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Implant Rehabilitation of the Atrophic Edentulous

Maxilla Including Immediate Fixed Provisional
Restoration Without the Use of Bone Grafting:
A Review of 1-Year Outcome Data from a
Long-Term Prospective Clinical Trial
Joseph A. Toljanic, DDS1/Russell A. Baer, DDS2/Karl Ekstrand, DDS, MS, PhD, Odont Dr3/
Andreas Thor, DDS, PhD4

Purpose: The literature suggests that predictable integration can be achieved when dental implant
placement is combined with immediate fixed provisional restoration in a variety of clinical situations.
Fewer data are available, however, regarding outcomes for immediate provisional restoration of
implants in the edentulous maxilla. This report presents 1-year data acquired from a long-term
prospective clinical trial designed to assess outcomes following the immediate provisional fixed
restoration of implants in the atrophic edentulous maxilla without the use of bone augmentation.
Materials and Methods: Fifty-one subjects diagnosed with an atrophic edentulous maxilla received a
total of 306 implants (six implants per subject) followed by fixed provisional restoration within 24 hours
of implant placement. No subjects underwent grafting to enhance bone volume in preparation for
implant treatment. Data acquired included bone quantity and quality, implant dimensions, implant
locations, and implant placement stability. Subjects returned for 1-year follow-up examinations to
assess implant integration and restoration function. Periapical radiographs were obtained and com-
pared to baseline images to assess marginal bone height maintenance. Results: At the 3-month follow-
up examination, 294 of 306 implants placed in 51 subjects were found to be integrated. This repre-
sents a cumulative implant survival rate of 96%. At the 1-year follow-up examination, mean marginal
bone loss of 0.5 mm was noted, with no further loss of implants. Conclusions: These results support
the contention that predictable long-term outcomes may be obtained for the atrophic edentulous max-
illa when treated with an implant rehabilitation protocol that includes immediate fixed provisional
restoration without the use of bone grafting. This strategy offers a promising treatment alternative for
the patient with an atrophic edentulous maxilla. INT J ORAIL MAXILLOFAC IMPLANTS 2009;24:518–526

Key words: dental implants, edentulous maxilla, immediate restoration

large body of evidence has accumulated over the

A past 10 years in support of immediate fixed provi-
sional restoration of dental implants.1–14 The combina-
1Former Professor and Chief, Section of Dentistry, The University
of Chicago, Illinois, and current Staff Prosthodontist, Jesse tion of immediate fixed provisional restoration with
Brown VA Medical Center, Chicago, Illinois. implant placement appears to offer a predictable
2Clinical Associate, Section of Dentistry, The University of
treatment option in a wide variety of clinical applica-
Chicago, Illinois. tions, with outcomes that rival those obtained using
3Associate Professor and Director, Postgraduate Education, The
standard delayed implant restoration protocols.1–14
University of Oslo, Norway.
4Assistant Professor, Oral and Maxillofacial Surgery, Department of Less information is currently available describing
Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden. outcomes for immediate fixed provisional restoration
of implants in the edentulous maxilla. It is commonly
Correspondence to: Dr Joseph Toljanic, Jesse Brown VA Medical anticipated that, following tooth extraction, the
Center (160), 820 S. Damen Avenue, Chicago, IL 60612.
Fax: +312-569-8089. Email: joseph.toljanic@va.gov
edentulous maxilla will exhibit marked progressive
loss of alveolar bone volume and density. The loss of
Presented as a poster at the 16th annual meeting of the Euro- alveolar bone may reduce the number of adequate
pean Academy of Osseointegration, Barcelona, Spain, in 2007. sites available for implant placement. Inadequate

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bone volume and density may further limit the abil- of implant placement. They reported an implant sur-
ity to achieve primary implant stability, permitting vival rate of 97.6% over an interval up to 3 years.24
postoperative implant micromotion to occur beyond While this initial work is clearly encouraging, addi-
currently accepted physiologic thresholds for suc- tional research appears warranted to better assess
cessful integration.15,16 the predictability of this protocol over time. The pur-
In spite of these inherent challenges, reports have pose of the present article is to report on outcomes
appeared in the literature describing favorable out- obtained to date from a prospective long-term clini-
comes for the edentulous maxilla. Tarnow and cal trial designed to further assess the efficacy of a
coworkers, in evaluating the efficacy of provisional treatment protocol that includes immediate fixed
restorations in both the mandible and maxilla, imme- provisional restoration of implants placed in the
diately loaded 34 implants in four subjects with atrophic edentulous maxilla without the use of bone
edentulous maxillae. 17 They reported no loss of augmentation procedures.
implants over a follow-up period from 1 to 3 years.
Horiuchi and coworkers reported similarly promising
outcomes in five subjects following immediate load- MATERIALS AND METHODS
ing of 44 implants; they obtained a 95.4% survival
rate over a 1- to 2-year follow-up interval.18 Fifty-one subjects recruited from a population of
Recent reports in the literature continue to patients under routine care at two participating cen-
describe good outcomes. Balshi and coworkers, in a ters (the University of Chicago, Section of Dentistry,
prospective study of 55 subjects who received 522 and Uppsala University Hospital, Sweden) were
implants immediately loaded with fixed provisional enrolled in the study. The mean age of this population
restorations, reported an implant survival rate of 99% was 65.8 years (range, 47 to 83 years), with a gender
over a mean follow-up interval of 2.78 years.19 Van distribution of 47% men and 53% women. Informed
Steenberghe and coworkers reviewed outcomes of written consent was obtained from all subjects fol-
164 implants placed in 24 subjects using a computer- lowing approved institutional review board guide-
ized tomographic (CT) scan–derived customized sur- lines for clinical research. Individuals identified as hav-
gical guide stent and a flapless surgical procedure fol- ing an atrophic edentulous maxilla based on clinical
lowed by immediate fixed provisional restoration. and radiographic examination were considered for
They reported a 100% implant survival rate at 1 year.20 study enrollment. A diagnosis of maxillary atrophy
Ibanez and coworkers treated subjects with one or was made using a classification system designed to
both arches edentulous. They reported a 100% sur- score alveolar bone quantity on a scale from A (mini-
vival rate for 217 implants placed into 26 edentulous mal alveolar bone resorption) to E (extreme bone
maxillae and restored with fixed provisional restora- resorption) and bone quality on a scale from 1 (mostly
tions within a 48-hour period over a follow-up interval compact bone present) to 4 (mostly trabecular bone
of 1 to 6 years.21 Ostman and coworkers placed 123 present).25 All scoring was made based on the clinical
implants in 20 subjects followed by provisional fixed judgment of the investigators after examination of
restoration within 12 hours.22 They then retrospec- each maxilla and visual assessment of panoramic radi-
tively compared these outcomes to a reference group ographs without the use of other imaging tools (eg,
of 20 patients previously treated with 120 implants grayscale measurements in Hounsfield units). Sub-
but who received no provisional restoration. The jects were considered eligible for enrollment if they
authors reported a 1-year implant survival rate received bone quantity scores of C, D, or E and bone
greater than 99% in the study population, as com- quality scores of 3 or 4. Because no bone augmenta-
pared to an implant survival rate of 100% in the refer- tion was permitted within 6 months of study enroll-
ence group. Malo and coworkers reported on 1-year ment, subjects were therefore required to have suffi-
outcomes for 32 patients who had undergone cient native bone volume to accept placement of the
implant rehabilitation in the edentulous maxilla fol- smallest implant available to the investigators (3.5
lowed by immediate provisional fixed restoration. The mm in diameter and 8 mm in length). Subject enroll-
authors employed a CT scan–derived surgical guide ment occurred consecutively for candidates identified
stent for implant placement combined with a proto- as having atrophic edentulous maxillae and who met
col that, most interestingly, limited the number of all other study inclusion/exclusion criteria (Table 1).
implants placed to four per patient.23 They reported a Strict adherence to these criteria would have permit-
cumulative implant survival rate of 97.6%. Most ted enrollment of an individual with a history of alve-
recently, Capelli and coworkers evaluated the out- olar bone augmentation more than 6 months prior to
comes of 246 implants placed in 41 subjects, who implant placement, but none of the participants had
received fixed provisional restorations within 48 hours any history of bone grafting.

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Table 1 Inclusion and Exclusion Criteria for Subject Enrollment

Inclusion criteria
1. Adults (defined as individuals 20 years of age or older)
2. History of a fully edentulous maxilla for a minimum of 3 months
3. Clinical and radiographic findings indicating bone quantity types C, D, or E at sites of proposed implant
placement (Lekholm and Zarb classification25)
4. Clinical and radiographic findings indicating bone quality scores of 3 or 4 at sites of proposed implant place-
ment (Lekholm and Zarb classification25)
5. Presence of natural healthy and/or restored mandibular teeth to level of second premolars
6. Ability to provide informed written consent.
7. Ability to return for all study visits as outlined in investigational plan
Exclusion criteria
1. Inability to comply with all study procedures as outlined in investigational plan
2. Presence of uncontrolled systemic disease
3. Presence of uncontrolled dental disease
4. History of chemotherapy or head and neck radiotherapy
5. History of alveolar bone augmentation surgery within 6 months of study treatment
6. History of tobacco product use within 6 months of study treatment
7. Subject pregnancy

Each subject underwent surgery following an osteotomy. Typically no action was taken to surgi-
investigational protocol that included the placement cally correct these areas of thread exposure. Where
of 6 implants into the maxilla. A threaded self- limited bone was available in the posterior maxilla,
tapping implant with microthreads in the collar area the distal osteotomy preparation was further modi-
was chosen for use in this study (OsseoSpeed, Astra fied to place the implant with a distal angulation (Fig
Tech, Sweden). This implant has a microroughened 2). This permitted the use of longer implants to maxi-
titanium surface that is chemically modified with mally engage native bone while at the same time
fluoride. It was theorized by the investigators that an positioning the implant platform posteriorly to
implant with these design features and surface modi- enhance the distribution of support for the restora-
fications might maximize the ability to obtain pri- tion. This angulated placement commonly resulted in
mary implant stability while enhancing the potential the implant being positioned adjacent to the ante-
for osseointegration. Screw-retained fixed provisional rior wall of the maxillary sinus (Fig 3). Following the
restorations were fabricated and delivered to each placement of three implants on one side, attention
subject within 24 hours of implant placement. was turned to the opposite side of the maxilla, where
the surgical procedures were repeated.
Surgical Protocol Transmucosal abutments were screwed into place
Implant surgery was performed under infiltrative on the implants (Fig 4). Straight or angled transmu-
local anesthesia using standard accepted soft tissue cosal abutments were chosen by the investigators to
flap designs. The flap was first raised on one side of correct for divergent implant placement angulations
the maxilla, extending from a point just posterior to and to enhance screw access hole positions for maxi-
the nasopalatine papilla distally to the site of antici- mum esthetic outcomes. Six stock copings available
pated placement of the distal implant. Osteotomies from the implant manufacturer were then cut to the
were initiated by introducing a pilot drill to the site. A desired size and screwed into place onto the trans-
clear acrylic resin surgical stent, fabricated by dupli- mucosal abutments for later use in retaining the
cating the denture prosthesis previously worn by the fixed provisional restoration. Finally, the soft tissue
subject, was used to guide osteotomy locations. Care flaps were sutured around the transmucosal abut-
was taken during the osteotomy site enlargement ments/retentive copings (Fig 5).
sequence to take into account the lack of bone den-
sity that was commonly encountered. This led to fre- Provisional Restoration Protocols
quent underpreparation of the osteotomy site rela- Provisional screw-retained fixed restorations were
tive to the planned implant diameter, with reliance fabricated using both direct and indirect methods in
on the self-tapping design of the implant to laterally this study.
compress the bony walls to maximize primary stabil- To initiate direct fabrication, complete maxillary
ity (Fig 1). Crestal bone fenestrations were commonly denture prostheses worn by the subjects at the time
encountered, which at times resulted in exposure of of study enrollment were commonly used. If the pros-
several implant threads on the buccal side of the thesis was ill-fitting and/or possessed inadequate

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Fig 1 The 2.5-mm twist drill used for final Fig 2 Panoramic image demonstrating implants in place on the day of surgery. Note the
osteotomy preparation next to the 4.5-mm- angulation of posterior implants following the anterior wall of maxillary sinus.
diameter implant inserted into the prepared
site. Note the differences in diameters
between the implant and the twist drill.

Fig 3 Periapical radiograph showing angu-

lation of the distal implant in close proxim-
ity to the anterior wall of the maxillary
sinus.

Fig 4 Intraoperative placement of transmu- Fig 5 Sutures were used to close the
cosal implant abutment cylinders. wound around the transmucosal abutments
and retentive copings immediately prior to
provisional restoration fabrication.

vertical dimension or occlusal contacts, a new den- and excessive focal contacts were reduced. Esthetics
ture prosthesis was fabricated. On the day of treat- were assessed and revised as needed (Fig 8). The use
ment, holes were drilled into the prosthesis corre- of this treatment protocol resulted in the delivery of
sponding to the locations of the six copings screwed the fixed provisional restorations within 3 hours of
onto the implant abutments (Fig 6). An autopolymer- implant placement.
izing acrylic resin was then painted around each of For indirect fabrication, fixed provisional restora-
the retentive copings to lute them to the prosthesis. tions were created as follows. Prior to treatment, max-
Following polymerization of the acrylic resin, the illary denture prosthesis fabrication was performed
retentive copings were unscrewed and the prosthesis up to the wax-up stage. The wax-up was duplicated
was removed from the mouth. The palate and flanges to permit fabrication of an acrylic resin surgical guide
of the prosthesis were then removed and glass-fiber stent and a custom impression tray. A clear acrylic
reinforcement material was luted into the lingual sur- resin copy of the denture prosthesis wax-up was also
face with additional autopolymerizing acrylic resin fabricated. Immediately after implant placement
(EverStick C & B fiber reinforcement, Preat Corp, Santa surgery, an abutment-level impression was made. The
Ynez, CA) (Fig 7). After the provisional restoration was clear acrylic resin copy of the denture prosthesis wax-
delivered, centric occlusal contacts were assessed up was then lined with a silicone impression material

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Fig 6 Prosthesis held in place in the Fig 7 Fixed provisional restoration finished Fig 8 Anterior view of fixed provisional
mouth. Note the easy visualization of the with removal of flanges/palate and with restoration demonstrating the esthetic out-
six retentive coping cylinders through previ- incorporation of glass fiber reinforcement come.
ously prepared holes. material into the lingual aspect of the pros-
thesis.

Fig 9 A clear acrylic resin denture prosthe-

sis duplicate was used to mount the master
cast onto an articulator.

Fig 10 Occlusal view of treatment site at

12 week follow-up interval.

(Provil, Heraeus-Kulzer, South Bend, IN) and placed surgical investigators during osteotomy preparation.
into the mouth. While it was in place, a registration of Primary stability measurements were made for each
centric relation was obtained. implant using a calibrated torque wrench (Torque-
After removal from the mouth, the master cast Lock Wrench, Intra-Lock International Inc, Boca Raton,
was inserted into the silicone impression material FL) that measured the amount of torque (in Ncm)
contained within the clear denture prosthesis dupli- required to fully seat the implant. Baseline periapical
cate and mounted on an articulator (Fig 9). The radiographs of all implants were obtained at implant
screw-retained provisional restoration was then fab- placement surgery using commercially available film
ricated on this mounted master cast. A titanium holders and a paralleling imaging technique. Marginal
mesh, laser-welded to the titanium copings, was bone height was determined on these images by
embedded into this restoration to increase fracture measuring the distance from a reference point,
resistance. These restorations were delivered within defined as the junction of the roughened and
24 hours of implant placement surgery. machined beveled surface, to the most coronal point
Postoperative medications included appropriate of bone-to-implant contact on both the mesial and
oral antibiotics and a topical antimicrobial rinse as distal sides of the implant. A single value for marginal
well as oral analgesics. Hygiene instructions included bone height was then calculated by obtaining the
gentle brushing for the first week without flossing mean of these two measurements for each implant.
for the first 4 weeks. After this time, subjects were All measurements were obtained to the nearest 0.1
instructed to resume normal brushing and flossing. mm under 7⫻ magnification by an independent radi-
Subjects were dismissed with instructions to main- ologist not affiliated with the two study treatment
tain a soft diet for 6 weeks. centers.
Subjects returned at posttreatment weeks 2 and 4
Data Acquisition and Subject Follow-up for follow-up examination. Assessment of healing at
Data recorded at the time of implant placement/pro- the surgical sites and function of the fixed provi-
visional restoration included the length and diameter sional restorations were performed at these visits
of each implant placed, along with implant locations. without removing the fixed provisional restorations.
Bone quantity and quality at each implant placement Subjects then returned at posttreatment week 12, at
site were scored based on visual inspection, radi- which time the provisional restorations were
ographic findings, and the tactile sense gained by the removed and implant integration clinically assessed

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Table 2 Marginal Bone Height at Implant Placement, Placement of

Definitive Restoration (20 to 24 Weeks), and at 1 Year
Marginal bone height
No. of
Time implants Mean ± SD Median Minimum Maximum

Implant placement 262 0.4 ± 0.5 0.3 0.0 2.8

20–24 wk 264 0.9 ± 0.7 0.9 0.0 4.3
1y 262 0.9 ± 0.8 0.8 0.0 4.1

Table 3 Distribution of Implants with Respect to Bone Quantity

and Quantity at Implant Placement24
Bone quantity
No. of
Bone quality A B C D E % implants

3 0 0 116 58 1 57 175
4 0 0 74 57 0 43 131
% 0 0 62 38 0
No. of implants 0 0 190 115 1 306

Table 4 Distribution of Implant Dimensions

Length (mm)
No. of
Diameter (mm) 8 9 11 13 15 17 % implants

3.5 2 3 30 77 13 2 42 127
4.0 0 5 21 80 4 1 36 111
4.5 0 1 11 41 2 0 18 55
5.0 0 0 1 11 1 0 4 13
% 1 3 21 68 6 1
No. of implants 2 9 63 209 20 3 306

in preparation for fabrication of the definitive fixed implant surgery, and the remaining 26 restorations
screw-retained restorations (Fig 10). Fabrication of were fabricated using the indirect technique. One sub-
the definitive restoration proceeded using standard ject was subsequently lost to follow-up 4 weeks after
accepted restorative procedures for a metal/acrylic implant placement for reasons unrelated to study par-
resin framework (titanium) prosthesis, with delivery ticipation. During the 12-week follow-up interval fol-
occurring 20 to 24 weeks after implant surgery. Fol- lowing implant placement/provisional restoration, 12
low-up periapical radiographs were obtained at the implants in five subjects were identified as integration
time of restoration delivery. failures requiring removal.Three of these subjects were
Subjects returned 6 months after implant surgery, no longer able to wear a fixed restoration and subse-
at which time the function of the definitive restora- quently were withdrawn from study participation. One
tion was assessed. This restoration was then removed, additional subject who remains under follow-up has
and implant integration was clinically evaluated. Sub- not reached the scheduled 1-year follow-up visit at this
jects then returned 1 year after implant surgery, at time. Of the 46 subjects reaching the 1-year follow-up
which time all restorations were again removed and interval, no additional implant integration failures have
inspected. Implants were assessed clinically for inte- occurred, resulting in a cumulative survival rate of 96%.
gration maintenance. Periapical radiographs were Mean marginal bone loss from implant surgery (base-
obtained and marginal bone height measurements line) to placement of the definitive fixed restoration
repeated to permit comparisons with baseline data. was found to be 0.5 mm (SD 0.7), with no additional
marginal bone loss encountered at the 1-year follow-
up interval (0.5 mm, SD 0.8) (Table 2).
RESULTS In assessing the distribution pattern of implant
placement in relationship to bone quantity and qual-
Following the investigational protocol, 306 implants ity, the majority of implants were noted to have been
were placed into the study population, retaining 51 placed in osseous tissue clinically rated as type C bone
fixed provisional restorations. Twenty-five of these quantity, although 38% of all implants were placed in
restorations were fabricated directly on the day of sites clinically rated as type D bone quantity (Table 3).

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Table 5 Distribution of Implant Locations

Central Lateral First Second First Second Third
incisors incisors Canines premolars premolars molars molars molars Total

No. 56 21 82 46 55 43 3 0 306
% 18 7 27 15 18 14 1 0 100

Table 6 Primary Implant Stability as Assessed by Seating Torque Values

Seating torque values (Ncm)
0–10 11–15 16–20 21–25 26–30 31–35 36–40 41–45 > 45 Unknown Total

No. 36 35 42 42 20 32 13 12 49 25 306
% 12 11 14 14 7 11 4 4 16 8 100

A more equal distribution for implant placement was implant stability is essential for success when immedi-
noted in types 3 and 4 bone quality (Table 3). ate fixed provisional restoration is included in implant
Marked variability was noted in the implant sizes rehabilitation. Based on a recent in-depth review of
selected for placement, although implants of 11 mm the literature on immediate provisional restoration of
and 13 mm in length and 3.5 mm, 4.0 mm, and 4.5 mm implants, one set of authors found strong support for
in diameter were most commonly used ( Table 4). the conclusion that primary implant stability is a req-
Marked variability was noted in implant placement uisite for obtaining predictable outcomes.26 Following
locations, although canine sites were most commonly a literature review that focused on published reports
selected, followed by second premolar and central of outcomes for immediate loading in completely
incisor sites (Table 5). A large variability in primary edentulous patients, another author found a similar
implant stability achieved for each implant, as assessed consensus of opinions regarding the importance of
via seating torque values, was also noted, although 38% primary implant stability.27
of all implants placed required a torquing force of 20 Factors that might favorably impact on achieving
Ncm or less to fully seat the implant (Table 6). primary implant stability in the edentulous maxilla
may include the use of implants with specific surface
modifications, underpreparation of osteotomy sites,
DISCUSSION and cross-arch splinting of implants.21,22 The technique
of distally tilting implants has also been recom-
Recent reports have provided support for a hypothesis mended for use in the posterior maxilla. This configu-
that good outcomes may be achieved in the edentu- ration, designed to avoid the placement of implants in
lous maxilla with the use of an implant rehabilitation bone of poorer quality and quantity in the area of the
protocol that includes immediate fixed provisional maxillary sinus, could enhance primary implant stabil-
restoration. Implant survival rates ranging from 97.6% ity by engaging more bone with longer implants.24
to 100% have been described over a follow-up interval Such a placement strategy may offer an effective alter-
of 1 year or longer for most subjects.19–24 Mean peri- native to sinus-lifting augmentation techniques for the
implant marginal bone loss of 0.76 to 1.15 mm has atrophic maxilla.24 In two recent studies that included
been reported. 20–24 The findings from the current an assessment of angulated implant placement in the
study are consistent with these reported outcomes, edentulous maxilla, the authors reported good inte-
where the 1-year implant survival rate was found to be gration outcomes for distally tilted implants.24,28
96%, with mean marginal bone loss of 0.5 mm. The Atrophy is a common clinical condition among
results of this study were obtained in subjects with patients with edentulous maxillae. Such a condition
atrophic maxillae. The favorable outcomes seen in this can create a more challenging environment for
more challenging population might be viewed as obtaining primary stability. Because the investiga-
added support for this treatment protocol. tional plan in the current study was specifically
Future reports describing outcomes with longer designed to select subjects with atrophic maxillae,
follow-up will certainly provide further insight regard- the investigators incorporated the strategies
ing the efficacy of this treatment approach. It may be described here, including the use of implants with
equally important to better understand the individual favorable surface qualities, underpreparation of
factors that may affect long-term outcomes. It appears osteotomy sites, and angulated implant placement in
to be generally accepted that achieving primary the area of the maxillary sinus with the intent of

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improving the primary stability of each implant. resulting in good outcomes. Of note, Malo and
Overall implant stabilization was enhanced by pro- coworkers reported good outcomes for a protocol
viding cross-arch stabilization through the use of that included the use of four implants in the edentu-
immediate fixed provisional restoration. lous maxilla followed by immediate provisional
The favorable outcomes as experienced in this restoration. 23 Such outcomes provide strong evi-
study might be interpreted as resulting from these dence for the efficacy of immediate provisional
combined surgical and restorative strategies. How- restoration while showing promise for a new
ever, it should be noted that more than one third of approach that would have important implications for
the implants placed in the study were seated with a routine clinical practice, where patient acceptance of
torque of 20 Ncm or less. While primary implant sta- treatment is frequently a matter of cost. Perhaps
bility likely plays a role in achieving successful out- cross-arch stabilization creates a group primary
comes, perhaps other factors may be acting sepa- implant stability that supersedes the value of individ-
rately or synergistically with implant stability to ual implant stability in enhancing outcomes. A study
obtain the degree of success currently being design that prospectively introduces suboptimal
reported in the literature. Efforts to better under- implant primary stability combined with cross-arch
stand all factors involved and their interrelationships stabilization may prove to be a fruitful path of inquiry
would help clinicians to predictably provide implant for future research to assess the relative merits of
rehabilitation to patients with an edentulous maxilla. individual implant stability. In a related side note, it
While some strategies may present as intuitively has been suggested that immediate loading of
appealing methods for enhancing primary stability, implants in the edentulous maxilla might provide a
outcomes as published in the literature make their positive stimulatory effect on osseous tissues and
actual value less clear. Increased implant length enhance osseointegration outcomes.22
would seem to offer an opportunity to further aug- Finally, the impact of the forces of occlusion gen-
ment primary implant stability. Ibanez and cowork- erated by an opposing dentition on implant rehabili-
ers, however, in describing outcomes when immedi- tation outcomes for the atrophic edentulous maxilla
ately loading implants in both the edentulous remains to be clarified. Questions linger regarding
maxilla and mandible, reported no failures with short the impact of the forces generated by a fully dentate
implants (≤ 10 mm).21 In the current study, 74 of the mandible when compared to that seen with a par-
300 implants placed were ≤ 11 mm, with only four of tially edentulous mandible with or without a remov-
these shorter implants experiencing integration fail- able partial denture restoration. Because the status
ures. Perhaps other factors limit the impact of of the mandibular dentition has been recorded in
implant length on outcomes. the present ongoing study, this issue might be clari-
Similarly, bone type as defined using currently fied as more outcome data are acquired over the
accepted indices of quantity and quality25 may not be planned 5-year follow-up interval.
as clearly linked to successful integration outcomes The outcomes described for the current study
as previously thought. It might be anticipated that have been drawn from an ongoing long-term clinical
poor quantity and quality bone should be viewed as trial with an investigational plan that includes 5-year
providing an inadequate bed for establishing primary subject follow-up. All 47 subjects are scheduled to
implant stability. Good integration outcomes in the remain under annual observation over this 5-year
edentulous maxilla have been reported, however, for interval, with the intent to continue reporting on out-
implants placed in types C and D bone quantity20,22 comes over time and so further contribute to the
as well as in types 3 and 4 bone quality.20–22 In the body of knowledge currently available with regard to
current study, all implants were placed in atrophic immediate loading of implants in the edentulous
maxillae with types C and D bone quantity and types maxilla.
3 and 4 bone quality. The high rate of integration
experienced here seems to suggest that as long as
there is sufficient bone to encase the implants of the CONCLUSION
dimensions proposed for use, then bone quality and
quantity may play a lesser role in outcomes than The outcomes from this ongoing study reported at
other factors in the edentulous maxilla. the 1-year follow-up interval suggest that predictable
Questions remain regarding the number of implant integration outcomes can be achieved when
implants needed to achieve predictable outcomes in implant placement is combined with immediate fixed
the edentulous maxilla. Recommended numbers provisional restoration in the atrophic edentulous
range from six to 10 implants per subject.19–22 In the maxilla. These outcomes are comparable to those
current study, six implants were used for each subject, reported elsewhere. Stable marginal bone levels were

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maintained. The use of such an implant rehabilitation 13. Degidi M, Piattelli A, Gehrke P, Carinci F. Clinical outcome of
strategy may offer a valuable alternative to patients 802 immediately loaded 2-stage submerged implants with a
new grit-blasted and acid-etched surface: 12-month follow-
who wish treatment to be provided more rapidly and
up. Int J Oral Maxillofac Implants 2006;21:763–768.
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