Crestal bone loss proximal to oral implants in older and younger adults

S. Ross Bryant, BSc, DDS, MSc, PhD,a and George A. Zarb, BChD, DDS, MS, MSb
University of British Columbia, Vancouver, British Columbia, Canada; University of Toronto,
Toronto, Ontario, Canada

Statement of problem. Older adults often have bone loss and may be at risk of bone resorption around oral
implants.
Purpose. This study tested the hypothesis that there is no difference in crestal bone loss proximal to oral
implants in the complete implant prosthesis sites of older and younger adults.
Material and methods. Two groups of 35 complete dental implant prosthesis sites (23 screw-retained fixed
prostheses and 12 bar-retained overdentures) were selected by matching sites in 32 older adults (60 to 74 years
old with 166 Bränemark implants) to sites in 34 younger adults (29 to 49 years old with 162 Bränemark implants)
on the basis of possible confounding factors including gender, prosthetic design, implant number, arch, year of
surgery, and opposing dentition. Statistical comparisons (Mann-Whitney test at P⬍.05) were made of mean
crestal bone level at loading and mean annual crestal bone loss during the first year, first to fourth year, after first
year, and after fourth year of loading with periapical radiographic measurements of the vertical distance in
millimeters from the apical edge of the implant collar to the most apical initial point of contact between the
implant and bone.
Results. No significant differences were found between the groups. Mean bone levels at loading were 1.4 mm
below the collar in both groups and mean annual crestal bone loss after the first year of loading was 0.04 mm/y
in both groups. However, significant differences were found between some old and young subgroups stratified by
arch and prosthetic design.
Conclusion. Within the limitations of this study, elders should expect no more rapid bone resorption around
oral implants in edentulous jaws than that seen in young adults. (J Prosthet Dent 2003;89:589-97.)

CLINICAL IMPLICATIONS
This study suggests that crestal bone loss around oral implants does not differ with age. Addi-
tional investigations are needed to differentiate clinical factors other than age that may influ-
ence such changes.

S everal publications summarized in a recent review1

attest to the efficacy and effectiveness of implant prosth-
requires a more scientifically tenable long-term investi-
gation over a broader age range.
odontics for elderly patients. The clinical determinants Aging tends to involve a compromise in the potential
of successful treatment outcomes include morbidity-free for both soft-tissue and skeletal healing processes,6,7 in
response and stable crestal bone levels that conform to addition to bone loss that can lead to osteoporosis.8
internationally proposed standards.2 Mean crestal bone Increased age has also long been correlated with alveolar
loss of 0.1 mm per year has been reported for threaded bone loss associated with poor oral hygiene and peri-
titanium Bränemark implants in either jaw of heteroge- odontitis and with tooth loss.9-11 The mean crestal bone
nous population groups after the first year of func- loss around teeth was found to be 0.3 mm/y among
tion.3,4 During the first year of implant loading, a mean those at least 70 years of age at the outset of a 10-year
observation period in comparison to less than half that
of 0.2 to 0.3 mm crestal bone loss has also been ob-
rate for younger cohorts.12 Average vertical residual
served around oral implants in 80- to 90-year-old pa-
ridge resorption exceeded 2 mm during the first year
tients.5 However, a more definitive conclusion about
after the extraction of teeth and insertion of complete
the effect of age on crestal bone loss around implants
dentures, whereas continuing resorption eventually sta-
bilized at 0.05 mm/y in the edentulous maxilla and 0.2
a
mm/y in the edentulous mandible between 10 and 25
Assistant Professor, Division of Prosthodontics, University of British years after extraction.10,11
Columbia.
b
Professor and Head of Prosthodontics, University of Toronto. This report is part of a larger ongoing investigation to
Presented at the 84th Annual Meeting of the Academy of Prosth- document the clinical effectiveness of diverse prosth-
odontics, Portland, Ore., May 2002. odontic applications of the Bränemark implant system

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(Nobel Biocare, Góteborg, Sweden). This study aimed Table I. Older and younger matched complete prosthesis
to test the hypothesis that there is no difference in crestal plans at stage-1
bone loss proximal to oral implants in the complete Maxilla Mandible Total (%)
implant prosthesis sites of older and younger adults. It is
based on outcomes of the complete implant prosthesis Complete fixed 6 17 23 (66%)
sites reported in a companion study that found older Complete overdenture 1 11 12 (34%)
Prostheses planned (%) 7 (20%) 28 (80%) 35
adults should expect cumulative implant success no dif-
ferent from that observed in younger adults.13 This
study compared an older group with a younger group on
the basis of crestal bone levels at prosthesis loading, the dentition). It was not possible to obtain an exact match
amount of crestal bone loss during the first year of load- in several instances for the implant number, year of stage
ing, the mean annual rate of crestal bone loss during the 1 surgery, or status of the opposing dentition. For ex-
period from the first to the fourth year of loading (all ample, a deviation of 1 implant per pair of planned pros-
implants had the potential to have been loaded for at thetic sites was considered an acceptable match, yielding
least 4 years), and the mean annual rate of crestal bone a slightly unequal number of implants per group. Fac-
loss during the periods after the first year and after the tors associated with both the surgical management and
fourth year after loading. the implant material, design and length were kept quite
consistent throughout the IPU study so they were con-
sidered less likely to confound the results. Matching was
MATERIAL AND METHODS
not possible for 7 complete mandibular overdenture
The original target group comprised 53 consecu- prostheses planned in 7 of the older patients, so those
tively treated partial or complete implant prosthesis sites sites and patients were eliminated from the study, leav-
planned in 46 older adults (at least 60 years of age) who ing 35 matched prosthetic sites treated in both groups.
had oral implant placement (stage 1) over a period of The older study group included 35 complete pros-
12.5 years in the Implant Prosthodontic Unit (IPU) of thesis sites with 166 Bränemark implants (Nobel Bio-
the University of Toronto. There were 42 complete im- care) placed in 32 older adults; the younger study group
plant prosthesis sites—23 fixed prostheses and 19 over- included 35 complete prosthesis sites with 162 Bräne-
denture prostheses—planned in 39 of the patients. Pros- mark implants (Nobel Biocare) placed in 34 younger
thesis sites were excluded from implant treatment in the adults. At stage 1 the older group ranged from 60 to 74
IPU if the patient had a systemic health problem that years of age (mean 66 years) by prosthetic site, com-
precluded a minor surgical procedure, a lack of bone pared with a range of 29 to 49 years of age (mean 42
volume to accommodate implants at least 7 mm long years) for the younger group. The matching procedure
and 3.75 mm wide, a history drug abuse or psychosis, or permitted the groups to be identical in terms of gender,
cosmetic expectations that could not be satisfied with a arch, and prosthetic plan. In this regard, 71% of the
pretreatment tooth arrangement or optimized denture. matched plans in both groups involved female patients.
Prosthetic sites in the older group were included in the In both groups, 80% of the matched prosthetic sites
study if the patient had persistent maladaptation to involved the mandible (Table I), and all of the sites
wearing an optimized complete denture in the site and if involved implants placed in the anterior jaw, so-called
the prosthetic plan could be matched to one in a zone I at or anterior to a vertical line through the mental
younger adult. Because age cannot be assigned ran- foramen. Also in both groups, 66% of the matched sites
domly, the possible influence of age on treatment out- were planned for fixed prostheses, usually with 5 or 6
comes could not be investigated by use of a randomized implants placed, and the balance were planned for over-
trial design. Consequently, to help control for potential denture prostheses, usually with 2 or 3 implants placed.
confounding factors, it was intended that each of the The older group had 24 sites opposed by a complete
complete implant prostheses planned for the older pa- denture, whereas the younger group had 23 such sites.
tients would be paired, in the order of stage 1 surgery, In comparison, the older group had 8 sites opposed by
with the first available match to a complete implant pros- natural teeth or fixed prostheses, whereas the younger
thesis planned in younger patients (less than 50 years of group had 5 such sites. The remaining sites in both
age) also treated consecutively in the IPU during the groups were opposed by either tooth- or implant-sup-
same period and otherwise based on the same inclusion ported removable prostheses.
and exclusion criteria. Paired matching of prosthetic The groups also demonstrated similarity related to
sites was attempted on the basis of gender, prosthetic factors not involved in the matching procedure. Over
design (fixed vs overdenture), implant number, arch 75% of the implants in both groups were 10 or 13 mm in
(maxilla vs mandible), year of stage 1 surgery, and status length, while less than 2% in both groups were under 10
of the opposing dentition (complete denture vs remov- mm. Using the classification system proposed by Lek-
able partial or overdenture vs fixed prosthesis or natural holm and Zarb14 (with the A to E jawbone quantity

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Fig. 1. Selected radiographs from typical series with crestal bone loss of 0.05 mm per year.

scale assigned ordinal values of 1 to 5 respectively), the to a standardized prosthodontic protocol stage 2 was
prosthetic sites in both groups demonstrated a mean followed by a brief healing period typically of 2 to 4
preoperative LZ jawbone quality of 2.5, and a mean weeks before initiating prosthodontic procedures to fab-
preoperative LZ jawbone quantity of about 2.8. ricate the final prosthesis. At insertion, the prosthesis
Chronic smoking behavior reported by the patients was refined to meet esthetic and functional require-
was associated with slightly less than 15 percent of the ments, the screws were tightened to appropriate levels,
sites in both groups. Not surprisingly, the typical sys- normally 20 Ncm for abutment screws and 10 Ncm for
temic health of the patients in the 2 groups differed prosthetic screws, and routine oral hygiene and fol-
substantially, with better health and fewer medications low-up instructions were provided. For the fixed im-
prevailing among the younger group. It is acknowl- plant prostheses, standardized screw-retained transmu-
edged that these and myriad other factors are likely to cosal abutments were used to attach a screw-retained
influence implant outcomes. However, the stated pur- rigid metal substructure on which acrylic resin teeth
pose of the current study was to examine the potential were processed. For the overdenture prostheses, stan-
influence of age on crestal bone loss rates proximal to dardized screw-retained transmucosal abutments were
oral implants because an apparent gap in related litera- used to attach a screw-retained Resilient Dolder bar
ture has been a deficiency in examining the age factor. (Swiss NF. Metals, Don Mills, Ontario, Canada) that
Consequently, the potential influence of the various permitted stabilization of the denture via a metal clip in
other factors will be reported in separate multivariate the denture base.
analyses involving the larger IPU database. Follow-up examinations, scheduled annually, in-
According to a standardized surgical protocol3 cluded standardized2 clinical and radiographic assess-
stage-1 involved the gentle preparation of host bone ment of original implants with the prostheses removed.
sites and insertion of Bränemark implants guided by a Cumulative survival rate (CSR) curves were developed
surgical template. After a 2-week period, the denture for both patient groups on the basis of the probability of
had a soft-liner placed and the patient was permitted its implant success at the midpoint of each yearly interval.
use. The implants were uncovered surgically (stage 2) The grouped CSR curves were examined for statistically
after an average healing period of 4 to 6 months, fol- significant differences, at the P⬍.05 level, over the ob-
lowed by prosthetic loading an average period of 10 servation period by use of the life-table survival function
months (5 to 25 months) after stage 1, and at least 4 of SPSS software (SPSS Inc., Chicago, Ill.) on a personal
years before the final date for data collection. According computer. Specifically, a Wilcoxon statistic was applied,

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crotek Scanmaker 35T, Microtek Lab Inc., Redondo

Beach, Calif.) and the resultant images were processed,
stored, and measured using the public domain software
NIH Image (U.S. National Institutes of Health, Be-
thesda, Md; available online from the NIH Image web-
site) on a personal computer. The set scale function
(NIH Image) was used to calibrate the vertical scale of
the image with the known distance across 6 threads (5 ⫻
0.6 mm ⫽ 3.0 mm) on the basis of the known Bräne-
mark implant thread pitch of 0.6 mm (⫾0.005 mm).
Crestal bone levels at the mesial and distal sites of
each image were assessed visually by one observer (R.B.)
with the linear measurement tool function of the NIH
Image software to measure the vertical distance in mil-
limeters from the apical edge of the implant collar to the
most apical initial point of contact observed between the
implant and bone (Fig. 2). This method has been shown
to be both valid and reliable.17 During the measurement
process, the observer was blinded to the patient identi-
fication data, the implant location, and the chronology
of radiographic series. Measurements were not made for
proximal sites where the observer could not identify ei-
ther the apical edge of the implant collar or the furthest
apical initial point of contact observed between the im-
plant and bone. The measurements were repeated a
minimum of 2 weeks later by the same observer, and the
final bone level for each proximal site (mesial and distal)
and time point, was calculated as the mean of each pair
Fig. 2. Computer-assisted measurement of crestal bone loss
of repeated measurements. The mean of variances (error
proximal to oral implant.
variance) and the differences between first and second
measurements were also calculated in addition to the
mean and standard deviation of the differences. It was
because it was developed for testing the homogeneity of arbitrarily decided that the reliability of a specific pair of
survival curves involving censored data with variable fol- repeated measurements would be considered suspect if
low-up periods as was necessary in this study because of their difference fell outside 1.96 standard deviations
staggered entry of prosthetic sites into the study, vari- from 0. In these instances, a third blinded measurement
able losses to follow-up expected because of death and was made and differences were calculated between this
migration, and ultimately because most of the implants measurement and the first 2. If the absolute value of
did not fail.15 both new differences still exceeded 0.56 mm, outside
A series of standardized periapical radiographs were 1.96 standard deviations from 0, the final bone level at
collected and digitized during the follow-up period for that time point was deemed unreliable and was excluded
each original implant retained in function (Fig. 1). A from further calculations. Otherwise the smallest of the
special holder attached to the implant abutment was new differences was assumed to originate from the most
designed to control imaging geometry by aligning the reliable pair of measurements, and the mean of that pair
film 100 mm from the x-ray cone, parallel to the long was calculated to replace the final bone level for that
axis of the implant and perpendicular to the x-ray time point.
beam.4,16 Size-2 radiographic film (Kodak Ultraspeed; For each proximal site, crestal bone loss outcomes for
Eastman Kodak, Rochester, NY) was used in combina- each annual period after loading were calculated by sub-
tion with an intraoral x-ray machine equipped with a tracting the bone level at the start of the year from the
long cone (Penwalt, Intrex Model 2426, 120 Volt, bone level at the end of the year. Descriptive cumulative
500/60 Hz, 12.5 Amps; SS White, Toronto, Canada) bone loss graphs for the groups were developed from
set at 70 kVp and 10mA for 0.28 seconds. Films were these data by plotting the cumulative sum of the mean
developed with appropriate fresh chemical solutions in crestal bone loss over time in the prosthetic sites from
an automatic processor (Siemens DENT-X 9000; Sie- each annual period after loading. The mean annual cr-
mens, Mississauga, Canada). The region of interest of estal bone loss during the period from the first to the
each radiograph was digitized with a slide scanner (Mi- fourth year of loading was calculated for each proximal

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site as the slope of a linear regression equation based on Table II. Number of observations available for bone level
all bone level data from the first to the fourth year after and loss calculations
loading by using the slope function of Excel software Number of prosthetic sites
(Microsoft Corporation, Redmond, Wash.) on a per- Older and younger groups
(stratified by arch & 0 to 1 1 to 4 1 to 17 4 to 17
sonal computer. It was considered missing if the obser- prosthesis) At load years years years years
vations included only 2 consecutive years. The mean
annual rate of crestal bone loss after the first year and Patient level
after the fourth year of loading were calculated for each Old 28 16 18 22 12
proximal site as the slope of a linear regression equation Young 31 24 25 29 25
Prosthetic site level
based on all bone level data from the first year on and
Old 31 17 19 23 12
from the fourth year on, respectively. They were consid-
Young 32 25 25 30 26
ered missing if the observations included only 2 consec- Mandible
utive years, or if they did not include data from at least 1 Old 24 14 16 20 12
time point from the fifth or subsequent years after load- Young 25 21 23 26 24
ing. Maxilla
For each prosthetic site, the crestal bone level at load- Old 7 3 3 3 0
ing and the various crestal bone loss outcomes were Young 7 4 2 4 2
calculated as the mean of all proximal site outcomes Mandible
derived for the prosthetic site. The unit of analysis for Old fixed 16 10 10 13 7
this study was the prosthetic site so the outcomes were Young fixed 14 11 13 15 13
Old overdenture 8 4 6 7 5
calculated as the mean of the prosthetic site outcomes
Young overdenture 11 10 10 11 11
for the older and younger groups. Four of the partici-
Maxilla
pants had both maxillary and mandibular prosthesis sites Old fixed 6 2 3 3 0
included in the study, implying that all of the prosthetic Young fixed 6 3 2 3 1
sites were not necessarily independent of each other. Old overdenture 1 1 0 0 0
Consequently, the group means were recalculated and Young overdenture 1 1 0 1 1
compared at the patient level of analysis. Furthermore,
the group mean values were also stratified on the basis of
arch (maxilla vs mandible) and original prosthetic plan compared with 149 plus 2 replacement implants in the
(fixed vs overdenture). That is, both maxillary and man- younger group. Follow-up examinations occurred over
dibular mean values were calculated and compared and an average of 8 and 11 years for the older and younger
then recalculated for the older fixed, older overdenture, groups, respectively. At the latest follow-up, between 4
younger fixed, and younger overdenture prosthesis sub- and 17 years had passed since prosthetic loading, and
groups. 50% of the prosthetic sites had been followed up for at
Comparison of the crestal bone level and loss out- least 10 years since loading. After loading 3 original
comes between the older and younger groups and sub- implants failed and were removed among the older
groups was made using the nonparametric Mann-Whit- group, compared with 10 additional failures in the
ney test function of SPSS software (SPSS Inc., Chicago, younger group. Those sites continuing to be followed
Ill.) at the P⬍.05 level. Not only were there usually less up included 29 prostheses supported by 132 original
than 25 results in each of the groups and subgroups implants in 27 older patients and 30 prostheses sup-
compared in this study, but also the bone level and loss ported by 122 original and 4 replacement implants in 29
outcomes were not anticipated to be normally distrib- younger patients. In total, patient death or migration
uted because data outliers would clearly favor bone loss resulted in 5 prosthetic sites, with 18 original implants
rather than bone gain. Consequently, a nonparametric being lost to follow-up in the older group compared
test was selected because it is more robust for circum- with 3 prosthetic sites with 13 original implants lost to
stances such as these in which the strict assumption of a follow-up in the younger group. In addition, 4 original
normal distribution is not available.15 implants in each group were lost to follow-up during the
study because of being left unconnected to the prosthe-
sis (“put to sleep”) because their position precluded
RESULTS prosthetic use. Prosthetic sites and implants lost to fol-
Before prosthetic loading, the older group had 9 low-up were censored from further calculations. Im-
original implants that failed, presenting with clinical mo- plants placed to compensate for failures were not in-
bility often accompanied by a radiolucent space at the cluded in the calculation of CSR or bone level or loss
implant bone interface, compared with 13 failures for outcomes. The CSR of the original implants was 92.6%
the younger group. At prosthesis placement, the older for the older group and 85.6% for the younger group,
group had 155 original implants loaded prosthetically, and no statistical significance (P⬍.05) could be attrib-

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Table III. Mean crestal bone level and annual loss in millimeters for older and younger groups

Older and younger groups Mean level Mean loss Loss 1 to

(stratified by arch & at load 0 to 1 Loss 1 to 4 17 years Loss 4 to 17
prosthesis) (SE) years (SE) years (SE) (SE) years (SE)

Patient level
Old 1.4 (.07) 0.15 (.05) 0.04 (.01) 0.04 (.01) 0.02 (.02)
Young 1.4 (.08) 0.24 (.09) 0.06 (.03) 0.04 (.01) 0.02 (.01)
Prosthetic site level
Old 1.4 (.06) 0.17 (.06) 0.04 (.01) 0.04 (.01) 0.02 (.02)
Young 1.4 (.09) 0.24 (.08) 0.06 (.03) 0.04 (.01) 0.02 (.01)
Mandible
Old 1.4 (.08) 0.11 (.05) 0.03 (.01) 0.04 (.02) 0.02 (.02)
Young 1.2 (.06) 0.17 (.08) 0.07 (.03) 0.04 (.02) 0.02 (.01)
Maxilla
Old 1.5 (.09) 0.41 (.15) 0.05 (.02) 0.10 (.04) n
Young 1.9 (.27) 0.56 (.31) ⫺0.09 (.01) 0.03 (.03) n
Mandible
Old fixed 1.4 (.10) 0.17 (.07) 0.05 (.02) 0.03 (.02) 0.005 (.006)*
Young fixed 1.2 (.10) 0.31 (.13) 0.08 (.04) 0.06 (.02) 0.05 (.02)*
Old overdenture 1.3 (.13) ⫺0.02 (.04) 0.01 (.01) 0.04 (.02) 0.05 (.05)
Young overdenture 1.2 (.07) 0.02 (.04) 0.06 (.04) 0.01 (.01) ⫺0.02 (.01)
Maxilla
Old fixed 1.5 (.10)* 0.25 (.07) 0.05 (.02) 0.10 (.04) n
Young fixed 2.1 (.26)* 0.65 (.43) ⫺0.09 (.01) 0.03 (.05) n
Old overdenture n n n n n
Young overdenture n n n n n
*Significant difference (P ⬍ .05) between groups using Mann-Whitney test statistic.
n, Inadequate number of observations for statistical testing.

Fig. 3. Cumulative mean annual bone loss for older and Fig. 4. Cumulative bone loss for older and younger mandib-
younger groups. Ld, Loading. No significant difference ular prostheses. Ld, Loading; Significant difference (P⬍.05)
(P⬍.05) between groups. between fixed groups after fourth year.

uted to the difference between survival curves. More same technique.17 The difference between measure-
detailed reporting of the implant failures was published ments ranged from ⫺1.83 mm to 2.14 mm, with a mean
previously.13 of 0.08 mm and a standard deviation of 0.29 mm. Of the
A total of 3652 bone level measurements were made repeated measurements, 234 (6.4%) were considered
and repeated. The error variance for the repeated mea- suspect because the absolute value of their differences
surements was 0.044 mm2, with an associated error were greater than 0.56 mm— outside 1.96 standard de-
standard deviation (the square root of the error vari- viations from 0. On 2 occasions the absolute value of the
ance) of 0.21 mm reflecting a measurement reliability new differences related to the third measurement still
comparable to that reported previously by use of the exceeded 0.56 mm, so the final bone level at those time

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points were excluded from further calculations. The

3650 final bone levels ranged from 0.59 mm to 6.25
mm, with a mean of 1.62 mm and a standard deviation
of 0.84 mm.

Crestal bone level at loading

At loading, the older group had crestal bone level
observations for 31 prosthetic sites in 28 patients with
140 original implants, compared to the younger group
with 32 prosthetic sites in 31 patients with 133 original
implants (Table II). At loading, the mean crestal bone
level among prosthetic sites was identical at 1.4 mm
below the collar in both groups (Table III), and statis-
tical significance (P⬍.05) could not be attributed to any Fig. 5. Cumulative bone loss for older and younger maxillary
small difference in the mean values. The only significant prostheses. * Excludes maxillary overdenture prosthesis groups
difference in crestal bone level at loading observed at the due to limited number of observations. Ld, Loading; No signif-
various other levels of analysis was that the younger icant difference (P⬍.05) between groups.
maxillary fixed prosthesis sites had a significantly lower
mean bone level at loading, 2.1 mm below the implant
collar, compared to 1.5 mm below the implant collar during these periods, nor to any other differences be-
among the matched older maxillary fixed prosthesis sites tween the groups and subgroups at the various levels of
(P⬍.05) (Table III). The maxillary overdenture sites analysis for these periods.
had an insufficient number of observations for statistical For the period after the fourth year of loading, the
comparison. mean annual crestal bone loss observed at the level of
both the prosthetic sites and the patients was 0.02
Crestal bone loss outcomes mm/y in both groups (Table III), and statistical signif-
During the first year of loading, the older group had icance (P⬍.05) could not be attributed to any small
mean annual crestal bone loss observations for 17 pros- difference in the mean values. However, the mean rates
thetic sites in 16 patients with 73 original implants com- for this period were about half as much as the rates
pared with the younger group with 25 prosthetic sites in reported for earlier periods including the overall mean
24 patients with 95 original implants (Table II). After after the first year of loading. Although beyond the
the fourth year of loading, the observations for the older scope of the hypothesis for this study, this observation
group had decreased to 12 prosthetic sites in 12 patients tempts the suggestion that the pace of crestal bone loss
with 49 original implants, compared with the younger may continue to decrease even after the first year of
group with 26 prosthetic sites in 25 patients with 102 loading. With the results stratified on the basis of arch
original implants (Table II). The mean crestal bone loss and prosthetic design, the only statistically significant
observed among the prosthetic sites during the first year difference (P⬍.05) found between the groups and sub-
was 0.2 mm in both groups (Table III), and statistical groups was that the older fixed mandibular prosthesis
significance (P⬍.05) could not be attributed to any group demonstrated a mean annual crestal bone loss rate
small difference in the means. Likewise, no significant of only 0.005 mm/y—approaching 0, compared with
differences in crestal bone loss were observed between 0.05 mm/y among the younger fixed mandibular pros-
old and young groups and subgroups at the various thesis group. This finding appears to reinforce the ob-
levels of analysis during the first year, excepting again the servation of a tendency for modest progressive crestal
older and younger maxillary overdenture sites because bone loss to persist relatively unabated among the
of an insufficient number of observations (Table III). younger fixed prosthesis group in the mandible, com-
The mean annual crestal bone loss observed among pared with a stabilization of crestal bone loss among the
the prosthetic sites during the first to the fourth year of older fixed prosthesis group in the mandible (Fig. 4).
loading was 0.04 mm per year in the older group, com- Regrettably, inadequate data numbers precluded a sim-
pared with a slightly greater mean of 0.06 mm per year ilar comparison of maxillary outcomes (Fig. 5).
in the younger group (Table III). In contrast, the overall
DISCUSSION
mean annual crestal bone loss observed among the pros-
thetic sites for the period after the first year of loading As in other parts of the skeleton, human jaws dem-
was 0.04 mm per year in both groups (Table 3, Fig. 3). onstrate specific predilections for progressive time-de-
Again, statistical significance (P⬍.05) could not be at- pendent bone loss, including variation in bone resorp-
tributed to any small differences between the groups tion patterns between maxillary and mandibular sites. It

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has therefore been important to document the tendency hypothesis is consistent with the finding of no significant
for bone resorption around oral implants ever since it difference in the rate of crestal bone loss observed be-
was proposed that bone-anchored prostheses could be tween the older and younger mandibular overdenture
sustained in the oral environment for a lifetime.18 The sites after the fourth year of loading because the 2 over-
determinants of clinical oral implant success include im- denture groups did not differ significantly (Mann-Whit-
mobility of individual implants, minimal crestal bone ney test at P⬍.05) in their number of years of edentu-
loss and no persistent morbidity.2 It is worth noting that lism. Consequently, the findings suggest that rates of
this original proposed low rate of bone loss of less than crestal bone loss around dental implants may be more
0.2 mm/y may be too liberal for young implant patients closely related to the number of years of preoperative
who could then be projected to lose up to 8 mm of bone edentulism than to the observed quantitative pattern of
over the ensuing 40 years. At any rate, on the basis of preoperative resorption. Combined with the observa-
these criteria, the oral implants in this study were equally tion that rates of crestal bone loss may decrease over
successful in older and younger adults. The mean annual time, a further hypothesis is offered that the proposed
rate of crestal bone loss during and after the first year of slightly elevated tendency for bone loss around implants
loading was statistically indistinguishable between the placed early in the edentulous experience may very well
groups settling at a rate less than 0.05 mm/y in both become attenuated with time. These observations de-
groups. This supports the original hypothesis and im- serve further investigation.
plies that, despite the average tendency for a slight Finally, the findings of this study reinforce the au-
amount of ongoing crestal bone loss proximal to oral thors’ previous conclusion13 that a treatment outcome
implants, both older and younger adults should antici- of morbidity free and stable periimplant bone levels en-
pate many years of implant prosthesis function in the sures 3 important convictions: (1) that age alone should
context of bone behavior patterns. not be used to exclude patients from being prescribed
Notwithstanding this general statement, it is impor- oral implants, (2) that osseointegrated implants can be
tant to examine the slightly higher rate of crestal bone maintained as patients age, and (3) that oral implant
loss, 0.05 mm/y, among the younger fixed mandibular biotechnology appears to lend itself equally well to di-
prosthesis subgroup after the fourth year of loading, verse prosthodontic applications in both younger and
compared with 0.005 mm/y among the older fixed older adults. In this it must be acknowledged that the
mandibular prosthesis group. Although there is little limitations of the study include an inability to generalize
short-term clinical significance in this difference, modest the results to partially edentulous adults, particularly
progressive bone loss could eventually become a prob-
those with implants placed in the posterior jaw where
lem for some younger adults. One hypothesis offered to
bone behavior may differ. The study also suffered from a
explain the apparent tendency for stabilization of crestal
limitation in the numbers of maxillary prosthesis sites,
bone level in the older group rather than in the younger
particularly maxillary overdenture sites, suggesting an
group is that the older group may have had a longer
additional limitation in the ability to generalize the con-
preoperative period of edentulism associated with
clusions related to crestal bone behavior in older adults.
greater preoperative resorption compared to the
As in previous studies on crestal bone behavior related to
younger group, thereby decreasing the opportunity for
oral implants, the results of this study apply to bone loss
additional bone resorption. Tallgren11 found that in-
rates proximal to Bränemark oral implants rather than
creased periods of edentulism were associated with a
necessarily to bone loss rates circumferentially surround-
predictable time-dependent decrease in the rate of sub-
ing the implants. Furthermore, the bone behavior doc-
sequent residual ridge resorption. Although indirectly
umented in this study was purely the vertical rate of
related to age, a difference in the number of years of
edentulism was indeed found between the subgroups. crestal bone loss, whereas it is acknowledged that crestal
The 7 older fixed mandibular sites involved in the com- bone behavior patterns around dental implants do ap-
parison had been edentulous for 25.0 years at stage-one pear to vary in the rate and extent of both vertical and
and had a mean LZ jawbone quantity of 3.4, whereas the horizontal resorption yielding in some instances a ten-
13 younger fixed mandibular sites had been edentulous dency for vertical defects or so-called saucerization of
for only 13.6 years at stage-one and had a mean LZ the crestal bone. These several aspects deserve further
jawbone quantity of 3.0. No significant difference was investigation.
found between these subgroups by comparing the mean
LZ jawbone quantity patterns. However, the mean
CONCLUSION
number of years of preoperative edentulism was signifi-
cantly different between the 2 groups, consistent with Within the limitations of this study, elderly patients
the hypothetical possibility that slightly slower crestal should expect highly comparable oral implant success,
bone loss may be anticipated proximal to oral implants including slow rates of crestal bone loss, to what occurs
placed later in the edentulous period. Furthermore, this in younger patients.

596 VOLUME 89 NUMBER 6

BRYANT AND ZARB THE JOURNAL OF PROSTHETIC DENTISTRY

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Comparing the efficacy of mandibular implant-retained

Noteworthy Abstracts overdentures and conventional dentures among middle-
of the aged edentulous patients: Satisfaction and functional
Current Literature assessment.
Manal A. Awad, James P. Lund, Eric Dufresne, and Jocelyne S.
Feine Int J Prosthodont 2003;16:117-122.

Purpose. The aim of this randomized clinical trial was to compare the relative efficacy of mandib-
ular overdentures retained by only two implants and a bar attachment with conventional dentures.
Materials and Methods. Edentulous adults, aged 35 to 65 years, were randomly assigned to two
groups that received either a mandibular conventional denture (n ⫽ 48) or an overdenture sup-
ported by two endosseous implants with a connecting bar (n ⫽ 54). All subjects rated their general
satisfaction and other features of their original dentures and their new prostheses (comfort, stability,
ability to chew, speech, esthetics, and cleaning ability) on 100-mm visual analogue scales prior to
treatment and 2 months postdelivery. Oral health-related quality of life was also evaluated pre- and
posttreatment.
Results. Multiple regression analysis revealed that the mean general satisfaction was significantly
higher in the overdenture group than in the conventional denture group (P⫽.0001). Age, gender,
marital status, and income were not significantly associated with ratings of general satisfaction.
Furthermore, the implant group gave significantly higher ratings on three additional measures of
the prostheses (comfort, stability, and ease of chewing; P⬍.05).
Conclusion. A mandibular two-implant overdenture opposed by a maxillary conventional denture
is a more satisfactory treatment than conventional dentures for edentulous middle-aged adults.—
Reprinted with permission of Quintessence Publishing

JUNE 2003 597