Crestal bone loss and the consequences of retained excess cement around dental implants

Crestal bone loss around dental implants has been a subject of discussion in implant dentistry since its inception. Many of the research and design developments related to dental implants have sought to limit the amount of crestal bone loss. While there are a variety of possible causes for crestal bone loss around dental implants, one iatrogenic cause that has become the subject of several articles is retained dental cement. The focus of this article will be to discuss the predisposing factors that can lead to retained cement and clinical strategies to minimize or prevent cement peri-implantitis. Case reports are presented in which retained cement resulted in significant peri-implant inflammation and bone loss around restored dental implants. Strategies for early detection to limit the damage from retained dental cement and cementing techniques are also discussed.     

Crestal bone changes around titanium implants. A histometric evaluation of unloaded non-submerged and submerged implants in the canine mandible

BACKGROUND: Today, implants are placed using both non-submerged and submerged approaches, and in 1- and 2-piece configurations. Previous work has demonstrated that peri-implant crestal bone reactions differ radiographically under such conditions and are dependent on a rough/smooth implant border in 1-piece implants and on the location of the interface (microgap) between the implant and abutment/restoration in 2-piece configurations. The purpose of this investigation was to examine histometrically crestal bone changes around unloaded non-submerged and submerged 1- and 2-piece titanium implants in a side-by-side comparison. METHODS: A total of 59 titanium implants were randomly placed in edentulous mandibular areas of 5 foxhounds, forming 6 different implant subgroups (types A-F). In general, all implants had a relatively smooth, machined coronal portion as well as a rough, sandblasted and acid-etched (SLA) apical portion. Implant types A-C were placed in a non-submerged approach, while types D-F were inserted in a submerged fashion. Type A and B implants were 1-piece implants with the rough/smooth border (r/s) at the alveolar crest (type A) or 1.0 mm below (type B). Type C implants had an abutment placed at the time of surgery with the interface located at the bone crest level. In the submerged group, types D-F, the interface was located either at the bone crest level (type D), 1 mm above (type E), or 1 mm below (type F). Three months after implant placement, abutment connection was performed in the submerged implant groups. At 6 months, all animals were sacrificed. Non-decalcified histology was analyzed by evaluating peri-implant crestal bone levels. RESULTS: For types A and B, mean crestal bone levels were located adjacent (within 0.20 mm) to the rough/smooth border (r/s). For type C implants, the mean distance (+/- standard deviation) between the interface and the crestal bone level was 1.68 mm (+/- 0.19 mm) with an r/s border to first bone-to-implant contact (fBIC) of 0.39 mm (+/- 0.23 mm); for type D, 1.57 mm (+/- 0.22 mm) with an r/s border to fBIC of 0.28 mm (+/- 0.21 mm); for type E, 2.64 mm (+/- 0.24 mm) with an r/s border to fBIC of 0.06 mm (+/- 0.27 mm); and for type F, 1.25 mm (+/- 0.40 mm) with an r/s border to fBIC of 0.89 mm (+/- 0.41 mm). CONCLUSIONS: The location of a rough/smooth border on the surface of non-submerged 1-piece implants placed at the bone crest level or 1 mm below, respectively, determines the level of the fBIC. In all 2-piece implants, however, the location of the interface (microgap), when located at or below the alveolar crest, determines the amount of crestal bone resorption. If the same interface is located 1 mm coronal to the alveolar crest, the fBIC is located at the r/s border. These findings, as evaluated by non-decalcified histology under unloaded conditions, demonstrate that crestal bone changes occur during the early phase of healing after implant placement. Furthermore, these changes are dependent on the surface characteristics of the implant and the presence/absence as well as the location of an interface (microgap). Crestal bone changes were not dependent on the surgical technique (submerged or non-submerged).     

Crestal bone changes around titanium implants: a methodologic study comparing linear radiographic with histometric measurements

Generally, endosseous implants can be placed according to a nonsubmerged or a submerged technique and in 1-piece or 2-piece configurations. Recently, it has been shown that peri-implant crestal bone reactions differ significantly radiographically as well as histometrically under such conditions and are dependent on a rough/smooth implant border in 1-piece implants and on the location of a microgap (interface) between the implant and the abutment/restoration in 2-piece configurations. The purpose of this study was to evaluate whether standardized radiography as a noninvasive clinical diagnostic method correlates with peri-implant crestal bone levels as determined by histometric analysis. Fifty-nine implants were placed in edentulous mandibular areas of 5 foxhounds in a side-by-side comparison in both submerged and nonsubmerged techniques. Three months after implant placement, abutment connection was performed in the submerged implant sites. At 6 months, all animals were sacrificed, and evaluations of the first bone-to-implant contact (fBIC), determined on standardized periapical radiographs, were compared to similar analyses made from nondecalcified histology. It was shown that both techniques provide the same information (Pearson correlation coefficient = 0.993; P < .001). The precision of the radiographs was within 0.1 mm of the histometry in 73.4% of the evaluations, while the level of agreement fell to between 0.1 and 0.2 mm in 15.9% of the cases. These data demonstrate in an experimental study that standardized periapical radiography can evaluate crestal bone levels around implants clinically accurately (within 0.2 mm) in a high percentage (89%) of cases. These findings are significant because crestal bone levels can be determined using a noninvasive technique, and block sectioning or sacrifice of the animal subject is not required. In addition, longitudinal evaluations can be made accurately such that bone changes over various time periods can be assessed. Such analyses may prove beneficial when trying to distinguish physiologic changes from pathologic changes or when trying to determine causes and effects of bone changes around dental implants.     

Crestal bone remodeling in loaded and unloaded implants and the microgap: a histologic study

PURPOSE: The aim of this study was to histologically evaluate the crestal bone response to loaded and unloaded implants in beagle dogs. MATERIALS AND METHODS: Sand-blasted and acid-etched implants (Bone System, Milano, Italy) were placed in the mandible of six beagle dogs. The two premolars and the first molars had been extracted 3 months previously. Each dog received 12 implants in the mandible, and a total of 72 implants were used in this study. Three months after implantation, second-stage surgeries were performed for placement of abutments or healing screws. Three dogs were killed after 6 months, and three dogs were killed after 12 months. All 72 implants were retrieved. RESULTS: No statistically significant differences were found in the amount of bone loss between test and control implants, both at 6 and 12 months. Statistically significant differences were found, in both groups, between the bone loss observed at 6 months and that found at 12 months. CONCLUSION: Loading does not seem to be a relevant factor in the peri-implant bone resorption observed during the first year of function. Our results support previous findings that bone crest level changes could depend on the location of the microgap.     

A radiographic evaluation of bone healing around submerged and non-submerged dental implants in beagle dogs

BACKGROUND: The rehabilitation of the oral cavity with dental implants has become a predictable treatment modality. However, there have been only a few direct comparisons evaluating the submerged and nonsubmerged placement techniques. The purpose of this study was to characterize radiographic peri-implant bone changes following the insertion of submerged and nonsubmerged implants in the beagle dog. METHODS: At the end of the extraction healing phase, 19 submerged and 19 nonsubmerged implants were randomly placed in a split-mouth study design and observed over an 18-week period. For submerged implants, a second stage surgery and transmucosal abutment attachment was performed at week 12. Standardized dental radiographs taken at baseline, week 12, and week 18 were used to measure peri-implant bone changes. The radiographs were analyzed with a simple computer assisted method. RESULTS: A total of 43 standardized radiographs were exposed to evaluate the 38 implants. During the study period, all submerged and nonsubmerged implants demonstrated peri-implant bone loss. At baseline, both submerged and nonsubmerged implants had similar bone levels (P > or = 0.05). When the mean peri-implant bone levels for submerged and nonsubmerged implants were compared from baseline to week 12, nonsubmerged implants had a significantly greater amount and rate of bone resorption than submerged implants (P < or = 0.05). Following week 12, the initially submerged implant had a significantly higher rate and amount of peri-implant bone loss than the nonsubmerged implants (P < or = 0.05). However, by the end of the study period, week 18, both submerged and nonsubmerged implants had comparable bone levels (P > or = 0.05). CONCLUSIONS: The study indicates that, although the temporal patterns of peri-implant bone resorption differed, there were no differences between submerged and nonsubmerged implants in the overall amount and rate of peri-implant bone loss.     

Factors associated with radiographic vertical bone loss around implants placed in a clinical study

The loss of vertical bone height over time has been assessed radiographically as part of the Dental Implant Clinical Research Group studies. Radiographs were assessed from implant placement, uncovering surgeries, and recall appointments. Overall, the study implants experienced most peri-implant vertical bone loss in the first year after placement, followed by a dramatic decrease in bone loss rate through the subsequent study intervals. Stratified analysis of data up to 72 months after implant uncovering indicates different bone loss patterns by: 1) arch; 2) jaw region; 3) case type; 4) bone quality; 5) surface type; 6) implant design; 7) smoking status; and 8) postoperative antibiotic treatment. These results will be used to build statistical mixed models to indicate which clinical factors are most predictive of peri-implant vertical bone loss, controlling for confounding and accounting for correlation of data over time and within study patients.     

Crestal bone loss evaluation in osseotite expanded platform implants: a 5-year study

Objective: The aim of this prospective clinical study was to evaluate the survival rates at 5 years of expanded platform implants placed in the anterior zone of the maxilla and immediately restored with single crowns. Materials and methods: Implants incorporating the platform‐switching concept were placed in fresh extraction sockets in the maxillary arch, with each patient receiving a provisional restoration immediately after implant placement. After 15 days, final screwed restorations were inserted. Mesial and distal bone heights were evaluated using digital radiography on the day following implant placement and at 1, 3, 6, 9, 12, 24, 36 months and 5 years. Primary stability was measured with resonance frequency analysis (RFA) using the Osstell Mentor device. Sixty‐four implants were placed in 32 men and 32 women ranging in age between 29 and 60 (mean: 39.64 ± 5.16 years). Results: Mean mesial bone loss was 0.08 mm (SD 0.42). Mean distal bone loss was 0.14 mm (SD 0.56). Over the course of the 5 years, the mean RFA value was 72.5 ± 3.1 SD. Conclusion: The platform‐switched implants remained stable over the course of 5 years and had an overall survival rate of 97.1%. To cite this article:
Calvo‐Guirado J L, Gómez‐Moreno G, López‐Marí L, Guardia J, Negri B, Martínez‐González J M. Crestal bone loss evaluation in osseotite expanded platform implants: a 5‐year study.
Clin. Oral Impl. Res. xx , 2011; 000–000
doi: 10.1111/j.1600‐0501.2010.02130.x     

Loss of crestal bone around dental implants: a retrospective study

The loss of crestal bone associated with dental implants is a significant clinical phenomenon. The occurrence of such bone loss will often compromise long-term prognosis and, if extensive, ultimately lead to failure. Relatively few studies have focused on the reasons for loss of crestal-supporting bone around implants, although numerous explanations for the phenomenon have been proposed. This retrospective investigation examines one potential causative factor for implant-associated crestal bone loss, which has only recently received attention, i.e., location of the implant/transmucosal abutment interface (ITAI) relative to the crestal bone. A retrospective clinical evaluation of 350 individual implants in 255 patients indicates a direct relationship between subgingival placement of the ITAI and loss of crestal supporting bone. In addition, scanning electron microscopic examination of 45 failed implants showed significant plaque accumulation at the ITAI, the transmucosal abutment/prosthesis interface (TAPI), and the interface between the implant smooth collar and subjacent plasma-spray coated surface.     

Influence of cyclosporin A on quality of bone around integrated dental implants: a radiographic study in rabbits

OBJECTIVES: To evaluate the influence of cyclosporin A (CsA) administration on bone around integrated dental implants assessed by a bone quality index and by quantitative subtraction radiography. MATERIAL AND METHODS: A total of 36 machine surface commercial implants were placed in 18 adult rabbits. After a 3-month healing period without any disturbance, the animals were randomly divided into three groups of six animals each. Group A was sacrificed at this time. CsA was injected subcutaneously in an immunosuppressive dose of 10 mg/kg/day in a test group (Group T), and a Group B served as a control, receiving only vehicle. After 3 months of cyclosporin administration, the animals of both Groups B and T were sacrificed. Radiographs were obtained at implant surgery and at the day of sacrifice with a CMOS sensor. Bone quality around the implants was compared between the groups using a bone quality index and quantitative subtraction radiography. RESULTS: The bone analysis showed that in Group T, the bone quality changed dramatically from a dense cortical to a loose trabecular bone structure (P<0.0001, chi(2) test) while in Groups A and B there were no significant differences. Quantitative digital subtraction radiography showed significantly (P<0.05) lower gray shade values (radiographic density) in a region of bone formation around the implants in Group T (118+/-12) than in Groups A (161+/-6) and B (186+/-10). CONCLUSION: Within the limits of this study, CsA administration has a negative effect on the quality of bone around integrated dental implant.     

Collagen fiber orientation in human peri-implant bone around immediately loaded and unloaded titanium dental implants

BACKGROUND: The main factor in determining the mechanical properties of bone is the collagen configuration. METHODS: This study investigated the birefringence in human bone around loaded and unloaded titanium dental implants to evaluate the collagen fiber orientation using circularly polarized light (CPL) and scanning electron microscopy (SEM). A total of 10 titanium dental implants, five immediately loaded and five unloaded, were used. The birefringence measurements were performed on digitized images of both loaded and unloaded implants. All images detected at 50x were measured using a software image analysis. RESULTS: In the bone around loaded implants, the transverse collagen fiber area was 45,481+/-3,037 pixel2 (mean+/-SD), while the area of longitudinal collagen fibers was 13,676+/-2,232 pixel2 (mean+/-SD). In the unloaded implants, the transverse collagen fiber area was 32,174+/-2,554 pixel2 (mean+/-SD), while the area of longitudinal collagen fibers was 89,073+/-1,960 pixel2 (mean+/-SD). The CPL measurements of the birefringence for transverse collagen fibers of loaded versus unloaded implants indicated that the differences were statistically significant (P <0.05). The results for the longitudinal collagen fibers of loaded versus unloaded implants were also statistically significant (P <0.05). CONCLUSIONS: In the bone around loaded dental implants, transverse collagen fibers were more abundant, while in the unloaded implants, collagen fibers run more longitudinally. The load seemed to determine the collagen fiber orientation.     

Comparative evaluation of the peri-implant bone tissue mineral density around unloaded titanium dental implants

OBJECTIVE: The mechanical properties of bone are greatly influenced by the percentages of organic and mineral constituents. Nevertheless, the information about the mineral content on a microscopic scale in peri-implant bone is scarce. The aim of this work was to analyze the bone mineral density of peri-implant bone under different techniques. DESIGN: Five unloaded titanium dental implants with a micro-structured surface (three XiVE plus and two Frialit 2, DENTSPLY-Friadent, Mannheim, Germany) were retrieved from the mandible of five patients after a 6-month period. scanning electron microscopy with backscattered electron signal (BSE), light microscopy (LM) with a double staining technique, fluorescence microscopy and confocal laser microscopy were used for measuring microscopic mineral content variations in peri-implant bone. Histomorphometry and image intensity (grey level) were evaluated using a software package for image analysis. RESULTS: The low mineral density index (LMDI) for LM was of 29.2+/-3.1 (mean+/-S.D.), while the high mineral density index (HMDI) was of 88.2+/-3.6 (mean+/-S.D.). The one-way ANOVA analysis showed a significant difference (P<0.001) among the groups. The pairwise Holm-Sidak test identified the differences among HMDI indexes for both LM and SEM values and also for cross-evaluation of the LMDI and HMDI values. The comparison between LMDI indexes for both SEM and LM did not show any significance. The fluorescence microscopy analysis showed clearly the difference between old (high mineralized) and new (low mineralized) bone tissue near the implant surface. Under confocal laser microscopy the same sections showed the area of bone modelling closest to implant surface. CONCLUSION: In this study it was found that bone around unloaded implants showed a low mineral density index under all the investigation methods used. It was also found that the conventional LM technique with the double staining method was able to intensely stain the bone area with a low mineral content.     

Factors affecting late fixture loss and marginal bone loss around teeth and dental implants

Background: The predictability and high success rate of implant treatment have averted attention from factors affecting fixture loss and bone loss around implants. Purpose: The goal of this study was to retrospectively evaluate late fixture loss and marginal bone loss around implants that have been in function for 5 years and to relate these findings to bone loss in the natural dentition. Materials and Methods: One hundred and forty‐three consecutively treated patients who had received an implantanchored fixed prosthesis and completed a 5‐year follow‐up were selected. Intraoral and panoramic radiographs were used to assess bone loss. Results: The bone loss was greater around remaining implants in patients who had lost implants after loading. No correlation was found between bone loss around implants and that around teeth. Only 2% of the fixtures were lost during 5 years of functional load. Most fixture losses occurred in the edentulous maxilla. Seven of the nine patients who lost fixtures were smokers. Conclusion: These findings show that patients who lost implants also lost more bone around the remaining implants. There was no correlation between bone loss around implants and that around teeth, indicating that different interacting mechanisms are involved.     

Removable prostheses may enhance marginal bone loss around dental implants: a long-term retrospective analysis

BACKGROUND: The aim of the study was to retrospectively evaluate marginal bone loss (MBL) around rough-surface dental implants, placed in a private clinic, and to construct a multivariate model based on formerly proposed prognostic variables. METHODS: Records of patients who were treated previously with dental implants were reviewed. The patients' latest annual clinical examinations and radiograms were used for data collection and the calculation of MBL. A patient-based multivariate model was constructed based on two successive iterations of statistical analysis. RESULTS: Eighty-two patients and 265 implants with > or =30 months of follow-up were evaluated. The overall survival rate was 95.8% (2.6% early loss and 1.5% late loss). By evaluating the data with the single implant as a unit of analysis, MBL was correlated with time. Higher MBL values were found in smokers and around implants supporting removable prostheses. In the patient-based analysis, only smoking and the presence of a removable prosthesis correlated with higher values of MBL. Odds ratios for higher rates of MBL were 1.95 and 2.57 for smokers and around removable prostheses, respectively. Neither time nor any of the other suspected variables correlated with higher MBL. CONCLUSIONS: The present study corroborated the notion that smoking correlates with higher MBL and implied that implants supporting removable prostheses tend to display more bone loss. Further studies are needed to elucidate the latter finding.     

Early cellular responses in cortical bone healing around unloaded titanium implants: an animal study

BACKGROUND: A clear understanding of the early cellular events leading to osseointegration of implants is currently lacking. To gain better insight, titanium implants were inserted in a rabbit model and histologic and histomorphometric analyses were performed at early time points after insertion. METHODS: Thirty-six cylindrical implants were inserted in the tibial diaphysis of six rabbits and left to heal for 1 to 42 days. Samples were processed into paraffin or methylmethacrylate sections, on which the surface of new bone, region of altered nuclear morphology, relative surface of basic multicellular units (BMUs) and blood vessels, and bone-to-implant contact were measured. RESULTS: After coagulum formation, osteoclasts and osteoblasts were observed at the bone surface 1 week after healing. In the preexisting bone, osteocytic lacunae appeared to be devoid of cells. This region of altered nuclear morphology continued to extend for 28 days (P <0.05) after implant insertion. This expansion was accompanied by an invasion of the damaged bone by BMUs that initiated intensive bone remodeling, which reached its maximum after 4 weeks (P <0.05) but was ongoing after 6 weeks of implant insertion. CONCLUSIONS: This study evaluated the early cellular events in cortical bone surrounding titanium implants. The insertion of an implant into bone initiates a series of biologic processes, including the formation of a hematoma, altered nuclear morphology of the osteocytes surrounding the implantation site, intensive bone remodeling, and the formation of new bone, eventually leading to the osseointegration of the implant.