residual dentition before placement of osseointegrated oral implants has
been emphasized (Bragger et al. 1997).
Peri-implantitis and soft tissue complications, such as peri-implant mucositis,
occurred in 8.6% of our patients after 5
years. This is a rather low incidence compared with the Roos-Jansaker (2007) study,
which reported that 79% of the patients
had peri-implant mucositis and 16% of the
patients had peri-implantitis after 914

years. In our study, we followed the same

criteria for biological complications as
Roos-Jansaker, and we found that 10 patients (22%) had peri-implant mucositis
and two patients (4%) had peri-implantitis
after a functional loading of at least 3 years.
Of the two patients with peri-implantitis, one had peri-implantitis on two out of
three implants on a three-unit FDP and
was one of the severely periodontally compromised patients with a general marginal
bone-level reduction of 42/3 of the root
length. This patient had not followed the
oral hygiene maintenance care program or
attended recall visits to the dental hygienist; had poor oral hygiene; smoked 20
cigarettes/day; and despite a clenching/
grinding habit, refused to use the occlusal
appliance we recommended. The other
patient with peri-implantitis had fractured
all three implants in a four-unit FDP that
was in function (described earlier under
mechanical complications).
The Lindhe & Meyle (2008) consensus
report shows that peri-implant infections
in all types of implant therapy are a very
common lesion. In the workshop, they
reported that peri-implant mucositis occurred in 80% of the subjects and 50% of
the implant sites. Peri-implantitis was
identified in 2856% of the subjects and
in 1243% of the implant sites. Peri-implant infections are usually linked with
poor oral hygiene, a history of periodontitis
(De Boever et al. 2009), and cigarette
smoking. Other risk factors, such as diabetes, alcohol consumption, and genetics,
are less well established, but the patient
must be informed about the higher risk.
Pjetursson et al. (2004) reported mechanical complications in FDPs after 5 years.
Only three available studies expressed

c 2010 John Wiley & Sons A/S

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis

success as the number of patients without

any complications during the observation
period. There is no available detailed information regarding whether or not all complications were reported from the dental
records including those of a minor degree.
We reported even the smallest veneer fracture polished during functional loading.
Pjetursson et al. (2004) also reported that
the most common mechanical complication was veneer fractures in 13.2% of
FDPs; the second was loss of screw access-hole restoration, which occurred in
8.2% of the anchors; and the third was
abutment or occlusal screw loosening,
which occurred in 5.8% of FDPs.
In this study, we found about 20%
veneer fractures, fractured abutments, or
loose bridge screws during the functional
time in 22% of the patients and loss of
screw access-hole restoration in two (4,3%)
patients. Three patients reported cheek
biting or enunciation problems. Lang
et al. (2004) reported that implant fracture
is a rare mechanical complication (0.4%
after 5 years and 1.8% after 10 years). We
documented two individuals (4.3%) with
abutment fractures and two (4.3%) with
implant fractures. All were identified as
bruxers. In our limited material, one bruxer
affected the survival and success rates; this
patient had multiple complications during
the follow-up period: loosening of supras-

tructure, peri-implantitis, fracture of abutments, and finally fracture of implants.

Bragger et al. (2001) found that mechanical complications were associated with
bruxism and extension of FDPs on implants; consequently, in bruxers, more implant-supported FDPs than FDPs on teeth
had porcelain fractures. Eighteen patients
were registered as bruxers from anamnesis
data or the clinical examination. Six of
these 18 patients had biological and/or
mechanical complications during the follow-up period. According to Roos-Jansaker
(2007), the complications were clustered in
patients. The four implants lost due to
implant fracture in the material were in
two patients, who were bruxers. Implant
losses and early or late failures were not
found for other reasons. Implant fractures
occurred after earlier warning signs such as
loosening suprastructures. Plausible explanations for the increased risk of mechanical
complications on implant-supported FDPs
(compared with tooth-supported FDPs) are
(1) lack of flexibility in periodontal fibers
and (2) limited proprioception due to the
absence of a periodontal ligament, which
leads to decreased tactile sensitivity. It is
possible that forces applied on implants
during bruxism are even larger than during
mastication (Engel et al. 2001).
Trulsson (2005) concluded in his
study that humans use periodontal afferent

signals to control jaw actions. When

dental implants are loaded mechanically,
a sensation (often called osseoperception)
is evoked. The sensory signals underlying
this phenomenon vary qualitatively
from signals evoked when natural teeth
are loaded. This can impair finemotor control of the mandible and put
more force on implants than on natural
teeth.
In conclusion, the success rate at the
patient level was found to be 46%. However, the success rate was affected by our
registrations of common and less serious
complications such as small veneer fractures. Mechanical complications were
more frequent than biological complications in implant-supported FDPs during
the first 3 years of loading in periodontally
healthy individuals who received adequate
dental hygiene support before and after
treatment with implants. Detrimental
complications can be expected in individuals with extreme occlusal forces,
indicating that those forces may even be a
bigger challenge to overcome when rehabilitating patients with implant-supported
FDPs.

Engel, E., Gomez-Roman, G. & Axman-Krcmar, D.

(2001) Effect on occlusal wear on bone loss
and periotest value of dental implants. The
International Journal of Prosthodontics 14:
144150.
Esposito, M., Hirsch, J.M., Lekholm, U. & Thomsen, P. (1998) Biological factors contributing to
failures of osseointegrated oral implants. (I). Success criteria and epidemiology. European Journal
of Oral Sciences 106: 527551.
Hardt, C.R., Grondahl, K., Lekholm, U. &
Wennstrom, J.L. (2002) Outcome of implant
therapy in relation to experienced loss of periodontal bone support: a retrospective 5-year study.
Clinical Oral Implants Research 13: 488494.
Hobkirk, J.A. & Wiscott, H.W.A. (2006) Biomechanical aspects of oral implants. Consensus report of
working group 1. Clinical Oral Implants research
17 (Suppl. 2): 5254.
Jemt, T. & Lekholm, U. (1995) Implant treatment
in edentulous maxillae; a 5-year follow-up
report on patients with different degrees of jaw
resorption. The International Journal of Oral &
Maxillofacial Implants 10: 303311.

Karoussis, I.K., Kotsovilis, S. & Fourmousis, I.

(2007) Review. A comprehensive and critical review of dental implant prognosis in periodontally
compromised partially edentulous patients.
Clinical Oral Implants Research 18: 669679.
Karoussis, I.K., Salvi, G.E., Heitz-Mayfield, L.J.A.,
Bragger, U., Hammerle, C.H.F. & Lang, N.P.
(2003) Long term implant prognosis in patients
with and without a history of chronic
periodontitis; a 10-year prospective cohort study
of ITI dental implant system. Clinical Oral
Implants Research 14: 329339.
Lang, N.P., Berglundh, T., Heitz-Mayfield, L.,
Pjetursson, B.E., Salvi, G.E. & Sanz, M. (2004)
Consensus statements and recommended clinical
procedures regarding implant survival and complications. The International Journal of Oral &
Maxillofacial Implants 19: 150154.
Lindhe, J. & Meyle, J. (2008) Peri-implant diseases:
consensus report of the sixth European workshop
on periodontology. Journal of Clinical Periodontology 35 (Suppl. 8): 282285.
Lobbezoo, F., Brouwers, J.E., Cune, M.S. & Naeije,
M. (2004) Dental implants in tooth grinders.

Acknowledgements:
The authors
thank Ms Birgitta Sunehed for technical
and administrative assistance.

References
Albrektsson, T., Zarb, G., Worthington, P. &
Eriksson, A.R. (1986) The long-term efficacy of
currently used dental implants: a review and
proposed criteria of success. The International
Journal of Oral & Maxillofacial Implants 1:
1125.
Bain, C.A. (2003) Implant installation in the smoking patient. Periodontology 2000 33: 185183.
Bragger, U., Aeschlimann, S., Burgin, W., Hammerle, C.H. & Lang, N.P. (2001) Biological and
technical complications and failures with fixed
dental prosthesis on implants and teeth after 4 to
five years of function. Clinical Oral Implants
Research 12: 2634.
Bragger, U., Burgin, W.B., Hammerle, C.H. & Lang,
N.P. (1997) Associations between clinical
parameters assessed around implants. Clinical
Oral Implants Research 8: 412421.
De Boever, A.L., Quirynen, M., Coucke, W., Theuniers, G. & DeBoever, J.A. (2009) Clinical and
radiographic study of implant treatment outcome
in periodontally susceptible and non-susceptible
patients: a prospective long-term study. Clinical
Oral Implants Research 20: 13411350.


c 2010 John Wiley & Sons A/S

1299 |

Clin. Oral Impl. Res. 21, 2010 / 12941300

Wahlstrom et al  Clinical follow-up of unilateral fixed dental prosthesis

Nederlands Tijdschrift voor tandheelkunde 111:

8590.
Lobbezoo, F., Van der Zaag, J. & Naeije, M. (2006)
Bruxism: its multiple causes and its effects on
dental implants an updated review. Journal of
Oral Rehabilitation 33: 293300.
Mombelli, A., Marxer, M., Gaberthuel, T., Grunder, U. & Lang, N.P. (1995) The microbiota of
osseointegrated implants in patients with a history
of periodontitis. Journal of Clinical Periodontology 22: 124130.
Ong, C.T., Ivanovski, S., Needleman, I. G., Retzepi,
M., Moles, D. R., Tonetti, M. S. & Donos, N.
(2008) Systematic review of implants outcomes in
treated periodontitis subjects. Journal of Clinical
Periodontology 35: 438462.
Pjetursson, B.E., Lang, N.P., Bragger, U. & Zwahlen, M. (2007) Comparison of survival and complication rates of tooth-supported fixed dental
prostheses (FDPs) and implant supported FDPs
and single crowns (SCs). Clinical Oral Implants
Research 18 (Suppl. 3): 97113.

1300 |

Clin. Oral Impl. Res. 21, 2010 / 12941300

Pjetursson, B.E., Tan, K., Lang, N.P., Bragger, U.,

Egger, M. & Zwahlen, M. (2004) A systematic
review of the survival and complication rates
of fixed partial dentures (FDPs) after an
observation period of at least 5 years. Clinical
Oral Implants Research 15: 625642.
Roos-Jansaker, A.M. (2007) Long time follow up of
implant therapy and treatment of periimplantitis.
Swedish Dental Journal 188 (Suppl.): 766.
Roos-Jansaker, A.M., Lindahl, C., Rehnvert, H.
& Renvert, S. (2006a) Nine-to-fourteen year
follow-up of implant treatment. Part I: implant
loss and associations to various factors. Journal of
Clinical Periodontology 33: 283289.
Roos-Jansaker, A.M., Lindahl, C., Rehnvert, H. &
Renvert, S. (2006b) Nine-to-fourteen year
follow-up of implant treatment. Part II: presence
of periimplant lesions. Journal of Clinical Periodontology 33: 290295.
Roos-Jansaker, A.M., Lindahl, C., Rehnvert, H. &
Renvert, S. (2006c) Nine-to-fourteen year followup of implant treatment. Part III: factors

associated with periimplant lesions. Journal of

Clinical Periodontology 33: 296301.
Serino, G. & Strom, C. (2009) Peri-implantitis in
partially
edentulous
patients:
association
with inadequate plaque control. Clinical Oral
Implants Research 20: 169174.
Shou, S. (2006) Outcome of implant therapy in
patients with previous tooth loss due to periodontitis. Clinical Oral Implants Research
17: 104123.
Shou, S. (2008) Implant treatment in periodontitis-susceptible patients: a systematic review.
Journal of Oral Rehabilitation 35 (Suppl. 1):
922.
Smith, D.E. & Zarb, G.A. (1989) Criteria for
success of osseointegrated endosseous implants. Journal of Prosthetic Dentistry 62: 567
572.
Trulsson, M. (2005) Sensory and motor function of
teeth and dental implants: basis for osseoperception. Clinical and Experimental Pharmacology
and Physiology 32: 119122.


c 2010 John Wiley & Sons A/S