Radiographic Bone Level Changes of Implant-Supported

Restorations in Edentulous and Partially

Dentate Patients: 5-Year Results
Hadi Gholami, DDS, Dr Med Dent1/Regina Mericske-Stern, Prof Dr Med Dent2/
Gerda Kessler-Liechti, Dr Med Dent3/Joannis Katsoulis, PD Dr Med Dent, MAS4

Purpose: To evaluate and compare crestal bone level changes and peri-implant status of implant-supported
reconstructions in edentulous and partially dentate patients after a minimum of 5 years of loading. Materials
and Methods: All patients who received a self-tapping implant with a microstructured surface during the
years 2003 and 2004 at the Department of Prosthodontics, University of Bern, were included in this study.
The implant restorations comprised fixed and removable prostheses for partially and completely edentulous
patients. Radiographs were taken immediately after surgery, at impression making, and 1 and 5 years after
loading. Crestal bone level (BIC) was measured from the implant shoulder to the first bone contact, and
changes were calculated over time (∆BIC). The associations between pocket depth, bleeding on probing
(BOP), and ∆BIC were assessed. Results: Sixty-one implants were placed in 20 patients (mean age, 62 ± 7
years). At the 5-year follow-up, 19 patients with 58 implants were available. Implant survival was 98.4% (one
early failure; one patient died). The average ∆BIC between surgery and 5-year follow-up was 1.5 ± 0.9 mm
and 1.1 ± 0.6 mm for edentulous and partially dentate patients, respectively. Most bone resorption (50%,
0.7 mm) occurred during the first 3 months (osseointegration) and within the first year of loading (21%, 0.3
mm). Mean annual bone loss during the 5 years of loading was < 0.12 mm. Mean pocket depth was 2.6
± 0.7 mm. Seventeen percent of the implant sites displayed BOP; the frequency was significantly higher
in women. None of the variables were significantly associated with crestal bone loss. Conclusion: Crestal
bone loss after 5 years was within the normal range, without a significant difference between edentulous
and partially dentate patients. In the short term, this implant system can be used successfully for various
prosthetic indications. Int J Oral Maxillofac Implants 2014;29:898–904. doi: 10.11607/jomi.3042

Key words: crestal bone level, edentulous, implant survival, partially dentate

O sseointegrated implants have been used suc-

cessfully to restore function to fully and partially
edentulous patients. Modifications of implant design
on both the macroscopic and microscopic levels have
been implemented to improve implant success rates.
Some clinical advantages have been reported for mod-
erately rough surfaces in comparison with smooth or
1Postdoctoral
Student, Department of Prosthodontics,
School of Dental Medicine, University of Bern, Switzerland.
2Director and Chair, Department of Prosthodontics,
School of Dental Medicine, University of Bern, Switzerland.
3Assistant Professor, Department of Prosthodontics,
School of Dental Medicine, University of Bern, Switzerland.
4 Associate Professor, Department of Prosthodontics,
School of Dental Medicine, University of Bern, Switzerland.
Correspondence to: Dr J. Katsoulis, Department of
Prosthodontics, School of Dental Medicine, University
of Bern, Freiburgstrasse 7, 3010 Bern, Switzerland.
Fax: +41-31-632-49-33. Email: joannis.katsoulis@zmk.unibe.ch
©2014 by Quintessence Publishing Co Inc.
rough surfaces.1 However, very few of the long-term
best-documented oral implants from the major oral
implant companies are still available on the market.2 In
addition, little is known about the impact of the type
of edentulism (partial or complete) on crestal bone
level changes around implants. In 2001, a new implant
system, Thommen (Thommen Medical), was released
to the market. To date, few clinical studies have report-
ed working with this implant system,3,4 although sev-
eral other dental implant systems have been properly
documented for 5 years or more.2 In a pilot study, clini-
cal procedures, prosthetic complications, and required
maintenance after 1 year of loading were shown to
be comparable to other implant systems.3,4 Accord-
ing to the authors, osseointegration of Thommen im-
plants was highly successful in a variety of patients,
and their stability was very good, although some mi-
nor problems were identified with the instruments for
prosthetic procedures. These instruments were subse-
quently improved, modified, or replaced. The system
offers implants with different platforms and a low

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shoulder design that may provide favorable results in
the esthetically demanding anterior maxilla.3 For the
current study, the Element implant (Fig 1a), which has
a cylindric screw design and a short machined neck of
1.0 mm, was selected. This implant type is more often
indicated for completely edentulous mandibles, an-
terior fixed crowns, and short partial dentures, com-
pared with the Contact (Fig 1b) implant, which has a
root-form screw design and a longer machined neck
of 1.5 mm. Furthermore, various abutments, healing
caps, and a sophisticated screwdriver are available,
making clinical application of the system easier. No dif-
ferences in failure rates, complications, or bone levels
were seen after 3 years between implants that were
loaded immediately or early.5 A limited number of
studies are available that have assessed longitudinally
the survival and success rates of implants and various
supporting restorations for 5, 10, or more years. Some
studies were published in the 1990s; most discussed
the Brånemark System (Nobel Biocare) and a few fo-
cused on ITI implants (Straumann).6–11
While some crestal bone loss of 1 to 2 mm in the ini-
tial phase after placement and during the first year of
loading has been observed and described as a normal
effect of the bone-remodeling process after the sur-
gical trauma of implant placement, continuing bone
loss should not occur or should not exceed 0.2 mm
per year.6 A distinction between early and late implant
failures was made and clinical manifestations were dis-
cussed by Esposito et al in 1999 and 2000.12,13 The re-
ported prevalence of peri-implantitis with progressive
crestal bone loss is between 0% and 14.4% in different
populations with various study durations.14
Currently, there is little information available on the
clinical long-term success of this specific implant sys-
tem for different clinical indications. A comparison of
survival and success rates between implants placed in
partially and completely edentulous jaws has not been
performed. Thus, the aim of the present study was to
compare the success rate of the cylindric, medium-
rough-surface Element implant (Thommen Medical)
when used to support removable and fixed dental
prostheses after a minimum of 5 years of functional
loading. The hypothesis was that the crestal bone level
of implants connected to rigid bars and fixed denture
prostheses remains stable, fulfilling the success crite-
ria, without any difference between partially and com-
pletely edentulous patients.
MATERIALS AND METHODS
Patients and Implant-Prosthetic Treatment
During a 1-year period (2003 to 2004), the Thommen
implant system (Thommen Medical) was used in a
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Gholami et al
a b
Figs 1a and 1b   (a) The SPI Element, with short polished collar,
as used in this study; (b) SPI Contact, which features a relatively
longer polished collar neck and a root-form design.
prospective pilot study for the treatment of partially
and completely edentulous patients who had been
referred to the Department of Prosthodontics, Univer-
sity of Bern.3,4 Signed informed consent was obtained
from all patients stating that the patients accepted
the treatment plan (placement and restoration of the
implants) and agreed to cover the related costs and
follow the maintenance program. Each patient was
interviewed, and medical histories were thoroughly
evaluated to ensure their good general health at the
time. Patients were categorized as class I or II accord-
ing to the American Society of Anesthesiologists clas-
sification.15 Adequate bone volume (height and width)
was a prerequisite for placement of implants with a
minimum length of 8 mm and minimum endosseous
width of 3.5 mm. Exclusion criteria for the placement
of implants were drug or alcohol abuse, psychiatric
problems, history of heart attack within the previous 6
months, uncontrolled diabetes or insulin dependence,
immunocompromised status, current chemotherapy
or leukocyte disorders, any health conditions that
would compromise a surgical procedure under local
anesthesia, extraction at an implant site fewer than 6
months before implant placement, and the presence
of irradiated bone, severe parafunctional habits, or
severe atrophy that required bone augmentation be-
fore implantation.16 Light smokers (fewer than 10 cig-
arettes per day) were included in the study but were
asked to participate in a smoking cessation program
prior to implant therapy.
The patients had partially or completely edentulous
jaws, and the prosthetic indications comprised various
reconstructions with fixed and removable prostheses
in the maxilla or mandible. All patients enrolled in
the study underwent the same clinical screening and
pretreatment protocol prior to implant placement.
The International Journal of Oral & Maxillofacial Implants 899
Gholami et al

a b
Figs 2a and 2b   Digital measurements of crestal bone levels in relation to the known implant length for (a) interforaminal implants
in the edentulous mandible and (b) single implants in a partially edentulous maxilla.

Active periodontal therapy consisting of motivation,
instruction in oral hygiene practices, scaling and root
planing, and periodontal surgery was performed until
any periodontal disease had been appropriately con-
trolled (no bleeding on probing [BOP] and no pockets
deeper than 6 mm). Restoration therapy (for any caries
lesions) was also carried out, and complete dentures
were adapted or new provisional prostheses were de-
livered prior to placement of implants.
Patients underwent implant placement surgery
within a 12-month period that ended in 2004. The im-
plants were placed according to the drilling protocol
prescribed by the manufacturer and surgical guides.
A standard healing period of 3 months for the man-
dible and 4 months for the maxilla was maintained.
No provisional prostheses were connected to the im-
plants during this time. The treatment was performed
by different trained clinicians but under the supervi-
sion of the same instructor in the same clinical setting.
Radiographs were obtained immediately after surgery,
at the time of impression taking (loading), and 1 and 5
years after loading of implants with the definitive pros-
theses. Panoramic radiographs were used when im-
plants were placed interforaminally in an edentulous
mandible, while single periapical radiographs were
obtained with film holders for all other indications. The
surgical and prosthetic procedures were identical for
all patients according to standard protocols, and stan-
dard instruments were used.
Follow-up Protocol
Five to 6 years after implant loading, all patients were
recalled for an examination by one trained and cali-
brated investigator who had not been involved in the
treatment. Peri-implant parameters were recorded,
and radiologic crestal bone levels were assessed digi-
tally (DBSWIN 4.5.2, Dürr Dental). Analog radiographs
were digitized with an adequate scanner (HP LaserJet
4000). Vertical changes in the bone level were mea-
sured on the mesial and distal sides of each implant,
with the implant shoulder used as a reference point
(Figs 2a and 2b). First bone-to-implant contact (BIC)
was defined as the distance between the implant
shoulder and the most coronal point of the implant in
contact with the alveolar bone.17 This value was calcu-
lated for each implant in the series of radiographs and
compared between surgery and follow-up appoint-
ments to determine the crestal bone level changes.
The known length and size and typical design of the
implants (distance of screw threads, implant shoul-
der) allowed for accurate reading of BIC by means of
computer software that allowed calibration to adjust
for distortion and magnification. Crestal bone changes
were expressed as ∆BIC for the corresponding inter-
vals and the overall observation time.
When all patients were recalled for the final radio-
graph after 5 years of loading, clinical peri-implant
parameters were recorded, namely pocket depth (PD)
and BOP, using a graded probe (with markings at 3, 6,
9, and 12 mm). PD and BOP were measured at four sites
(mesial, distal, buccal and lingual, in millimeters, for
PD), and the presence or absence of BOP was reported
as percentage of measured sites.
Different criteria to determine implant success have
been proposed by various authors using clinical and
radiologic parameters.18–22 Survival of implants, mean-
ing that the implant is still in function, is presented via
life table analysis in the current study. A distinction
was made between early failures (during the healing
phase) and late failures (after loading with a provision-
al or definitive prosthesis). To clinically assess peri-im-
plant health, various measurement parameters were
defined, usually adopted from periodontology23,24 (eg,
radiographic measurements8,25). The gold standard to

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 Gholami et al

Table 1   Cumulative Implant Survival Rate over 5 Years

No. of failed No. surviving Cumulative
Time interval No. of patients Implants No. of dropouts implants during interval survival rate
Before loading 20 61 0 1 98.4% 98.4%
0 to 1 y 20 60 0 0 100% 98.4%
1 to 2 y 20 60 0 0 100% 98.4%
2 to 3 y 20 60 0 0 100% 98.4%
3 to 4 y 20 60 2 0 100% 98.4%
4 to 5 y 19 58 0 0 100% 98.4%

determine implant success is the measurement of ra- Table 2   Demographic and Implant Information
diologic crestal bone level changes on the mesial and with Respect to Crestal Bone Level
distal sides of the implants. As proposed by Albrekts- Changes (∆BIC)
son et al,18 therefore, a bone loss equal to or less than
No. of No. of ∆BIC (mm)
0.2 mm per year was defined as acceptable. implants implants (mean ± SD)
placed (20 at 5 y (19 (surgery
Statistical Analysis patients) patients)* to 5 y)
All data were subjected to statistical analysis using Dental Edentulous 38 35 1.5 ± 0.9
status
SPSS software (version 18, SPSS). Descriptive statistics
Partially 23 23 1.1 ± 0.6
were used for patient demographics and calculation of
edentulous
∆BIC. The cumulative survival rate was calculated for
Jaw Mandible 26 24 1.5 ± 1.1
all implants placed. Nonparametric testing was per-
Maxilla 35 34 1.3 ± 0.7
formed to compare ∆BIC between groups. The Pearson
Location Anterior 40 38 1.4 ± 0.9
correlation coefficient was used to assess the associa-
Posterior 21 20 1.3 ± 0.9
tion between PD and ∆BIC.
Gender Male 30 28 1.5 ± 0.9
Female 31 30 1.3 ± 0.9
RESULTS Implant   8 mm 5 5 1.2 ± 0.7
length
11 mm 32 31 0.9 ± 0.7
Patients and Implants 14 mm 24 22 1.7 ± 1.0
A total of 20 patients (10 women and 10 men) received
Implant 3.5 mm 26 25 1.5 ± 0.9
a total of 61 placed implants and were enrolled in the diameter
study. The mean age at the time of implant placement 4.2 mm 35 33 1.2 ± 0.8
was 62.1 ± 7.2 years. Only two patients were younger
Total* 61 58* 1.4 ± 0.9
than 50 years. The patients were similar in terms of
*One implant in the posterior maxilla failed during the healing phase,
gender, dental status, and number and distribution and two implants were lost in the anterior mandible after 3 years
of implants. In one woman, one implant failed during (the patient died).
the healing period, resulting in a 98.4% implant suc-
cess rate after the entire observation period (Table 1). Crestal Bone Level Changes
Thus, a total of 60 implants (34 in the maxilla, 26 in The loaded implants (n = 60) exhibited successful os-
the mandible) were loaded and assessed radiographi- seointegration without peri-implant radiolucency dur-
cally from the beginning of the prosthetic treatment. ing the observation period. Table 2 demonstrates an
In all, 16 implant overdentures (1 in the maxilla sup- overview of patients, implants, and mean ∆BIC after
ported by four implants and 15 in the mandible on 5 years. The average ∆BIC in edentulous and partially
33 implants) and 23 single crowns in the anterior and dentate patients between surgery and the 5-year fol-
posterior regions of both arches were delivered to the low-up was 1.5 ± 0.9 mm and 1.1 ± 0.6 mm, respec-
patients. At the 1-year follow-up exam, all 20 patients tively (Mann-Whitney U test, P = .071) (Table 3). The
were available with 60 implants, while at the 5-year fol- bone remodeling process in both partially dentate and
low-up two implants were lost to follow-up since one edentulous patients was most pronounced during the
male patient with an implant-supported mandibular period after surgery (50% of implants) and during the
overdenture had died. Thus, a total of 58 implants in 9 first year of loading (21%). Thereafter, from loading to
men and 10 women completed a minimum of 5 years the 5-year follow-up, the bone level changes showed
of observation. a stable mean annual bone loss of < 0.12 mm (Fig 3).

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Gholami et al

Soft Tissue Parameters

Table 3   Mean Crestal Bone Level Changes
over Time, with Percentages of The average PD was 2.58 ± 0.73 mm at the 5-year
Completed Bone Loss over Time follow-up. Slightly increased PD values were found in
patients who still had their natural teeth. When dental
Surgery– Loading– status and the jaw were considered together as a sin-
loading 1y 1–5 y Total
gle effect, PD was deeper in the maxilla and in jaws still
Edentulous 0.7 mm 0.4 mm 0.4 mm 1.5 mm
(46%) (27%) (27%) (100%)
exhibiting natural teeth (P < .006). Thirty percent of all
implants exhibited one or more sites with positive BOP,
Partially 0.6 mm 0.2 mm 0.3 mm 1.1 mm
edentulous (55%) (18%) (27%) (100%)
ie, 17% of all implant sites, with a higher frequency in
female patients (P = .009). The Pearson correlation co-
Total 0.7 mm 0.3 mm 0.4 mm 1.4 mm
(50%) (21%) (29%) (100%) efficient did not reveal correlations between PD and
∆BIC or between BOP and ∆BIC.

0.0  DISCUSSION
Mean crestal bone level (mm)

–0.5 
–1.0 
The implant survival rate did not reach 100% in this
study, since one implant failed during the healing pe-
–1.5 
Partially edentulous riod and two implants were excluded from the study.
–2.0  However, the survival rate can be considered satisfac-
–2.5  tory, especially taking into consideration the learning
–3.0 
curve with the new implant system. The two implants
Edentulous in the patient who passed away did not show any signs
–3.5  of problems during the initial follow-up appointments.
–4.0  Although it appears that a sandblasted acid-etched
Surgery Loading 1 y 2y 3y 4y 5y implant surface may shorten the healing time and
Fig 3  Crestal bone level changes in edentulous and partially
moderately roughened surfaces display a stronger
edentulous patients. bone response,1 in the present study standard heal-
ing times were used (3 months for the mandible and
4 months for the maxilla). Unlike other previously de-
scribed conical implant systems,26,27 the present im-
Edentulous
>2 mm  plants were not placed at the crestal bone level; rather,
Partially edentulous
the machined 1-mm neck was left out of the bone.
1.5–2 mm  The mean level of supracrestal implant positioning is
shown in Fig 3 (surgery). Furthermore, conical implants
Bone loss

1–1.5 mm  have a longer conical intrabony part. This was not the
0.5–1 mm 
<0.5 mm 
0 5 10
No. of implants
Fig 4   Frequency of measured bone loss in edentulous and par-
tially dentate patients from surgery to the 5-year follow-up.
Five percent of all implant sites in the edentulous pa-
tients and no implants in the partially dentate patients
exhibited crestal bone loss ≥ 2 mm, while > 85% and
94% of implants had < 1.5 mm of bone loss, respec-
tively (Fig 4). In all, six implants showed bone loss
≥ 2 mm after an observation time of 5 years.
case with the cylindric implant used in the present
study. Therefore, the pronounced loss of crestal bone
of up to 3.6 mm was most likely a result of the collar
length.26 Furthermore, this study26 had a mean fol-
15 20 low-up time of 3 years for 19 implants and 5 years for
only two implants, limiting the strength of the results.
However, this increased bone loss was not observed
with the present implant design. Currently, the pres-
ent implant system has been in use for 11 years. The
first generation of these implants, which was used in
the present study, featured a sandblasted, acid-etched,
medium-rough surface.
The time point of measurements is crucial when
comparing crestal bone level changes in different
studies. In many studies, baseline was set as the day
of reentry and loading.20,28–30 In the present study, the
healing period was included in ∆BIC measurements,
which resulted in 46% (edentulous) and 55% (partially
dentate) higher total ∆BIC values in relation to total

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bone loss. There are different ways of reporting crestal
bone loss in clinical studies, but only minor variations
in the measured values have been seen. Standardized
radiographs were not taken annually and the mean an-
nual bone loss, as reported in the studies, is therefore an
extrapolation, calculated over the entire observation
time. If this type of reporting had been applied to the
measurements in the present study, the annual crestal
bone loss would be less than 0.1 mm. One long-term
study reported only 0.05 mm of crestal bone loss per
year for different types of implants in the edentulous
mandible supporting fixed prostheses.28 In another
long-term study on interforaminal ITI implants (Strau-
mann) with plasma-sprayed surfaces, a mean crestal
bone loss of 0.54 mm was found after an average ob-
servation period of 16.5 years31; this translates into
an average of less than 0.1 mm of bone loss per year.
Bone loss around implants in the edentulous maxilla
within a time period of 5 or more years was less than
1 mm with ITI implants in another study; the healing
period was not stated.29 A more recent retrospective
study with three different implant systems reported
> 2 mm crestal bone loss after an observation period
of 4 years.30 That study used Straumann implants with
a sandblasted/acid-etched surface, and no differences
between the three implant systems were observed.
It has been commonly reported that most bone re-
modeling occurs during the healing period and dur-
ing the first year of loading. Factors such as surgical
trauma, occlusal overload, biologic width, the implant-
abutment microgap, implant crest remodeling, and
peri-implantitis are considered the causes of initial
crestal bone loss around implants.32 Petrie and Wil-
liams in 200533 concluded that wide, long, nontapered
implants were more likely to show favorable long-term
results. Another study reported that implant length
failed to affect the implant success rate in patients
who had undergone maxillary sinus augmentation
prior to implant surgery.34 One study of narrow-diam-
eter (3.5-mm) implants failed to show a lower survival
rate.35 The present data with these microstructured
medium-rough implants showed a tendency toward
the best results when the implants had a standard di-
ameter of 4.2 mm and length of 11 mm.
Subtraction radiography may be a highly precise
method to evaluate crestal bone level changes,25 but
clinical studies typically use periapical radiographs,
whether traditional or, more recently, digital. The accu-
racy and reliability of oral radiographic methods have
been studied in human cadavers and in animal mod-
els,28,36 with insignificant overall errors found. In the
present study, film holders were used for radiographs,
except for interforaminal implants in an edentulous
arch, where a high mouth floor often prevented the
use of film holders. Panoramic radiographs of good
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Gholami et al
quality were obtained and measurements were done
using known implant dimensions as landmarks.
Other indices, eg, the modified bleeding index ac-
cording to Mombelli and Lang,23 have been used to
evaluate peri-implant parameters in other studies;
however, BOP and PD are easy to use and provide valid
information. One limitation of the present study was
the very small number of patients/implants and the
heterogeneity of prosthetic indications. Thus, a mul-
tivariable regression analysis of 58 implants (or 116
sites) in 18 patients is questionable.
PD of the implants was not associated with BIC, but
PDs were significantly higher in the maxilla than in the
mandible. This may be explained by the thick palatal
mucosa in the maxilla. ∆BIC values for implants in par-
tially dentate jaws had the tendency to be lower. One
explanation may be that the crestal bone of healthy
teeth contributed to the stability of the crestal bone
at the adjacent implant sites. For single-tooth replace-
ment with ITI implants, crestal bone loss from the time
of crown placement up to 9 years was minimal (around
0.5 mm). All implant sites had healthy adjacent natu-
ral teeth with stable crestal bone. All patients were in
good health, and major systemic problems or medi-
cations that could adversely affect osseointegration
or the stability of the crestal bone were not present.
Conclusions cannot be drawn for the implants that lost
≥ 2 mm of crestal bone, and it should be noted that
these findings are still within the limits of normal varia-
tion. However, the number of implants was small and
patients with different dental status and locations of
implants were included. Therefore, the significance of
these findings should not be overstated. However, the
compliance of the patients involved during the obser-
vation period of 5 to 6 years was excellent. The hypoth-
esis that mean crestal bone remains stable around the
implants was confirmed, since crestal bone changes
remained within the range of known success criteria.
CONCLUSIONS
Within the limitations of the present study, it can be
concluded that peri-implant parameters of the spe-
cific microstructured medium-rough implants were
stable and the bone loss around implants was within
the range designated by implant success criteria over 5
years of functional loading in partially and completely
edentulous patients. Thus, the present implant system
can be considered reliable, effective, and comparable
to other systems in the short term for the rehabilita-
tion of partially or completely edentulous patients.
More studies with more implants and longer observa-
tion periods are needed to provide a higher level of
evidence.
The International Journal of Oral & Maxillofacial Implants 903
Gholami et al
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this
study.
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