Ingemar Abrahamsson Tord Berglundh

Effects of different implant surfaces and designs on marginal bone-level alterations: a review

Authors afliations: Ingemar Abrahamsson, Tord Berglundh, Department of Periodontology, The Sahlgrenska Academy, University of Gothenburg, Go teborg, Sweden Correspondence to: Ingemar Abrahamsson Department of Periodontology The Sahlgrenska Academy University of Gothenburg Box 450 S-405 30 Go teborg Sweden Tel.: 46 31 786 3585 Fax: 46 31 786 3791 e-mail: ingemar.abrahamsson@odontologi.gu.se
Conicts of interest: The authors have declared no conicts of interest.

Key words: ankylos, bone level, bone loss, dental implants, implant design, implant geometry, implant surface, machined, micro-thread, OsseoSpeed, Osseotite, platformswitch, SLA, TiOblast, TiUnite and turned Abstract Objective: The purpose of this review was to evaluate the effect of different implant surfaces and designs on marginal bone-level (MBL) alterations. Material and methods: A MEDLINE search (PubMed) was performed to identify clinical, prospective and controlled studies using a sufcient sample size (410 subjects) and with a follow-up time of !3 years. Results: Ten publications fullled the inclusion criteria. Two studies evaluated the inuence of implant surface characteristics and two studies reported on the effect of implant design on MBL changes. Six publications analyzed the combined effect of different implant surfaces and designs on MBL alterations. As revealed from available studies, there is no evidence that modied surfaces are superior to non-modied implant surfaces in marginal bone preservation. One study reported on signicantly improved MBL preservation for implants with a conical and micro-threaded marginal collar than implants with a cylindrical and non-threaded marginal portion after 3 years in function. No implant system was found to be superior in marginal bone preservation.

Date: Accepted 20 May 2009

To cite this article: Abrahamsson I, Berglundh T. Effects of different implant surfaces and designs on marginal bone-level alterations: a systematic review. Clin. Oral Impl. Res. 20 (Suppl. 4), 2009; 207215. doi: 10.1111/j.1600-0501.2009.01783.x

Marginal bone-level (MBL) alterations around implants are a frequently used outcome variable in longitudinal studies evaluating implant therapy. Absence of signs of marginal bone loss in radiographs indicates maintained integration between the implant device and the surrounding tissues. The nding of marginal bone loss, however, should be interpreted in relation to the function time for the implant. Thus, the bone remodeling that occurs early after implant installation should be distinguished from the marginal bone loss that may be detected around implants during function. Although the question on the causes of marginal bone loss around implants in function remains to be unraveled, the traditional concept of load as a reason

for bone loss has to be addressed in relation to bone loss as a result of onset and progression of peri-implant disease. In this context, it is relevant to examine the possible inuence of specic implant characteristics on marginal bone preservation. For the purpose of this review on the effect of different implant surfaces and designs on MBL alterations, the type of studies to be selected for data extraction is critical. Longitudinal cohort studies represent the most common clinical study design in implant dentistry. Information from such studies may be useful in descriptive research on implant therapy using e.g. implant loss and other biological complications as outcome variables. In the attempt to analyze the potential inuence of different surface

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modications or certain designs of dental implants, however, a study design using adequate controls is required. In addition, the types of implants to be compared should have been placed using a randomization protocol and, in the case of an intra-individual study design, the possible inuence of implant position and subject variance is eliminated. When using a two-sample study design, however, the subjects in the group to receive test devices must exhibit similar characteristics regarding the distribution of age, gender, systemic health, smokers, socioeconomic status and recipient sites for implants as those in a control group. It is obvious that retrospective studies suffer from the risk of bias in the selection of subjects and the control of subject-related factors as presented above may be insufcient. The desired type of studies for the specic question in the current review should therefore be prospective and controlled. Another prerequisite for the evaluation process of the current review is the followup period. As pointed out above, bone remodeling that can be related to a healing process after implant installation should, in this case, be disregarded. Thus, results from clinical and experimental studies revealed that most pronounced bone-level changes were identied after the surgical trauma elicited during implant installation and abutment connection, while after the connection of prosthesis, i.e. start of functional load, only minor signs of bone loss
Table 1. Implant surface characteristics
Authors Type of study Time for follow-up (yrs)

strand et al. 2004b; Berglundh occurred (A et al. 2005). The study inclusion criteria in the present review therefore also included a follow-up period of at least 3 years. Thus, studies considered to be eligible for this review were clinical prospective, controlled studies using a subject sample of a sufcient size and with a follow-up time of !3 years. Given the prerequisites, the purpose of this review was to evaluate the effect of different implant surfaces and designs on MBL alterations.

sufcient sample size (410 subjects) and with a follow-up time of !3 years. Studies that were excluded from the analyses were reports that lacked (i) a prospective study design, (ii) appropriate controls, (iii) results from MBL alterations assessed in radiographs, (iv) data from follow-up of !3 years and (v) sufcient sample size (number of subjects).

Results
The search resulted in a list of 69 publications and following screening of abstracts the number was reduced to 39. A full-text analysis that was performed to identify potentially relevant publications that fullled the inclusion criteria resulted in 10 publications, which are presented in Tables 13. The studies that were not included after the full-text analyses and the reasons for exclusion are outlined in Table 4. The main reasons for exclusion of publications were: (i) function-time o3 years, (ii) insufcient controls, (iii) retrospective study design and (iv) absence of data or incomplete data presentation regarding MBL changes. The study target of the included prospective studies varied regarding factors that potentially inuenced the outcome variable MBL change. Thus, two studies reported data on implants that differed with respect to surface characteristics and two studies reported on the inuence of

Material and methods

Search strategy

A MEDLINE search (PubMed) was performed for articles published in English until November 2008. The following search terms were used in different combinations: dental implants, bone level, TiUnite, TiOblast, Osseotite, OsseoSpeed, SLA, micro-thread, Ankylos, Machined, Turned, implant design, implant surface, implant geometry and platformswitch. In addition, publications related to the retrieved articles and relevant review publications were screened for studies that were not identied in the electronic search. Titles and abstracts were screened for information on the type of study, follow-up time, sample size and evaluation methods. Thus, studies included in the analyses were clinical, prospective and controlled using a

No. of subjects/ implants 50/133 Astra Tech implants Turned vs. TiOblast surface FPD 51/149 Tioblast Turned FPD Periodontitissusceptible patients

Study target

Findings

Gotfredsen & Karlsson (2001)

m Wennstro et al. (2004)

5 Prospective, randomized, controlled (intra-individual), multicenter (6 centers) 5 Prospective, randomized, intra-individual controls

Comparing two different surface types Marginal bone levels on intra-oral radiographs

Drop-outs: 5 subjects (5 yrs) MBL change (TiOblast/Turned) BL-2 yrs: 0.22/0.26 mm (NS) BL-5 yrs: 0.52/0.22 mm (NS)

Comparing two different surface types Marginal bone level change assessed on intra-oral radiographs (implant & subject level)

Drop-outs: 4 subjects (5 yrs) Failure rate (5 yrs): 5.9% and 2.7% (subject and implant level) MBL change: TiOblast/Turned BL-1 yr: 0.33/0.29 mm (NS) BL-2 yrs: 0.28/0.22 mm BL-3 yrs: 0.4/0.27 mm BL-4 yrs: 0.46/0.32 mm BL-5 yrs: 0.48/0.33 mm (NS) 46% and 41% of Turned and TiOblast implants exhibited no bone loss at 5 yrs

FPD, xed partial dentures; MBL, marginal bone level; yrs, years.

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Abrahamsson & Berglundh Effects of implant surfaces and designs on MBL alterations

Table 2. Implant design

Authors Type of study Time for follow-up (yrs) 3 No. of subjects/ implants 85/277 self-tapping (Turned) 104/337/ICE (Turned) Study target Findings

Davarpanah et al. (2001)

Multicenter prospective (4 centers)

Comparing two different implant designs Exposed threads on intra-oral radiographs

Lee et al. (2007) Prospective, randomized, intra-individual controls

Astra implants with TiOblast surface 17 subjects each receiving: 1 single tooth implant (conical with microthreads) 1 TiOblast (TB) implant (cylindrical)

Drop-out: 5 subjects/12 implants (8 ST/4 ICE) MBL (# threads) (ST/ICE): 01 (1.8 mm): 218/275 (91.6%/89.6%) 12 (2.4 mm): 11/14 (4.6%/4.6%) 23 (3 mm): 5/11 (2.1%/3.6%) 34 (3.6 mm): 4/7 (1.7%/2.2%) No baseline data reported Descriptive statistics only Comparing two different Drop-outs: 0 MBL change: single tooth/TB/P-value implant designs BL-1 yr: 0.14/0.28/0.002 Marginal bone level on BL-2 yrs: 0.21/0.48/0.001 intra-oral radiographs BL-3 yrs: 0.24/0.51/0.001

ICE, incremental cutting edges; MBL, marginal bone level; ST, self-tapping; yrs, years.

implant design. In the remaining six publications, the combined effect of different implant surface and design on MBL change was analyzed.
Implant surface characteristics (Table 1)

Gotfredsen & Karlsson (2001) reported on MBL changes between baseline (BL) and 5 years on Astra Tech (Astra Tech AB, Mo lndal, Sweden) Implants in 50 partially edentulous subjects who received xed partial dentures (FPDs). Implants with a TiOblast or a turned surface were placed alternately in each patient, with the rst implant type chosen at random. Five subjects did not show up at the 5-year follow-up visit. The MBL change between baseline (BL delivery of the prosthetic construction) and 2 years was 0.22 mm for the TiOblast implants and 0.26 mm for the turned implants. The corresponding change between BL and 5 years was 0.52 and 0.22 mm, respectively. The difference in MBL between implants with a TiOblast surface and a turned surface at 5 years was not statistically signicant. A similar study design with intra-individual controls was used by Wennstro m et al. (2004). They reported on MBL alterations between BL and 5 years at Astra Tech implants with either a TiOblast surface or a turned surface in 51 subjects. Four of the subjects were lost to follow-up at 5 years. The MBL change between BL and 1 year was 0.33 mm for the TiOblast surface implants and 0.29 mm for the implants with a
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turned surface. After 3 and 5 years of function, the MBL change had increased to 0.4 and 0.48 mm at the TiOblast sites and to 0.27 and 0.33 mm at the turned surface sites. The different MBL change between the two surface types at 5 years was not statistically signicant. It was reported that 41% of the TiOblast implants and 46% of the turned implants exhibited no MBL alteration between BL and the 5-year examination.
Implant design (Table 2)

Two publications evaluated the effect of implant design on MBL alterations. In a multicenter, prospective study, the original self-tapping (ST) Biomet 3i implant was compared with a modied self-cutting implant, i.e. the incremental cutting edges (ICE) implant (Davarpanah et al. 2001). Eighty-ve partially edentulous subjects received 277 ST implants while 337 ICE implants were placed in 104 subjects. Five subjects were lost to follow-up at 3 years. While no MBL change data from BL were reported, the number of implant threads coronal to the MBL were counted on intraoral radiographs representing 3 years. After 3 years in function, the MBL at implants available for analysis was found between the reference point and the rst thread (0 1.8 mm) in 91.6% of the ST implants and 89.6% of the ICE implants. In 4.6% of both implant types, the MBL was located between the rst and the second thread (1.82.4 mm).

The MBL at the remaining implants (3.8% and 5.8% of the ST and ICE implants, respectively) was found between the second and the fourth thread (2.43.6 mm). No statistical analysis was reported. Lee et al. (2007), in a study with intraindividual controls, evaluated bone-level changes at implants with a similar type of surface (TiOblast) but with different designs. One of the implant types had a conical and micro-threaded marginal collar (ST), while the second type was designed with an unthreaded cylindrical collar (TB). Each of the 17 subjects was treated with one two-unit FPD supported by two implants (one implant of each type). The sequence of implant types was randomized. The MBL change between BL and 1 year and between BL and 2 years was 0.14 and 0.21 mm for the ST and 0.28 and 0.48 mm for TB implants. At the 3-year examination, the MBL change from BL amounted to 0.24 mm at ST implants and 0.51 mm at TB implants. The different outcome in MBL change between the two implant designs was statistically different for all three time periods evaluated. The MBL change during the third year in function was, however, only 0.03 mm for both implant types.
Combination of design (Table 3) implant surface and

Meijer et al. (2004) reported 5-year results from a prospective study on 90 subjects who received removable overdentures
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Table 3. Combination of implant surface and design

Authors Type of study Time for No. of subjects/ follow-up implants (yrs) 3 5 66 patients 184 Astra Tech implants (Tioblast) nemark 187 Bra implants (Turned) FCP Study target Findings

Engquist et al. Prospective, randomized, (2002) strand et al. controlled A (2004a)

Heijdenrijk et al. (2006)

Prospective, randomized, controlled

Meijer et al. 2004

Prospective Randomized controlled

Ozkan et al. (2007)

Prospective Controlled Not randomized

3 (full cohorts)

strand et al. A (2004b)

Prospective, randomized, controlled, split-mouth Multi-center (ve centers)

Drop-outs: 3 subjects 1 subject: 1 yr loss of bridge 2 subjects: 35 yrs deceased nemark) MBL change (Astra Tech/Bra BL-3 yrs: 0.28/0.08 mm (maxilla) (NS) BL-3 yrs: 0.22/0.22 mm (mandible) (NS) BL-3 yrs: 0.25/0.15 mm (maxilla mandible) (NS) BL-5 yrs: 0.44/0.1 mm (maxilla) (NS) BL-5 yrs: 0.13/0.29 mm (mandible) (NS) BL-5 yrs: 0.29/0.2 mm (maxilla mandible) (NS) Drop-outs: 3 subjects (5 yrs) Comparing the effect of 40/80 divided in two groups (1/2: IMZ/Straumann) (1) 20 subjects; two two-part 2 different implant TPS implants, non-submerged designs and 2 (different?) MBL change (mean) BL-3 yrs: IMZ: 1.2 mm implant surface types (IMZ) BL-3 yrs: Straumann: 1.3 mm (2) 20 subjects; two one-part Marginal bone levels on BL-5 yrs: IMZ: 1.6 mm TPS implants, non-submerged intra-oral radiographs BL-5 yrs: Straumann: 1.8 mm (Straumann) No statistically signicant difference Overdentures in the mandible between groups at 3 or 5 yrs Comparing three different Drop-outs (5 yrs): 7 subjects 30 subjects; 60 implants, nemark group and 3 ITI group) (4 Bra surface types and three IMZ implants (TPS surface) nemark/ITI) different implant designs MBL change (IMZ/Bra 30 subjects; 60 implants, nemark implants BL-5 yrs: 1.4/0.7/0.9 mm (NS) Marginal bone levels on Bra intra-oral radiographs (Turned surface) 30 subjects; 60 implants, ITI implants (TPS surface) Comparing two different Drop-outs: 0 28 patients MBL change: CAM/FRI 53 Camlog implants (2-stage) implant designs and two BL-1 yr: 0.16/0.19 mm different surface types; 45 Frialit implants (2-stage) BL-2 yrs: 0.23/0.25 mm blasted and acid-etched/ FPD BL-3 yrs: 0.25/0.28 mm high temperature acidNo statistically signicant etched difference between groups Marginal bone level change assessed on intra-oral radiographs Drop-outs: 2 subjects (3 yrs) Comparing different 28 subjects nemark MBL change: ITI/Bra 77 ITI implants (TPS 1 stage) implant designs, nemark implants F. placement BL: 1.4/1.8 mm installation techniques 73 Bra BL 1 yr: 0.2/0.2 mm and surface types. (Turned 2 stage) BL 3 yrs: 0.1/0 mm Marginal bone levels FPD Peri-implantitis occurred at 9.1 assessed on intra-oral of the TPS-surfaced ITI implants radiographs nemark but at none of the Bra implants (Po0.05). Between the 1- and the 3-yr examination 87.1% of the ITI implants and 95.5% of the nemark implants exhibited a Bra bone loss of 0.4 mm, indicating a steady state of MBL Comparing two different surface types and two different implant designs Marginal bone levels on intra-oral radiographs

MBL, marginal bone level; yrs, years.

supported by two implants in the mandible. Three types of implants were used and in each of 30 subjects two implants of nemark or ITI implants either IMZ, Bra were installed using a randomization protocol. The mean MBL alteration at 5 years was 1.4, 0.7 and 0.9 mm for the IMZ, nemark and ITI implants, respectively. Bra

The differences between the three implant types were not statistically signicant. In two publications, data from 66 subjects who were treated with complete xed dentures supported by Astra Tech Implants nemark with a TiOblast surface or Bra s System (Nobel Biocase, Gothenburg, Sweden) implants with a turned surface were

strand et al. reported (Engquist et al. 2002; A 2004a). Three subjects did not attend the 5-year examination. One subject lost the implant-supported bridge during the rst year in function and the other two died after the 3-year follow-up. The mean MBL alteration between BL and 3 years of function was 0.25 mm for the Astra Tech implants and
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Table 4. Studies excluded after full-text analysis

Authors Arlin (2007) Type of study Retrospective Time for follow-up 0.89.7 years No. of subjects/implants 342/836 533 SLA implants 303 TPS implants 74/198 25/58 TiUnite implants 27/52 Osseotite implants 22/88 Turned implants 210 MK II Nobel Biocare 151 Dual acid-etched 3i implants (1) 30 subjects; 60 implants, IMZ implants (TPS surface) (2) 30 subjects; 60 implants, nemark implants Bra (Turned surface) (3) 30 subjects; 60 implants, ITI implants (TPS surface) nemark MS xtures 29 subjects Bra 1-stage nemark MS xtures 29 subjects Bra 2-stage 25 patients TPS xtures 1-stage 45/131 75 implants narrow abutment (platform switching) 56 implants with normal abutment 528/1583 619 ICE 545 Osseotite 419 self-tapping 81 subjects (87) 21 subjects (87) 90/450 TiUnite nemark implants 152/750 Turned Bra (historic controls) 15 subjects TiUnite Turned nemark (MKII), 5/20 Bra (2-piece) 5/20 Conical transmucosal (NB), (1-piece) nemark Turned 11 subjects Bra surface 11 patients Tioblast surface 11 subjects 11 implants, SLA 1 mm subcrestal 11 implants, SLA in level with the crest 68 subjects 101 implants 1.8 mm smooth collar 100 implants 2.8 mm smooth collar SLA and TPS surfaced implants 50/133 Astra Tech implants Turned vs. TiOblast surface 97 subjects 247 dual acid-etched implants 185 Turned implants 27 subjects 28 implants external hex butt joint 45 implants tapered Morse Turned 6 subjects TPS 6 subjects Reasons for exclusion Function-time o3 years Retrospective design Incomplete data on MBL changes Function-time o3 years Retrospective design? Incomplete data on MBL changes Function-time o3 years Retrospective design Incomplete data on MBL changes Function-time o3 years

Aalam & Nowzari (2005)

Prospective? Randomized? Controlled

2 years postloading

Al-Nawas et al. (2007) Batenburg et al. (1998)

Retrospective, cohort study 41 year

Prospective Randomized Controlled

1 year postloading

Becker et al. (2000)

Prospective, longitudinal, multicenter

15 months postloading (mean) Up to 3 years

Function-time o3 years

Cappiello et al. (2008)

Prospective, controlled

1 year post-loading

Function-time o3 years

Davarpanah et al. (2002)

Prospective, multicenter

15 years

Function-time o3 years Incomplete data on MBL changes

Finne et al. (2007) Friberg & Jemt (2008) berg et al. Fro (2006) Gatti & Chiapasco (2002) Hallman et al. (2005)

Prospective multicenter, controlled? (Nobel Perfect & Nobel Direct) Retrospective, historic controls Early loading protocols Prospective, randomized, controlled (split-mouth) Prospective, randomized, controlled, pilot

1 year 2 years 1 year

Function-time o3 years Insufcient controls Function-time o3 years Insufcient controls Function-time o3 years

18 months

2 years

Function-time o3 years

mmerle Ha et al. (1996) nggi et al. Ha (2005)

Retrospective Restored after interpositional bone grafting in the maxilla Prospective randomized, controlled Retrospective

5 years

Retrospective design

1 year

Function-time o3 years

Up to 3 years

Function-time o3 years Retrospective design

Karlsson et al. (1998) Khang et al. (2001) Machtei et al. (2006) Marchetti et al. (2008)

Prospective, randomized, controlled (intraindividual), multicenter Prospective, randomized, controlled (intraindividual?) Retrospective

2 years

Function-time o3 years

3 years

Incomplete data on MBL changes

16 years

Retrospective Restored after LeFort I osteotomy and bone grafting

Mean 8.5 years (612 years)

Function-time o3 years Retrospective design Incomplete data on MBL changes Retrospective design Insufcient sample size

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Table 4. (continued)
Authors Oates et al. (2007) PuchadesRoman et al. (2000) Rocci et al. (2003) Type of study Prospective, randomized, controlled Retrospective Time for follow-up 6 weeks No. of subjects/implants 31 subjects 31 SLA implants 31 chemically modied 30 subjects 15 Astra Tech single tooth implants nemark single tooth implants 15 Bra 22/66 TiUnite 22/55 Turned Reasons for exclusion Function-time o3 years

2 years

Function-time o3 years Retrospective design Function-time o3 years

Schincaglia et al. (2007)

Shin et al. (2006)

Prospective, randomized, controlled Immediate loading protocol in the posterior mandible Prospective, randomized, controlled, split-mouth Immediate loading protocol in the posterior mandible Prospective, randomized, controlled

1 year

1 year

10 subjects 20 Tioblast 22 Turned

Function-time o3 years

Spiekermann et al. (1995) Van Steenberghe et al. (2000) Vanden Bogaerde et al. (2004) Vela-Nebot et al. (2006)

Retrospective Prospective, split-mouth randomized design Prospective, multicenter, historic controls Early loading protocols Prospective controlled

68 subjects 35 Turned neck (Ankylos) 34 rough-surfaced neck (Stage 1) 38 rough-surfaced neck with microthreads (Oneplant) Mean 5.7 years (up 136/300 to 11 years) TPS and IMZ 2 years TiOblast nemark MK II Bra 18 months 31/111 TiUnite nemark ?/? Turned Bra 30 control cases normal width of abutment 30 test cases reduced width of abutment nemark MKII 19/76 Turned Bra 17/68 Sandblasted/acid-etched Frios implants 48/115 (test) Nobel Direct (test) Nobel Perfect (test) 97/380 Historic controls

1 year

Function-time o3 years

Retrospective design Function-time o3 years

Function-time o3 years Insufcient controls Function-time o3 years

6 months after abutment connection 4 3 years (37 years)

Zechner et al. (2004)

Retrospective, controlled

Retrospective design

stman et al. O (2007)

Prospective

1 year

Function-time o3 years Insufcient controls

MBL, marginal bone level.

nemark 0.15 mm for the implants of the Bra s System . The corresponding changes between BL and 5 years were 0.29 and nemark 0.2 mm for the Astra Tech and Bra s System implants, respectively. The differences between the implant types at the 3and 5-year examinations were not statistically signicant. Heijdenrijk et al. (2006) reported on results from a study on 40 subjects who were treated with overdentures supported by two implants. All 80 implants were placed using a non-submerged technique and were either two-part implants (IMZ) or one-part implants (ITI/Straumann, Straumann Waldenburg, Switzerland). Both types of implants had a TPS surface, but no information regarding the specic sur-

face characteristics of the two implant types was provided. The number of drop-out subjects during the 5 years of follow-up was three. From BL to 1 year in function, MBL change amounted to 0.7 mm in the one-part group and to 0.6 mm in the twopart group. The amount of additional bone loss during the second year in function was 0.5 mm for both implant types. The annual bone loss during the third, fourth and fth year of function was small and did not differ between the one- and two-part implants. After 5 years in function, the MBL change from BL was 1.8 mm at the ITI implant and 1.6 mm at the IMZ implant. This difference was not statistically signicant. Ozkan et al. (2007) evaluated MBL change at Camlog (Camlog Biotechnologies AB,

Basel, Switzerland) and Frialit (Friatec AG, Mannheim, Germany) implants after 1, 2 and 3 years in function. Fifty-three Camlog implants with a blasted and acid-etched surface were placed in 14 subjects, and 45 Frialit implants with a high-temperature acidetched surface were placed in another 14 subjects. Both types of implants were placed using a two-stage technique. All subjects attended the 3-year follow-up visit. The MBL changes between BL and 1, 2 and 3 years in function were small and similar for both implant types. The MBL change from BL to 3 years in function was 0.25 and 0.28 mm for the Camlog and Frialit implants, respectively. No statistically signicant differences of mean MBL alterations between the two implants types were found.
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In a 3-year randomized, split-mouth, strand et al. 2004b) multi-center study (A examined bilateral implant-supported FPDs in the posterior areas of the maxilla in 28 subjects. Implants of the ITI Dental Implant s System were placed in one side of the nemark Sysmaxilla and implants of the Bra s tem in the contralateral side. The implants of the two systems differed regarding surface characteristics and design. While the ITI implants were one-part implants with a nemark implants were TPS surface, the Bra two-part implants with a turned surface. Two subjects died before the 3-year follow-up. At BL the mean MBL was situated 1.4 and 1.8 mm apical of the reference point at ITI nemark implants, respectively. The and Bra MBL changes between BL and 1 and 3 years of function were 0.2 and 0.1 mm (gain) at nemark ITI implants and 0.2 and 0 mm at Bra implants, respectively. There was no statistically signicant difference regarding MBL alterations between the two implant systems at any time interval. Between the 1-year and the 3-year examination, 87.1% of the ITI nemark imimplants and 95.5% of the Bra plants exhibited a bone loss of 0.4 mm.

Discussion
Few studies have provided information on the inuence of different implant surfaces and designs on MBL alterations. In the present review, only two studies were found that evaluated MBL alterations at implants that were identical except for the surface characteristics. In both studies, Astra Tech implants were used and comparisons were made between implants with either a TiOblast or a turned surface using a study design with intra-individual controls (Gotfredsen & Karlsson 2001; Wennstro m et al. 2004). None of the studies provided data that pointed to a favorable outcome for the implants with the modied surface (TiOblast) after 5 years. On the contrary, a smaller amount of marginal bone loss, although not statistically significant, was found at implants with a turned surface than at those with a TiOblast surface. Thus, data from available studies indicate that there is no evidence of improved marginal bone preservation for any particular surface modication. In the second category of studies included in the current review, the potential
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inuence of implant design on MBL changes was evaluated. In one of the studies, the difference between the implant types to be compared was related to the thread design of the apical portion of the implant (Davarpanah et al. 2001). The potential inuence on MBLs with regard to such an implant characteristic is unclear. In addition, the data presented on the particular outcome variable in this study were difcult to interpret due to the lack of baseline data and comparisons of bone-level changes. In the second study in this category of studies, Lee et al. (2007) analyzed MBL changes at Astra Tech implants with similar surface characteristics (TiOblast) but with different designs of the marginal portion of the implants. An intraindividual study design was applied in this study and statistically signicant differences in MBL changes were found between implants with a conical and microthreaded conguration and those with a cylindrical and non-threaded marginal portion after 1, 2 and 3 years. In this context, it is interesting to realize that the differences in the mean values presented for each of the two implant types in the study by Lee et al. (2007) were of the same magnitude as those reported for the implant types in Table 1 reported above (implant surfaces). While the studies in Table 1(Gotfredsen & Karlsson 2001; Wennstro m et al. 2004) failed to demonstrate statistically signicant differences between implant types in study samples of about 50 subjects, the results in the study by Lee et al. (2007) were obtained from the smallest study sample (17 subjects) of all studies included in this review. Another interesting observation related to the data presented by Lee et al. (2007) is the absence of differences between the implant types during the third year of function. Thus, differences that were established between the implants with the conical and microthreaded conguration and the implants with the cylindrical and non-threaded design during the rst and second year were sustained during the third year. The potential effect of the differences in the design of the implants in the study by Lee et al. (2007) is difcult to interpret because the implants differed with regard to two particular designs: the conical conguration and the micro-threads. The possible inuence of the micro-threads on the marginal bone

was addressed in an experimental study in dogs (Abrahamsson & Berglundh 2006). It was reported that the MBL was located at a more coronal position at implants with than without micro-threads in the marginal portion. Thus, the possible effect of micro-threads may be related to the bonehealing events that occur following implant placement rather than marginal bone preservation during function. In the third category of studies in the present review, comparisons were made between different implant systems. The particular differences between implants were, hence, not restricted to either surfaces or designs alone, but rather a combination of these factors. Nevertheless, none of the six studies in this group demonstrated statistically signicant differences in MBL alterations after 3 or 5 years. The interpretation of results, however, must be made with caution because no overall comparisons between studies can be made. Thus, Meijer et al. (2004) failed to demonstrate statistically signicant differnemark and ITI ences between IMZ, Bra implants. Furthermore, in the study by Heijdenrijk et al. (2006), the difference in MBL changes between the Straumann/ITI implants and the IMZ implants were about 0.1 and 0.2 mm after 3 and 5 years, respectively. The overall bone loss over the period for the two implant types, however, varied between 1.2 and 1.3 mm at 3 years and between 1.6 and 1.8 mm at 5 years. These results reported by Heijdenrijk et al. (2006) sare in contrast to those presented by A trand et al. (2004b). Although the Strau strand mann/ITI implants in the study by A et al. (2004b) had a similar type of surface as those reported by Heijdenrijk et al. (2006) (TPS), the Straumann/ITI implants strand et al. (2004b) in the study by A demonstrated a gain in bone levels after 3 years. It should be pointed out, however, that the implants in the study by Heijdenrijk et al. (2006) supported removable overdentures in the mandible, while the strand et al. implants in the study by A (2004b) supported FPDs in the posterior segment of the maxilla. Thus, the implants in the two studies not only had different functional but also different environmental prerequisites. Results from meta-analyses in a systemic review revealed that implants supporting overdentures exhibited markedly higher rates of biological complications than
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Abrahamsson & Berglundh Effects of implant surfaces and designs on MBL alterations

those supporting partial- or complete-xed reconstructions (Berglundh et al. 2002). This observation once again points to the importance of well-conducted and controlled clinical studies to elucidate the inuence of design and other characteristics on treatment outcome in implant therapy.

2.

3.

Conclusions
1. Controlled prospective studies evaluating the effect of implant surface and

designs on MBL changes !3 years are few. As revealed from such studies, there is no evidence that modied surfaces are superior to non-modied implant surfaces in marginal bone preservation. One study reported on signicantly improved MBL preservation for implants with a conical and microthreaded marginal collar than implants with a cylindrical and non-threaded marginal portion after 3 years in func-

4.

tion. The interpretation of the results from this study is difcult due to the presence of two differences in design and the absence of differences in MBL changes during the third year of function. Comparisons between implants of different systems involve evaluations of combinations of surface and designs. No implant system was found to be superior in marginal bone preservation.

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