T. Albrektsson Implant survival and complications.

N. Donos
on behalf of Working Group 1
The Third EAO consensus conference
2012

Authors’ affiliations: Abstract

T. Albrektsson, Department of Biomaterials, Objectives: The task of this working group was to analyze biological, technical and aesthetic
Gothenburg University, Gothenburg, Sweden
Department of Materials Science & Technology, complications of single crowns on implants and fixed dental prostheses with or without cantilevers
Malmö University, Malmö, Sweden on implants over 5 years or more. In addition, the group analyzed economic aspects on such
N. Donos, Periodontology unit, Department of implant treatment.
clinical research, UCL Eastman Dental Institute,
London, UK Materials and methods: A systematic search of the relevant literature was conducted and critically
reviewed. Four manuscripts were presented to cover the topics.
Corresponding author:
Results: The consensus statements prepared by the group and later accepted at the plenary
Tomas Albrektsson
Department of Biomaterials session as well as suggestions for future research are presented in this article. The four reviews by
Box 412 Jung et al., Pjetursson et al., Romeo & Storelli and Scheuber et al. are printed separately and
405 30 Gothenburg, Sweden
present detailed analyses of the research topics.
Tel.: +46 3178 62945
Fax: +46 3178 62941
e-mail: tomas.albrektsson@biomaterials.gu.se

Conflicts of interest
The authors have not declared any potential
conflicts.
Members of working group: Urs Brägger, Marco Esposito,
Eugenio Romeo, Theodoros Kapos, Ralf Kohal, Timo
Närhi, Bjarni Pjetursson, Stefano Storelli, Daniel Thoma,
Cristiano Tomasi, Georg Watzek, Marcel Zwahlen, Roger
Zwahlen.
Date:
Accepted 16 June 2012
To cite this article:
Albrektsson T, Donos N. Implant survival and complications.
The Third EAO consensus conference 2012.
Clin. Oral Implants Res. 23(Suppl. 6), 2012, 63–65
doi: 10.1111/j.1600-0501.2012.02557.x
Osseointegration has been proven a reliable
mode of fixation for oral implants. Clinical
long-term results with positive outcomes
have been documented for 20 years or more.
However, there is still a need to sum up
detailed information on implant survival and
complication rates with respect to single
crowns on implants and implant-supported
fixed dental prostheses with or without canti-
levers. The long-term outcome of single
crowns on implants is one factor guiding the
clinician whether implant treatment or con-
ventional fixed partial dentures would be the
preferred treatment alternative, but economic
aspects including costs for the chosen treat-
ment (be that a single crown or an FDP) go
beyond a mere survival analysis. The reviews
focused on clinical results of single crowns
and FDPs were, therefore, coupled with
another review focused on economic aspects.
The following reviews were the subject for
group discussions and the final consensus
statements:
Pjetursson B, Thoma D, Jung R, Zwahlen
M, Zembic A. A systematic review of the
survival and complication rates of implant
supported fixed dental prostheses (FDPs) after
a mean observation period of at least 5 years.
Jung R. E., Zembic A, Pjetursson B, Zwah-
len M, Thoma D. Systematic review of the
survival rate and the incidence of biological,
technical and aesthetic complications of sin-
gle crowns on implants reported in longitudi-
nal studies of at least 5 years.
Romeo E, Storelli S. Systematic review of
the survival rate and the incidence of biologi-
cal, technical and aesthetic complications of
fixed dental prostheses with cantilevers on
implants reported in longitudinal studies of
at least 5 years.
Scheuber et al. (2012). Implants vs. short-
span fixed bridges: Survival, complications,
patient benefits. A systematic review on Eco-
nomic aspects.
Based on these four reviews, the partici-
pants of the group prepared consensus state-
ments, clinical recommendations, and
implications for research in written form that
were approved during the plenary session.
These statements are presented here in a con-
densed version.
Survival rate and complications of
single crowns on implants
Major conclusions from the paper
In the present systematic review, both pro-
spective and retrospective studies were evalu-
ated. Based on 23 prospective studies
including 1312 dental implants, the 5-year
implant survival rate was estimated to be
97.7% and based on four prospective studies
including 124 implants the 10-year implant
survival rate was estimated to be 94.9%. The
included retrospective studies presented simi-
lar implant survival rates.
Based on 14 prospective studies reporting
on 754 implant-supported SCs and three pro-

© 2012 John Wiley & Sons A/S 63

Albrektsson & Donos
Implant survival and complications
spective studies reporting on 104 implant-
supported SCs the 5- and 10-year survival
rate of implant-supported SCs were estimated
to be 96.3% and 89.8%, respectively. The
included retrospective studies presented simi-
lar crown survival rates.
Despite high survival of SCs, technical,
biological and aesthetic complications were
frequently observed reaching rates of 8.8%,
7.1% and 7.1%, respectively. Considering
these varying extents of clinical complica-
tions, substantial amounts of chair time have
to be accepted by the patient and the dental
services after the insertion of implant-sup-
ported SCs.
Clinical implications
Based on the currently available evidence,
the group recommends the following:
1). Implant-supported single crowns (ISCs)
are to be considered a safe and effective
treatment modality as documented by
high survival rates after 5 and 10 years.
2). Technical complications are frequently
observed, most notably abutment- and
screw loosening.
3). The presence of biological and aesthetic
complications should be taken into con-
sideration, even though being less fre-
quent than technical ones.
4). Subjects receiving ISCs ought to present
healthy oral conditions or receive prior
satisfactory treatment to the resolution
of any present disease and be included in
a well-structured maintenance system.
Consensus statements
The outcome of the meta-analysis demon-
strated high implant survival rates for single
tooth implants and the respective single
crowns after 5 and 10 years. Despite varying
rates of technical, biological and aesthetic
complications that need to be expected, this
treatment modality for the restoration of a
single tooth gap can be considered as a safe
and predictable therapeutic option.
Clinical recommendations
Considering high implant and single crown
survival rates observed in prospective and ret-
rospective studies with a mean follow-up of 5
and 10 years, this treatment modality can be
recommended for single tooth gaps. Clini-
cians must be aware that complications may
occur to various extents. Most notably, abut-
ment- and screw loosening were reported
with the highest technical complications.
Although the dental literature reports soft
tissue and aesthetic complications very
64 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/63–65
inconsistently and without any standardiza-
tion and classification, these complications
have to be considered and strengthen the
need for a well-established maintenance pro-
gram.
Survival rate and complications of
fixed dental prostheses
Major conclusions
In the present systematic reviews, both pro-
spective and retrospective cohort studies and
case series were evaluated.
• Based on 14 prospective studies including
2256 dental implants, the 5-year implant
survival rate was 95.7% and based on six
prospective studies including 804
implants the 10-year implant survival
rate was 92.8%. The included retrospec-
tive studies presented similar rates of
implant survival.
• Based on 15 prospective studies reporting
on 886 implant-supported FDPs and three
prospective studies reporting on 219
implant-supported FDPs the 5- and 10-
year survival rates of implant-supported
FDPs were 93.6% and 86.7%, respectively.
•
Despite high survival of FDPs, biological
and technical complications such as,
veneer fractures, soft tissue complica-
tions, abutment or screw loosening, loss
of access hole restoration, and loss of
retentions were frequent.
• Only 66.4% of patients were completely
free from any type of reported complica-
tions. This, in turn, means that substan-
tial amount of chair time has to be
accepted by the patient and the dental ser-
vices following treatment with implant-
supported FDPs.
Clinical implications
Based on the currently available evidence,
the group recommends the following:
•
lmplant-supported fixed dental prostheses
(FDPs) should be used in a clinical setting
when appropriate indications exist.
•
The FDPs are to be considered a safe and
predictable treatment method with high
survival rates after 5 and 10 years.
•
The group strongly suggests that practi-
tioners should place great effort in choos-
ing reliable components and materials of
implant-supported FDPs.
• Technical complications may occur fre-
quently and as such a correct framework
design is essential in maintaining long-
term stability of the FDPs.
• Subjects receiving implant-supported
FDPs ought to present healthy oral condi-
tions or receive prior satisfactory treat-
ment to the resolution of any present
disease and be included in a well-struc-
tured maintenance system.
Survival rate and complications of
fixed dental prostheses with
cantilevers on implants
Even though the available data appear to
support the conclusion that ICFDP (Implant
supported single Crown Fixed Dental Pros-
thesis)are to be considered a reliable treat-
ment in partially edentulous patients with
survival rates similar to the standard FDP on
implants, the group felt that the available lit-
erature on this topic was limited. This was
also reflected to the amount of conclusions
made based on this systematic review.
Some of the limiting factors were as fol-
lows:
Non homogenous study designs or follow-
up periods
Small sample size of implants and pros-
theses
No relevant data on aesthetic outcomes
No sufficient data on length of the canti-
lever
More RCT studies are needed to analyze
the prognosis of ICFDP and the relative com-
plications in different areas of the oral cavity
and with different reconstructive/restorative
designs.
Clinical recommendations
Based on the available evidence from studies
on partially edentulous patients the group
recommends the following:
1. ICFDP with one cantilever of the size of
a premolar supported by two or more
implants is a valid treatment concept in
partially edentulous patients with sur-
vival rates similar to the standard FDP
on implants. There is limited evidence to
support the use of ICFDP supported by
only one implant.
2. The use of ICFDP could be a safe and
valid treatment alternative to avoid
implantations in compromised anatomi-
cal locations and to reduce costs.
Consensus statement
The group agreed that ICFDP rehabilitations
appear to be a reliable treatment option in
partially edentulous areas:
© 2012 John Wiley & Sons A/S

On the basis of the present literature, the
prevalence of implant failure, mechanical or
technical and biological complications and
MBL (Marginal Bone Loss) rates appear to be
similar to the standard FDP rehabilitations.
The group opinion is that ICFDP rehabilita-
tions could be indicated in cases where more
complex treatment is needed for end abut-
ment FDPs.
However, since there is no data showing
the effect of the actual cantilever extension
on failure and complications, the opinion of
the group is to limit as much as possible the
extension of the cantilever until supported by
additional studies.
Research recommendations
The group concluded that based on the avail-
able evidence evaluated in the present three
reviews (Jung et al. (2012), Pjetursson et al.
(2012), Romeo & Storelli (2012)):
• There is a clear need for improvement, not
only in the design of clinical studies but
also in the quality of reporting in the field
of implant- supported reconstructions.
• Publications on all observational clinical
studies must fulfill the present recom-
mendation on the definition of the essen-
tial factors to be reported in cohort and
case series studies (The STROBE State-
ment).
• To address through well- designed RCTs
specific issues such as screw retained vs.
cemented restorations, materials etc. (The
CONSORT Statement).
• Appropriate statistical analysis needs to
be performed on patient and implant level
accounting for clustering of data.
• Long-term cohort studies on implant sup-
ported reconstructions should have com-
plete follow-up information for all
patients, preferably with similar, well-
defined observation periods.
• In terms of reporting, survival/success of
implants/implant supported reconstruc-
References
Jung, R.E., Zembic, A., Pjetursson, B., Zwahlen, M.
& Thoma, D. (2012) Systematic review of the sur-
vival rate and the incidence of biological, techni-
cal and esthetic complications of single crowns
on implants reported in longitudinal studies of at
least 5 years. Clinical Oral Implant Research 23
(Suppl. 6): 2–21.
Pjetursson, B., Thoma, D., Jung, R., Zwahlen, M. &
Zembic, A. (2012) A systematic review of the sur-
© 2012 John Wiley & Sons A/S
Albrektsson & Donos
Implant survival and complications
tions and presence or absence of biologi-
cal, technical/mechanical and aesthetic
complications should be well defined,
assessed, and properly reported.
Economic aspects on implants
versus short-span fixed bridges
Conclusions based on the retrieved information
from the review
Initial costs for single implant crowns and
FDPs on teeth are similar but this may vary
dependent on the national fee system.
The conditions of neighboring teeth and of
the alveolar ridge define the complexity
(costs) of the treatment.
Failure rates reported with single implants
crowns and FDPs are similar.
The long-term financial economic compari-
son shows a similar outcome for single
implant crowns and FDPs.
Other factors than costs and survival rates
such as patient or provider reported factors
may be more decisive when choosing between
implant crowns and FDPs on teeth.
The utility for the patient to keep healthy
adjacent teeth unprepared makes the implant
crown more economic.
Consensus statements related to decision
making between single implant crown and an
FDP on teeth
Based on economic data retrieved through
this review and on the reported similar sur-
vival rates with the two treatment modali-
ties, decision making considering only
financial aspects is not recommended.
The complexities and related morbidity
and co-morbidity of the two treatment
options need to be considered.
Objective information on both treatment
options should be provided to enable patients
to value the consequences.
vival and complication rates of implant supported
fixed dental prostheses (FDPs) after a mean obser-
vation period of at least 5 years. Clinical Oral
Implant Research 23(Suppl. 6): 22–38.
Romeo, E. & Storelli, S. (2012) Systematic review of
the survival rate and the incidence of biological,
technical and esthetic complications of fixed den-
tal prostheses with cantilevers on implants
reported in longitudinal studies of at least
65 |
Through education a denser network of
competent providers need to be created to
offer access to both treatment modalities.
Insurance coverage should include both
treatment options.
Knowledge on health economics should be
improved in the dental profession.
Clinical recommendations
When choosing between single implant
crowns or FDPs on teeth, the complexities
and related morbidities of the two treatment
options need to be considered during the
decision making process.
The biological costs of circumferential
preparation of healthy teeth need to be taken
into consideration.
If adjacent teeth need circumferential prep-
aration, an interposed implant crown is not
economic.
The morbidity of hard and soft tissue pro-
cedures that might be related to a single
implant placement should also be taken into
account.
For the fixed replacement of a single tooth
less invasive methods other than FDPs
requiring circumferential preparation of tooth
substance should be given due consideration.
Patients need to be informed about the
advantages and disadvantages of each thera-
peutic option.
Research recommendations
In studies in the field of implant dentistry,
economic evaluations should include cost-
utility assessments.
To perform such assessments a clinical
study should also include assessments of
costs, time, change in quality of life, and
patient-reported outcomes.
5 years. Clinical Oral implant Research 23(Suppl.
6): 39–49.
Scheuber, S., Hicklin, S. & Brägger, U. (2012)
Implants versus short-span fixed bridges: survival,
complications, patient benefits. A systematic
review on Economic aspects. Clinical oral
implant Research 23(Suppl. 6): 50–62.
Clin. Oral Implants Res. 23(Suppl. 6), 2012/63–65