longevity of teeth and implants a systematic review

Longevity 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

was to describe the incidence of tooth and implant

loss reported in long-term studies. Prospective lon-

gitudinal studies reporting on teeth or implants

survival with a follow-up period of at least 10 years

were considered. Papers were excluded if the drop

out rate exceeded 30% or if <70% of the initial

subject sample was examined at 10 years of follow-

up. Seventy publications on teeth were identified as

potentially relevant for the focussed question. The

analysis of the abstracts yielded 37 studies eligible

for full-text analysis. The inclusion criteria were met

in 11 of the publications that included in all 3015

subjects. The initial search on implant studies gen-

erated 52 publications that possibly could be in-

cluded. Following the evaluation of the abstracts

and full-text analysis nine publications were found

to fulfil the inclusion criteria. The nine studies

included 476 subjects. The incidence of tooth loss

among subjects with a follow-up period of 10–

30 years varied from 1.3% to 5% in the majority of

studies, while in two epidemiological studies on

rural Chinese populations the incidences of tooth

loss were 14% and 20%. The percentage of implants

reported as lost during the follow-up period varied

between 1% and 18%. In clinically well-maintained

patients, the loss rate at teeth was lower than that at

implant. Bone level changes appeared to be small at

teeth as well as at implants in well-maintained

patients. Comparisons of the longevity at teeth and

dental implants are difficult due to heterogeneity

among the studies.

KEYWORDS: implants, longevity, teeth, prospective

study

Accepted for publication 4 November 2007

Introduction

Decision-making in treatment planning should be

based on scientific evidence. In the clinical situation

when deciding on either treating a tooth disorder or

extracting the tooth in favour of implant placement,

data that provide guidelines for the choice of strategy

are sparse. Although implant therapy is regarded as a

safe and reliable method in the treatment of complete

and partial edentulism, complications of technical and

biological nature occur (1). The ultimate complication

in implant therapy is the loss of implants, as for teeth

the extraction is the definitive failure. To determine the

longevity of teeth and implants, information on the

occurrence of these final events on a long-term basis

must be provided.

The objective of this systematic review was to

describe the incidence of tooth and implant loss

reported in prospective longitudinal studies with a

follow-up of at least 10 years. Alterations in marginal

bone support at teeth and implants were also

addressed.

Material and methods

Type of studies

Prospective longitudinal studies with a follow-up period

of at least 10 years were considered. Thus, cohort

studies, controlled clinical trials and randomized clinical

trials that provided data on tooth and ⁄or implant loss

over the indicated time period were analysed. Studies

reporting life-tables were analysed with respect to the

proportion of subjects or implants ⁄ teeth that were

followed ‡10 years. Publications were excluded if

<70% of the initial subject sample was examined at

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2007.01831.x

Journal of Oral Rehabilitation 2008 35 (Suppl. 1); 23–32

10 years of follow-up, or if data corresponding to

10 years of observation could not be achieved. Studies

in which the rate of subject dropout at 10 years

exceeded 30% were also excluded.

Subjects

Subjects who were part of epidemiological studies or

enrolled in maintenance programmes of treatment

studies on teeth were included in the review. Implant-

related studies comprised edentulous and partially

edentulous subjects who were treated with endosseous

dental implants supporting fixed or removable recon-

structions. Studies that reported data on implant-tooth

connected prostheses were not included in the review.

Variables

Number and age of subjects included at baseline and

the number of subjects lost to follow-up were recorded.

The number of teeth present at baseline and the

number of installed implants were retrieved, as well

as the number of (i) teeth and implants lost during the

study and (ii) subjects who had experienced tooth or

implant loss. Data on marginal bone loss around teeth

and implants were also recorded.

Weighted mean values were calculated for the

number of teeth and implants at baseline and the

number ⁄percentage of teeth and implants lost during

follow-up. For studies in which information on implant

loss was not clearly defined, the inverse of the cumu-

lative survival rate was calculated.

Search strategy

A search in PubMed was performed in May 2007 to

retrieve articles published in the English language. The

search terms used and the resulting matches were as

follows:

1 dental implants AND longitudinal studies (1664)

2 dental implants AND longitudinal (286)

3 dental implants AND clinical trial (810)

4 dental implants AND cohort studies (1677)

5 dental implants AND prospective studies (534)

6 dental implants AND survival (815)

7 dental implant AND longevity (54)

8 dental implants AND randomized clinical trial (314)

9 dental implants AND prospective (1713)

10 oral epidemiology AND tooth loss (434)

11 oral epidemiology AND longitudinal AND teeth

(149)

12 oral epidemiology AND periodontal disease (2344)

13 oral epidemiology AND caries (2843)

14 tooth loss AND prospective (361)

15 tooth loss AND cohort (138)

16 tooth loss AND longitudinal (200)

17 [‘Dental Health Surveys’ (Mesh)] AND tooth loss

(516)

18 [‘Dental Health Surveys’ (Mesh)] AND bone loss

(633)

19 [‘Dental Health Surveys’ (Mesh)] AND attachment

loss (958)

20 [‘Dental Health Surveys’ (Mesh)] AND implant loss

(197)

Manual search included bibliographies of previous

reviews and of selected publications. Furthermore, a

‘search for related articles’ in PubMed was applied for

all studies that were evaluated in full text.

Results

Teeth

From the screening of titles obtained from the database

search, 70 publications were identified as potentially

relevant for the focussed question. The evaluation of

abstracts yielded 37 studies eligible for full-text analysis.

11 publications met the inclusion criteria. The 26

excluded studies and the reasons for exclusion are

listed in Table 1.

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-

jects who were classified as regular dental care

attendants (8–10). One study reported data from

institutionalized patients (11) and one study evaluated

subjects with untreated periodontitis (12). Three pub-

lications were grouped together as they reported on

findings from the same subject sample included in an

epidemiological survey (5–7). The follow-up period in

the 11 studies ranged between 10 and 30 years. In

several studies the data were reported according to age

categories and for these studies weighted mean values

were calculated. The age of the subjects at baseline

varied between 20 and 65 years. The total number of

subjects recorded at baseline in the 11 studies was 3015.

The number of subjects examined at the end of the

studies was 2304.

C . T OMA S I et al.24

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd

The mean number of teeth per subject at baseline was

reported in 10 of the studies and ranged from 21 to 26.

The incidence of tooth loss among subjects with a

follow-up period of 10–30 years varied from 1.3% to

5% in the majority of studies. Results presented in

epidemiological studies on rural Chinese population

samples, however, revealed an incidence of tooth loss

of 14–20% (2, 3). The proportion of individuals that

experienced tooth loss showed a range of 25–75% with

the highest figure in the studies on the Chinese

populations and in patients with untreated periodonti-

tis. Rosling et al. (2001) reported that the percentage of

subjects that experienced tooth loss was 64% for

patients with high susceptibility to periodontitis, while

among subjects with a ‘normal’ susceptibility the

corresponding figure was 26%. Main causes for tooth

extraction, when reported in the studies, were caries

and tooth fracture.

Data regarding marginal bone loss could be retrieved

from four studies, all from Sweden. The calculated

10-year rate of bone loss varied between 0.2 and

0.8 mm. For subjects who were evaluated in epidemi-

ological studies the corresponding figure was 0.6 mm.

Implants

The initial search generated 52 publications that possi-

bly could be included. Following the analysis of the

abstracts 39 of these studies were rejected. Hence, full-

text analysis was made in 23 studies, out of which nine

publications were found to fulfil the inclusion criteria.

The 14 excluded studies and the reasons for exclusion

are listed in Table 3.

The nine studies on implants included in this review

are reported in Table 4. The longest follow-up period

was 20 years. The age of the subjects at the time of

implant placement ranged between 18 and 80 years.

The overall number of subjects who received implants

was 476, while the number of subjects attending a final

examination was 355.

The majority of the studies reported data on

implants of the Branemark System. Four studies

reported data on implants placed in edentulous jaws

to support an overdenture (13–16) while other three

studies regarded implants placed in edentulous jaws to

support fixed prosthetic reconstructions (17–19). The

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

18%. Only four studies presented information on the

number of subjects who had experienced implant loss.

The calculated proportion of such subjects in this

group of studies ranged between 3% and 29%. Causes

for implant loss were rarely reported. On the other

hand, the timing of implant loss was frequently

described. Between 9% and 100% of the implant loss

in the various studies were reported as ‘early loss’, i.e.

implants that were removed before the connection of

the prosthetic reconstruction.

Data on the amount of marginal bone loss over a

10-year period could be retrieved from eight studies.

In these studies the amount of bone loss was given in

mm per year or as a difference between the baseline

and the final follow-up examination. Most studies also

described the amount of bone loss that occurred

during the first year in function in addition to the

subsequent bone level alterations. The calculated 10-

year bone loss varied between 0.7 and 1.3 mm in the

available studies.

Table 1. Excluded publications on teeth and reasons for

exclusion

Reference Reason for exclusion

Ahlqwist et al. (1999) (20) % Subject drop

out >30%

Baljoon et al. (2005) (21) Same

Bergstrom et al. (2000)(22) Same

Bergstrom (2004) (23) Same

Burt et al. (1990) (24) Same

Ettinger & Qian (2004) (25) Same

Fure (2003) (26) Same

Halling & Bjorn (1986) (27) Same

Hamalainen et al. (2004) (28) Same

Hiidenkari et al. (1997) (29) Same

Hujoel et al. (1999) (30) Same

Ismail et al. (1990) (31) Same

Jansson et al. (2002) (32) Same

Krall et al. (1999) (33) Same

Krall et al. (2006) (34) Same

Neely et al. (2005) (35) Same

Petersson et al. (2006) (36) Same

Rohner et al. (1983) (37) Same

Tezal et al. (2005) (38) Same

Warren et al. (2002) (39) Same

Fardal et al. (2004) (40) Same

Heitz-Mayfield et al. (2003) (41) Retrospective design

Schatzle et al. (2003a), Schatzle

et al. (2004), Schatzle et al.

(2003b) (42–44)

Retrospective design

Eickholz et al. (2006) (45) Regenerative therapy

L O NG E V I T Y O F T E E T H AND IM P L AN T S 25


Table

2.Prospectivestudiesonteeth

Study

Follow-up

Subject

sample

Age

range

No.

subjects

Dropout

(decea

sed)

Mea

nno.

teethbaseline

Tooth

loss

(%)

Subjects

exhibiting

tooth

loss

Boneloss

in

10yea

rsCau

sesfortooth

loss

Axelssonetal.

(2004)(8)

30yea

rsGen

eral

population

Wellmaintained

20–6

5375

118(49)

24.8

3.6%

NR

NR

62%

Rootfracture

23%

Endodontic

Bae

lum

etal.

(1997)(2)

10yea

rsGen

eral

Epidem

iologic

China

20–6

0+

587

147

25.5

20%

75%

NR

EndodonticOR3.9

Buckley&

Crowley

(1984)(12)

10yea

rsUn-treated

periodontal

patients

15–5

882

NR

14%

Perio

6%

Non-perio

61%

NR

NR

Chen

etal.(2001)(3)

10yea

rsMales

only

Epidem

iologic

China

20–5

9200

23(5)

25.7

14.1%

NR

NR

Perio.break

down

caries,en

do

Gab

reetal.

(1999)(11)

10yea

rsMen

talretarded

Institution

41.0

mean

136

21(19)

20.7

17.9%

NR

NR

NR

Norderydetal.

(1999)(5)

Hugo

son&

Lau

rell

(2000)(7)

Lau

relletal.

(2003)(6)

17yea

rsGen

eral

Epidem

iologic

15–6

0574

141(25)

24.1

5%

34%

0.6

mm

58%

Perio

36%

Caries

Pau

lander

etal.

(2004)(4)

10yea

rsGen

eral

Epidem

iologic

50mean

429

120

22.9

4.1%

39%

0.54mm

Cariesan

d

attach

men

tloss

predictors

of

tooth

loss

Roslingetal.

(2001)(9)

12years

Highsuscep

tibility

Norm

al

suscep

tibility

45.5

mean

41.8

mean

109

225

61(9)

7

24.1

23.5

7.8%

1.3%

64%

26%

0.8

mm

0.3

mm

NR

Wen

nstrom

etal.

(1993)(10)

12yea

rsGen

eral

population

Publicden

tal

clinic

18–6

5298

73(8)

23.7

3%

25%

0.2

mm

NR

OR,oddsratio.



Comparisons between teeth and implants

Due to the heterogeneity among the studies a meta-

analysis using statistical comparisons between teeth and

implants was not feasible. A graphic illustration of the

different studies on teeth and implants with regard to

the outcome of tooth ⁄ implant loss and the sample size

is presented in Fig. 1. Weighted mean values for loss

rates were calculated and plotted when data were

reported in subgroups. Tooth studies included larger

subject samples than studies on implants. The rate of

tooth and implant loss varied between as well as within

the two categories of studies.

Discussion

In the present systematic review the longevity of teeth

and dental implants was described. Comparisons

between long-term investigations on teeth and im-

plants, however, are difficult due to the differences in

the subjects included and the overall lack of implant

studies employing an epidemiological approach in

study design. Thus, implant publications in the current

review were in general longitudinal cohort studies of

well-defined groups of subjects who all received

implant therapy. In other words, the evaluation in this

category of studies was confined to a distinct group of

subjects who required a certain treatment of partial or

complete edentulism. The character of tooth studies, on

the other hand, was in most cases entirely different.

Although well-maintained groups of subjects were

included in some studies, many of the included studies

on teeth in the present review comprised ‘untreated’

subjects who did not receive appropriate regular main-

tenance. In addition, the epidemiological approach that

was employed in several studies provided a sample

representing a general population, while in other

studies the participants exhibited varying susceptibility

to periodontitis. The differences in the character of

tooth- and implant studies must, therefore, be consid-

ered in the comparisons of longevity criteria.

Many publications that were identified in the Pub-

Med search fulfilled the criteria of 10 years of follow-up

but were excluded from the evaluation due to other

grounds. The most common reason for not including

such a study on teeth in the present review was the rate

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.

This finding may be explained by the variations in study

character and subject sample between tooth- and

implant studies as discussed above.

One particular problem in the evaluation of studies to

be eligible for the present review was the question

whether the longitudinal study applied a prospective or

retrospective design. The decision taken in this review

to describe the longevity of teeth and dental implants

prompted the selection of prospective studies. In several

identified publications during the search, the study

design was clearly stated and described, while in other

reports the description of the study methods raised

doubts with regard to the use of a prospective or

retrospective design. A retrospective design was the

common reason for excluding studies on both teeth and

implants.

The main outcome variable that was evaluated in the

current review was tooth- and implant loss. The

incidence of tooth loss varied considerably. Thus, in

one study on an untreated old rural population in

China (2) the loss rate was 20%, while in an epidemi-

ological study on a general population in China tooth

loss occurred in 14% (3). A third investigation that

reported a mean tooth loss rate that amounted to 18%

was performed in a small cohort of patients institution-

Table 3. Excluded publications on implants and reasons for

exclusion

Authors ⁄ year Reason for exclusion

Jemt & Johansson (2006) (46) % subject drop out >30%

Attard & Zarb (2003) (47) Retrospective design

Merickse-Stern et al.

(2001) (48)

Retrospective design

Naert et al. (2000) (49) <80% of subjects at 10 years

follow-up

Hultin et al. (2000) (50) Subgroup of (51)

Bragger et al. (2005) (52) Connection teeth-implants

Gunne et al. (1999) (53) Connection teeth-implants

Yanase et al. (1994) (54) Non-endosseous implants

Nystrom et al. (2004) (55) Bone grafting before implant

placement

Roos-Jansaker et al.

(2006) (56)

Cross-sectional with

retrospective analysis

Willer et al. (2003) (57) Unclear design and description

of the study lacking

information

Attard & Zarb (2004a) (17) Retrospective design

Attard & Zarb (2004b) (13) Retrospective design

Zarb & Zarb (2002) (58) Retrospective design



Table

4.Prospectivestudiesonim

plants

Study

Follow-

up

Subject

sample

Age

range

No.

subjects

Dropout

(decea

sed)

No.

implants

placed

Implant

type

Implant

loss

Tim

ingof

implantloss

Subjects

exhibiting

implant

loss

(%)

Boneloss

on

10yea

rs

Dep

orter

etal.

(2002)(14)

10yea

rsEden

tulous

Overden

ture

56mean

52

9(6)

156

Endopore

8%

9%

earlyloss

15%

0.71mm

Ekelundetal.

(2003)(18)

Carlssonetal.

2000(59)

Lindquistetal.

1996(60)

20yea

rsEden

tulous

Fixed

33–6

447

3(2)at

15yea

rs

17(6)at

20yea

rs

273

Branem

ark

1%

66%

earlyloss

NR

0.9

mm

Karoussisetal.

(2004)(61)

10yea

rsPeriodontal

patients

19–7

8127

38(9)

179

ITI

7.3%

NR

NR

0.74mm

9yea

rsdata

Lek

holm

etal.

(1999)(51)

10yea

rsPartially

eden

tulous

18–7

0127

38(5)

461

Branem

ark

10%

76%

earlyloss

29%

0.7

mm

Meijeretal.

(2004)(15)

10yea

rsEden

tulous

Overden

ture

57mean

29

32

1 7(4)

58

61

IMZ

Branem

ark

7.1%

18%

75%

earlyloss

55%

earlyloss

10%

20%

NR

Nae

rtetal.

(2004)(16)

10yea

rsEden

tulous

Overden

ture

36–8

536

10(9)

73

Branem

ark

2%

100%

earlyloss

3%

0.86mm

Rasmussonet

al.

(2005)(19)

10yea

rsEden

tulous

Fixed

50–8

036

8(3)

199

Astra

3.9%

100%

earlyloss

NR

1.3

mm

7yea

rsdata

ITI,Strau

man

nden

talim

plants.



alized for mental disease (11). Thus, the three studies

referred to represent subject samples that may not be

comparable to those reported in the implant studies of

the present review. Furthermore, in the studies involv-

ing Scandinavian populations the 10-year rate of tooth

loss was below 5%.

Moreover the incidence of implant loss varied. While

most implant studies presented loss rates <10% (62),

few publications contained data on 17–18% lost

implants. It is evident that a major part of the number

of lost implants reported occurred between the implant

installation and before the connection of the supra-

structure. Three studies reported on implants support-

ing overdenture type reconstructions (13–16), which

pooled together did not present higher loss rates than

other studies reported. The finding is in contrast with

the data presented in a previous systematic review on

biological and technical complications in implant ther-

apy (1). In this review it was concluded that the

incidence of implant loss in overdenture therapy was

twice as high as that when using fixed reconstructions

on implants. In one study in the current review two

different implant systems were compared using a

randomized controlled clinical trial design (15). The

subjects that were included received an overdenture

supported by two implants of either IMZ or Branemark

implants. A significantly larger probing depth for IMZ

implants was reported at the 1-year and 10-year

examinations. The incidence of implants loss at

10 years, however, was twice as high in Branemark

implants as in IMZ implants.

Marginal bone loss was not considered as a suitable

variable for meta-analysis due to the heterogeneity of

data that was reported. For teeth, such data were

frequently lacking and also in the case when data on

bone loss were obtained from attachment level mea-

surements, results were presented either in mm ⁄yearor in total mm for the follow-up period. In one study

with long follow-up and more strict maintenance, a

gain in attachment levels at the end of observation

period was reported. It is interesting to note that there

was no apparent relation between marginal bone loss

and the rate of tooth loss rate. The problem of

heterogeneity of data was more pronounced in studies

on implants than in studies on teeth. The use of mean

bone loss at the subject level may hide the presence of

an implant or a tooth presenting pathological bone

loss. Another important consideration in the compar-

ison of the longevity of teeth and dental implants is

the fact that the number of years in service for teeth is

much larger than that of implants despite the study

design of similar follow-up periods. Thus, in a 40-year-

old subject who is enrolled in a longitudinal study, the

teeth have already history of about 30 years of service.

The corresponding function period for an implant,

however, will commence at the time of implant

installation. A further comment to the data obtained

from the implant studies in the present review is the

fact that the types of implants that were evaluated are

no longer available. The requested follow-up docu-

mentation for implants that are currently in use

appears to be lacking. Finally, it must be realized that

Tooth ( ) vs. Implant ( ) Loss

Rosling 2001

Paulander 2004

Norderyd 1999

Chen 2001

Baelum 1997

Rosling 2001

Axelsson 2004Wennström 1993

Buckley 1984

Gabre 1999

Ekelund 2003Naert 2004Rasmusson 2005

Karoussis 2004Deporter 2002

Lekholm 1999

Meijer 2004

Meijer 2004

0

5

10

15

20

25

0 100 200 300 400 500

No. of subjects followed

% lo

ss

Fig. 1. Rate of tooth and implant

loss in relation to subject sample.



in studies on teeth the subjects may exhibit varying

systemic and local compromising conditions, while

studies on implants in most cases demonstrate ideal

conditions regarding subject selection and situation of

oral tissues.

Conclusions

1 In clinically well-maintained patients, the survival

rates of teeth were higher than that of implants.

2 In well-maintained patients, the bone level

changes appeared to be small at teeth as well as

at implants.

3 Comparisons of the longevity of teeth and dental

implants are difficult due to marked heterogeneity

among the studies. Thus, in most implant studies the

subjects were selected for a dedicated treatment

procedure, while in studies on teeth most the

conditions that existed for a random population were

described (epidemiological study).

4 The number of subjects evaluated in studies on teeth

was considerably larger than that in studies on

implants.

Conflicts of interest

The authors declare no conflicts of interests.

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Correspondence: Cristiano Tomasi, Department of Periodontology,

Institute of Odontology, The Sahlgrenska Academy at Goteborg

University, Box 450 SE 405 30 Goteborg, Sweden.

E-mail: [email protected]



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