Guest Editorial

Towards Optimized Treatment Outcomes for Dental Implants

Editor's note: This issue presents the proceedings of thesymposium "Towards Optimized Treatment Outcomesfor Dental Implants" held at the University of TorontoApril 24-25, 1998. The organizing committee, chairedby Dr George Zarb, University of Toronto, and Dr TomasAlbrektsson, Göteborg University, designed a very ambi-tious program, including thought-provoking literaturereviews by 12 selected speakers and stimulating study-group discussions, with the purpose of developing a con-sensus report. Besides the reviewers, an internationalpanel comprising clinicians, researchers, educators, andeditors with expertise in the field of dental implants wereinvited to participate in the working groups. Drs Zarband Albrektsson provide the background of the sympo-sium in their Guest Editorial. Elsewhere in this issue theyoffer their interpretation of correct clinical reporting,which will be of value not only for future authors, butalso for readers of publications on treatment outcomes ofclinical practice and research.

We are proud to be able to publish the papers pre-sented at the symposium and the resulting consensusdocument just 5 months after it took place. This achieve-ment has been possible thanks to the kind and efficientcollaboration of the organizers, the reviewers/authors,and of course the professional staff at QuintessencePublishing Co.

A minor disadvantage of publishing these proceedingsin a regular issue of the I]P is that the "normal submis-sions" will have to wait an extra period of 2 months. Ihope that those authors awaiting publication of their arti-cles will agree that the interesting contributions in thisissue are valuable not only for implant dentistry, butshould also enrich the specialty of prosthodontics.

Gunnar E. CarlssonEditor-in-Chief

F ive simple tools—the lever, wedge, wheel and axle,pulley, and screw—have existed for millennia. Each of

these tools and their underlying principles have beenrefined, improved, and combined in various ways to pro-duce other tools and engineering principles (no longersimple), which in turn have revolutionized the applica-tion of modern dental techniques. This process has beenparticularly important in the disciplines of surgery andprosthodontics. Archimedes, in the third century BC,understood the operation of the mechanical screw,which represents a basic tenet of endosseous stabiliza-tion, albeit limited in its time- and biologically depen-dent efficacy and effectiveness.

A scientific transition in the nature of interfacialscrew-host bone behavior involving commercially puretitanium implants was reported by Per-lngvar Brânemarkin 1977, and the field of dental implants entered a newera of therapeutic possibilit iesJ Interestingly,Brânemark's results and the success criteria proposed bya National Institutes of Health consensus conference in1979 were published almost simultaneously.^ The latterdocument, a well-intentioned synthesis of largely retro-spective observations, was quickly eclipsed byBrânemark's and others' emerging confirmatory results.Consequently, in 1986, in collaboration with PhilipWorthington and Anders Ericsson, we proposed successcriteria^ rather than mere survival statistics in ourdescription of desirable treatment outcomes for osseoin-tegrated implants. Our clinical yardstick and subsequent"fine tuning" versions'*'̂ underscored the clinical natureof the induced interfacial response, together with thesubtle yet profound clinical implications of such toothabutment analogues: they had to be painless, immobile,surrounded by bone in a steady state, and capable ofbeing employed for diverse prosthodontic solutions, fromsingle-crown support to retention of extensive maxillofa-cial prostheses.

We sought to include strict success criteria in thecontext of patient-mediated concerns regarding absenceof pain, discomfort, and infection, as well as the addi-tional caveat of a satisfactory appearance. In retrospect,patient concerns were perhaps insufficiently empha-sized, at least in a quantifiable context. Nonetheless,

Volume 11, Number 5, 1998 385 The International lournal of Prosthodontics

over the years we were gratified to note that severalprospective studies in leading refereed journals adoptedour yardstick. However, not all reports on new implantsystems did so. Commercial claims insidiously under-mined scientific standards as celebrity groups ofosseointegrated implant proponents sought to competewith the scrupulously constructed scaffolding of interna-tional scholarship that was emerging. Sloganeering andself-promotion have traditionally sought inroads into thescience of dentistry, but the advent of osseointegrationelicited an unparalleled commercial culture that soughtto usurp the commitment to evidence-based manage-ment of the sequelae of oral diseases. The most glaringexample was the profession's newfound fascination withcosmetic dentistry, which provided the rhetoric to mar-ket services of dubious health necessity. Oral renovationbegan to replace oral health as the profession's clarioncall for the decade. And dental implants as a prostho-dontic treatment alternative inevitably spawned surgicaltechniques and restorative hardware that ran the risk ofbecoming ends in themselves.

Hence our perceived need for a symposium on"Towards Optimized Treatment Outcomes for DentalImplants." With the support of the University of Toronto,the Medical Research Council of Canada, DentistryCanada, Göteborg University Craniofacial Reconstruc-tion Unit, and Quintessence Publishing Co, Inc, we wereable to organize a meeting that comprised the scholarslisted on pages 387 and 388. By bringing togetherreviewers, researchers, and educators from the interna-tional scholarly community, we succeeded in carryingout informed discourse and provocative exchange. Theresult is the consensus report on page 389, which synthe-sizes the symposium discussions and reflects the scrupu-lous and judicious wordsmithing of those "high priests"of scientific clinical reporting editors representing someof clinical dentistry's most distinguished journals: Drs

•^William Becker, Gunnar E. Carlsson, Arnold Franks,Michael Fritz, William Laney, Daniel Laskin, PatrickLloyd, Glen McGivney, and Hans-Peter Weber. Withtheir help and that of the symposium's participants, wehave reinforced our conviction that the pen is still mighti-er than the drill—or an implant's design. The notes pro-vided by co-chairs of the working groups also con-tributed significantly to the synthesis "Determinants ofCorrect Clinical Reporting," which begins on page 517,and should be regarded as adjunctive to the consensusreport.

We therefore hope that this consensus will provide ayardstick by which all editors will judge future reports onimplant treatment efficacy and effectiveness. We alsohope that the obvious lack of quantifiable data especiallyin the areas of patient-mediated concerns will spawnmuch-needed research, in the meantime, David Locker'svery apt statement demands careful scrutiny: "patients,having weighed the involved costs and discomforts,should be satisfied that there has been an improvement;and that they are better off in certain dimensions of theirlife that they consider to be valuable" (personal commu-nication, April 1988). Together with all symposium par-ticipants, we remain convinced that in our ongoing pur-suit of reliable outcome measures, our profession mustnever lose sight of its mission: the enrichment of ourpatients' quality of life.

George A. Zarb, B ChD, DDS, MS, MS, FRCD(C)University of Toronto

Tomas Albrektsson, MD, PhDGöteborg University

References

1. Brânemark P-l, Hansson BO, Adel R, Breine U, Lindstrom J,Hallen O, Ohman A. Osseointegrated Implants in theTreatment of the Edentulous Jaw. Experience from a Ten-yearPeriod. Stockholm; Almquist and Wiksell, 1977.

2. US Department of Health and Human Services. Dentalimplants: Benefit and risk. An HIH-Harvard ConsensusDevelopment Conference. US Dept of Health and HumanServices, December 1980.

3. Albrektsson T, Zarb CA, Worthington P, Eriksson AR. Thelong-term efficacy of currently used dental implants: Areview and proposed criteria of success. Int J OralMaxillofac Implants 1986;! :11-25.

4. Smith DE, Zarb CA. Criteria for success of osseointegratedendosseous implants. J Prosthet Dent 1989;62:567-572.

5. Albrektsson R, Zarb CA. Current interpretations of theosseointegrated response: Clinical significance. Int |Prosthodont 1993;6:95-105.

The International lournal of Prosthodontics 386 Volume I I , Number 5, 1998