Review Reports - Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

Your retrospective analysis provides new insights into whether simultaneously augmented and placed implants are more prone to implant loss. Your work is relevant and essential.

Please deliver more insight into the distribution of augmentation procedures. As sinus elevation procedures are well-examined and described as approaches with low failure rates, there is a lack of data on simultaneous horizontal augmentation. I would suggest doing a subgroup analysis on his topic. Mixing all these different procedures might bias the results.

Moreover, incomplete augmentation and exposed implant surface > 1mm have been described as increasing the risk of later peri-implant issues. Do your data allow for the analysis of this question? This would be of much more interest as the distribution of the implants or the socioeconomic status of the patients.

Please cite more existing literature in the discussion and compare it with your results.

Some precise suggestions:

Line 92, 93:

We do not have evidence that overload might correlate with late implant loss. There are only a few weak animal studies with questionable study design and small sample sizes, supporting this theory. I would suggest removing this factor.

Line 99-101:

Do you mean: implants placed in native bone?

I guess this wording may be misinterpreted.

The sentence sounds as if you might compare augmentation with bone substitutes compared to autogenous bone.

Line 150

Please describe the internal index you used for categorizing patients.

Comments for author File: Comments.pdf

Author Response

January 12, 2026

Response to Peer Review: Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset

Submission ID: jfb-4086613

Dear Reviewer,

We wish to express our sincere appreciation to the Editor and the Reviewers for their rigorous and insightful critique of our manuscript, "Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset."The peer review process has provided a valuable opportunity to refine our methodological justifications and expand upon the clinical implications of our findings.

The revised manuscript represents a significant refinement of our original work. Specifically, we have tightened the methodological framework by aligning our terminology with the binary outcome analysis (implant failure vs. success). Furthermore, we have significantly expanded the Discussion section to incorporate a more nuanced analysis of socioeconomic determinants and their measurable impact on clinical outcomes. Also, the Limitation chapter have expanded according the reviewers remarks. By integrating these revisions, we believe the study now offers a more robust and clinically relevant exploration of the risk factors associated with dental implant success in augmented sites.

Guy Tobias

Corresponding author

On behalf of the authors.

Reviewer 1:
Dear authors,

Your retrospective analysis provides new insights into whether simultaneously augmented and placed implants are more prone to implant loss. Your work is relevant and essential.

Thank you for your kind words.

Please deliver more insight into the distribution of augmentation procedures. As sinus elevation procedures are well-examined and described as approaches with low failure rates, there is a lack of data on simultaneous horizontal augmentation. I would suggest doing a subgroup analysis on his topic. Mixing all these different procedures might bias the results.

Answer: We appreciate the reviewer's insight. While this paper includes all variables accessible to us, we are already in the process of analyzing further parameters for future research. We agree with the concern regarding bias and have updated the Limitations section to reflect this point.

Limitations

This study’s retrospective design, relying on administrative coding, presents several limitations. While the large sample size provides substantial statistical power, we lacked granular data on key confounding variables such as smoking status, history of periodontitis, and the specific graft materials utilized. Furthermore, our cohort included a variety of surgical approaches, such as sinus elevation and horizontal augmentation. As these procedures may have inherently different failure rates, the current lack of granular data prevented us from performing a dedicated subgroup analysis on simultaneous horizontal augmentation. This procedural heterogeneity may introduce bias, as mixing distinct clinical techniques could mask specific outcomes associated with each approach. Additionally, our definition of failure was binary (implant removal); consequently, we could not account for implants experiencing marginal bone loss that remained in situ, which may lead to an underestimation of the true prevalence of peri-implantitis. Finally, the follow-up period was variable, and while the GEE model accounts for intra-subject correlation, a comprehensive long-term survival analysis (e.g., a 10-year Kaplan-Meier curve) was not feasible for the entire cohort.

Moreover, incomplete augmentation and exposed implant surface > 1mm have been described as increasing the risk of later peri-implant issues. Do your data allow for the analysis of this question? This would be of much more interest as the distribution of the implants or the socioeconomic status of the patients.

Answer: We appreciate your constructive feedback. The data analyzed in this study are derived from clinical medical records and administrative coding used by practitioners in their daily routine. Unfortunately, the specific information you mentioned is not captured within these medical records, which limited our ability to perform the suggested analysis.

Please cite more existing literature in the discussion and compare it with your results.

Answer- Thank you for your comment. Accordingly, we have rewritten part of the Discussion section and incorporated additional relevant references:

Our data demonstrates a clear clinical gradient: patients in the lowest SES quintile experienced a failure rate of 3.07%, a statistically significant increase compared to the 2.06% observed in the highest SES group. This disparity persisted even after rigorous adjustment for clinical variables such as bone density, implant location, and systemic health markers, suggesting that social determinants of health exert a measurable, independent influence on long-term osseointegration.

While historical data has established a link between low SES and the severity of periodontal disease [45], recent evidence suggests that the impact on implant outcomes is driven by more nuanced factors than mere access to care.

The mechanisms likely involve a convergence of three primary domains:

Behavioral and Lifestyle Clusters:Lower SES is frequently associated with higher rates of tobacco use, suboptimal nutritional intake (specifically Vitamin D and antioxidants essential for bone healing), and poorer glycemic control, all of which are known inhibitors of implant success [46].
Psychosocial Stress and Biology:Chronic "weathering" or allostatic load—the physiological wear and tear resulting from chronic socioeconomic stress—may impair the immune response and osteoblast activity, potentially compromising the early healing phase [47].
Health Literacy and Maintenance:Disparities in health literacy often translate to lower adherence to complex post-operative protocols and professional maintenance schedules [48]. In lower SES populations, "reactive" dental attendance often replaces "preventative" maintenance, allowing peri-implant mucositis to progress to irreversible peri-implantitis undetected.

In the context of a universal healthcare setting, where surgical access is ostensibly equitable, these findings expose a paradox: equal access to the procedure does not guarantee equal outcomes. The data suggests that clinical success is heavily contingent upon the patient’s post-operative environment [49]. Consequently, achieving equity in implant dentistry requires a shift from a "one-size-fits-all" approach to a model of proportionate universalism, where vulnerable populations receive intensified post-operative support, culturally tailored education, and subsidized maintenance pathways [50].

Monje A, Wang HL, Nart J. Association of Preventive Maintenance Therapy Compliance and Peri-Implant Diseases: A Cross-Sectional Study. J Periodontol. 2017 Oct;88(10):1030-1041. doi: 10.1902/jop.2017.170135. Epub 2017 May 26. PMID: 28548886.

Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S, Weyant RJ, Mathur MR, Guarnizo-Herreño CC, Celeste RK, Peres MA, Kearns C, Benzian H. Ending the neglect of global oral health: time for radical action. Lancet. 2019 Jul 20;394(10194):261-272. doi: 10.1016/S0140-6736(19)31133-X. PMID: 31327370.

Some precise suggestions:

Line 92, 93:

Answer: Thank you for this valid point. In line with your suggestion, we have removed this factor from our discussion.

Line 99-101:

Do you mean: implants placed in native bone?

I guess this wording may be misinterpreted.

The sentence sounds as if you might compare augmentation with bone substitutes compared to autogenous bone.

Answer: Thank you for this comment. Upon further review, the authors concur with your observation and have revised the manuscript accordingly.

Line 150

Please describe the internal index you used for categorizing patients.

Answer- Thank you for the comment. Accordingly, we have expanded the information regarding the internal index in the revised manuscript.

Cohort Definition and Variables

Clinic location served as a proxy for socioeconomic status (SES) based on an internal index that categorized clinics into low, medium, or high SES groups. This classification aligns with the Israel Central Bureau of Statistics (CBS) methodology, which assigns a socioeconomic rank to residential areas via a clustering system. Accordingly, the study population was divided into three primary cohorts: clusters 1–3 representing low SES, clusters 4–6 representing medium SES, and clusters 7–9 representing high SES.

Reviewer 2 Report

Comments and Suggestions for Authors

Topic is interesting data is well presented

I would suggest to include table include significant literature number of implants

Type of grafts used, time given before loading....etc.

Author Response

January 12, 2026

Response to Peer Review: Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset

Submission ID: jfb-4086613

Dear Reviewers,

Guy Tobias

Corresponding author

On behalf of the authors.

Reviewer 2

Topic is interesting data is well presented

Thank you for your kind words.

I would suggest to include table include significant literature number of implants

Type of grafts used, time given before loading....etc.

Answer: We thank the reviewer for this observation. While this paper utilizes all parameters accessible to us at this time, we concur that additional variables could provide further depth. Consequently, we have revised the Limitations section to reflect this.

Limitations

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors.

The manuscript examines implant retention and failure in dental implants placed in association with bone grafting, using a large scale dataset. The conceptual and methodological consistency across the Introduction, Materials and Methods, Results, Discussion, and Conclusions demonstrates a strong level of internal coherence, with a clear and well articulated logical progression.

The Introduction appropriately establishes the theoretical and clinical framework of the study, addressing the need for bone support in implant dentistry, the influence of implant placement timing, the controversies associated with the use of bone grafting, and the distinction between early and late failure. In addition, the inclusion of socioeconomic factors as an emerging dimension of analysis is well justified and aligned with contemporary literature. It is pleasing to observe a clear and well structured introduction presented in this manner. The Materials and Methods section responds consistently to the questions posed in the Introduction. The operational definition of implants placed with simultaneous bone grafting, the categorization of implant placement timing, anatomical stratification, type of prosthetic rehabilitation, and the incorporation of socioeconomic status as an explanatory variable are adequately described and appropriately support the subsequent statistical analysis. In this context, the use of generalized estimating equation models is methodologically appropriate to control for the dependence of multiple implants within the same patient, thereby strengthening the validity of the results. The Results are presented in an orderly manner and are directly linked to the previously defined variables. All factors anticipated in both the Introduction and the Methodology are effectively analyzed. The differentiation between early and late failures, as well as the comparison between implants placed with bone grafting and the overall implant population, are appropriately aligned with the objectives of the study. The Discussion appropriately interprets the reported findings, maintaining a direct correspondence between the observed results and the conceptual framework developed in the manuscript. The discussion of the impact of socioeconomic status, implant placement timing, and anatomical location is well supported by the observed data and the cited literature. The Limitations section explicitly acknowledges the constraints inherent to the retrospective design and the use of administrative data, highlighting the absence of information on relevant clinical variables such as smoking status, prior periodontitis, and the specific type of bone graft material. The Conclusions maintain a prudent tone consistent with the scope of the study. The manuscript reinforces the notion that dental implant placement with simultaneous bone grafting represents a clinically predictable procedure, while emphasizing the relevance of modulating factors such as sex, socioeconomic status, and implant placement timing.

The authors are requested to consider the following observations:

It is recommended that the use of the concept of survival be reviewed and clarified throughout the manuscript. Although this term is employed in its conventional clinical meaning in implant dentistry, understood as the persistence of the implant in situ during the observation period, from a methodological perspective the analysis performed corresponds to an assessment of implant failure rather than a formal survival analysis in terms of time to event. Specifically, outcomes were treated as binary variables, failure versus no failure, and were analyzed using generalized estimating equation models, without the estimation of actuarial curves or proportional hazard models. This approach is consistent with the heterogeneity of follow up durations inherent to registry based studies. In this context, the authors are encouraged to explicitly align the terminology used with the analytical approach, clarifying that the results represent estimates of the risk and distribution of implant failure during the observed period rather than measures of survival in the strict statistical sense.

In addition, socioeconomic status was operationalized as a contextual indicator at the clinic level, derived from the geographic location of the treatment center, thereby reflecting the socioeconomic environment of care rather than the individual characteristics of patients. In this regard, it is recommended that this distinction be further emphasized in the interpretation of the results, avoiding individual level inferences. The observed association between lower socioeconomic status and higher implant failure rates should be explicitly presented as a contextual effect, potentially influenced by structural and behavioral factors related to access to care, continuity of treatment, and maintenance patterns, rather than as a direct attribution to individual patient socioeconomic status.

Finally, it is noted that the manuscript does not explicitly address as a limitation the absence of detailed information regarding the type of implant used, including material, surface characteristics, design, or manufacturer. This omission represents a relevant methodological weakness, particularly considering that the data originate from a clinical dental records center rather than from a purely administrative database, and that such information is typically documented in surgical clinical records. Given that implant characteristics may have a particular influence on early implant failure, it is recommended that the authors explicitly incorporate this limitation in the appropriate section, clarifying whether this information was not consistently or systematically available in the analyzed database, and more clearly delineating the scope of their conclusions at the level of procedure and clinical context rather than at the level of specific implant device performance.

Sincerely, the reviewer.

Author Response

January 12, 2026

Response to Peer Review: Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset

Submission ID: jfb-4086613

Dear Reviewers,

Guy Tobias

Corresponding author

On behalf of the authors.

Reviewer 3:

Dear authors.

Answer- Thank you for your kind words.

Answer: Thank you very much.

The authors are requested to consider the following observations:

It is recommended that the use of the concept of survival be reviewed and clarified throughout the manuscript. Although this term is employed in its conventional clinical meaning in implant dentistry, understood as the persistence of the implant in situ during the observation period, from a methodological perspective the analysis performed corresponds to an assessment of implant failure rather than a formal survival analysis in terms of time to event. Specifically, outcomes were treated as binary variables, failure versus no failure, and were analyzed using generalized estimating equation models, without the estimation of actuarial curves or proportional hazard models. This approach is consistent with the heterogeneity of follow up durations inherent to registry based studies. In this context, the authors are encouraged to explicitly align the terminology used with the analytical approach, clarifying that the results represent estimates of the risk and distribution of implant failure during the observed period rather than measures of survival in the strict statistical sense.

Answer- We thank the reviewer for this important methodological clarification. We concur that our analysis, utilizing Generalized Estimating Equation (GEE) models for binary outcomes, evaluates the incidence of implant failure rather than providing a formal time-to-event survival analysis. In accordance with your suggestion, we have reviewed the manuscript and refined the terminology, replacing references to 'survival analysis' with 'implant failure rates' or 'clinical success' where appropriate including changing the article name to “Clinical Success Rates of Dental Implants with Bone Grafting in a Large-Scale National Dataset“. This ensures the terminology precisely aligns with our analytical approach and the nature of our registry-based data.

In addition, socioeconomic status was operationalized as a contextual indicator at the clinic level, derived from the geographic location of the treatment center, thereby reflecting the socioeconomic environment of care rather than the individual characteristics of patients. In this regard, it is recommended that this distinction be further emphasized in the interpretation of the results, avoiding individual level inferences. The observed association between lower socioeconomic status and higher implant failure rates should be explicitly presented as a contextual effect, potentially influenced by structural and behavioral factors related to access to care, continuity of treatment, and maintenance patterns, rather than as a direct attribution to individual patient socioeconomic status.

Answer: Thank you for the comment. Accordingly, we have expanded the information regarding the internal index in the revised manuscript.

Cohort Definition and Variables

Finally, it is noted that the manuscript does not explicitly address as a limitation the absence of detailed information regarding the type of implant used, including material, surface characteristics, design, or manufacturer. This omission represents a relevant methodological weakness, particularly considering that the data originate from a clinical dental records center rather than from a purely administrative database, and that such information is typically documented in surgical clinical records. Given that implant characteristics may have a particular influence on early implant failure, it is recommended that the authors explicitly incorporate this limitation in the appropriate section, clarifying whether this information was not consistently or systematically available in the analyzed database, and more clearly delineating the scope of their conclusions at the level of procedure and clinical context rather than at the level of specific implant device performance.

Answer- Answer: We thank the reviewer for this observation. While this paper utilizes all parameters accessible to us at this time, we concur that additional variables could provide further depth. Consequently, we have revised the Limitations section to reflect this.

Limitations

Sincerely, the authors.