JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No.

1 (59 - 64): The Predictive Value of Radiographic Diagnosis of Implant Instab

The Predictive Value of Radiographic Diagnosis of

Implant Instability
Kerstin Gröndahl, DDS, PhD/Ulf Lekholm, DDS, PhD

The positive predictive value of radiographic identification of unstable Brånemark implants was
evaluated. Based on approximately 2,000 patients with implants followed during a 3-year period, a
total of 84 patients were radiographically detected to have suspected failing implants. A total of 481
implants had been placed in these patients, but because of the study design and some patient
dropouts, the evaluation was carried out in only 79 of the identified patients, who had 413
implants. Calculations were performed based on the number of occasions the implants were
examined (n = 482) because some patients were assessed on more than one occasion. Results
indicated a high positive predictive value (83%) to radiographically identify failing implants, and
only 5% were clinically found to be failing without having been detected radiographically. In nine
jaws (11%), the fixed prosthetic restorations were unnecessarily detached because of inaccurate
radiographic diagnosis. The study indicated that radiographic identification of unstable implants is
reliable when performed as part of annual examinations and when examining patients on a
long-term routine basis. The timing for these assessments should be annual during the first 3 years
of follow up for the unexperienced clinician and may thereafter be individualized with more
clinical experience.
(INT J ORAL MAXILLOFAC IMPLANTS 1997;12:59–64)
Key words: dental implant, diagnostic performance, osseointegration, radiography

I n connection with annual follow-up examinations of patients treated with oral implants, radiographic
assessments have an important role. The radiographic technique used in conjunction with the Brånemark
implant system (Nobel Biocare, Göteborg, Sweden)1 has been described by Hollender and Rockler, 2 by
Strid,3 and by others. Intraoral radiographs, using a strict paralleling technique, are obtained on an
annual basis. From these, the condition of the peri-implant bone tissues, the degree of marginal bone loss,
and the state of the mechanical components may be judged.

When evaluating the outcome of oral implant treatment, it has been suggested4 that individual
implant stability should be tested. This is a pertinent requirement when smaller patient samples are
evaluated or when strict research projects are performed. However, it cannot be done unless the fixed
prosthetic restorations are first removed from the implants, as reported in some multicenter studies of the
Brånemark implant system.5-7 It cannot be considered practical to detach all fixed prostheses and
individually test the stability of each implant if larger patient populations are checked. For example, at
the Brånemark Clinic, Göteborg, Sweden, more than 24,000 implants have been placed in approximately
4,500 jaws since 1965. To test clinical stability of each of these implants annually would mean that more
than one dentist should be completely occupied with removing and reattaching the fixed prostheses every
year.
Consequently, other techniques such as radiographic assessment for examining the condition of the
implants must be utilized. A certain risk for erroneous judgments must be anticipated. To make the

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (59 - 64): The Predictive Value of Radiographic Diagnosis of Implant Instab

presence of a soft tissue layer adjacent to the implant surface radiographically visible, it has to be wide
enough to overcome the limitations imposed by the resolution of the radiographic technique. According
to Worthington and coworkers, 8 clinical signs, such as a dull note on percussion and persistent
discomfort from individual implants, may be evident long before a peri-implant radiolucency appears.
According to Zarb and Schmitt,9 the relatively crude resolution level of the radiographic technique will
result in poor accuracy in radiographic diagnosis of implant stability. The Periotest device (Siemens,
Bensheim, Germany) has been evaluated by Salonen et al,10 and they found it to be suitable for assessing
mobility of various implants. They claimed that increased Periotest values occurred before radiographic
signs of inflammation occurred, as evidenced by panoramic radiography. The only study published
concerning the diagnostic accuracy of intraoral radiographic examinations to distinguish between
clinically stable and unstable implants is one by Sundén et al.11 The report demonstrated that the
diagnostic accuracy was at least as good as the diagnostic accuracy of many other radiographic
procedures, such as approximal caries diagnosis and diagnosis of minor periodontal bone lesions.12-14
The authors concluded, however, that despite relatively good diagnostic accuracy, the possibility of
predicting clinical implant instability can be low in populations with low prevalence of implants showing
loss of osseointegration. For patients examined at the Brånemark Clinic, the losses have been reported to
vary from 1.5% after healing,15 to 2.5% after one year of function.16-18
The aim of the present report was to study the positive predictive value, ie, the probability that an
implant is clinically unstable, when the radiographic evaluation has demonstrated signs of loss of
osseointegration of the Brånemark implant system, judged in connection with annual checkups.
Materials and Methods
During a time interval of approximately 3 years, approximately 2,000 patients with fixed prostheses
supported by about 8,000 osseointegrated implants were recalled for annual examination. The follow-up
visit included both clinical tests, performed at the Brånemark Clinic, and radiographic examination,
performed at the Department of Oral Diagnostic Radiology, Göteborg University, Göteborg, Sweden.
Only patients treated according to the standard protocol1 were included, ie, no patients with grafts, and
no patients involved in other research projects were accepted.

The clinical examination included assessment of prosthesis stability, oral mucosa, and occlusion. 19
Since the clinical examinations followed the radiographic examinations, radiographic examinations were
performed without knowledge about the clinical conditions. The radiographs were taken with a dental
x-ray machine operating at 60 kVp. The paralleling technique was used with a focus-film distance of
approximately 25 cm. Film of speed group E (Kodak Ektaspeed, Eastman Kodak, Rochester, NY) was
used and developed immediately in automatic developing machines.
For each patient, all implants were judged with respect to presence or absence of peri-implant
radiolucency by one of the six oral radiologists in the Department of Oral Diagnostic Radiology on a
routine basis. If one or several implants were suspected to have lost osseointegration, the patient was
coded as a failure. The Brånemark Clinic received information about the suspected implant or implants in
a written report.
The primary criterion used for the diagnosis of radiographically suspected failing implants was a
radiolucency observed around the implant. Other radiologic signs used by the observers could be
swelling of the mucosa in the maxillary sinus or a diffuse inferior border of the maxillary sinus, not seen

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in earlier radiographs. Another indirect sign was changes in the peri-implant trabecular bone pattern over
time. No patients having an obviously failing implant were included in the study. Figures 1a to 1e show
some of the implants that were reported as failures.
In the event of a suspected loss of osseointegration, the intention was, within a 6-month period after
the radiographic evaluation, to clinically test the stability of the implant after removing the fixed
restoration. Testing was carried out by gently rotating the anchorage unit using an abutment screwdriver
and without counteracting the torque via a clamp. If any mobility was present, or if any sign of pain or
discomfort was noticed, the implant was regarded as nonintegrated and was subsequently removed. If the
implant was clinically stable and without any signs of discomfort, it was regarded as osseointegrated.
Eighty-four patients (33 women, 51 men) were identified with radiographic diagnosis of unstable
implants during at least one of the annual checkups. At the time of implant placement, the mean age of
these patients was 60 years (range 37 to 81 years). Two of the subjects had been treated in both jaws,
resulting in a total of 86 jaws. Altogether 477 implants of various designs and lengths (Brånemark
implant system, Nobel Biocare) had originally been placed. An additional four implants were placed
during the study period; thus, a total of 481 implants were placed. Of the 481 implants, 357 were used to
support 60 maxillary complete prostheses, 65 were used to support 12 mandibular complete prostheses,
27 were used to support 6 maxillary partial prostheses, and 32 were used to support 8 mandibular partial
prostheses. Fifteen implants supporting five partial prostheses in jaws treated bilaterally, but where only
the contralateral fixed restorations were detached, were excluded. Up to the time of the first annual
checkup, 24 implants in 19 jaws were lost because of failed osseointegration. Furthermore, two implants
in different jaws were left sleeping. Consequently, a total of 440 implants constituted the intended base
of the present research project (Fig 2).
Of the total number of patients (n = 84) originally accepted for study, five were not clinically tested
via removal of their fixed prostheses even though the radiographs indicated complications. Consequently,
five prostheses (four complete maxillary prostheses and one complete mandibular), corresponding to 27
implants, were not fulfilling the criteria for acceptance. The research material, thus, was reduced to 81
jaws including 413 implants.
Because indications of lost osseointegration could occur for the same implants several times or for
various implants within the same jaw at different examinations (70 jaws, once; 7 jaws, twice; 4 jaws,
three times), the results were not based on the number of placed implants, but rather on the number of
occasions the various implants had been analyzed (n = 482) (Fig 2).
Results
Based on radiographic examination, 79 patients were identified with one or several unstable implants.
The majority of the radiographically detected failing implants were observed during the first three annual
checkups: 51 unstable implants were observed at the first checkup; 20 at the second checkup; 15 at the
third checkup; 3 at the fourth checkup; 3 at the fifth checkup; 0 at the sixth checkup; and 4 at the seventh
checkup.
Altogether, 138 implants were radiographically reported as suspicious for loss of osseointegration
(Fig 3). Of these, it was clinically found that 114 (82.6%) were failing, and these implants were
subsequently removed. The remaining 24 implants were regarded as stable. Of these, 15 occurred in jaws
where at least one unstable implant was present. Consequently, the prostheses were removed from nine
jaws (11.1%) in which no unstable implants were found. All but one (Fig 1a) of the marked implants
were found clinically unstable. Figures 4a to 4d show the longitudinal peri-implant bone changes at this

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (59 - 64): The Predictive Value of Radiographic Diagnosis of Implant Instab

clinically stable implant, which was reported as suspicious for loss of osseointegration at the 1-year
radiographic examination.
In connection with the clinical tests, another 16 implants were found unstable without having been
detected radiographically (Fig 3). The remaining 328 (95.3%) implants, for which no radiographic or
clinical signs of implant instability were noted, were all regarded stable.
Discussion
The present study showed a high positive predictive value (about 83%), suggesting that the radiographic
test result could be reliable for the identification of clinically unstable Brånemark implants. In only about
10% of the patients, prostheses were unnecessarily detached as the result of an inaccurate radiographic
diagnosis. In connection with the clinical tests performed after removing the prostheses, it was observed
that another 16 implants were nonintegrated despite lack of radiographic signs, indicating a 5% level of
underestimation of failing implants.
The majority of detected losses (approximately 90%) were observed during the first 3 years of
clinical function, a finding that is in agreement with what has been reported by others.6,7,20 The present
results also support the findings from other studies,6,7,20 revealing that the highest frequency of failures
(about 77%) occurred in the maxilla. However, the present study was based on a selected group of
patients, since all obvious failures were excluded from the follow-up protocol, which certainly could
have influenced the outcome.
The “true” predictive negative value could not be evaluated because patients without radiographic
signs were not tested with respect to clinical implant instability. In the selected group (79 patients
representing 81 jaws), the negative predictive value was 95%, though. If assuming that this value could
be applied to the total patient population equal to approximately 2,000 patients with about 8,000
implants, another 400 clinically unstable implants might have existed. However, the frequency of
suspected nonintegrated implants in this patient group was found to be roughly 27% (130/480), a value
much higher than the 1.5% to 2.5% previously reported for the Brånemark system in connection with
healing or after the first years of function.5-7,15,17,18,21 Failure often does not occur alone, a fact well
known by the radiologists. Failures are often associated with advanced resorption and poor bone
quality, 15,21-23 factors that were not analyzed in the present report. To obtain complete knowledge of
this issue, a randomized sample should be studied, wherein all prostheses are removed, making it
possible to confirm the “true” prevalence of unstable implants.

Based on the results by Sundén and coworkers,11 one can assume that the observers used a very
stringent criterion for considering an implant radiolucency or other radiographic signs to be present,
since such a high positive predictive value was obtained. Using a less strict criterion should have
increased the number of false positive diagnoses. The optimal decision criterion depends on the
prevalence of implant instability and the consequences associated with correct and incorrect decisions.
The individual implant stability test, suggested by Albrektsson et al,4 may be an optimal way of
checking. In clinical practice, it may not be considered advantageous to individually test the stability of
each implant when analyzing the success rate because such a procedure is quite time consuming.
Moreover, the removal of restorations could involve wear on the implant components. Instead,
radiographic examinations must be regarded as a reasonable alternative when examining patients on a
long-term routine basis.

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (59 - 64): The Predictive Value of Radiographic Diagnosis of Implant Instab

The oral radiologists reading the intraoral radiographs of the current study had much experience in
evaluating postoperative radiographs of patients with implants. Besides their professional skill, the most
important factor influencing the results was the good diagnostic quality of the radiographs. High-quality
images are certainly essential for detection of subtle pathologic changes. A question that has to be raised
is, do the costs for the radiographic examinations, both monetary and in the form of radiation dosages to
the patients, justify annual radiographic examinations? This is a decision that must be made in light of
the possible risk of achieving a severe underestimation of implant losses, if not performing the
assessments regularly. Annual radiographic examinations also have other objectives. One purpose is to
enable detection of implant and abutment screw fractures, even though these are rare.6,7,17,18,24
Another aim is to evaluate changes in marginal bone height over time. However, several long-term
studies6,7,20,24 have shown these to be small.
During the last two decades, a considerable number of scientific articles demonstrating excellent
long-term results of the Brånemark implant system have been published. Most of these studies have used
radiography as an instrument to evaluate the success rates, without discussing the diagnostic accuracy in
respect to radiographic diagnosis of various peri-implant changes. The time has come for a more critical
approach to the use of radiography in the evaluation of implant treatment efficacy. Radiography should
be performed only when it is likely to benefit the patient. Intervals between repeated examinations ought
to be determined based on the prevalence of various pathologic changes associated with implant
treatment and their consequences.
Conclusion
This study has shown a high positive predictive value for the identification of implant instability in
connection with the Brånemark implant system. Radiography is a valuable method to be used in annual
follow-up examinations of implant patients. For the inexperienced clinician, it is recommended that
radiographic examinations be conducted on an annual basis during the first 3 years of implant function.
However, over time more knowledge must be collected, and more individually based intervals for
radiographic examinations may need to be followed.

Kerstin Gröndahl

Associate Professor, Department of Oral

Diagnostic Radiology, Göteborg University,
Faculty of Odontology, Göteborg, Sweden.

Ulf Lekholm

Professor and Director, Brånemark Clinic, Public

Dental Health Care, Göteborg, Sweden; Faculty of
Odontology, Göteborg, Sweden.

Footnotes 5
FIGURES

Figure 1a-e

Figs. 1a to 1e The marked implants were all radiographically reported as failures.

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Figure 2

Fig. 2 Study design.

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JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (59 - 64): The Predictive Value of Radiographic Diagnosis of Implant Instab

Figure 3

Fig. 3 Distribution of examined implants with regard to clinical outcome.

Figure 4

Fig. 4 Serially obtained radiographs. Note the radiolucency at the most distally placed implant
at 1-year checkup. The implant was found clinically stable at clinical examination. The
radiolucency is not visible in radiographs obtained at 2- and 3-year follow-up examinations.
(From left) Year 0, Year 1, Year 2, Year 3.

The Predictive Value of Radiographic Diagnosis of Implant Instability Kerstin

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