Immediate rehabilitation of theedentulous jaws with full fixedprostheses supported by four implants:interim results of a single cohortprospective study

Enrico AgliardiStefano PanigattiMatteo Clerico`Cristina VillaPaulo Malo`

Authors affiliations:Enrico Agliardi, Private Practice, Bollate, Milano,ItalyStefano Panigatti, Private practice, Milano, ItalyMatteo Clerico`, Private practice, Arese (MI), ItalyCristina Villa, Private practice, Monza, ItalyPaulo Malo`, MaloClinic, Lisbon, Portugal

Correspondence to:Enrico Agliardivia Roma 1520021 BollateMilano, Italye-mail: eagliardi@studioagliardi.it

Key words: dental implants, edentulous mandible, edentulous maxilla, immediate loading,

tilted implants

Abstract

Objectives: The purpose of this study was to prospectively evaluate the clinical and

radiographic outcomes of immediately loaded full-arch fixed prostheses supported by a

combination of axially and non-axially positioned implants in a large cohort of patients

with completely edentulous jaws, up to 5 years of function.

Materials and methods: One hundred and seventy-three edentulous patients (80 males and

93 females) were enrolled according to specific selection criteria. Each patient received a

full-arch fixed prosthesis supported by two distal tilted implants and two anterior axially

placed implants. The provisional functional acrylic prosthesis was delivered the same day as

surgery in all cases. All cases were finalized 46 months later. The patients were scheduled

for follow-up at 6 and 12 months of function, and annually up to 5 years. At each follow-up

plaque and bleeding score was assessed and radiographic evaluation of marginal bone level

was performed.

Results: The overall follow-up range was 459 months. A total of 154 immediately loaded

prostheses (61 in the maxilla and 93 in the mandible) were in function for at least 1 year and

were considered for the analysis. Four axially placed implants failed in the maxilla and one

tilted implant in the mandible, all within 6 months of loading. No further implant failure

occurred to date. Implant survival at 1 year was 98.36% and 99.73% for the maxilla and the

mandible, respectively. Marginal bone loss at 1 year averaged 0.9 0.7mm in the maxilla

(204 implants) and 1.2 0.9mm in the mandible (292 implants). No difference was found

in marginal bone loss between axial and tilted implants. Plaque and bleeding scores

progressively improved from 6 to 12 months. Fracture of the acrylic prosthesis occurred in

14% of total cases.

Conclusions: The present preliminary results from a relatively large sample size suggest

that the present technique can be considered a viable treatment option for the immediate

rehabilitation of both mandible and maxilla.

In the recent years, the immediate loading

procedure for the rehabilitation of edentu-

lous jaws using osseointegrated implants has

gained popularity among clinicians. This

was due to both the excellent success rates

for several types of immediately loaded pros-

thetic reconstructions, and the technical

advantages and simplification introduced

by such procedure as widely reported in

previous reviews (Attard & Zarb 2005;

Ioannidou & Doufexi 2005; Del Fabbro

et al. 2006; Nkenke & Fenner 2006; Avila

et al. 2007; Esposito et al. 2007; Jokstad

& Carr 2007; Sennerby & Gottlow 2008).

However, the rehabilitation of edentu-

lous jaws is often complicated by poor bone

Date:Accepted 5 September 2009

To cite this article:Agliardi E, Panigatti S, Clerico` M, Villa C, Malo` P.Immediate rehabilitation of the edentulous jaws withfull fixed prostheses supported by four implants: interimresults of a single cohort prospective study.Clin. Oral Impl. Res. 21, 2010; 459465.doi: 10.1111/j.1600-0501.2009.01852.x

c 2010 John Wiley & Sons A/S 459

quality, especially in the posterior region,

and reduced bone volume due to long-term

edentulism. Bone grafting procedures to

increase the bone volume available for

implant placement may be a viable treat-

ment option but they often imply demand-

ing surgical procedures and can be

associated to complications, morbidity

and high costs. Therefore their acceptance

by patients is often poor.

In order to overcome such limitations,

different therapeutic alternatives have been

proposed, such as long distal cantilever

(Shackleton et al. 1994), short implants

(Goene et al. 2005; Renouard & Nisand

2005; Malo et al. 2007) or implants placed

in specific anatomical areas like, for the

maxilla, the pterygoid region, the tuber or

the zygoma (Bahat 1992; Khayat & Nader

1994; Venturelli 1996; Balshi et al. 1999;

Branemark et al. 2004; Galan Gil et al.

2007; Aparicio et al. 2008; Malo et al.

2008). Any of these procedures requires

considerable surgical expertise and has its

own advantages, limits, surgical risks and

complications involving biological and fi-

nancial costs.

In the last years, several clinical studies

have reported that tilting of the implants

may represent another feasible treatment

option (Krekmanov 2000; Krekmanov et

al. 2000; Aparicio et al. 2001; Fortin et al.

2002; Malo et al. 2003, 2005; Calandriello

& Tomatis 2005; Capelli et al. 2007;

Agliardi et al. 2008, 2009). Such technique

is related to several surgical and prosthetic

advantages, like the possibility of placing

long implants with improvement of bone

anchorage, the reduction of the need for

bone grafting, the avoidance of long canti-

levers and the possibility of increasing the

distance between anterior and posterior

abutments, with improvement of the load

distribution.

Furthermore, no difference in the mar-

ginal bone loss between tilted and axially

placed implants, placed in either jaw has

been reported, suggesting that tilting of the

implants causes no detrimental effect on

the osseointegration process (Krekmanov

2000; Aparicio et al. 2001; Capelli et al.

2007; Koutouzis & Wennstrom 2007;

Agliardi et al. 2009). A high degree of

patient satisfaction was also reported as

related to this clinical procedure (Capelli

et al. 2007; Testori et al. 2008; Agliardi

et al. 2009).

The aim of this prospective study was to

assess the clinical and radiographic out-

come of immediately loaded full-arch fixed

prostheses supported by a combination of

axially and non-axially placed implants in a

large cohort of patients with edentulous

jaws, up to 5 years of function. This article

reports preliminary data on implants survi-

val and peri-implant bone loss.

Materials and methods

Study protocol

Thiswas an open, single cohort prospective

study in which patients with severely re-

sorbed mandible or maxilla were consecu-

tively enrolled and treated.

The investigation was conducted accord-

ing to the principles embodied in the

Helsinki Declaration of 1975 for biomedi-

cal research involving human subjects, as

revised in 2004. At the preliminary visit all

patients were duly informed on the nature

of the study and on any possible alternative

treatment. Before enrolment a written in-

formed consent was obtained.

Selection criteria

Patients of any race and gender were in-

cluded in the study if they were at least 18

years old and in good general health condi-

tion, physically and psychologically able to

undergo conventional implant surgery and

restorative procedures (ASA-1, ASA-2).

Further inclusion criteria were: presence

of atrophic fully edentulous mandible or

maxilla, in need for bone augmentation

procedures, or presence of teeth with an

unfavourable long-term prognosis; rehabi-

litation with oral implants was the elective

treatment; patients manifested their prefer-

ence for a fixed solution but were reluctant

to undergo grafting procedures.

Exclusion criteria were: presence of ac-

tive infection or inflammation at the sites

intended for implantation; presence of sys-

temic diseases (i.e. haematologic disease,

uncontrolled diabetes, serious coagulopa-

thies and diseases of the immune system);

irradiation to the head or neck region

within 12 months before surgery; presence

of unresorbed allograft at the implant site;

severe bruxism or clenching habits; preg-

nancy; poor oral hygiene; poor motivation

to return for scheduled follow-up visits.

Preliminary radiographic screening was

performed using panoramic orthopantomo-

graphs and computed tomography (CT)

scans. A careful clinical examination of

the patients was performed assessing jaw

size and relations, bone volume and occlu-

sal relations. Figs 1 and 2 show examples of

a panoramic radiograph and a CT scan,

respectively, for a patient included in the

study.

The included patients were treated in a

dental clinic by a single surgeon (E.A.) with

considerable clinical expertise in immedi-

ate loading procedures.

According to the above criteria from

April 2004 to January 2009 a total of 173

patients have been rehabilitated with an

immediately loaded implant supported

fixed full prosthesis supported by four im-

plants in the mandible or in the maxilla. A

total of 692 implants was inserted (404 in

the mandible and 288 in the maxilla).

Pharmacological treatment associated withsurgical procedure

Antibiotic prophylaxis was prescribed 1h

before surgery, consisting of 2 g of amox-

icillin and clavulanic acid (Augmentins

,

Roche S.p.A., Milan, Italy).

Starting 3 days before surgery and then

daily for 7 days following surgery, chlor-

hexidine digluconate 0.2% mouthwash

(Curasepts

, Curaden HealthCare s.r.l.,

Saronno, Italy) was prescribed. A sedative

presurgery medication with 5mg i.v.

Fig. 1. Pre-operative OPG.

Agliardi et al Immediate loading in fully edentulous jaws

460 | Clin. Oral Impl. Res. 21, 2010 / 459465 c 2010 John Wiley & Sons A/S

diazepam (Valiums

, Roche S.p.A.) was

administered.

Implant surgery was performed using lo-

cal anaesthesia with articaine chlorhydrate

4% and epinephrin 1 : 100,000 (Alfacaina

N, Weimer Pharma, Rastat, Germany).

Corticosteroids (dexamethasone 4mg,

Soldesams

, Laboratorio Farmacologico

Milanese S.r.L., Milano, Italy), anti-in-

flammatory drugs (ketorolac trometha-

mine 30mg, Lixidols

, Roche S.p.A.)

and anti-acidity drugs (ranitidine, Zantacs

50mg, Glaxo Wellcome S.p.A., Verona,

Italy) were given during the surgery.

Surgical procedure for the mandible

A crestal incision was made from the first

molar region to the contralateral side. The

incision started on the lingual side of the

crest, and was as smaller as possible in

order to preserve vascularization as much

as possible and reduce the patient discom-

fort. A full-thickness buccal flapwas raised

exposing the vestibulary bony wall.

After flap reflection and detection of the

mental foramina, the length of the mental

nerve loop and the shape of the bone were

assessed, using an atraumatic instrument,

in order to determine the ideal angulation

of the posterior implants.

Soon before implants placement all com-

promised teeth were extracted, when pre-

sent, and sockets were carefully debrided.

All patients received four intraforaminal

implants (Branemark Systems

MKIV or

NobelSpeedyt Groovys

, Nobel Biocare

AB, Goteborg, Sweden). At first the two

distal tilted fixtures were placed. The

drill was inserted crestally in correspon-

dence with the alveolar nerve foramen

and tilted by about 301 relative to theocclusal plane. Thereafter, the two mesial

fixtures were inserted at the level of the

lateral incisors.

Bone density was assessed by the clin-

ician during the early phase of drilling and

scored according to the Lekholm and Zarb

classification (Lekholm& Zarb 1985). The

implant site was usually under prepared by

avoiding countersink, so as to maximize

implant stability.

A torque controller (Osseocares

, Nobel

Biocare AB) with a torque limit of 50Ncm

was used during implant placement. A

manual wrench was also used in case of

incomplete seating of the fixture.

Multi-unit abutments (MUAs

, Nobel

Biocare AB) were connected to the im-

plants. On the distal fixtures abutments

with an inclination of 301 relative to thefixture axis were placed (n 202), to allowfor an optimal prosthetic screw access,

while standard abutments were placed

over themesial fixtures (n 202). A torquecontroller (Osseocare

s

, Nobel Biocare AB)

with a torque limit of 50Ncm was used to

tight abutment screws at 25Ncm.

Surgical procedure for the maxilla

A crestal incision was performed starting

from the pterygomaxillary region and a

mucoperiosteal buccal flap was raised ex-

posing the vestibular bony wall so as to

identify the anterior wall of the maxillary

sinus.

The most distal implants were firstly

placed, engaging the anterior wall of the

maxillary sinus. They were inserted with

an angulation of about 30451 relative tothe occlusal plane. In order to control if the

implant site was entirely bordered by bone

and to assess the proper axis of the drill, a

direction pin was positioned into the im-

plant site before fixture insertion and a

radiograph taken. In case of risk of perfora-

tion of the sinus membrane, the drilling

axis was corrected. The two axial implants

were then inserted in the lateral incisors

position. All the implant sites were under-

prepared avoiding countersinking so as en-

gage as much cortical bone as possible.

Multi-unit abutments (MUAs

, Nobel

Biocare AB) were connected to the im-

plants. On the distal fixtures, abutments

with an inclination of 301 relative to thefixture axis were placed (n 144), whilestandard (n 127) or 171 (n 20) abut-ments were placed over the mesial fixtures

(n 202). The same torque controller usedfor mandible was used to tight abutment

screws at 25Ncm.

Delivery of the provisional prosthesis

After positioning the coping, the soft tis-

sues were sutured with a 5-0 resorbable

suture (monocryl or vicryl, Johnson

& Johnson Intl., St Stevens, Woluwe,

Belgium) and an impression was taken by

means of a silicon putty (Elite Implant

Impression Material, Zhermack S.p.A.,

Badia Polesine, Italy) directly on the cop-

ing. Healing capswere then positioned over

the multi-unit abutments.

Fig. 2. Pre-operative CT-Scan.

Agliardi et al Immediate loading in fully edentulous jaws

c 2010 John Wiley & Sons A/S 461 | Clin. Oral Impl. Res. 21, 2010 / 459465

No later than 3h of surgery an acrylic

provisional prosthesis with 10 teeth was

delivered. Again a torque controller was

used to tight prosthetic screws at 15Ncm.

Centric and lateral contacts were limited

to the intercanine zone. An orthopantomo-

graph was made to check implant position

and the coupling between prosthetic com-

ponents (Fig. 3).

Post-surgical phase

After surgery patients were instructed to

avoid brushing and any trauma to the

surgical site. Cold food was suggested for

the first day and a soft diet for the first

week. Pain killers (sodium naproxene,

Synflex Fortes

, Recordati, Milano, Italy)

were prescribed in case of pain.

After 46 months of function, in the

absence of pain and inflammation, the

patients underwent the final prosthetic

protocol. The final prosthesis was fabri-

cated using the CAD-CAM Proceras

Sys-

tem (Nobel Biocare, Stockholm, Sweden)

(Fig. 4).

Variables assessed

The following outcome measures were

evaluated in this study:

(a) Implant survival: Implant functional

and stable (the stability of individual

implantswas tested using two opposing

instruments pressure after unscrewing

the prosthesis), no peri-implant radiolu-

cency on radiographs, no suppuration

or pain at the implant site, no signs of

peri-implantitis, no neuropathies or

persistent paraesthesia.

(b) Marginal bone level: All radiographs

were scanned at 600 dpi with a scan-

ner and the marginal bone level (the

most coronal bone-to-implant con-

tact) was assessed onmesial and distal

aspects using an image analysis soft-

ware. The implant neck was the re-

ference for each measurement. Mesial

and distal values were averaged so as

to have a single value for each im-

plant.

(c) Plaque index and bleeding index:

Every implant was inspected on four

sites. The sites in which plaque or

bleeding could be detected were re-

corded as positive or negative, as de-

scribed previously (Francetti et al.

2008).

(d) Prosthesis success (i.e. prosthesis

functional and stable): A prosthesis

was considered failed if the function

was compromised for any reason.

All biological complications such as peri-

implantitis, periimplant mucositis, bleed-

ing on probing, suppuration, fistulas,

abscesses numbness of the lower lip or

chin, as well as mechanical or prosthetic

complications, like fracture of the implant

or of any prosthetic component, were re-

corded.

Follow-up

During the first month after surgery the

patients were seen once a week for control

visits, in which tissue healing and prosthe-

sis function were evaluated. Further visits

were scheduled at 6 and 12 months and

yearly thereafter up to 5 years.

During the first year plaque index and

bleeding index were assessed every 6

months. Orthopantomographs and, when

possible, periapical radiographs were taken

at any scheduled control visit to assess the

marginal bone loss and the overall bone

level throughout the study. Fig. 5 shows

OPT follow-up.

At the 1-year control visit stability of the

implants and prosthesis as well as proper

occlusion were also checked.

Data analysis

Cumulative implant survival rate was as-

sessed using the KaplanMeier statistics

Fig. 3. Post-surgical OPG.

Fig. 4. Final prosthesis.

Fig. 5. OPG with final prosthesis.

Agliardi et al Immediate loading in fully edentulous jaws

462 | Clin. Oral Impl. Res. 21, 2010 / 459465 c 2010 John Wiley & Sons A/S

(life table analysis). Marginal bone loss

around axially placed and tilted implants

was compared using paired Students t-test.

For the analysis of the plaque and bleeding

index the Pearson w2-test was used.P 0.05 was considered as the significancelevel.

Results

A total of 692 implants (92 Branemark

System MKIV and 600 Nobel Speedy

Groovy, all with TiUnite surface) were

placed in 173 patients [80 males and 93

females, mean age at surgery 57.3 8.5(SD) years, range 4274 years]. Forty-eight

of the included patients (27.8%) were smo-

kers. Seventy-two maxillary and 101 man-

dibular prostheses were delivered. All

prostheses were supported by four im-

plants. All implants could be seated with

an insertion torque of at least 30Ncm. All

provisional prostheses could be delivered

the same day of surgery as planned.

Implant distribution according to im-

plant type and implant length is detailed

in Tables 1 and 2, respectively.

The outcome analysis is based on those

154 patients (89% of total patients treated)

that have had their prosthesis in function

for at least 1 year at the time of the present

clinical report.

Ninety-three prostheses (372 implants)

were immediately loaded in the mandible.

The follow-up range was 1255 months

(mean value 26.9 12.5m). Patients haddifferent types of opposing dentition: remo-

vable prostheses (50 cases), natural teeth

(15 cases), natural teeth and fixed pros-

theses on natural teeth (12 cases), fixed

prostheses on natural teeth (three cases),

implant-supported bridges (nine cases),

natural teeth and two implant-supported

bridges (four cases).

Sixty-one prostheses (244 implants)

were immediately loaded in the maxilla.

The follow-up range was 1259 months

(mean value 31.3 14m). The opposingdentitions were implant-supported fixed

prostheses (25 cases), removable prostheses

(22 cases), natural teeth (nine cases) and

fixed prostheses on teeth (five cases).

No complications occurred during the

surgical phase. None of the patients reported

any post-surgical biological complication.

Four axially placed implants in the max-

illa (in four female patients) and one tilted

implant in the mandible (in one male

patient) failedwithin 6 months of function,

due to mobility. In all cases implant failure

did not compromise prosthesis function.

All implants could be successfully re-

placed. No late failures have been recorded

to date. No relation was found between

implant failure and the opposing dentition.

The overall cumulative implant survival

after 1 year was 99.19% (98.36% and

99.73% for implants placed in the maxilla

and mandible, respectively, as shown in

the two life table analyses of Tables 3 and 4

that include only cases with more than 1-

year follow-up).

The only prosthetic complication in this

study was the fracture of the acrylic pros-

thesis that occurred in 24 cases (15.6%), of

which 14 in the mandible (15%) and 10 in

the maxilla (16.4%).

The average marginal bone loss after 1

year from implant placement was

0.9 0.7mm in the maxilla (204 im-plants in 51 patients) and 1.2 0.9mmin the mandible (292 implants in 73 pa-

tients). Such differencewas not statistically

significant. No significant differences in

bone loss were found between axially

placed and tilted implants.

A progressive decrease in plaque and

bleeding scores was observed in the first

year.

Plaque index averaged 29.1% at 6

months (from 153 patients) and 20.7% at

12 months (from 124 patients); bleeding on

probing averaged 7.4% at 6 months and

2.6% at 12 months. The improvement at

12 months was statistically significant for

both indexes.

Discussion

This prospective study aimed at evaluating

the clinical and radiographic outcomes of a

technique for the immediate rehabilitation

of patients with edentulous jaws. The pre-

liminary results indicate that such techni-

que may lead to excellent prognosis, at

least in the short term. To our knowledge,

this is the largest prospective study on

patients treated using a combination of

axially placed and tilted implants in either

jaw.

The excellent results of the present study

are well comparable with previous retro-

spective (Malo` et al. 2003, 2005) and pro-

spective single cohort studies (Capelli et al.

2007; Agliardi et al. 2008, 2009; Testori et

al. 2008) that adopted similar techniques.

Indeed, in some of these prospective reports

(Capelli et al. 2007; Agliardi et al. 2008,

2009; Testori et al. 2008), six implants

instead of four were used for the immediate

maxillary rehabilitation. Furthermore, a

different implant system was adopted in

two of these studies (Capelli et al. 2007;

Testori et al. 2008), with a different type

and angulation of the implantabutment

connection for the tilted implants, and also

a different technique for the fabrication of

the final prosthesis.

The incidence of fracture of the acrylic

prostheses in the present study (15.6% of

the total cases) was lower as compared

with that reported by Malo et al. (2003)

(27%), and similar to that previously re-

ported by Francetti et al. (2008) and

Agliardi et al. (2008) (11%). This compli-

cation was observed mainly in men with a

short face morphotype, usually between 3

and 6 months of function. It could be

hypothesized that a possible cause for

such trouble was the progressive modifica-

tion of the diet, from a diet consisting of

Table1. Implant distribution according tothe implant type

Maxilla Mandible Total

MKIV 44 48 92Speedy groovy 244 356 600Total 288 404 692

Table2. Implant distribution according to the implant length

18mm 15mm 13mm 11.5mm 10mm 8.5mm Total

Number of implants (% maxilla) 18 (6.25) 164 (56.94) 49 (17.01) 40 (13.88) 17 (5.91) 0 288 (100)Number of implants (% mandible) 0 210 (51.98) 101 (25) 53 (13.11) 28 (6.93) 12 (2.98) 404 (100)Number of implants (% total) 18 (2.6) 374 (54.05) 150 (21.68) 93 (13.44) 45 (6.5) 12 (1.73) 692 (100)

Agliardi et al Immediate loading in fully edentulous jaws

c 2010 John Wiley & Sons A/S 463 | Clin. Oral Impl. Res. 21, 2010 / 459465

soft food to a one including hard food.

Another factor in the genesis of provisional

prosthesis fracture could be the progressive

wear of the resin due to repeated degluti-

tion and mastication cycles. It was noted

thatmost of the fractures took place next to

one of the anterior temporary abutments,

which is a weak point of the prosthetic

reconstruction. All the fractures had been

promptly repaired by the clinician without

sending the prostheses back to the labora-

tory, thereby avoiding further discomfort to

the patient. No correlation between these

fractures and the type of opposing dentition

could be found.

For the rehabilitation of the edentulous

mandible and maxilla, especially in those

cases of extremely reduced posterior ridges,

the ideal approach should endeavour at the

following: minimization of the total num-

ber of implants to decrease surgical mor-

bidity, reduction of the distal cantilever

without compromising the functional sup-

port, avoidance of demanding bone grafting

procedures and decrease of total treatment

time and costs. The latter item may be

achieved by adopting an immediate loading

protocol. Another predictable and cost-

effective solution for the immediate reha-

bilitation of the fully edentulous mandible

can be represented by implant-supported

overdentures (Bryant et al. 2007). How-

ever, due to their partial mucosal support

in the posterior regions, patients with ex-

tremely reduced posterior mandible might

experience pain due to compression of the

retroforaminal zones during mastication.

With the present protocol the level of

patients satisfaction was very good, post-

surgical discomfort was limited and an

immediate recovery of mastication and

aesthetic function could be provided. In

general, the treatment acceptance by pa-

tients was extremely favourable.

The progressive reduction of plaque and

bleeding scores reflected a good compliance

of the patients to the oral hygiene instruc-

tions. In this instance, the role of the dental

hygienist could be of utmost importance,

not only for the professional cleaning but

also for its active role in patients education

and motivation.

Concluding remarks

The results of the present prospective study

show that a combination of axially placed

and tilted implant for the immediate reha-

bilitation of edentulous jaws leads to ex-

cellent clinical outcomes. The advantages

of the immediate loading procedure, the

reduced morbidity, the high patients

satisfaction and the relatively low costs of

this surgical technique should be taken

into account when a decision among the

alternative therapeutic options has to be

made.

References

Agliardi, E., Francetti, L., Romeo, D. & Del Fabbro,

M. (2009) Immediate rehabilitation of the

edentulous maxilla: preliminary results of a single

cohort prospective study. The International

Journal of Oral & Maxillofacial Implants 24,

887895.

Agliardi, E.L., Francetti, L., Romeo, D., Taschieri, S.

& Del Fabbro, M. (2008) Immediate loading in the

fully edentulous maxilla without bone grafting:

the V-II-V technique. Minerva Stomatologica 57:

251263.

Aparicio, C., Ouazzani, W. & Hatano, N. (2008)

The use of zygomatic implants for prosthetic

rehabilitation of the severely resorbed maxilla.

Periodontology 2000 47: 162171.

Aparicio, C., Perales, P. & Rangert, B. (2001) Tilted

implants as an alternative to maxillary sinus

grafting: a clinical, radiologic, and periotest study.

Clinical Implant Dentistry & Related Research

3: 3949.

Attard, N.J. & Zarb, G.A. (2005) Immediate and

early implant loading protocols: a literature review

of clinical studies. The Journal of Prosthetic

Dentistry 3: 242258.

Avila, G., Galindo, P., Rios, H. &Wang, H.L. (2007)

Immediate implant loading: current status from

available literature. Implant Dentistry 16: 235

245.

Bahat, O. (1992) Osseointegrated implants in the

maxillary tuberosity: report on 45 consecutive

patients. The International Journal of Oral &

Maxillofacial Implants 7: 459467.

Balshi, T.J., Wolfinger, G.J. & Balshi, S.F. (1999)

Analysis of 356 pterygo-maxillary implants in

edentulous arches for fixed prosthesis anchorage.

The International Journal of Oral & Maxillofa-

cial Implants 14: 398406.

Branemark, P.I., Grondahl, K., Ohrnell, L.O., Nils-

son, P., Petruson, B., Svensson, B., Engstrand, P.

& Nannmark, U. (2004) Zygoma fixture in the

management of advanced atrophy of the maxilla:

technique and long-term results. Scandinavian

Journal of Plastic and Reconstructive Surgery

and Hand Surgery 38: 7085.

Bryant, S.R., MacDonald-Jankowski, D. & Kim, K.

(2007) Does the type of implant prosthesis affect

outcomes for the completely edentulous arch?

The International Journal of Oral & Maxillofa-

cial Implants 22 (Suppl.): 117139.

Calandriello, R. & Tomatis, M. (2005) Simplified

treatment of the atrophic posterior maxilla via

immediate/early function and tilted implants: a

prospective 1-year clinical study. Clinical Im-

plant Dentistry & Related Research 7: 112.

Capelli, M., Zuffetti, F., Testori, T. & Del Fabbro,

M. (2007) Immediate rehabilitation of the com-

pletely edentulous jaws with fixed prostheses

supported by upright and tilted implants. A multi-

center clinical study. The International Journal of

Oral & Maxillofacial Implants 22: 639644.

Del Fabbro, M., Testori, T., Francetti, L., Taschieri,

S. & Weinstein, R. (2006) Systematic review

of survival rates for immediately loaded

dental implants. The International Journal

of Periodontics and Restorative Dentistry 26:

249263.

Table3. Life table analysis for implants placed in the maxilla

Interval(months)

Number ofpatients

Number ofimplants

Failedimplants

Intervalsurvival (%)

Cumulativesurvival (%)

012 61 244 4 98.36 98.361224 61 240 0 100 98.362436 39 155 0 100 98.363648 24 94 0 100 98.364860 11 43 0 100 98.36

Table4. Life table analysis for implants placed in the mandible

Interval(months)

Number ofpatients

Number ofimplants

Failedimplants

Intervalsurvival (%)

Cumulativesurvival (%)

012 93 372 1 99.73 99.731224 93 371 0 100 99.732436 58 231 0 100 99.733648 29 116 0 100 99.734860 7 28 0 100 99.73

Agliardi et al Immediate loading in fully edentulous jaws

464 | Clin. Oral Impl. Res. 21, 2010 / 459465 c 2010 John Wiley & Sons A/S

Esposito, M., Grusovin, M.G., Willings, M.,

Coulthard, P. & Worthington, H.V. (2007) Inter-

ventions for replacing missing teeth: different

times for loading dental implants. Cochrane Da-

tabase of Systematic Reviews. Chichester, UK:

John Wiley & Sons Ltd.

Fortin, Y., Sullivan, R. & Rangert, B.R. (2002) The

marius implant bridge: surgical and prosthetic

rehabilitation for the completely edentulous upper

jaw with moderate to severe resorption: a 5-year

retrospective clinical study. Clinical Implant

Dentistry & Related Research 4: 6977.

Francetti, L., Agliardi, E., Testori, T., Romeo, D.,

Taschieri, S. & Del Fabbro, M. (2008) Immediate

rehabilitation of the mandible with full prosthesis

supported by axial and tilted implants: interim

results of a single cohort prospective study. Clin-

ical Implant Dentistry & Related Research 10:

255263.

Galan Gil, S., Penarrocha Diago, M., Balaguer

Martnez, J. & Marti Bowen, E. (2007) Rehabili-

tation of severely resorbed maxillae with zygo-

matic implants: an update. Medicina oral,

patologa oral y ciruga bucal 12: E216E220.

Goene, R., Bianchesi, C., Huerzeler, M., Del Lupo,

R., Testori, T., Davarpanah, M. & Jalbout, Z.

(2005) Performance of short implants in partial

restorations: 3-year follow-up of osseotite im-

plants. Implant Dentistry 14: 274280.

Ioannidou, E. & Doufexi, A. (2005) Does loading

time affect implant survival? A meta-analysis of

1,266 implants. The Journal of Periodontology

76: 12521258.

Jokstad, A. & Carr, A.B. (2007) What is the effect on

outcomes of time-to-loading of a fixed or remo-

vable prosthesis placed on implant(s)? The Inter-

national Journal of Oral & Maxillofacial

Implants 22 (Suppl.): 1948. Erratum in: The

International Journal of Oral & Maxillofacial

Implants (2008) 23: 56.

Khayat, P. & Nader, N. (1994) The use of osseoin-

tegrated implants in the maxillary tuberosity.

Practical Periodontics and Aesthetic Dentistry

6: 5361.

Koutouzis, T. & Wennstrom, J.L. (2007) Bone level

changes at axial- and non-axial-positioned im-

plants supporting fixed partial dentures. A 5-year

retrospective longitudinal study. Clinical Oral

Implants Research 18: 585590.

Krekmanov, L. (2000) Placement of posterior man-

dibular and maxillary implants in patients with

severe bone deficiency: a clinical report of proce-

dure. The International Journal of Oral & Max-

illofacial Implants 15: 722730.

Krekmanov, L., Kahn, M., Rangert, B. & Lindstrom,

H. (2000) Tilting of posterior mandibular and

maxillary implants of improved prosthesis sup-

port. The International Journal of Oral & Max-

illofacial Implants 15: 405414.

Lekholm, U. & Zarb, G.A. (1985) Patient selection

and preparation. In: Branemark, P.-I., Zarb, G.A.

& Albrektsson, T., eds. Tissue-Integrated Pros-

theses: Osseointegration in Clinical Dentistry,

201209. Chicago, IL: Quintessence.

Malo, P., de Araujo Nobre, M. & Rangert, B. (2007)

Short implants placed one-Stage in Maxi-

llae and Mandibles: a retrospective clinical study

with 1 to 9 years of follow-up. Clinical Implant

Dentistry & Related Research 9: 1521.

Malo, P., De Araujo Nobre, M. & Lopes, I. (2008) A

new approach to rehabilitate the severily atrophic

maxilla using extramaxillary anchored implants

in immediate function: A pilot study. Journal of

Prosthetic Dentistry 100: 354366.

Malo, P., Rangert, B. & Nobre, M. (2003) All-on-

Four immediate-function conceptwith Branemark

system implants for completely edentulous mand-

ibles: a retrospective clinical study.Clinical Implant

Dentistry & Related Research 5 (Suppl. 1): 29.

Malo, P., Rangert, B. & Nobre, M. (2005) All-on-4

immediate-function concept with Branemark

System implants for completely edentulous max-

illae: a 1-year retrospective clinical study.Clinical

Implant Dentistry & Related Research 7 (Suppl.

1): S88S94.

Nkenke, E. & Fenner, M. (2006) Indications for

immediate loading of implants and implant suc-

cess. Clinical Oral Implants Research 17 (Suppl.

2): 1934.

Renouard, F. & Nisand, D. (2005) Short implants in

the severely resorbed maxilla: a 2-year retrospec-

tive clinical study. Clinical Implant Dentistry &

Related Research 7: 104110.

Sennerby, L. & Gottlow, J. (2008) Clinical out-

comes of immediate/early loading of dental im-

plants. A literature review of recent controlled

prospective clinical studies. Australian Dental

Journal 53 (Suppl. 1): S82S88.

Shackleton, J.L., Carr, L., Slabbert, J.C. & Becker,

P.J. (1994) Survival of fixed implant-supported

prostheses related to cantilever lengths. The Jour-

nal of Prosthetic Dentistry 71: 2326.

Testori, T., Del Fabbro, M., Capelli, M., Zuffetti, F.,

Francetti, L. & Weinstein, R.L. (2008) Immediate

occlusal loading and tilted implants for the reha-

bilitation of the atrophic edentulous maxilla: 1-

year interim results of a multicenter prospective

study. Clinical Oral Implants Research 19: 227

232.

Venturelli, A. (1996) A modified surgical protocol

for placing implants in the maxillary tuberosity:

clinical results at 36 months after loading with

fixed partial dentures. The International Journal

of Oral & Maxillofacial Implants 11: 743749.

Agliardi et al Immediate loading in fully edentulous jaws

c 2010 John Wiley & Sons A/S 465 | Clin. Oral Impl. Res. 21, 2010 / 459465