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10-Year Survival and Success Rates of 511 Titanium Implants with a

Sandblasted and Acid-Etched Surface: A Retrospective Study in 303 Partially
Edentulous Patients

Article  in  Clinical Implant Dentistry and Related Research · March 2012

DOI: 10.1111/j.1708-8208.2012.00456.x · Source: PubMed

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10-Year Survival and Success Rates of 511 Titanium
Implants with a Sandblasted and Acid-Etched
Surface: A Retrospective Study in 303 Partially
Edentulous Patients cid_456 839..851

Daniel Buser, DMD;* Simone F. M. Janner, DMD;† Julia-Gabriela Wittneben, DMD, MMSc;‡
Urs Brägger, DMD;§ Christoph A. Ramseier, DMD;¶ Giovanni E. Salvi, DMD**

ABSTRACT
Purpose: This retrospective study assessed the 10-year outcomes of titanium implants with a sandblasted and acid-etched
(SLA) surface in a large cohort of partially edentulous patients.
Materials and Methods: Records of patients treated with SLA implants between May 1997 and January 2001 were screened.
Eligible patients were contacted and invited to undergo a clinical and radiologic examination. Each implant was classified
according to strict success criteria.
Results: Three hundred three patients with 511 SLA implants were available for the examination. The mean age of the
patients at implant surgery was 48 years. Over the 10-year period, no implant fracture was noted, whereas six implants
(1.2%) were lost. Two implants (0.4%) showed signs of suppuration at the 10-year examination, whereas seven implants
had a history of peri-implantitis (1.4%) during the 10-year period, but presented with healthy peri-implant soft tissues at
examination. The remaining 496 implants fulfilled the success criteria. The mean Plaque Index was 0.65 (10.64), the mean
Sulcus Bleeding Index 1.32 (10.57), the mean Probing Depth 3.27 mm (11.06), and the mean distance from the implant
shoulder to the mucosal margin value -0.42 mm (11.27). The radiologic mean distance from the implant shoulder to the
first bone-to-implant contact was 3.32 mm (10.73).
Conclusion: The present retrospective analysis resulted in a 10-year implant survival rate of 98.8% and a success rate of
97.0%. In addition, the prevalence of peri-implantitis in this large cohort of orally healthy patients was low with 1.8%
during the 10-year period.
KEY WORDS: dental implant, implant success rate, implant surface, implant survival rate, peri-implantitis, SLA surface

*Professor and chairman, Department of Oral Surgery and Stomatol-
ogy, School of Dental Medicine, University of Bern, Bern, Switzerland;
†
senior lecturer, Department of Oral Surgery and Stomatology, School
of Dental Medicine, University of Bern, Bern, Switzerland; ‡senior
lecturer, Division of Fixed Prosthodontics, School of Dental Medicine,
University of Bern, Bern, Switzerland; §associate professor and head,
Division of Fixed Prosthodontics, School of Dental Medicine, Univer-
sity of Bern, Bern, Switzerland; ¶senior lecturer, Department of Peri-
odontology, School of Dental Medicine, University of Bern, Bern,
Switzerland; **associate professor, Department of Periodontology,
School of Dental Medicine, University of Bern, Bern, Switzerland
Reprint requests: Prof. Dr. Daniel Buser, Department of Oral Surgery
and Stomatology, Freiburgstrasse 7, CH-3010 Bern, Switzerland;
e-mail: daniel.buser@zmk.unibe.ch
© 2012 Wiley Periodicals, Inc.
DOI 10.1111/j.1708-8208.2012.00456.x
INTRODUCTION
Implant therapy, today a widely accepted treatment
modality in dental medicine, was initiated more than 40
years ago by two research teams in Europe. Both groups
tested titanium implants and reported bone anchorage
with direct bone-to-implant contact,1,2 today referred to
as osseointegration. During the development phase of
this new treatment approach in the 1970s and 1980s, two
implant surfaces dominated the market – a machined,
rather smooth surface, and a coated, titanium plasma-
sprayed surface (TPS), which was rather rough and
microporous. For both implant surfaces, satisfactory
survival and success rates were reported in up to 15 years
of follow-up.3–12 Depending on the duration of the
follow-up period, the survival rates ranged from 90 to
95% in most studies.

839
840 Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012
In the 1990s, preclinical research started to focus
on surface characteristics of titanium implants. Several
experimental studies in various animal models tested
moderately rough or micro-rough titanium surfaces,
which were produced with different techniques, such as
sand- or gritblasting, acid-etching, or a combination of
both. These preclinical studies clearly demonstrated
faster and improved bone apposition and higher
removal torque values during early wound healing of up
to 6 months.13–21
These modern, moderately rough titanium surfaces
were subsequently tested in numerous clinical studies.
These studies, most of them midterm studies with a
5-year follow-up, demonstrated promising results, with
clearly improved outcomes compared with the two origi-
nal implant surfaces.22–34 The reported 5-year outcomes
yielded implant survival rates of greater than 95%.
One of these modern implant surfaces is the sand-
blasted and acid-etched (SLA) surface, which today is
scientifically well documented, based on numerous pre-
clinical,13,15,16,18 and clinical studies with up to 5 years of
follow-up.24,27,28,32,35 Based on the fact that long-term
results (i.e., 310-year outcomes) of dental implants with
a micro-rough surface are still scarce, the aim of the
present retrospective study was to assess the 10-year sur-
vival and success rates of titanium implants with an SLA
surface in a large cohort of partially edentulous patients.
MATERIALS AND METHODS
Study Sample
The records of all patients were checked, who were sur-
gically treated with implants between May 1997 and
January 2001 at the Department of Oral Surgery or at the
Department of Periodontology and Fixed Prosthodon-
tics, School of Dental Medicine, University of Bern. Only
partially edentulous patients who received at least one
tissue-level implant with an SLA surface (Straumann
Dental Implant System, Straumann, Basel, Switzerland)
were eligible to be included in the study. These patients
were then contacted and invited to participate in a clini-
cal investigation. All patients gave written informed
consent after being informed in detail about the objec-
tives of the study. The study was conducted according to
principles stated in the Helsinki Declaration.
Implant surgeries followed surgical principles
which had been followed at the University of Bern since
the mid 1990s.36 The implants were inserted in the
correct prosthetic position with good primary stability.
The border between the smooth and the micro-rough
SLA surfaces was positioned slightly subcrestally.
Clinical and Radiographic Examination
At the 10-year follow-up, information such as medical
conditions, medications, smoking history, self-reported
biological and technical complications, and enrollment
in a maintenance care program was collected by means
of a questionnaire. In addition, all implant restorations
were photographed. Subsequently, an orthopanto-
mogram was taken for a radiological overview, and a
periapical radiograph was taken of each implant that
fulfilled the inclusion criteria.
The following clinical and radiographic parameters
were assessed:
• Presence or absence of peri-implant suppuration
and/or fistula
• Modified Plaque Index (mPLI) at six sites around the
implant37
• Modified Sulcus Bleeding Index (mSBI) at six sites
around the implant37
• Probing Depth (PD), measured with a periodontal
probe to the nearest millimeter at six sites around
the implant38
• DIM value. The Distance from the Implant shoulder
to the mucosal Margin (DIM) was measured with a
periodontal probe to the nearest millimeter at six
sites around the implant38
• DIB value. Periapical radiographs were taken by an
experienced examiner using the long cone tech-
nique to assess the Distance from the Implant
shoulder to the first Bone-to-implant contact (DIB)
on the mesial and distal aspects by an experienced
examiner (S.J.). For each implant, one DIB value
was calculated as the average of the mesial and distal
values obtained.39
Implant Classification
Based on clinical and radiographic criteria used since
1990 in studies reporting the outcomes of dental im-
plants (Table 1),38 each implant was classified as success-
ful, surviving, or failed (Table 2) by a periodontist (G.S.).
Data Analysis
Mean values 1 standard deviations, ranges, and fre-
quency distributions are presented.

TABLE 1 Criteria of Success38
Absence of persistent subjective complaints such as pain,
foreign body sensation and/or dysesthesia
Absence of a peri-implant infection with suppuration
Absence of mobility
Absence of a continuous radiolucency around the implant
Descriptive statistics were generated using a statis-
tical analysis software package (SAS/STAT® User’s
Guide, Version 9.2, 2009, SAS Institute Inc., Cary, NC,
USA).
RESULTS
The records of 358 patients fulfilling the inclusion cri-
teria were identified. Of those, 55 patients (15.4%) were
not available for a clinical examination for various
reasons (Table 3). Three hundred three patients agreed
to participate in the study: 160 female patients (52.8%)
and 143 male patients (47.2%). They had a mean age of
48 years at implant surgery. If a patient had had several
implant surgeries, the age at the first surgery was used.
The largest age group were the baby boomers: 70% of
patients were 40 years or older (Figure 1). In contrast,
only 15.8% of the patients were younger than 30 years at
the time of surgery.
The 511 implants were inserted in three different
indications for partial edentulism, which are listed in
Table 4. There were 170 single-tooth gaps, the most fre-
quently represented indication, 139 distal extension
situations, and 43 extended edentulous spaces.
The 511 screw-type implants inserted included
three different screw diameters (3.3 mm, 4.1 mm, and
4.8 mm) and three different platform or neck dimen-
sions (3.5 mm, 4.8 mm, and 6.5 mm; Table 5). Most
often, a standard screw with a 4.1 mm diameter was
inserted (54.6%), followed by wide-body, wide-neck,
and, rarely, narrow-neck implants. 438 implants
TABLE 2 Classification of Each Implant
Clinical Status
Removed, lost, mobile or fractured implant
Implant with a history of an acute infection with suppuration and progressive bone loss
Implant with an acute infection with suppuration and progressive bone loss
Implant fulfilling the success criteria
10-Year Survival and Success Rates of SLA Implants 841
TABLE 3 Fifty-Five Patients Were Not Available to
Attend the Examination
• 1 patient was pregnant
• 6 patients had passed away during the 10-year period
• 6 patients could not be located any more
• 9 patients could not come due to severe illness (dementia
or other diseases)
• 16 patients had moved away or lived in foreign countries
• 17 patients did not want to come for an examination for
various reasons
(85.8%) had a standard neck height of 2.8 mm with a
machined surface. Seventy-three implants (14.2%) had
a shorter, machined neck of 1.8 mm, mainly in esthetic
sites in the anterior maxilla. Concerning implant length,
10 mm and 12 mm implants were used in 81% of
implant sites; 14 mm and 6 mm implants were rarely
used (Table 6).
Concerning implant locations (Table 7), the first
molar site in the mandible was the most frequent loca-
tion (133 implants), followed by the second premolar
sites in the mandible (65 implants), and the first premo-
lar sites in the maxilla (61 implants). Consequently, 267
implants were located in the posterior mandible, fol-
lowed by 151 implants in the posterior maxilla, and
85 implants in anterior maxilla (Table 8). Only eight
implants were located in the anterior mandible.
Three hundred fifty-eight implant sites (70%) had
sufficient bone volume, allowing a standard implant
placement without a bone grafting procedure (Table 9).
Ninety implant sites (17.6%) had an insufficient crest
width, requiring a guided bone regeneration procedure,
either with a simultaneous or staged approach. Sixty-
three sites (12.4%) in the posterior maxilla had insuffi-
cient bone height, requiring a sinus floor elevation
(SFE) procedure, either with a simultaneous or staged
approach. For a simultaneous SFE, both the lateral
Classification
Implant failure
Surviving implant
Surviving implant
Successful implant
842 Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012

Figure 1 Age distribution of 303 patients at time of surgery.

window and the transcrestal osteotome surgical tech-
niques were utilized.
Four hundred fifty-five implants (89%) were placed
in the Department of Oral Surgery, and 56 (11%) in the
Department of Periodontology and Fixed Prosthodon-
tics. Implant surgeries were carried out by 26 different
clinicians. Three hundred fifty-seven implants (70%),
however, were placed by one surgeon (D.B.).
Overall 10-Year Success and Survival Rates
During the 10-year period, 6 of the 511 implants were
lost or had to be removed. None of them had fractured.
Consequently, these six implants were classified as fail-
ures (1.2%). The remaining 505 implants were exam-
ined and classified according to the criteria described by
Buser and colleagues.38 The clinical examination did not
reveal a fistula in any of the implants. Two implants
(0.4%) showed an acute peri-implant infection with
suppuration in the peri-implant sulcus. One of the
affected patients was a heavy smoker with a recurrent
infection at one implant and severe bone loss (Figure 2,
A and B). These two implants were classified as
surviving implants with peri-implantitis. In addition,
seven implants had a history of acute peri-implant
infection with suppuration and associated progressive
bone loss. Among those was a patient with two implants
with peri-implantitis which manifested 9 months fol-
lowing implant placement (Figure 3A). The cause of
that biological complication was excess cement follow-
ing delivery of the restoration, requiring a surgical revi-
sion with an apical repositioning of the flap following
debridement (Figure 3B). At the 10-year examination,
the peri-implant mucosa was healthy around both
implants and the periapical radiograph showed a stable
but reduced bone level (Figure 3, C and D). All seven
implants with a history of peri-implantitis were free of
infection at the 10-year follow-up examination, but
clearly showed progressive bone loss, with increased DIB
values. These seven implants (1.4%) were classified
as surviving implants. The remaining 496 implants
(97.0%) met the success criteria and hence were
classified as successful implants.
Based on this classification (Table 10), this retro-
spective analysis with 303 partially edentulous patients

TABLE 4 Various Indications for Implant Therapy in 303 Patients

Indications Jaw Indications % Implants %

Single tooth gaps max 100 48.3 100 33.3

mand 70 70
Distal extension situations max 46 39.5 94 49.9
mand 93 161
Extended edentulous spaces max 24 12.2 44 16.8
mand 19 42
Total 352 100 511 100
 10-Year Survival and Success Rates of SLA Implants 843

TABLE 5 Different Implant Types Examined in This TABLE 8 Distribution of Implant in Posterior and
Study Anterior Sites
Implant Type n % Location n % Subtotal %

Standard screw (S 4.1 RN) 279 54.6 Anterior maxilla 85 16.6 93 18.2
Wide body screw (S 4.8, RN) 143 28.0 Anterior mandible 8 1.6
Wide neck screw (S 4.8, WN) 73 14.3 Posterior maxilla 151 29.5 418 81.8
Narrow neck screw (NN 3.3) 16 3.1 Posterior mandible 267 52.3
Total 511 100.0 Total 511 100 511 100

RN, Regular Neck (4.8 mm); WN, Wide Neck (6.5 mm); NN, Narrow
Neck (3.5 mm).

meaning that the implant shoulder was visible due to

mucosal recession.
demonstrated a 10-year implant survival rate of 98.8%
Radiographic Parameters
and a 10-year implant success rate of 97.0%.
The radiographic DIB analysis showed a mean value of
Clinical Parameters 3.32 1 0.73 mm (range 1.2–7.2 mm; Table 11). The fre-
quency analysis (Figure 5) yielded 250 implants (49.5%)
Clinical examination of the 505 implants revealed a with DIB values between 2.51 mm and 3.50 mm, reflect-
mean mPLI of 0.65 1 0.47 and a mean mSBI of ing no or minimal bone loss during the 10-year period
1.32 1 0.37 (Table 11). The mean PD value was (Figure 6). 57 implants (11.3%) had DIB values of less
3.27 1 0.79 mm (range 1–9 mm; Figure 4A). The DIM than 2.5 mm, indicating no bone loss or even bone gain
values demonstrated a mean value of 0.42 1 1.04 mm, during the 10-year period (Figure 7). On the other hand,
indicating a slightly submucosal position of the implant 176 implants (34.9%) had DIB values between 3.51 and
shoulder. The distribution plot (Figure 4B) showed 4.5 mm, which indicate moderate bone loss during the
that roughly 35% of the implants had a positive DIM, 10-year period (Figure 8). Finally, 22 implants (4.4%)
yielded DIB values 3 4.51 mm, corresponding to pro-
gressive bone loss, including the implants with peri-
implant infections (Figures 2A and 3A). In the latter two
subgroups, some implants showed a narrow radiolucent
TABLE 6 Different Implant Lengths
gap along the implant surface in the crestal area
Implant Length n %
(Figure 9).
6 mm 12 2.3
8 mm 83 16.3 DISCUSSION
10 mm 238 46.7
The objective of the present retrospective study was to
12 mm 175 34.3
assess the 10-year survival and success rates of titanium
14 mm 2 0.4
dental implants with an SLA surface in a large cohort
Total 511 100.0
of partially edentulous patients. The study yielded an

TABLE 7 Distribution of Implant Locations

Number of Implants Placed Per Location n %

No. of implants 1 16 27 28 13 9 19 15 7 22 33 29 17 0 236 46.2

Implant locations* 17 16 15 14 13 12 11 21 22 23 24 25 26 27 n = 511 100
47 46 45 44 43 42 41 31 32 33 34 35 36 37
No. of implants 16 71 29 20 2 1 1 0 2 2 17 36 62 16 275 53.8

*Locations according to WHO classification.

844 Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012

implant survival rate of 98.8% and an implant success

TABLE 9 Types of Implant Surgery
rate of 97.0% after at least 10 years of function.
Type of Surgery n %
The present study included the assessment of 303
Standard placement without a bone grafting 358 70.0 partially edentulous patients who received SLA implants
procedure in two departments of the School of Dental Medicine,
Implant placement with a simultaneous 53 10.4 University of Bern, over a period of 31/2 years in the late
GBR procedure 1990s. During the first 18 months of the study period
Implant placement following ridge 37 7.2
(1997/1998), only partially edentulous patients with
augmentation with GBR
posterior sites of sufficient bone volume were treated
Implant placement following a SFE 30 5.9
with the new implant surface through enrolment in a
(window technique)
Implant placement and simultaneous SFE 25 4.9
prospective study on early loading after 6–8 weeks of
(osteotome technique) healing.24,40 This initial group included 104 implants. By
Implant placement and simultaneous SFE 8 1.6 the end of 1998, this new implant surface was available
(window technique) for all indications and to all surgeons practicing in
Total 511 100 both departments. Therefore, the percentage of standard
implant placement without bone grafting in 70% of the
GBR, Guided Bone Regeneration; SFE, Sinus Floor Elevation.
sites was higher than in a later report on a different
patient pool treated between 2002 and 2004, in which

(A) (B)

(C) (D)

Figure 2 A, The radiograph 9 months post-implant placement (3/2000) shows a peri-implant radiolucency around implant 24 and
on the mesial aspect of implant 25. Excess cement is visible, which caused an acute peri-implant infection with suppuration requiring
a surgical revision with a debridement. B, The radiograph 2 years following surgical revision (2002) shows progressive bone loss, but
a well-corticalized bone crest. The Distance from the Implant shoulder to the first Bone-to-implant contact (DIB) values measure
>5 mm. C, The clinical status at the 10-year examination shows healthy peri-implant soft tissues, but an advanced recession of the
mucosa at both implants with a history of peri-implantitis. D, The 10-year radiograph demonstrates stable peri-implant bone at a
reduced level. The DIB values measure >5 mm. Both implants were classified as surviving implants.
 10-Year Survival and Success Rates of SLA Implants 845

(A) (B)

Figure 3 A, Clinical status at the 10-year examination in a female with heavy smoking. The implant in area 47 without keratinized
mucosa shows increased probing depths and suppuration in the sulcus. The implant in area 45 with keratinized mucosa has no
pathological findings. B, The 10-year radiograph shows progressive bone loss around the distal implant in area 47 with a Distance
from the Implant shoulder to the first Bone-to-implant contact (DIB) value >7 mm. Implant 45 also shows a moderate crestal bone
loss with a DIB value of around 4.4 mm.

roughly 50% of the implants were placed without bone
grafting.41
This retrospective study clearly demonstrated that
implant therapy is primarily applied in partially eden-
tulous patients today at the University of Bern, since
more than 90% of patients presented with partial eden-
tulism.41 Based on this observation, the present study
was limited to indications of partially edentulous
patients. The single-tooth gap situation, with almost
50%, was the most frequent indication for implant
placement in the present study, and more than 80% of
the implants were located in areas with high functional
load (e.g., premolar and molar sites). Most frequently,
the standard screw implant with a 4.1 mm screw diam-
eter and with an endosseous length of 10 or 12 mm was
utilized. In summary, it can be concluded that the
study patient pool included a routine group of partially
edentulous patients, typical for a university-based
competence center in implant surgery in the late 1990s.
Most of the patients were referred for implant surgery,
and the implant restorations were carried out by the
referring dentists in their private offices.
This retrospective study with 511 titanium SLA
implants demonstrated a 10-year implant survival rate
of 98.8% and a 10-year implant success rate of 97.0%.
All implants had a minimum of 10 years of function,
and some of them had been in place for up to 12 years.
Thus, the calculated rates are true 10-year survival and
success rates, and not estimated cumulative rates, as have
often been used in the past. In comparison with previ-
ously published long-term studies of implants with the
same shape but a coated, microporous TPS surface,5,7,42
this study shows better clinical outcomes at 10 years for
the modern, moderately rough SLA surface.
The cumulative survival rates of tissue-level
implants with the TPS surface in various studies were

TABLE 11 Clinical and Radiologic Parameters at the

TABLE 10 Classification of 511 Implants 10-Year Examination

Classification n % Parameter Min Max Mean SD

Implant failures 6 1.2 mPLI 0 3 0.65 0.64

Surviving implants: peri-implantitis at 2 0.4 mSBI 0 2 1.32 0.57
examination PD (in mm) 1 9 3.27 1.06
Surviving implants: history of peri-implantitis 7 1.4 DIM (in mm) -5 4 -0.42 1.27
Successful implants 496 97.0 DIB (in mm) 1.17 7.20 3.32 0.73
Total 511 100.0 mPLI, Modified Plaque Index; mSBI, Modified Sulcus Bleeding Index; PD,
10-year implant success rate 97.0 Probing Depth; DIM, Distance from the Implant shoulder to the mucosal
10-year implant survival rate 98.8 Margin; DIB; Distance from the Implant shoulder to the first Bone-to-
implant contact.
846 Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012

(A)

(B)

Figure 4 A, Distribution of probing depth values of 505 implants (in %). B, Distribution of distance from the implant shoulder to
the mucosal margin values of 505 implants (in %).

95.3% at 5 years,42 96.8% at 8 years,5 and 96.2% at 10
years.7 It should be noted that the latter study included
hollow-type implants with the TPS surface. In that
group, five fractures of hollow-cylinder or hollow-screw
implants were observed in a total of 20 implant failures.
The risk of implant fracture was also noted in a 6-year
study with a fracture rate of 2.7% with these hollow-
body implants.9 The 6-year survival rate was 95.2% in
this study. As a consequence, both implant types were
taken off the market by the manufacturer in the late
1990s. In the present study, not one single fracture was
observed, since only solid-screw tissue-level implants of
various shapes and diameters were utilized – predomi-
nantly standard diameter (S 4.1) or wide diameter
(S 4.8) implants.
The present study reveals that favorable 5-year
results in previous reports with SLA implants24,27,28,32,35,40
could be maintained over a 10-year period. The 5-year

Figure 5 Frequency distribution of distance from the implant shoulder to the first bone-to-implant contact values of 505 implants.

Figure 6 Typical radiographic status at two tissue-level implants
with minimal bone loss after 10 years of function. The peri-
implant bone crest levels are stable around both implants. The
distance from the implant shoulder to the first bone-to-implant
contact values measure 2.8 mm for implant 46, and 3.4 mm for
implant 47.
survival rates in all these studies were above 98%. In the
present study, the 10-year implant survival rate was
98.8%. At the follow-up examination, only two implants
showed acute peri-implant infection with suppuration
and progressive bone loss. In addition, seven implants
had a history of an acute peri-implant infection during
the 10-year period, requiring an anti-infective therapy.
In one patient with two implants, this infection was
associated with excess cement, requiring a surgical revi-
sion with the removal of the cement remnants.43 All
seven implants with infections could be successfully
treated, since they presented with healthy peri-implant
Figure 7 10-year radiograph of an implant in area 35 with
excellent bone integration and a distance from the implant
shoulder to the first bone-to-implant contact value <2 mm.
10-Year Survival and Success Rates of SLA Implants 847
Figure 8 The 10-year radiograph shows a moderate bone loss
at implant 13. The peri-implant crestal bone is well corticalized.
The distance from the implant shoulder to the first bone-to-
implant contact values measured 4.2 mm for implant 13, and
3.6 mm for implant 14. Implant in area 16 has a titanium
plasma-sprayed surface.
soft tissues, but there were increased DIB values at the
10-year examination, indicating progressive bone loss.
These nine implants, representing 1.8% of all implants,
were classified as surviving but non-successful. This
corresponds to a low prevalence of peri-implantitis,
and confirms the results of other 5- and 10-year studies
with the SLA surface.24,32,35,44 In addition, long-term out-
comes of implants with a turned surface placed in
periodontally healthy patients showed a prevalence of
5% peri-implantitis with progressive bone loss after 16
to 22 years of follow-up.45 The low prevalence of peri-
implantitis in the present study is in contrast with other
Figure 9 The two implants show both moderate to progressive
bone loss with narrow radiolucent gaps in the crestal area. The
distance from the implant shoulder to the first bone-to-implant
contact values are around 4.2 mm (46) and 5.0 mm (45). Both
implants never had signs of a peri-implant infection with
suppuration during the 10-year period.
848 Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012
reports, in which higher frequencies of peri-implantitis
were reported.46–48 The main reason for this significant
difference in prevalence is most likely the different defi-
nitions used for the diagnosis of peri-implantitis in
these studies. In the present study, peri-implantitis was
defined as a peri-implant infection with suppuration in
the presence of progressive bone loss.
There is currently major debate over whether an
increased PD of 36 mm and bleeding on probing (BoP)
alone can be used as indicators of peri-implantitis.
This must be questioned, since a PD of 6 mm is quite
common in approximal aspects of implants in the
esthetic zone.45 This is supported by the results on the
dimensional changes of peri-implant soft tissues around
single-unit crowns on implants in the anterior maxilla
over 2 years.49 Although the mesial and distal DIM were
beyond the physiologic PD (i.e., 2–6 mm), these values
remained stable over time and were associated with
healthy peri-implant soft tissue conditions.49
In the present study, the mSBI was assessed to
examine the health status of the peri-implant mucosa.
The mean mSBI of 1.3 indicates an overall healthy peri-
implant mucosa. Most frequently, an mSBI of 1 was
found, corresponding to a bleeding spot upon probing
in the peri-implant sulcus.37 A mSBI of 2 was much less
frequently found, and a mSBI of 3 in only 0.15% of the
sites. In the absence of suppuration and progressive
bone loss, this condition is considered as peri-implant
mucositis. The findings in the present study suggest that
peri-implant mucositis does not necessarily progress to
peri-implantitis over time. Thus, the assessment of PD
and BoP alone are unsuitable for the diagnosis of peri-
implantitis. The combination of peri-implant suppura-
tion and progressive bone loss is mandatory for this
diagnosis.
For the long-term success of implants, stable peri-
implant bone crest levels are considered important.
Thus, periapical radiographs have been routinely
used to measure peri-implant bone levels.50 For non-
submerged tissue-level implants with the implant
shoulder located clearly supracrestally, the DIB value,
measuring the distance between the implant shoulder
and the first radiographic bone-to-implant contact,38,39
was established in the early 1990s. For non-submerged
tissue-level implants with a 2.8 mm machined neck, the
initial DIB values post surgery measure roughly 2.5 mm,
since it is recommended that the border between
the machined and SLA surface be located slightly
subcrestally.36 In esthetic sites, implants with a short,
1.8 mm machined neck are inserted slightly deeper into
the tissue to allow submerged healing.51 Hence, the
initial DIB values post surgery measure about 1.5 mm or
less.
In the present study, roughly 20% of the implants
had a short neck design, mainly in the esthetic zone. The
mean DIB value was 3.32 mm at the 10-year examina-
tion, which is comparable with previous long-term
studies with tissue-level implants. In a prospective,
5-year study with SLA implants in posterior sites with
non-submerged healing, the mean DIB was 2.79 mm.24
Tissue-level implants with the TPS surface demon-
strated a mean DIB value of 3.10 mm at 8 years.7
However, mean DIB values alone are not meaningful;
more important is the frequency analysis of DIB values,
to identify the percentage of implants with progressive
bone loss.
Due to the retrospective nature of the present study,
baseline radiographs of good quality were not available
for every implant. Thus, the amount of bone loss could
only be estimated. With the above-mentioned initial
DIB values post surgery in mind, only DIB values greater
than 4.5 mm were considered as progressive bone loss in
the current study. This would represent a bone loss of
more than 0.2 mm per year, which has often been used
in the literature as a success factor.50 The frequency
analysis demonstrated only 22 implants with a DIB
value 34.51 mm. Of those, nine implants had either a
history of peri-implantitis or current peri-implantitis
with suppuration at the 10-year examination. The
remaining 13 implants had an increased DIB value
without any signs of a peri-implant infection during the
10-year period. The typical radiographic observations
were narrow radiolucencies along the implant surface in
the crestal area, extending 1–2 mm below the crest level.
This confirms that progressive bone loss is not always
caused by peri-implantitis. There may be other reasons
for crestal bone loss, such as excessive functional load or
combined factors.52 It is unclear to what extent crestal
bone loss with different defect characteristics can be
associated with a chronic infection combined with func-
tional adaptation, leading to a catabolic effect.
In conclusion, this retrospective 10-year study with
511 implants with an SLA surface in 303 partially eden-
tulous patients demonstrated high 10-year survival and
success rates. The low prevalence of patients with peri-
odontitis and heavy smokers, as well as the good level of

compliance with maintenance care, may, at least in part,
explain the low frequency of biological implant compli-
cations in the present study. Susceptibility to periodon-
titis,53,54 cigarette smoking55 and lack of compliance with
supportive periodontal therapy56 have been shown to be
risk factors associated with increased implant loss and
prevalence of peri-implantitis. Moreover, these excellent
10-year results were favored by the fact that the percent-
age of standard implant placement without bone graft-
ing in sites with sufficient bone volume was higher than
in daily practice today. In addition, the positive long-
term outcomes may also have benefited from the fact
that roughly 70% of the implants were placed by a
single, experienced implant surgeon.
This publication presents only the patient pool and
the overall survival and success rates at 10 years of
follow-up. The data of this retrospective analysis will
serve as a baseline for a second examination at 15 years.
Additional publications will present a more detailed
analysis of numerous questions of interest, such as the
rate of biologic complications analyzed according to
various risk factors, the rate of technical complications,
the analysis of microbiological samples taken in the
peri-implant sulcus and at adjacent teeth, and a detailed
analysis of the radiographs in relation to implant type,
implant location, and type of surgical placement.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the statistical exper-
tise of Mr. Walter B. Bürgin, Biomed. Ing. The compe-
tent assistance of Mrs. Olivia Schrag, Claudia Moser,
Yvonne Rohner, Laura Krummen, and Monika Fuhrer is
highly appreciated. We also thank Mrs. Jeannie Wurz for
the language editing of the manuscript. The study was
supported by departmental funds of the University of
Bern, and by a research grant from the ITI Foundation
for the Promotion of Implant Dentistry (ITI Grant Nr.
637–2009).
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