Periodontology 2000, Vol. 66, 2014, 7–12 © 2014 John Wiley & Sons A/S.
ey & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Implant therapy: 40 years of
experience
MARC QUIRYNEN, DAVID HERRERA, WIM TEUGHELS & MARIANO SANZ
Dental implants placed under favorable conditions
in healthy patients have success rates of over 95%,
even after 15 years of follow up. In spite of this
excellent outcome, technical, biologic and esthetic
complications do occur (17, 27, 30, 31). Moreover,
the outcome can be less desirable if dental
implants are placed in patients affected with sys-
temic diseases or other compromising conditions
(2, 4, 13, 22, 25). Metabolic disorders or immune
deficiencies can, for example, give rise to surgical
complications and may also interfere with bone
apposition and/or remodeling at the implant–bone
interface. Similarly, radiation therapy in the surgical
area may significantly reduce cellularity and vascu-
larity, and hence affect the healing of oral
implants. In compromised patients, implant-based
treatment may be a questionable choice. Medica-
tion, such as biphosphonates and/or anticoagu-
lants, may also affect the outcome of implant
placement or increase the frequency of postopera-
tive complications. The placement of dental
implants in such patients must adhere to strict
treatment protocols (19, 20).
The clinical protocol for the placement of dental
implants has changed significantly over the past
40 years (Table 1). From the initial ‘biocompatibility’-
oriented protocol, aiming at osseointegration and
long-term success, there has been an evolution
toward less stringent criteria for implant placement
in order to ‘speed the healing process’ and
‘improve the esthetic results’, although it is still
questionable whether patients will ultimately bene-
fit from these changes. The purpose of this volume
of Periodontology 2000 is to evaluate the new
developments in implantology, review their scien-
tific evidence and analyze their indications, advan-
tages and disadvantages. It is organized into 16
chapters dealing with diagnostic and
therapeutic concepts, from the use of current
PERIODONTOLOGY 2000
three-dimensional radiographic techniques to
guided surgical implantation and enhanced surgical
protocols. The overall goal is to guide the clinician
in decision making around implant therapy and
to provide an understanding of the etiology and
therapy of peri-implant diseases.
Indication/treatment planning
Whereas initially only fully edentulous patients with
optimal jaw bone dimensions (width and height)
were the basic indication for implant therapy, now
nearly every edentulous space is considered as suit-
able for implant placement. In situations where
insufficient bone is available for implant therapy,
bone-augmentation techniques are routinely consid-
ered. Benic & Ha €mmerle (3) concluded that such
techniques are highly predictable if the proper indi-
cations are respected and appropriate healing time
is allowed for bone regeneration. Another approach
is the use of the zygoma when the maxillary bone is
severely atrophic. As discussed by Aparicio et al. (1),
the zygomatic implant technique offers the possibil-
ity to treat highly complex situations with low mor-
bidity. The bone height in the posterior maxilla is
often limited and a sinus lift procedure is recom-
mended. Besides the conventional lateral window
technique, a less invasive transalveolar approach is
described by Pjetursson & Lang (26). As an alterna-
tive to surgical bone regeneration, various studies
have reported successful outcome with the use of
short implants in the mandible as well as in the
maxilla. Nisand & Renouard (24) discuss the indica-
tions and evidence-based efficacy of the use of
short and narrow implants. The esthetic outcome of
implant therapy is addressed by Merheb et al. (21)
and Thoma et al. (34). Merheb et al. (21) review
the optimal implant-placement within the bone
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Quirynen et al.

Table 1. Changes to the original ‘standard’ implant protocol of the 1970s to 1980s

Current changes to implant protocols

‘Original’ protocol (strict, biocompatibility = crucial) ‘Present’ protocol (less strict, speed and
esthetics = crucial)
Indication/planning

Primarily fully edentulous patients All type of indications

Strict inclusion/exclusion criteria Rare exclusion criteria

Minimal jaw bone width of 7–8 mm Guided bone regeneration for horizontal augmentation

Minimal jaw bone height of 10 mm Guided bone regeneration for vertical augmentation

Planning based on two-dimensional radiographs Three-dimensional cone beam computed tomography

and virtual planning
Six to eight implants in edentulous jaw Three to six implants in edentulous jaw

Anterior to the maxillary sinus Sinus augmentation techniques

Timing

Four to 6 months of healing after tooth extraction Immediate placement

Two-stage surgery One-stage surgery

Submerged healing (3–6 months) Nonsubmerged healing

No denture immediately after implant insertion Immediate loading

Surgical protocol

Only specialists General dentists

No surgical guides Guided implant placement

Presurgical antibiotics No standard antibiotic prophylaxis

Presurgical atropine to reduce saliva flow No atropine

Low-speed placement + excessive cooling Higher-speed placement, no cooling

Two surgical aspirators (operation area and mouth) Single aspiration

Palatally/lingually pediculated flap Crestal incision

Prosthetic protocol

Abutments not removed after the second surgery Prosthesis on implant level

Titanium abutments Different materials in mucosa

Implants interconnected Free-standing implants

Screw retained Cemented

Cast chromium cobalt/goldframework Computer numeric controlled-milled titanium

framework
Occlusion in resin Occlusion in porcelain/metal

Prosthesis design focused on cleansability Prosthesis design focused on esthetics

Implant material/design

Minimally rough implants Moderately rough implants

Commercially pure Grade I titanium implants Grade III–V titanium implants

External hex connection implant-abutment Internal connection

8

Table 1. (Continued)
Current changes to implant protocols
Implants diameter: ≥ 3.5 mm and length: ≥ 10 mm
No platform switch
Overall appreciation
Very ‘strict’ protocol, biocompatibility = crucial
envelope to achieve acceptable long-term results,
and Thoma et al. (34) focus on the peri-implant soft
tissues and their impact on the esthetic outcome.
The treatment of the fully edentulous patient is dis-
cussed by Emami et al. (8), from the use of full-
mouth fixed rehabilitations to overdentures retained
by two to four implants. This latter treatment
option can offer excellent results with a satisfactory
cost–benefit ratio.
Implant treatment strategies
The original implant protocol was based on the place-
ment of dental implants in healed ridges (at least
6 months after tooth extraction) and respecting an
extended healing time (of 3–6 months) in order to
obtain optimal osseointegration. The advent of
implants with a moderately rough surface has accel-
erated osseointegration and decreased the required
healing time (40, 41). This healing period may even be
reduced to a minimum, and immediate loading pro-
tocols have been used with a high degree of predict-
ability under specific clinical conditions. These
indications, and the scientific evidence, are reviewed
by De Bruyn et al. (6).
Similarly, the placement of dental implants at the
time of tooth extraction has significantly reduced
the treatment time and patient morbidity. This sur-
gical protocol, however, can be associated with
esthetic complications as a result of remodeling of
the hard/soft tissue after tooth extraction (5, 7, 11,
28). Vignoletti & Sanz (38) review the incidence of
complications as well as the evidence-based out-
comes of immediately placed implants. Implants
with rough surfaces have raised concerns about the
possible negative impact of enhanced biofilm for-
mation (29), even though studies have failed to
show significant differences in bone loss or in the
incidence of peri-implant infections for implants
with minimally and moderately rough surfaces (16,
23, 35, 41).
Experience with implant surgery
Short/narrow implants
Platform switch
Less ‘strict’ protocol, speed and esthetics = crucial
Surgical protocol
The ‘classical’ implant surgical protocol has chan-
ged significantly over the years (Table 1). The focus
on maximal attention to sterility has diminished,
and even the need for systemic antibiotic cover is
questioned (9, 32). The introduction of three-
dimensional imaging has led to improvements in
preoperative diagnosis and implant surgery (12).
The complex anatomy of the jaws and the implica-
tions in implant surgery are discussed by Jacobs
et al. (14), and the use of cone beam computed
tomography for diagnosis/planning of dental
implant therapy is reviewed by Jacobs & Quirynen
(15). Guided surgery can improve the positioning
of implants, shorten the surgical time and reduce
postoperative complications. The advantages/disad-
vantages of guided implant surgery, either dynamic
or static, are reviewed respectively by Vercruyssen
et al. (36) and Vercruyssen et al. (37).
Peri-implant diseases
Two major infectious processes, designated apical
peri-implantitis and marginal peri-implant diseases,
may develop around successfully integrated dental
implants. Clinical studies have demonstrated that
apical peri-implantitis is strongly linked with periapi-
cal pathology around an extracted tooth at the
implant site (18). Temmerman et al. (33) discuss the
etiology, diagnosis and treatment of apical peri-im-
plantitis. Marginal peri-implant diseases are defined
as inflammatory processes of infectious origin of
the marginal peri-implant tissues. Similarly to peri-
odontitis, marginal peri-impant diseases have a mul-
tifactorial etiology (Fig. 1). Two types of marginal
peri-implant diseases have been identified. Peri-
implant mucositis affects the peri-implant mucosa
without evidence of peri-implant crestal bone
loss, whereas peri-implantitis denotes inflammation
9
Quirynen et al.

Genetics/Host (e.g. quality immune response)

Environment (e.g. periodontopathogens and beneficial bacteria)

Lifestyle (smoking, oral hygiene, diet and stress)

Hardware (sand-blasted and acid-etched implant/abutment,

connection, platform, etc.)

Procedure (guided bone regeneration, type of restoration, Fig. 1. Complexity of peri-implanti-

cemented/screw, etc.)
tis, underlining the multicausality
Hard/Soft tissue (density, vascularization, thickness of mucosa, model and the interaction among
etc.) different causal factors.

associated with bone loss. Whilst peri-implant muco-
sitis has clinical and histopathological characteristics
similar to gingivitis, peri-implantitis exhibits distinct
characteristics in terms of rate of progression and
histopathology. Concerning treatment response,
peri-implant mucositis is reversible with appropriate
therapy, but the treatment of peri-implantitis is
unpredictable and suffers from the lack of an
evidence-based treatment protocol. Figuero et al.
(10) discuss the two marginal peri-implant diseases in
terms of etiopathogenesis, diagnosis and therapy.
The chronic inflammation that defines peri-
implant diseases depends not only on the degree of
microbial accumulation and the composition of the
implant-associated biofilm, but also on factors relat-
ing to the implant and the patient. Some of the
patient risk factors may be behaviourally based, and
therefore modifiable, such as lack of oral hygiene and
smoking; however, other risk factors are not modifi-
able, such as genetic susceptibility to infection and
systemic health status (e.g. diabetes).
Prosthetic protocol/materials
As shown in Table 1, changes have also occurred in
implant composition and macro-design, in implant–
abutment connection and in restorative materials
and protocols. Although the new types of material
and therapy can influence the outcome of implant
therapy, they are not dealt with in this volume of
Periodontology 2000.
Conclusions
Implant dentistry has changed significantly during
the past 40 years. At the introduction of the osseoin-
tegration principle, implant placement and restora-
tion were mostly carried out by specialists, but such
treatments are now increasingly being performed by
general dentists. A clear shift has also been seen in
the indications for implants, from fixed full prosthe-
ses to overdentures, and later to partial bridges and
solitary implants. Implants were initially only placed
in healed extraction sites with convenient bone
parameters (bone height ≥ 10 mm and bone width
≥ 7 mm), and were loaded after a submerged healing
period, but these prerequisites have now been partly
abandoned. At the same time, patients have become
more demanding, with requests for faster treatment
and with clearly higher esthetic expectations.
Diagnostic improvements in implantology include
the introduction of computed tomography technol-
ogy. The clinician suddenly obtained the ability to
examine the jaw anatomy in more detail. The identifi-
cation of lingual foraminae, a double mental fora-
men, an undercut in the canine–premolar area of the
mandible, an extension of the alveolar canal to the
midline, sinus pathology, a widened naso-palatine
canal, an artery underneath the maxillary canine or in
the lateral wall of the sinus, and so forth, made treat-
ment planning more difficult, but also reduced the
risk for neurovascular disturbance and/or serious
hemorrhage. A three-dimensional analysis of the jaw
bone and surrounding soft tissues has made guided
surgery possible. However, a review of the current lit-
erature indicates that the accuracy of the available
diagnostic techniques is not always perfect, and that
clear guidelines, as detailed in several chapters of this
volume, have to be carefully followed in order to pre-
vent the malpositioning of implants (12).
Improvements in implant surface topography and
macro- and microdesign have facilitated the osseoin-
tegration process and paved the way for new con-
cepts in implantology, such as short implants,
immediate loading and immediate placement (39).
However, immediate placement might not always be
as successful, from the esthetic point of view, as the
conventional approach to implant therapy, and

10

therefore should be carried out with appropriate cau-
tion. Guided bone regeneration is becoming an
accepted treatment option, either prior to, or simulta-
neously with, implant insertion. The use of resorbable
barrier membranes can simplify surgical procedures,
but requires careful attention to new guidelines, as
highlighted in this volume. It is now generally
accepted that horizontal bone augmentation is a pre-
dictable therapy, but this is not the case for vertical
augmentation. Current advances in implantology are
adversely affected by an unexpected high prevalence
of peri-implantitis. As no well-defined treatment is
currently available to arrest peri-implantitis, or to
regenerate bone lost to infection, the prevention of
peri-implantitis becomes even more important.
Finally, it is, of course, always important to keep
the patient at the center of any treatment planning
and to consider carefully his/her special wishes and
expectations. Not all patients need a fixed restoration.
A simple overdenture can offer several advantages for
many patients, including a less demanding position-
ing of the implants, lower costs and simplicity of
maintenance.
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