Evaluation of a Single-Tooth Implant

Robert H. Johnson, DDS, MSD1/G. Rutger Persson, DDS, DOdont1

Fifty-nine commercially pure titanium implants in 59 subjects were compared with internal con-
trol teeth for 3 years. Nineteen coated implants of identical design were placed in 17 of the sub-
jects and compared with the titanium implants. Demographic data, microbial DNA, aspartate
aminotransferase levels, Plaque Index, width of adjacent keratinized tissue, probing depths,
bleeding on probing, relative attachment levels, mobility, and radiographic bone height were
studied. The only statistically significant changes over time were improved plaque scores in the
subjects and slight bone loss around the implants. There were no differences between the 2
types of implants. Mobility was less and probing depth and bleeding on probing were greater in
the implant sites than in the control sites. (INT J ORAL MAXILLOFAC IMPLANTS 2000;15:396–404)

Key words: dental implants, dental radiography, oral diagnosis, patient satisfaction,
surface properties

METHOD AND MATERIALS

A variety of factors apparently can influence suc-
cess rates of dental implants. Among them are
the quantity and quality of bone in the selected A 3-year prospective study of single-tooth Ti
site,1–4 the presence or absence of keratinized tissue implants was performed at the University of Wash-
around the implant,5–10 the reason for tooth loss ington, School of Dentistry, Seattle, Washington.
and the overall periodontal status,11–13 the type of Subjects were selected in accordance with the regu-
microflora present in the sulci/pockets of the nat- lations of the University’s Human Subjects Review
ural teeth and implants,14–19 the patient’s plaque Committee. To qualify, individuals had to be in
control,20 and the quality of professional mainte- good health and have relatively intact dentitions
nance, including the type of instruments used to free from active periodontal inflammation. The site
clean the implants.21–28 Smoking29–32 and parafunc- had to have adequate mesiodistal space between
tional habits 33–35 have been associated with adjacent teeth and at least 9 mm of vertical bone
increased failure rates. The surface characteristics of height. The surgeon was prepared to use ridge aug-
implants have sparked discussion.36–39 Another con- mentation techniques to overcome a thin alveolar
sideration in a clinical investigation is the impact of housing. A minimum of 4 months had to elapse
the actual testing on the supporting tissues. between tooth extraction and implant surgery.
The objectives of the current study were: (1) to One periodontist placed all of the implants
evaluate the role of some of the reported risk factors (Genetics Implant System Inc, Seattle, WA), leaving
on a commercially pure grade 2 titanium (Ti) sin- the head of the implant flush with the crest of the
gle-tooth implant and compare the results with alveolar bone. If more than 1 implant was placed in
those of a contralateral natural control tooth, and the patient, the second and third were 6/4 titanium
(2) to compare the Ti implant with a Ti plasma- alloy implants coated with 35 µm of Ti plasma fol-
sprayed, hydroxyapatite-coated 6/4 titanium alloy lowed by 25 µm of porous hydroxyapatite (HA). At
implant (HA) of identical design placed at the same the time of the second-stage surgery, the surgeon
time in the same patients. placed a restorative post and core and modified the
emergent core to fit the occlusal scheme. One
restorative dentist, using the same dental laboratory,
1Professorof Periodontics, School of Dentistry, University of fabricated all of the crowns; the final impressions
Washington, Seattle, Washington. were made approximately 8 weeks after second-
stage surgery. The occlusion of each crown was
Reprint requests: Dr Robert H. Johnson, Department of
carefully checked and adjusted if required.
Periodontics, P.O. Box 357444, University of Washington, Seattle,
WA 98195-7444. Fax: (206) 616-7478. E-mail: rhjperio@ The subjects then reported to the authors to
u.washington.edu begin the investigation. The subjects were seen 8

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times: at baseline and at 3, 6, 12, 18, 24, 30, and 36 Oral hygiene instructions were given to all sub-
months after final restoration. The patients’ age, jects during the first 2 visits (baseline and 3 months)
gender, medical conditions, history of smoking, and and then reinforced if needed throughout the 3
reason for tooth loss were noted. The time between years. Each patient received an ultrasoft manual
tooth loss and placement of the implant, placement toothbrush. Subjects with anterior implants were
of the implant and second-stage surgery, and sec- given Super Floss (Oral-B Laboratories, Belmont,
ond-stage surgery and final crown cementation were CA) for interproximal cleaning to protect the
recorded, as were the length and diameter of each height of the papillae. Individuals with posterior
implant. Implant placement sites were grouped into implants were instructed in the use of an interprox-
maxillary anterior, maxillary posterior, mandibular imal brush and sometimes Super Floss. On one
anterior, and mandibular posterior regions. The occasion in each of 2 patients, a universal scaler for
type of bone was classified as dense or porous by the dental implants (Steri-Oss, Yorba Linda, CA) was
surgeon. Complications encountered at the time of used to clean around the implant. With these 2
the 2 surgeries, during the postoperative healing exceptions, the implants and control teeth were not
period, at crown placement, and at any of the 8 data cleaned professionally during the 3 years of the
collection visits were noted, along with any correc- investigation. Polishing agents were never
tive intervention. A natural tooth (usually in the employed.
contralateral position to the implant) was selected to
serve as an internal control. Statistical Analyses
At each visit over the 3 years, the subjects were Descriptive statistics were used to analyze the study
asked about any change in health status and medica- material. Differences in change over time between
tions. They rated their satisfaction with the appear- each implant and its control tooth were studied
ance, the function, and the overall process of receiv- using paired t test and Chi-square analyses.
ing their implant(s) and crown(s) on a scale of 0 to Changes over time were studied for implants and
2, where 0 = not pleased, 1 = moderately pleased, teeth separately using 1-way analysis of variance
and 2 = very pleased. Possible altered sensation at (ANOVA) and Kruskal-Wallis non-parametric
the implant site was reported as none (0), mild (1), ANOVA. SPSS software version 8.0 (Chicago, IL)
moderate (2), or severe (3). Two sets of gingival was used for data analyses.
crevicular fluid samples were collected from each
implant and control tooth to determine aspartate
aminotransferase (AST) levels40 and DNA detection RESULTS
of Bacteroides forsythus, Porphyromonas gingivalis, and
Prevotella intermedia.41 One hundred ninety-two individuals were screened,
The following clinical data were recorded on the from whom 59 subjects were accepted for the
implants and control teeth. Probing depth (PD) and placement of a non-coated, commercially pure
relative attachment level (RAL) were measured on the grade 2 Ti implant. Nineteen HA-coated implants
mesiobuccal (MB), buccal (B), distobuccal (DB), and were placed in 17 of the same subjects. The
lingual/palatal (L) using an automated probe and an implants were placed in the following sites: 58%
automated attachment level probe (Florida Probe mandibular posterior, 26% maxillary anterior, 15%
Corp, Gainesville, FL), respectively, each calibrated maxillary posterior, and 1% mandibular anterior.
to 0.1 mm and a standardized pressure of 0.2 N. Six surgical sites exhibited a bony dehiscence or
Bleeding on probing (BOP), Plaque Index (PI),42 narrow alveolar housing that required regenerative
width in mm of B and L keratinized tissue, and procedures or splitting and expansion of the ridge.
mobility using the Periotest (Siemens, Bioresearch, Forty-eight of the implants had a diameter of 4.75
Milwaukee, WI) were also recorded. Baseline and mm; the other 30 were 3.75 mm in diameter. Rela-
annual periapical radiographs were taken of the tive to length, 42% were 10 mm, 37% were 13 mm,
implants and control teeth. Linear measurements and 21% were 16 mm long. An average of 7.3
were made on digitized images of the radiographs.43 months (8.2 months for the maxillary sites and 6.5
At baseline and years 1, 2, and 3, the amount of mesial months for mandibular sites) elapsed prior to surgi-
and distal radiographic bone change in mm was calcu- cal uncovering and attachment of the restorative
lated by comparing the distance from the apical mar- post and core. Temporary crowns were immediately
gin of the crown to the bone crest at implant sites. In placed on anterior implants; definitive crowns were
the case of control teeth, the measurements were cemented a mean of 8.5 weeks after second-stage
made between the bone crest and either the cemen- surgery.
toenamel junction or a crown margin.

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Table 1 Distribution (%) of Titanium Implant Sites and Teeth

with Bleeding on Probing at Baseline and at Years 1, 2, and 3
No. of
surfaces Baseline Year 1 Year 2 Year 3
with BOP Ti Tooth Ti Tooth Ti Tooth Ti Tooth
0 57.9 75.9 52.6 74.1 66.1 87.9 58.5 81.8
1 26.3 17.2 33.3 17.2 28.6 6.9 28.3 16.4
2 12.3 5.2 12.3 6.9 5.4 5.2 13.2 1.8
3 1.8 1.7 1.8 1.7 0.0 0.0 0.0 0.0
4 1.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0
BOP = bleeding on probing.

Demographic Data was reported by 11.7% and 8.6% of the subjects at

At the time of implant placement, the mean age of baseline and 3 months, respectively. Thereafter, the
the 59 subjects was 36.4 years (SD 11.8; age range subjects were basically symptom-free; only 4
16 to 71). Females comprised 64% of the patients. patients reported mild transitory symptoms at one
All were reasonably healthy, although 11 individuals of the remaining visits.
were being treated for a variety of conditions—dia- No difference in the level of satisfaction was
betes mellitus, high blood pressure, anemia, asthma, found over time. After 3 years, 92% of the partici-
duodenal ulcers, hypothyroidism, glaucoma, pants were “very pleased” with the procedures
epilepsy, anxiety, and depression. Five women gave involved in the placement and restoration of the
birth during the study. One woman began therapy implant and with the implant’s function; 8% were
for breast cancer but attended all 8 of her scheduled “moderately pleased.” All of the patients who
visits. Only 2 subjects smoked, 1 of whom was received an anterior implant were “very pleased”
recovering from alcoholism. Twenty-eight subjects with the cosmetic results. Of those with a posterior
identified caries, root canal failure, a dental abscess, implant, 86.2% were “very pleased” and 13.8%
or a failed restoration as the reason for tooth loss. were “moderately pleased.”
In 15 patients the permanent teeth were congeni-
tally missing, and in 2 individuals, impacted teeth Clinical Data
had been extracted. Trauma or resorption subse- Non-parametric Mann-Whitney tests failed to
quent to orthodontic treatment was reported by 14 demonstrate a significant difference in plaque scores
patients. None of the patients listed periodontal dis- between implant and control tooth sites at either
ease as the etiologic agent. The estimated duration baseline or year 3. However, both the implant and
between tooth loss and placement of the implant tooth plaque scores improved significantly during
varied from 4 to 528 months (ie, 44 years), with a the course of the study (P < .05, nonparametric
mean of 92.7 months (ie, 7.7 years). test). At baseline, 71.4% of the implant and 63.5%
of the tooth surfaces were plaque-free; at year 3, the
Implant Survival Rate values were 86.8% and 80.3%, respectively.
One of the 59 Ti implants was removed within the Bleeding on probing was recorded as “present or
first year (3-year survival rate = 98.3%). In prepar- absent” at each of the 4 sites (DB, B, MB, and L)
ing the surgical site, the mesial aspect of the drill around the implants and control teeth. Distribution
hole encroached on a prominent nasopalatine canal. of the proportion of sites presenting with BOP at
Therefore, integration of that side of the implant the annual examinations can be seen in Table 1.
never occurred. One patient moved away immedi- The control teeth presented with significantly fewer
ately after the crown was cemented and could not sites exhibiting BOP at both baseline (P < .05, non-
be followed. None of the 19 HA implants was lost. parametric test) and 3 years (P < .001) than did the
implants. No relationship was found between BOP
Symptoms and Satisfaction and either gingival width or plaque scores.
Significantly more symptoms (0 = none, 1 = mild, The mean width of keratinized tissue on the
2 = moderate, 3 = severe) were reported at the facial and lingual of the control tooth at baseline
implant sites at baseline and at the 3-month visit was greater than it was on the implant. The implant
than at later times (P < .001, Kruskal-Wallis demonstrated means of 3.0 mm (SD 1.3) and 2.7
ANOVA). A score of “1” (mild altered sensation) mm (SD 1.3) on the facial and lingual, respectively.

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Table 2 Clinical and Radiographic Findings, Titanium Implants and

Control Teeth
Baseline Year 1 Year 2 Year 3
Parameter Mean SD Mean SD Mean SD Mean SD
Implants
Probing depth MB (mm) 2.8 1.1 3.3 1.1 3.1 1.2 3.3 1.5
Probing depth B (mm) 2.1 1.0 3.2 0.7 3.2 1.2 2.3 1.1
Probing depth DB (mm) 2.8 1.0 3.2 0.7 3.1 1.2 3.3 1.2
Probing depth P/L (mm) 2.2 1.0 2.4 0.9 2.4 0.8 2.2 0.9
Probing depth mean (mm) 2.5 0.7 2.8 1.1 2.7 0.7 2.8 0.8
Bone height M (mm) 3.2 0.9 3.8 0.8 3.8 0.8 3.9 0.9
Bone height D (mm) 3.2 0.8 3.9 0.8 3.9 0.8 3.9 1.1
Control teeth
Probing depth MB (mm) 2.4 0.7 2.4 0.7 1.9 0.7 2.5 0.8
Probing depth B (mm) 1.9 0.6 1.7 0.7 1.6 0.6 1.6 0.6
Probing depth DB (mm) 2.3 0.6 2.2 0.7 2.0 0.6 2.1 0.8
Probing depth P/L (mm) 1.6 0.6 1.7 0.5 1.7 0.6 1.5 0.5
Probing depth mean (mm) 2.1 0.4 2.0 0.4 1.9 0.4 2.0 0.5
Bone height M (mm) 1.9 0.7 2.1 0.9 2.2 0.7 2.2 0.9
Bone height D (mm) 2.1 0.9 2.1 0.8 2.1 0.7 2.4 0.9
MB = mesiobuccal; B = buccal; DB = distobuccal; P/L = lingual/palatal; M = mesial; D = distal. Bone
heights were assessed via digitized radiographs.

For the tooth, the mean was 3.7 mm (SD 1.3) on control teeth ranged from –4 to +16. Most of the
the facial and 3.9 mm (SD 1.5) on the lingual. Sta- scores (92.4%) were in the –4 to +9 range, which,
tistical analyses (ANOVA) failed to demonstrate any when converted to Miller’s44 original classification
change in gingival width over time at either the for tooth mobility, equates with a “0” or “no distin-
implant or control sites. Statistical analyses failed to guishable movement.”45 In the remaining 7.6% of
demonstrate a relationship among gingival width, the teeth, the Periotest scores of +10 to +16 trans-
plaque scores, and BOP. late to a Miller’s class “1.” Mobility scores for the
Baseline and annual PD data for implants and implants ranged between –7 and +6. Thus, 100% of
control teeth are presented in Table 2. At baseline, the implants were within Miller’s “0” classification.
PD values were statistically significantly greater at The mean paired difference in the change in Peri-
the implant sites than at the corresponding control otest values over time between implants and teeth
tooth sites (P values varied between .001 and .05; was 1.6 units (SD 3.3; 95% confidence interval 0.5
independent t test). The mean PD difference was 0.4 to 2.6) and significantly different (t = 3.5; P < .001)
mm (t = 3.6, P < .001). At year 3, the PDs around the with a lesser degree of mobility for implants (Fig 2).
implants were statistically significantly greater than The Periotest data were analyzed to determine
around the control teeth. The mean PD difference whether there was a difference in the mobility scale
was 0.8 mm (standard error 0.1; 95% confidence among implants of different length. In the posterior
interval 0.5 to 1.0; t = 6.2; P < .001). When the regions at year 3, the 16-mm implants had a statisti-
changes over time for PD between implants and cally significantly lower Periotest reading than did
matched control teeth were compared, the mean the 10-mm implants (mean difference 4.2; P < .001,
paired difference in PD was 0.5 mm (SD 1.1; 95% one-way ANOVA, Bonferroni test), as well as the
confidence interval 0.2 to 0.8; t = 3.0; P < .01), with a 13-mm implants (mean difference 3.1; P < .01).
greater increase in PD at implant sites. The PD at Moreover, all of the 16-mm implants had a diame-
implant sites increased over time in 43 (73%) of the ter of 3.75 mm; the shorter implants were a mix of
cases. There was no statistically significant change in 3.75 mm and 4.75 mm. No differences in mobility
RAL at either the implant sites (F = 1.2; P < .3) or the were found between the 10-mm and 13-mm
tooth sites (F = 0.4; P < .9) between baseline and year implants. Relative to implant width and mobility,
3 (Fig 1). An increase in RAL ≥ 1 mm was found at 9 implants that were 13 mm long and 4.75 mm in
implant sites (15.3%) and 4 tooth sites (6.8%). diameter displayed statistically significantly lower
The Periotest has a range between –8 and +50, Periotest readings than did the implants that were
representing increasing mobility. The scores for the 13 mm long and 3.75 mm in diameter (P < .0001).

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1.0 4
0.9 Control tooth Ti implant
Control tooth Ti implant 3
0.8
0.7
Mean RAL change (mm)

Mean Periotest score

0.6
0.5 1
0.4
0.3 0
0.2
–1
0.1
0.0
–2
–0.1
–0.2 –3
Baseline Year 1 Year 2 Year 3 Baseline Year 1 Year 2 Year 3

Fig 1 Changes in relative attachment level (RAL) in mm Fig 2 Mean Periotest scores for titanium implants and control
between baseline and years 1, 2, and 3 for titanium implants and teeth at baseline and years 1, 2, and 3. The instrument’s range is
control teeth. A positive value indicates a loss of attachment, and from –8 to +50. The lower (more negative) the score, the tighter
a negative value indicates a gain in attachment. the implant or tooth.

The lack of variation in implant length at anterior threshold value for evidence of disease activity.40
sites did not allow for similar comparison. These values were not consistently found at specific
sites and were equally distributed between the
Radiographic Bone Height implants and control teeth. The AST values failed
Radiographic bone height values for the implants to identify sites of changed RAL, PD, or radio-
and control teeth can be found in Table 2. Statistical graphic bone height.
analysis (one-way ANOVA) failed to demonstrate a Different models were used in regression analy-
difference over time for the control teeth. At Ti ses in an attempt to identify significant explanatory
implant sites, there was a statistically significant variables (eg, patient’s age or gender, reason for
change (loss) in bone height between baseline and tooth loss, time interval between tooth loss and
year 1 (mean difference at mesial sites 0.6 mm; stan- implant placement, surgical site) that were associ-
dard error 0.1; P < .01; and mean difference at distal ated with changes over time for radiographic bone
sites 0.7 mm; standard error 0.2; P < .001). There height or RAL measurements. No such variables
was no significant change between years 1 and 2, were identified.
years 1 and 3, or years 2 and 3.
Ti Versus HA Implants
Laboratory Data Nineteen Ti plasma-sprayed, HA-coated 6/4 Ti
The presence of P gingivalis, P intermedia, or B alloy implants were placed in 17 of the 59 patients
forsythus was found only once at 4 implants and 3 at the time of placement of the commercially pure
control teeth from more than 900 samples col- grade 2 Ti implants. The same clinical and labora-
lected. Mean baseline AST values were 170 µIU tory data were collected from the 19 HA-coated
(SD 145) for the implant sites and 186 µIU (SD implants over the 3 years of the investigation. The
129) for the control teeth. The corresponding val- 17 subjects were treated as a subgroup, and statisti-
ues after 3 years were 263 µIU (SD 213) and 299 cal analyses were performed to compare all of the
µIU (SD 300), respectively. The changes over time variables for the 2 types of implants. All of the
were statistically significant (F = 4.3; P < .001), coated implants were successfully integrated. Statis-
although not between implants and control teeth. tical analyses failed to demonstrate any differences
Only 2.4% of the AST samples demonstrated a in study outcomes between the 2 types of implants
value greater than 800 µIU, which is considered the for any of the parameters studied.

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DISCUSSION lent 3-year survival rate was the healthy periodontal

status of the subjects. The laboratory data support
The importance of good plaque control by the this contention. DNA testing revealed a lack of the
patient and judicious maintenance with appropriate purported pathogens P gingivalis, B forsythus, and P
devices by the dental health care provider has been intermedia. These micro-organisms were identified
stressed.20–28 Warnings about damaging the surfaces in less than 1% of the samples, they were equally
of implants with steel curettes and ultrasonic scalers distributed between implants and control teeth, and
have been made. 24 Patients may have difficulty they never appeared more than once in any given
cleaning effectively around an implant. Ridge subject. Similarly, very few crevicular fluid samples
resorption at the surgical site, crown margins, and reached the threshold AST value which would have
for some implants, a collar of greater diameter than indicated the presence of disease activity around the
that of the body of the implant all can complicate a implants or control teeth.
patient’s plaque control efforts. In the system being Some authors believe that the quality of bone is
tested, the collar and the threads are the same the most important determinant in the loss of an
dimension, which facilitates plaque control. Mainte- implant. Failure rates of 35% have been reported in
nance therapy in the current study was basically lim- the presence of Type IV bone.1 In the current inves-
ited to oral hygiene instruction at baseline and at 3 tigation, the surgeon identified those surgical sites
months after cementation of the crown. The sub- in which the bone was “soft and spongy.” He then
jects accepted the challenge of caring for their own threaded only the coronal half of the bone to permit
implants. The percentages of plaque-free surfaces at self-tapping of the final half of the implant. In dense
baseline and at year 3 for the implants were 71.4 and bone, the site was threaded the full length of the
86.8, respectively. At baseline no plaque was implant. Statistical analyses revealed no differences
detected on 63.5% of facial and lingual/palatal sur- in any of the many variables examined over the 3
faces of the control teeth. The percentage of years, regardless of the softness of the bone.
plaque-free surfaces rose to 80.3% by the end of the The bone in the maxilla is less dense than that in
study. This excellence in plaque control may have the mandible. Reported survival rates of maxillary
been an important factor for the successful results implants usually are not as high as those for
that were obtained. mandibular implants.2,37 Some investigators2 have
Attempts to obtain accurate probing depths had better results in the posterior maxilla than in the
around implants may be thwarted if the collar juts anterior maxilla, while others50 claim that the lowest
out beyond the body of the implant. In the current rates of survival occur in the posterior maxilla. In the
system, the collar and external threads are the same mandible, more problems and lower survival rates
diameter, which facilitates the taking of these mea- have been reported in the molar region4,33,34,50 than
surements. One might ask if the tests conducted in the anterior region, which is associated with
during the investigation could damage the implant’s excellent and predictable results. The fact that only
surface and hence potentially influence survival. 1 of the 78 implants placed during the current study
Sixty-four PD and RAL measurements were made was in the anterior mandible makes the survival rate
around each implant with a 0.2-N-force stainless of 98.7% even more impressive.
steel instrument over the course of the study. Prob- Implants under 10 mm in length have the lowest
ing sometimes produced bleeding and elicited signs reported survival rates. 4,37 The shortest implant
of discomfort from the patients. However, despite placed in the current study was 10 mm. Statistically,
the lack of special treatment for subjects or implants, 16-mm implants, each with 3.75-mm diameters, had
the changes in PD and RAL at both implant and lower Periotest readings than either the 10-mm or
control tooth sites were small, within margin of 13-mm implants, which were evenly divided
measurement error, and clinically insignificant. between 3.75-mm and 4.75-mm diameters. The
The results of several investigations indicate that clinical relevance of this is questionable, because all
the microflora surrounding implants in partially of the implants, regardless of length, displayed no
edentulous mouths is similar to that found around visible mobility.
the remaining teeth.11–17,19,46–49 In the current study, There was some bone loss around the implants,
none of the subjects gave a history of periodontitis especially in the first year, which is consistent with
as the reason for tooth loss. They presented with other studies.51,52 Implants usually are placed so that
minimal PD, BOP, and radiographic bone loss. their coronal surface is left flush with the presurgical
Their personal plaque control was good and level of the alveolar crest. Crestal bone must be
improved throughout the course of the investiga- removed to accommodate the collar and any coronal
tion. Therefore, one apparent reason for the excel- projections such as an external hex or a cover screw.

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During the healing phase between first-stage and 35 µm of Ti plasma and 25 µm of porous HA were
second-stage surgeries, bone can re-form around the threaded, single-tooth, and the same dimensions.
collar and even cover the head of the implant. Jung et Comparisons were restricted to implants placed in
al53 have reported that regardless of implant design, the same patient. No differences were found in any
rapid alveolar bone loss will occur in the first 3 to 12 of the clinical or laboratory data. These data are
months after the placement of the second-stage abut- consistent with those of Evans et al,55 who com-
ment. This resorption continues until the apical mar- pared commercially pure Ti threaded implants and
gin of the polished neck or collar of the implant is HA-coated threaded implants of similar geometric
reached. Bone loss slows dramatically when contact is design and dimensions. They found no difference in
made with the first thread or area of surface rough- mobility, PD, percentage of osseointegration, or
ness.51,52 The design and vertical dimension of the crestal bone position.
collar therefore impacts the amount of initial bone The patients overwhelmingly responded that
loss. In the system under investigation, there is no they were “very pleased” with both the appearance
external hex. Moreover, the polished collar is the and the overall success of their restored implants.
same diameter as the outside dimension of the The only reported symptoms were “mild” altered
threads and is only 1 mm in height. Thus the sensation and were restricted to the first 3 months
omnipresent bone loss that occurs in the first year after cementation of the crown. The few subjects
should be restricted to 1 mm. The current data sup- who were “moderately pleased” with the surgical
port this. The crestal resorption, as measured radi- and restorative procedures and the function of their
ographically, was on average 0.6 mm on the mesial implants stated that the process had taken longer
surface of the implant and 0.7 mm on the distal, than they had expected or that the embrasure spaces
which is well within the 1-mm range (Table 2). between the implant and adjacent teeth were food
The radiographs of 6 patients displayed more traps. The only patients who ranked their cosmetic
bone loss on the mesial or distal of the implants satisfaction as “moderately pleased” had implants
than the norm. The person with the most loss was placed in mandibular posterior sites and received
a smoker and a recovering alcoholic and had an gold castings rather than ceramometal crowns.
allogenic bone graft and expanded polytetrafluo-
roethylene (e-PTFE) placed at the time of surgery
to cover exposed threads resulting from a thin CONCLUSIONS
alveolar housing. The only other smoker in the
study was also among the 6 subjects with greater The 3-year data of this prospective study suggest
bone loss. Two of the 6 were in orthodontic reten- that both types of implants (Ti and HA) were suc-
tion, having just completed active treatment to cre- cessful and functional, with a high degree of patient
ate space for an implant. In both, a facial dehis- acceptance. The implants were less mobile than the
cence was noted at the time of surgery, and a bone control teeth. The rest of the collected clinical data
graft and e-PTFE were placed. The fifth subject revealed some statistically significant differences (eg,
had undergone orthodontic therapy as a result of a PD and BOP) when the implants were compared to
congenitally missing mandibular second premolar. the control teeth, but none of the differences were
The surgeon described the bone as extremely soft, considered clinically significant. Radiographically,
and a pinhead-sized abscess occurred immediately slight bone loss was recorded on the mesial and dis-
postoperatively. The sixth patient’s implant, replac- tal surfaces of the implants in the first year; minimal
ing a maxillary central incisor that had been lost loss, if any, was noted over the next 2 years. The
because of facial trauma 30 years earlier, was in tested bacterial flora and AST levels of the peri-
close proximity to a large nasopalatine canal. Thus, implant tissues were consistent with healthy gingival
all 6 subjects presented with factors that potentially conditions. Among the important reasons for the
placed the implants at risk29–32 and may be useful high survival rate of the studied implants were the
considerations during treatment planning. Never- lack of a history of periodontal disease as the cause
theless, the subset of 6 implants displayed no of tooth loss and the excellent personal plaque con-
detectable mobility or other clinical signs for con- trol practiced by each subject.
cern after 3 years.
The influence of an implant’s composition and
surface texture on survival rates has been addressed
in numerous papers.36–39,54 In the current prospec-
tive investigation, both the commercially pure Ti
implants and the 6/4 Ti alloy implants coated with

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402 Volume 15, Number 3, 2000 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
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ACKNOWLEDGMENTS 17. Silverstein LH, Kurtzman D, Garnick JJ, Schuster GS, Ste-
flik DE, Moskowitz ME. The microbiota of the peri-implant
The investigation was supported by the Elam M. and Georgina region in health and disease. Implant Dent 1994;3:170–174.
Hack Memorial Research Fund, Department of Periodontics, 18. Sordyl CM, Simons AM, Molinari JA. The microbial flora
University of Washington, and by the Regional Clinical Dental associated with stable endosseous implants. J Oral Implantol
Research Center, NIH/NIDR grant #P30 DE09743. The 1995;21:19–22.
authors would like to thank Dr Stan Sapkos of Genetic Implant 19. Kohavi D, Greenberg R, Raviv E, Sela MN. Subgingival and
Systems for placing the implants, Dr James W. Cherberg for supragingival microbial flora around healthy osseointegrated
fabricating the crowns, and Ms Teresa Oswald for performing implants in partially edentulous patients. Int J Oral Maxillo-
the laboratory tests. fac Implants 1994;9:673–678.
20. Meffert RM, Langer B, Fritz ME. Dental implants: A
review. J Periodontol 1992;63:859–870.
21. Thomas-Neal D, Evans GH, Meffert RM. Effects of various
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OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF The International Journal of Oral & Maxillofacial Implants 403
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404 Volume 15, Number 3, 2000 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF
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