Longevity of teeth and implants a systematic review


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Longevity of teeth and implants a systematic review

  1. 1. Journal of Oral Rehabilitation 2008 35 (Suppl. 1); 23–32Longevity of teeth and implants – a systematic review ¨C. TOMASI, J. L. WENNSTROM & T. BERGLUNDH Department of Periodontology, Institute of Odontology,The Sahlgrenska Academy at Goteborg University, Goteborg, Sweden ¨ ¨SUMMARY The objective of this systematic review included 476 subjects. The incidence of tooth losswas to describe the incidence of tooth and implant among subjects with a follow-up period of 10–loss reported in long-term studies. Prospective lon- 30 years varied from 1.3% to 5% in the majority ofgitudinal studies reporting on teeth or implants studies, while in two epidemiological studies onsurvival with a follow-up period of at least 10 years rural Chinese populations the incidences of toothwere considered. Papers were excluded if the drop loss were 14% and 20%. The percentage of implantsout rate exceeded 30% or if <70% of the initial reported as lost during the follow-up period variedsubject sample was examined at 10 years of follow- between 1% and 18%. In clinically well-maintainedup. Seventy publications on teeth were identified as patients, the loss rate at teeth was lower than that atpotentially relevant for the focussed question. The implant. Bone level changes appeared to be small atanalysis of the abstracts yielded 37 studies eligible teeth as well as at implants in well-maintainedfor full-text analysis. The inclusion criteria were met patients. Comparisons of the longevity at teeth andin 11 of the publications that included in all 3015 dental implants are difficult due to heterogeneitysubjects. The initial search on implant studies gen- among the studies.erated 52 publications that possibly could be in- KEYWORDS: implants, longevity, teeth, prospectivecluded. Following the evaluation of the abstracts studyand full-text analysis nine publications were foundto fulfil the inclusion criteria. The nine studies Accepted for publication 4 November 2007 reported in prospective longitudinal studies with aIntroduction follow-up of at least 10 years. Alterations in marginalDecision-making in treatment planning should be bone support at teeth and implants were alsobased on scientific evidence. In the clinical situation addressed.when deciding on either treating a tooth disorder orextracting the tooth in favour of implant placement, Material and methodsdata that provide guidelines for the choice of strategyare sparse. Although implant therapy is regarded as a Type of studiessafe and reliable method in the treatment of completeand partial edentulism, complications of technical and Prospective longitudinal studies with a follow-up periodbiological nature occur (1). The ultimate complication of at least 10 years were considered. Thus, cohortin implant therapy is the loss of implants, as for teeth studies, controlled clinical trials and randomized clinicalthe extraction is the definitive failure. To determine the trials that provided data on tooth and ⁄ or implant losslongevity of teeth and implants, information on the over the indicated time period were analysed. Studiesoccurrence of these final events on a long-term basis reporting life-tables were analysed with respect to themust be provided. proportion of subjects or implants ⁄ teeth that were The objective of this systematic review was to followed ‡10 years. Publications were excluded ifdescribe the incidence of tooth and implant loss <70% of the initial subject sample was examined atª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2007.01831.x
  2. 2. 24 C . T O M A S I et al. 10 years of follow-up, or if data corresponding to 11 oral epidemiology AND longitudinal AND teeth 10 years of observation could not be achieved. Studies (149) in which the rate of subject dropout at 10 years 12 oral epidemiology AND periodontal disease (2344) exceeded 30% were also excluded. 13 oral epidemiology AND caries (2843) 14 tooth loss AND prospective (361) 15 tooth loss AND cohort (138) Subjects 16 tooth loss AND longitudinal (200) Subjects who were part of epidemiological studies or 17 [‘Dental Health Surveys’ (Mesh)] AND tooth loss enrolled in maintenance programmes of treatment (516) studies on teeth were included in the review. Implant- 18 [‘Dental Health Surveys’ (Mesh)] AND bone loss related studies comprised edentulous and partially (633) edentulous subjects who were treated with endosseous 19 [‘Dental Health Surveys’ (Mesh)] AND attachment dental implants supporting fixed or removable recon- loss (958) structions. Studies that reported data on implant-tooth 20 [‘Dental Health Surveys’ (Mesh)] AND implant loss connected prostheses were not included in the review. (197) Manual search included bibliographies of previous reviews and of selected publications. Furthermore, a Variables ‘search for related articles’ in PubMed was applied for Number and age of subjects included at baseline and all studies that were evaluated in full text. the number of subjects lost to follow-up were recorded. The number of teeth present at baseline and the Results number of installed implants were retrieved, as well as the number of (i) teeth and implants lost during the Teeth study and (ii) subjects who had experienced tooth or implant loss. Data on marginal bone loss around teeth From the screening of titles obtained from the database and implants were also recorded. search, 70 publications were identified as potentially Weighted mean values were calculated for the relevant for the focussed question. The evaluation of number of teeth and implants at baseline and the abstracts yielded 37 studies eligible for full-text analysis. number ⁄ percentage of teeth and implants lost during 11 publications met the inclusion criteria. The 26 follow-up. For studies in which information on implant excluded studies and the reasons for exclusion are loss was not clearly defined, the inverse of the cumu- listed in Table 1. lative survival rate was calculated. The 11 included studies are presented in Table 2. Six studies were epidemiological surveys of general popu- lations (2–7), while three publications described sub- Search strategy jects who were classified as regular dental care A search in PubMed was performed in May 2007 to attendants (8–10). One study reported data from retrieve articles published in the English language. The institutionalized patients (11) and one study evaluated search terms used and the resulting matches were as subjects with untreated periodontitis (12). Three pub- follows: lications were grouped together as they reported on 1 dental implants AND longitudinal studies (1664) findings from the same subject sample included in an 2 dental implants AND longitudinal (286) epidemiological survey (5–7). The follow-up period in 3 dental implants AND clinical trial (810) the 11 studies ranged between 10 and 30 years. In 4 dental implants AND cohort studies (1677) several studies the data were reported according to age 5 dental implants AND prospective studies (534) categories and for these studies weighted mean values 6 dental implants AND survival (815) were calculated. The age of the subjects at baseline 7 dental implant AND longevity (54) varied between 20 and 65 years. The total number of 8 dental implants AND randomized clinical trial (314) subjects recorded at baseline in the 11 studies was 3015. 9 dental implants AND prospective (1713) The number of subjects examined at the end of the 10 oral epidemiology AND tooth loss (434) studies was 2304. ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  3. 3. LONGEVITY OF TEETH AND IMPLANTS 25Table 1. Excluded publications on teeth and reasons for 10-year rate of bone loss varied between 0.2 andexclusion 0.8 mm. For subjects who were evaluated in epidemi- ological studies the corresponding figure was 0.6 mm.Reference Reason for exclusionAhlqwist et al. (1999) (20) % Subject drop out >30% ImplantsBaljoon et al. (2005) (21) Same The initial search generated 52 publications that possi-Bergstrom et al. (2000)(22) ¨ SameBergstrom (2004) (23) ¨ Same bly could be included. Following the analysis of theBurt et al. (1990) (24) Same abstracts 39 of these studies were rejected. Hence, full-Ettinger & Qian (2004) (25) Same text analysis was made in 23 studies, out of which nineFure (2003) (26) Same publications were found to fulfil the inclusion criteria.Halling & Bjorn (1986) (27) ¨ Same The 14 excluded studies and the reasons for exclusionHamalainen et al. (2004) (28) Same are listed in Table 3.Hiidenkari et al. (1997) (29) SameHujoel et al. (1999) (30) Same The nine studies on implants included in this reviewIsmail et al. (1990) (31) Same are reported in Table 4. The longest follow-up periodJansson et al. (2002) (32) Same was 20 years. The age of the subjects at the time ofKrall et al. (1999) (33) Same implant placement ranged between 18 and 80 years.Krall et al. (2006) (34) Same The overall number of subjects who received implantsNeely et al. (2005) (35) SamePetersson et al. (2006) (36) Same was 476, while the number of subjects attending a finalRohner et al. (1983) (37) Same examination was 355.Tezal et al. (2005) (38) Same The majority of the studies reported data onWarren et al. (2002) (39) Same ˚ implants of the Branemark System. Four studiesFardal et al. (2004) (40) Same reported data on implants placed in edentulous jawsHeitz-Mayfield et al. (2003) (41) Retrospective design to support an overdenture (13–16) while other threeSchatzle et al. (2003a), Schatzle ¨ ¨ Retrospective design et al. (2004), Schatzle et al. ¨ studies regarded implants placed in edentulous jaws to (2003b) (42–44) support fixed prosthetic reconstructions (17–19). TheEickholz et al. (2006) (45) Regenerative therapy total number of implants placed in the nine studies was 1460. The percentage of implants reported as lost during the follow-up period varied between 1% and The mean number of teeth per subject at baseline was 18%. Only four studies presented information on thereported in 10 of the studies and ranged from 21 to 26. number of subjects who had experienced implant loss.The incidence of tooth loss among subjects with a The calculated proportion of such subjects in thisfollow-up period of 10–30 years varied from 1.3% to group of studies ranged between 3% and 29%. Causes5% in the majority of studies. Results presented in for implant loss were rarely reported. On the otherepidemiological studies on rural Chinese population hand, the timing of implant loss was frequentlysamples, however, revealed an incidence of tooth loss described. Between 9% and 100% of the implant lossof 14–20% (2, 3). The proportion of individuals that in the various studies were reported as ‘early loss’, i.e.experienced tooth loss showed a range of 25–75% with implants that were removed before the connection ofthe highest figure in the studies on the Chinese the prosthetic reconstruction.populations and in patients with untreated periodonti- Data on the amount of marginal bone loss over atis. Rosling et al. (2001) reported that the percentage of 10-year period could be retrieved from eight studies.subjects that experienced tooth loss was 64% for In these studies the amount of bone loss was given inpatients with high susceptibility to periodontitis, while mm per year or as a difference between the baselineamong subjects with a ‘normal’ susceptibility the and the final follow-up examination. Most studies alsocorresponding figure was 26%. Main causes for tooth described the amount of bone loss that occurredextraction, when reported in the studies, were caries during the first year in function in addition to theand tooth fracture. subsequent bone level alterations. The calculated 10- Data regarding marginal bone loss could be retrieved year bone loss varied between 0.7 and 1.3 mm in thefrom four studies, all from Sweden. The calculated available studies.ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  4. 4. 26 Table 2. Prospective studies on teeth Subjects No. Drop out Mean no. Tooth exhibiting Bone loss in C . T O M A S I et al. Study Follow-up Subject sample Age range subjects (deceased) teeth baseline loss (%) tooth loss 10 years Causes for tooth loss Axelsson et al. 30 years General population 20–65 375 118 (49) 24.8 3.6% NR NR 62% Root fracture (2004) (8) Well maintained 23% Endodontic Baelum et al. 10 years General 20–60+ 587 147 25.5 20% 75% NR Endodontic OR 3.9 (1997) (2) Epidemiologic China Buckley & Crowley 10 years Un-treated 15–58 82 NR 14% Perio 6% 61% NR NR (1984) (12) periodontal Non-perio patients Chen et al. (2001) (3) 10 years Males only 20–59 200 23 (5) 25.7 14.1% NR NR Perio. breakdown Epidemiologic caries, endo China Gabre et al. 10 years Mental retarded 41.0 mean 136 21 (19) 20.7 17.9% NR NR NR (1999) (11) Institution Norderyd et al. 17 years General 15–60 574 141 (25) 24.1 5% 34% 0.6 mm 58% Perio (1999) (5) Epidemiologic 36% Caries Hugoson & Laurell (2000) (7) Laurell et al. (2003) (6) Paulander et al. 10 years General 50 mean 429 120 22.9 4.1% 39% 0.54 mm Caries and (2004) (4) Epidemiologic attachment loss predictors of tooth loss Rosling et al. 12 years High susceptibility 45.5 mean 109 61 (9) 24.1 7.8% 64% 0.8 mm NR (2001) (9) Normal 41.8 mean 225 7 23.5 1.3% 26% 0.3 mm susceptibility Wennstrom et al. ¨ 12 years General 18–65 298 73 (8) 23.7 3% 25% 0.2 mm NR (1993) (10) population Public dental clinic OR, odds ratio.ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  5. 5. LONGEVITY OF TEETH AND IMPLANTS 27Table 3. Excluded publications on implants and reasons for category of studies was confined to a distinct group ofexclusion subjects who required a certain treatment of partial or complete edentulism. The character of tooth studies, onAuthors ⁄ year Reason for exclusion the other hand, was in most cases entirely different.Jemt & Johansson (2006) (46) % subject drop out >30% Although well-maintained groups of subjects wereAttard & Zarb (2003) (47) Retrospective design included in some studies, many of the included studiesMerickse-Stern et al. Retrospective design on teeth in the present review comprised ‘untreated’ (2001) (48)Naert et al. (2000) (49) <80% of subjects at 10 years subjects who did not receive appropriate regular main- follow-up tenance. In addition, the epidemiological approach thatHultin et al. (2000) (50) Subgroup of (51) was employed in several studies provided a sampleBragger et al. (2005) (52) ¨ Connection teeth-implants representing a general population, while in otherGunne et al. (1999) (53) Connection teeth-implants studies the participants exhibited varying susceptibilityYanase et al. (1994) (54) Non-endosseous implants to periodontitis. The differences in the character ofNystrom et al. (2004) (55) ¨ Bone grafting before implant placement tooth- and implant studies must, therefore, be consid- ˚Roos-Jansaker et al. Cross-sectional with ered in the comparisons of longevity criteria. (2006) (56) retrospective analysis Many publications that were identified in the Pub-Willer et al. (2003) (57) Unclear design and description Med search fulfilled the criteria of 10 years of follow-up of the study lacking but were excluded from the evaluation due to other informationAttard & Zarb (2004a) (17) Retrospective design grounds. The most common reason for not includingAttard & Zarb (2004b) (13) Retrospective design such a study on teeth in the present review was the rateZarb & Zarb (2002) (58) Retrospective design of subject dropouts that exceeded 30%. This feature is a frequent problem in epidemiological research using large population samples. The reasons for excluding implant studies of 10 years of follow-up were different.Comparisons between teeth and implants This finding may be explained by the variations in studyDue to the heterogeneity among the studies a meta- character and subject sample between tooth- andanalysis using statistical comparisons between teeth and implant studies as discussed above.implants was not feasible. A graphic illustration of the One particular problem in the evaluation of studies todifferent studies on teeth and implants with regard to be eligible for the present review was the questionthe outcome of tooth ⁄ implant loss and the sample size whether the longitudinal study applied a prospective oris presented in Fig. 1. Weighted mean values for loss retrospective design. The decision taken in this reviewrates were calculated and plotted when data were to describe the longevity of teeth and dental implantsreported in subgroups. Tooth studies included larger prompted the selection of prospective studies. In severalsubject samples than studies on implants. The rate of identified publications during the search, the studytooth and implant loss varied between as well as within design was clearly stated and described, while in otherthe two categories of studies. reports the description of the study methods raised doubts with regard to the use of a prospective or retrospective design. A retrospective design was theDiscussion common reason for excluding studies on both teeth andIn the present systematic review the longevity of teeth implants.and dental implants was described. Comparisons The main outcome variable that was evaluated in thebetween long-term investigations on teeth and im- current review was tooth- and implant loss. Theplants, however, are difficult due to the differences in incidence of tooth loss varied considerably. Thus, inthe subjects included and the overall lack of implant one study on an untreated old rural population instudies employing an epidemiological approach in China (2) the loss rate was 20%, while in an epidemi-study design. Thus, implant publications in the current ological study on a general population in China toothreview were in general longitudinal cohort studies of loss occurred in 14% (3). A third investigation thatwell-defined groups of subjects who all received reported a mean tooth loss rate that amounted to 18%implant therapy. In other words, the evaluation in this was performed in a small cohort of patients institution-ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  6. 6. 28 C . T O M A S I et al. Table 4. Prospective studies on implants Subjects No. exhibiting Follow- Subject No. Drop out implants Implant Implant Timing of implant Bone loss on Study up sample Age range subjects (deceased) placed type loss implant loss loss (%) 10 years Deporter et al. 10 years Edentulous 56 mean 52 9 (6) 156 Endopore 8% 9% early loss 15% 0.71 mm (2002) (14) Overdenture Ekelund et al. 20 years Edentulous 33–64 47 3 (2) at 273 ˚ Branemark 1% 66% early loss NR 0.9 mm (2003) (18) Fixed 15 years Carlsson et al. 17 (6) at 2000 (59) 20 years Lindquist et al. 1996 (60) Karoussis et al. 10 years Periodontal 19–78 127 38 (9) 179 ITI 7.3% NR NR 0.74 mm (2004) (61) patients 9 years data Lekholm et al. 10 years Partially 18–70 127 38 (5) 461 ˚ Branemark 10% 76% early loss 29% 0.7 mm (1999) (51) edentulous Meijer et al. 10 years Edentulous 57 mean 29 1 58 IMZ 7.1% 75% early loss 10% NR (2004) (15) Overdenture 32 7 (4) 61 ˚ Branemark 18% 55% early loss 20% Naert et al. 10 years Edentulous 36–85 36 10 (9) 73 ˚ Branemark 2% 100% early loss 3% 0.86 mm (2004) (16) Overdenture Rasmusson et al. 10 years Edentulous 50–80 36 8 (3) 199 Astra 3.9% 100% early loss NR 1.3 mm (2005) (19) Fixed 7 years data ITI, Straumann dental implants.ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  7. 7. LONGEVITY OF TEETH AND IMPLANTS 29 Tooth ( ) vs. Implant ( ) Loss 25 20 Baelum 1997 Meijer 2004 Gabre 1999 15 Chen 2001 % loss Buckley 1984 10 Lekholm 1999 Deporter 2002 Rosling 2001 Karoussis 2004 Meijer 2004 Norderyd 1999 5 Axelsson 2004 Rasmusson 2005 Wennström 1993 Paulander 2004 Naert 2004 Ekelund 2003 Rosling 2001 0Fig. 1. Rate of tooth and implant 0 100 200 300 400 500loss in relation to subject sample. No. of subjects followedalized for mental disease (11). Thus, the three studies Marginal bone loss was not considered as a suitablereferred to represent subject samples that may not be variable for meta-analysis due to the heterogeneity ofcomparable to those reported in the implant studies of data that was reported. For teeth, such data werethe present review. Furthermore, in the studies involv- frequently lacking and also in the case when data oning Scandinavian populations the 10-year rate of tooth bone loss were obtained from attachment level mea-loss was below 5%. surements, results were presented either in mm ⁄ year Moreover the incidence of implant loss varied. While or in total mm for the follow-up period. In one studymost implant studies presented loss rates <10% (62), with long follow-up and more strict maintenance, afew publications contained data on 17–18% lost gain in attachment levels at the end of observationimplants. It is evident that a major part of the number period was reported. It is interesting to note that thereof lost implants reported occurred between the implant was no apparent relation between marginal bone lossinstallation and before the connection of the supra- and the rate of tooth loss rate. The problem ofstructure. Three studies reported on implants support- heterogeneity of data was more pronounced in studiesing overdenture type reconstructions (13–16), which on implants than in studies on teeth. The use of meanpooled together did not present higher loss rates than bone loss at the subject level may hide the presence ofother studies reported. The finding is in contrast with an implant or a tooth presenting pathological bonethe data presented in a previous systematic review on loss. Another important consideration in the compar-biological and technical complications in implant ther- ison of the longevity of teeth and dental implants isapy (1). In this review it was concluded that the the fact that the number of years in service for teeth isincidence of implant loss in overdenture therapy was much larger than that of implants despite the studytwice as high as that when using fixed reconstructions design of similar follow-up periods. Thus, in a 40-year-on implants. In one study in the current review two old subject who is enrolled in a longitudinal study, thedifferent implant systems were compared using a teeth have already history of about 30 years of service.randomized controlled clinical trial design (15). The The corresponding function period for an implant,subjects that were included received an overdenture however, will commence at the time of implant ˚supported by two implants of either IMZ or Branemark installation. A further comment to the data obtainedimplants. A significantly larger probing depth for IMZ from the implant studies in the present review is theimplants was reported at the 1-year and 10-year fact that the types of implants that were evaluated areexaminations. The incidence of implants loss at no longer available. The requested follow-up docu- ˚10 years, however, was twice as high in Branemark mentation for implants that are currently in useimplants as in IMZ implants. appears to be lacking. Finally, it must be realized thatª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
  8. 8. 30 C . T O M A S I et al. in studies on teeth the subjects may exhibit varying 7. Hugoson A, Laurell L. A prospective longitudinal study on systemic and local compromising conditions, while periodontal bone height changes in a Swedish population. J Clin Periodontol. 2000;27:665–674. studies on implants in most cases demonstrate ideal 8. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a ¨ conditions regarding subject selection and situation of plaque control program on tooth mortality, caries and oral tissues. periodontal disease in adults. Results after 30 years of main- tenance. J Clin Periodontol. 2004;31:749–757. 9. Rosling B, Serino G, Hellstrom MK, Socransky SS, Lindhe J. ¨ Conclusions Longitudinal periodontal tissue alterations during supportive therapy. Findings from subjects with normal and high 1 In clinically well-maintained patients, the survival susceptibility to periodontal disease. 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