immediate fixed restoration of implants in the atrophic ... · of implants in the atrophic...

Continuing Education

Immediate Fixed Restoration

of Implants in the Atrophic

Edentulous MaxillaAuthored by Joseph A. Toljanic, DDS, Andreas Thor, DDS, PhD,

Russell Baer, DDS and Karl Ekstrand, DDS, MS

Course Number: 102.2

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ABOUT THE AUTHORS

Dr. Toljanic is a board-certifiedprosthodontist at the University ofChicago, where he is a full professorand co-chief of dentistry. He alsomaintains a part-time practice with afocus on implant rehabilitation. He

can be reached at (773) 702-9873 [email protected]: Astra Tech funds ongoing research from whichdata were drawn and included in this artice.

Dr. Thor is a maxillofacial surgeon at Uppsala UniversityHospital, Uppsala, Sweden. His researchfocus is on biomaterials, bonereconstruction, and dental implants. He canbe reached at 46 (0) 18-611-6450 [email protected].

Dr. Baer is a clinical associate at theUniversity of Chicago. He maintains aprivate practice with a focus on implantrehabilitation. He can be reached at (773)702-6812 or [email protected]. Disclosure: Dr. Baer is an investigator in clinicalresearch partially funded by Astra Zenica.

Dr. Ekstrand is a board-certified prosthodontist at theUniversity of Oslo, where he is the director of PostgraduateEducation in Pros-thodontics. He can be reached at 46-70-593-1199 or [email protected]: This research is supported by a grant fromAstra Tech. The data reported here were presented at the16th annual meeting of the European Academy ofOsseointegration, Barcelona, Spain, in October 2007.

INTRODUCTION

With more than 40 years of clinical use, endosseousdental implants are recognized as one of the safest andmost predictable options for tooth replacement. Implantsare now routinely used to replace teeth in edentuloussegments ranging from a single tooth to a fully edentulousjaw, providing patients with both functional and aestheticoutcomes that can approximate the natural dentition. Long-term outcomes also indicate survival rates of better than90% after 5 years (Table 1).

Patient expectations for implant rehabilitation have nowmoved beyond demands for safety and function to includeaesthetics and ease of treatment, including shortertreatment times. In response to these demands, a largebody of evidence has been generated over the past 10years supporting the use of immediate fixed provisionalrestoration of dental implants in a wide variety of clinicalsituations.1-6 Combining implant placement with immediateprovisionalization meets patient expectations by providing arestoration on the day of implant surgery. Further, the


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Recommendations for Fluoride Varnish Use in Caries Management

LEARNING OBJECTIVES:

After reading this article, the individual will learn:

• a clinical technique for implant placement andimmediate fixed provisional restoration of the atrophicedentulous maxilla, and

• early outcomes for the presented protocol.

Immediate Fixed Restorationof Implants in the AtrophicEdentulous Maxilla

Table 1. Summary of Experience With Immediate Provisional Restoration of Implants.

Number of Implants Follow-up ImplantLead author patients placed interval survival %

Ostman5 20 123 1 year 99.2Tarnow6 4 34 1 to 3 years 100.0

Jaffin7 34 236 up to 5 years 93.0

van Steenberghe8 27 184 up to 1 year 100.0

Malo9 32 128 1 year 97.6

Capelli10 41 246 up to 3 years 97.6

restoration looks and feels more natural and comfortable ascompared to traditional temporary removable prostheses.The provisional fixed restoration also guides peri-implantsoft-tissue healing, creating a more natural tissue contourand a better aesthetic outcome. The outcomes of implantrehabilitation protocols that include immediate provisionalrestoration approach those with delayed restoration inmany clinical applications.1-6 In the authors’ experience,patients typically respond most favorably to immediateprovisionalization. Patients frequently comment that animmediate fixed provisional restoration has improved theiroverall sense of satisfaction with the treatment, and theyindicate that this aspect of care is one reason for selectinga treatment plan that includes implant rehabilitation.

However, limited data are available on clinical outcomesof immediate provisional restoration of implants to restore theedentulous maxilla5-10 (Table 1). Following tooth extraction,the maxilla commonly exhibits marked alveolar boneresorption, resulting in a significant loss of bone volume anddensity. This may limit the availability of sites for implantplacement and reduce the ability to achieve adequateprimary implant stability. Provisional restoration of implantslacking adequate primary stability may result in excessiveimplant micromotion during healing, leading to a failure of theimplant to integrate.11 While bone augmentation grafting ofthe maxilla remains an option for increasing alveolar bonevolume, the additional treatment time and cost does not meetthe demands of many patients.

Additional data regarding implant treatment outcomesfor the edentulous maxilla are warranted in order to betterunderstand the range of patient care options. Clinicians usethese data to guide their patients in making informedtreatment decisions. This article reviews preliminaryfindings from an ongoing clinical trial designed to assessthe efficacy of immediate restoration of implants placed intoan edentulous atrophic maxilla. Bone augmentation wasnot part of the surgical procedure.

STUDY DESIGN

Individuals were eligible for enrollment if they were healthy adults with an atrophic edentulous maxilla and did notuse tobacco products. The investigators determined maxillary

atrophy using a classification system designed to score (1)alveolar bone quantity on a scale from type A bone (minimalalveolar bone resorption) through type E bone (extremealveolar bone resorption), and (2) bone quality on a scale fromtype 1 bone (mostly compact bone) through type 4 bone(mostly trabecular bone).12 Scores were assigned based onclinical and radiographic examination, with subjects identifiedas eligible for enrollment with bone quantity scores of C, D, orE and bone quality scores of 3 or 4 (at the proposed sites ofimplant placement). As bone grafting was not part of the studyprotocol, sufficient existing bone volume was then required forimplant placement. Bone volume was assessed clinically byvisual inspection, palpation, and radiographically withpanoramic imaging. The smallest implant used in this study


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Immediate Fixed Restoration of Implants in the Atrophic Edentulous Maxilla

Figure 1. A 2.5-mm twist drill used for finalosteotomypreparation and a4.5-mm-diameterimplant to be insertedinto the prepared site.Note the difference in diameters betweenthe implant and twist drill.

Figure 2. Panoramic imaging demonstrating implant placementon the day of surgery. Note distal angulation of posteriorimplants following the anterior wall of the maxillary sinus.

was 3.5 mm in diameter and 8 mm in length. Based on thesecriteria, 51 subjects were enrolled and underwent treatment at2 participating clinical centers. Informed written consent wasobtained from all subjects following approved institutionalreview board guidelines.

Data acquired during this study include bone quantity andquality scores at the site of implant placement, the size of theimplants used, and implant location. Periapical radiographswere obtained at the time of implant placement, placement ofthe definitive restoration, and at each follow-up visit in order toassess crestal bone height over time. Finally, the level ofprimary stability achieved for each implant at the time ofplacement was obtained, measured in Ncm of force requiredto seat the implant fully using a calibrated torque wrench(Torque-Lock Wrench [Intra-Lock International]). Follow-upoccurred at 6 and 12 months after placement of the implantsand restorations, and then annually for a total follow-up periodof 5 years.

IMPLANT SURGERY

All subjects received 6 implants in the maxilla. Theimplants selected for use were threaded, self-tapping titaniumimplants with micro-threads in the collar region (Os-seoSpeed[Astra Tech]). These implants have a titanium oxide, blast-roughened surface further modified by the inclusion of fluorideions during the manufacturing process.

Implant placement surgery was performed underinfiltration local anesthesia using a standard soft-tissue flapdesign. Each osteotomy was initiated by introducing a pilotdrill to the site. Care was then taken during enlargement ofthe osteotomy sites to account for the lack of bone densityand volume that was commonly encountered. Thisfrequently led to underpreparation of the osteotomy sitediameter relative to the implant diameter that was plannedfor insertion, with reliance on the self-tapping design of theimplant to laterally compress the bony walls during seatingto maximize primary stability (Figure 1). In addition, theposterior implants were commonly placed with a distalangulation, positioning them immediately adjacent to theanterior wall of the maxillary sinus (Figures 2 and 3). Thispermitted the use of longer implants to engage more bone,while also creating a posterior shift of the implant platform

to better support the provisional restoration whileminimizing posterior cantilevers. Transmucosal abutmentswere screwed into place (Figure 4). Straight or angledtransmucosal abutments were chosen in order to correct forimplant placement angulation and to prevent unaestheticoutcomes arising from screw access holes exiting throughthe facial surfaces of the teeth. Six copings were cut to the


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Figure 3.Periapical radiographshowing distalangulation of theposterior implant inclose proximity to theanterior wall of themaxillary sinus.

Figure 4. Interoperativeplacement oftransmucosal implantabutment cylinders.

Figure 5. Retentive copingcylinders customshaped prior toscrewing onto thetransmucosalabutments.

desired size for each subject (Figure 5). These copingswere screwed onto the transmucosal abutments. Finally,the flaps were sutured closed around the transmucosalabutments/retentive copings (Figure 6).

IMMEDIATE PROVISIONAL RESTORATION

Fabrication of the provisional screw-retained fixedrestoration commenced immediately after implantplacement. The subjects’ existing complete maxillarydentures were used to fabricate the provisional fixedrestoration. When the occlusion or vertical dimension wereincorrect in the existing denture, a new removable completedenture was fabricated prior to treatment. On the day ofimplant placement, holes were drilled into the prosthesiscorresponding to the 6 retentive copings (Figure 7). Theholes were of sufficient diameter to allow easy visualizationof the copings (Figure 8). An autopolymerizing resin was thenpainted around each of the retentive copings to lute themonto the denture prosthesis (Figure 9). As the resin waspolymerizing, the subject was periodically asked to open andclose in order to ensure maintenance of the pre-establishedvertical dimension and proper occlusal contacts.

Following resin polymerization, all 6 copings wereunscrewed, and the prosthesis was removed from themouth with the copings luted to the prosthesis (Figure 10).Any voids noted between the copings and the prosthesiswere then filled with additional resin. The palate andflanges of the prosthesis were removed. Glass fiberreinforcement was then placed into a trough cut in theexterior lingual surface of the prosthesis to increasefracture resistance (EverStick C & B fiber reinforcement[Preat]; Figure 11).

The resultant fixed provisional restoration was finished,polished, and then screwed back onto the implant abutments(Figure 12). Centric occlusion was assessed, and excessivecontacts were reduced to create even bilateral contact.Aesthetics was assessed and revised as needed with inputfrom the patient (Figure 13). Periapical radiographs wereobtained of all implant sites to confirm fit of the restoration ontothe implants and to establish baseline crestal bone heightdata. Finally, the screw holes were covered with a temporaryrestorative material (Fermit [Ivoclar Vivadent]).


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Figure 6. Closure of the woundaround transmucosalabutments andretentive copingsimmediately prior tofabrication of theprovisional restoration.

Figure 7.Initial preparation of the denture prosthesisbefore trial placementin the mouth.

Figure 8. Denture prosthesisheld in place. Notevisualization of the 6 retentive copingcylinders throughpreviously preparedholes.

Figure 9.Autopolymerizing resinbeing painted ontocoping cylinders.

An alternative restorative procedure included makingimpressions immediately after implant placement andpouring a master cast. A screw-retained provisional fixedrestoration was then fabricated in the laboratory on this castusing all of the steps outlined above. Under thesecircumstances, the restoration was delivered within 24hours of implant placement.

Postsurgical management for all subjects includedprescribing systemic antibiotics (generic amoxicillin 500 mgQID x 7 days or generic clindamycin 150 mg TID x 7 daysfor penicillin-allergic subjects), a topical antimicrobial rinse(chlor-hexidine gluconate 0.12% to be used on an ongoingbasis), and oral analgesics (ibuprofen 600 mg TID x 3 daysto be continued as needed for pain control, with narcotic-based analgesics as needed for pain control). Subjectswere instructed to maintain a soft diet for 6 weeks. Hygieneinstructions included gentle brushing of the treated area forthe first 4 weeks, followed by normal brushing and flossing.Subjects returned after 2 and 4 weeks for follow-upexaminations. Healing of the surgical sites and function ofthe fixed provisional restoration were assessed at thesevisits. Subjects were then scheduled to return at 12 weeksfor further study follow-up and to commence fabrication ofdefinitive fixed restorations.

EARLY STUDY OUTCOMES

Fifty-one subjects underwent study treatment; 50subjects with a total of 300 implants returned 12 weeksafter treatment (one subject was lost to follow-up). At thisvisit, the fixed provisional restorations were evaluated. Therestorations were then unscrewed, and all implants wereclinically and radiographically examined to determineintegration outcomes prior to commencing fabrication of thedefinitive fixed restoration (Figure 14). It was determinedthat 288 of the 300 implants were judged clinically to beintegrated and ready for definitive restorative treatment.Periapical radiographs taken at this time intervaldemonstrated close apposition of bone at the implantsurface without evidence of interfacial radiolucencies(Figures 15 and 16). This represents an early implantsurvival rate of 96%. Twelve implants in 5 subjects werenoted to be nonintegrated, requiring removal. Forty-seven


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Figure 10. Prosthesis removedfrom the mouth with 6retentive copings lutedin place.

Figure 11. Fixed provisionalrestoration finished with removal of flanges and palate,with incorporation of glass fiberreinforcement material.

Figure 12. Fixed provisionalrestoration screwedinto place with screwholes covered withtemporary restorativematerial.

Figure 13. Anterior view of thefixed provisionalrestoration.

Figure 14. Occlusal view of apatient at 12 weeks.

of 50 fixed provisional restorations placed were found tohave remained in function throughout the 12-week follow-up period, representing a provisional prosthesis successrate of 94%. These 47 subjects subsequently underwentsuccessful definitive fixed restorative treatment. Of the 12implants that were not judged clinically to be integrated, 2implants were subsequently replaced in 2 subjects (oneimplant per subject) without interrupting the wearing of theimmediate provisional restoration or the subsequentfabrication of the definitive fixed restoration. The remaining3 subjects experienced a total of 10 implant failuresrequiring removal of the fixed restoration without follow-upimplant placement (Table 2). These subjects weresubsequently restored with a removable denture and werenot continued in the study.

DISCUSSION

Restoration of the edentulous maxillawith implants can present significantchallenges for the clinician. Marked loss ofbone volume and density is a limiting factorfor placement of a sufficient number ofimplants, located in strategic positions, toallow fabrication of a fixed restoration. Thebone loss further impedes obtaining primaryimplant stability, which is important forimmediate provisional restoration. Amongthe challenges in clinical implantology isidentification of approaches to treat thepatient with an atrophic maxilla. The protocolunder investigation is aimed at determining the efficacy of anapproach that accomplishes that goal without the need forbone augmentation, which often presents problems forpatients in terms of discomfort, extended treatment time, andadded expense. The protocol described above will continueto observe patients for a total of 5 years to assess the long-term efficacy of treatment.

CONCLUSION

Limited data are currently available describing implantrehabilitation outcomes that include immediate provisional

restoration of the edentulous maxilla. Early results obtainedfrom this study suggest that implant integration can bepredictably achieved when combined with immediate fixedprovisional restoration, without the use of bone grafting in theatrophic edentulous maxilla. This protocol has distinctadvantages, but longer follow-up is needed before thedescribed approach is recommended as a treatment option.


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Figures 15 and 16.Radiographs ofimplants at 12 weeks.Note impressioncopings in place for making finalimpression.Occlusalview of a patient at 12 weeks.

Table 2. Nonintegration Results.

Subject 107: 1 nonintegrated implant – implant replaced/fixed restoration placed

Subject 114: 1 nonintegrated implant – implant replaced/fixed restoration placed

Subject 205: 3 nonintegrated implants – no implant replacement/removable restoration placed

Subject 214: 4 nonintegrated implants – no implant replacement/removable restoration placed

Subject 225: 3 nonintegrated implants – no implant replacement/ removable restoration placed


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REFERENCES

1. Cooper LF, De Kok IJ, Rojas-Vizcaya F, et al. Theimmediate loading of dental implants. Compend ContinEduc Dent. 2007;28:216-225.

2. Ganeles J, Wismeijer D. Early and immediately restored andloaded dental implants for single-tooth and partial-archapplications. Int J Oral Maxillofac Implants.2004;19(suppl):92-102.

3. Toljanic JA, Baer RA. Same-day implant placement andprovisionalization for single-tooth implants: a techniqueupdate and review of clinical experiences. Dent Today.2005;24:73-77.

4. Attard NJ, Zarb GA. Immediate and early implant loadingprotocols: a literature review of clinical studies. J ProsthetDent. 2005;94:242-258.

5. Ostman PO, Hellman M, Sennerby L. Direct implant loading inthe edentulous maxilla using a bone density-adapted surgicalprotocol and primary implant stability criteria for inclusion. ClinImplant Dent Relat Res. 2005;7(suppl 1):S60-S69.

6. Tarnow DP, Emtiaz S, Classi A. Immediate loading ofthreaded implants at stage 1 surgery in edentulous arches:ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants. 1997;12:319-324.

7. Jaffin RA, Kumar A, Berman CL. Immediate loading of dentalimplants in the completely edentulous maxilla: a clinicalreport. Int J Oral Maxillofac Implants. 2004;19:721-730.

8. van Steenberghe D, Glauser R, Blomback U, et al. Acomputed tom-ographic scan-derived customized surgicaltemplate and fixed prosthesis for flapless surgery andimmediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent RelatRes. 2005;7(suppl 1):S111-S120.

9. Malo P, Rangert B, Nobre M. All-on-4 immediate-functionconcept with Branemark System implants for completelyedentulous maxillae: a 1-year retrospective clinical study.Clin Implant Dent Relat Res. 2005;7(suppl 1):S88-S94.

10. Capelli M, Zuffetti F, Del Fabbro M, et al. Immediaterehabilitation of the completely edentulous jaw with fixedprostheses supported by either upright or tilted implants: amulticenter clinical study. Int J Oral Maxillofac Implants.2007;22:639-644.

11. Szmukler-Moncler S, Salama H, Reingewirtz Y, et al. Timingof loading and effect of micromotion on bone-dental implantinterface: re-view of experimental literature. J Bio-med MaterRes. 1998;43:192-203.

12. Branemark P-I, Zarb GA, Albrek-tsson T. Tissue-IntegratedPros-theses: Osseointegration in Clinical Dentistry. Chicago,IL: Quintes-sence; 1987:201-202.

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POST EXAMINATION QUESTIONS

1. Implant placement with immediate provisionalization inthe atrophic edentulous maxilla poses clinicalchallenges due to ____.a. post-extraction increase in bone density that

impedes osteotomy preparationb. marked decrease in bone volume/density

post-extractionc. lack of micromotion following implant placementd. inability to perform sinus lift bone grafting

2. Osteotomy preparation for the atrophic maxilla prior toimmediate provisional restoration should include ____.a. underpreparation relative to

implant diameter to maximize primary stabilityb. guide pins to ensure parallel placement of implantsc. preparation to minimize lateral compression of

bony walls during implant insertiond. mesial inclination of posterior implants to permit

longer implants that engage more bone

3. Using a previously worn removable complete dentureprosthesis for fabricating the immediate fixedprovisional restoration ____.a. is not recommended for the atrophic edentulous maxillab. maintains the current occlusal contacts and vertical

dimensionc. is indicated only when planning a removable provisional d. limits the ability to achieve an aesthetic final result

4. An alternative to direct fabrication of the immediatefixed provisional restoration is ____.a. delaying restoration for 3 weeks to allow adequate

soft-tissue healingb. fabrication of an attachment retained removable

overdenturec. a pre-implant surgery impression to process

unsplinted, single-unit fixed provisional crownsd. immediate post-implant surgery impression for

a fixed provisional restoration delivered within 24 hours of surgery

5. After immediate fixed provisional restoration of implants,gentle brushing of the treatment area ___.a. can commence immediatelyb. can commence in 2 weeksc. can commence in 4 weeksd. can commence in 8 weeks

6. Definitive fixed restoration of the atrophic edentulousmaxilla following implantation/immediateprovisionalization ____.a. can commence in 4 weeksb. can commence in 8 weeksc. can commence in 12 weeksd. can commence in 6 months

7. The following system is used to score alveolar bonequantity:a. Type 1 indicates minimal alveolar bone resorption.b. Type A indicates minimal alveolar bone resorption.c. Type E indicates mostly trabecular bone.d. Type 4 indicates mostly compact bone.

8. Placing posterior implants with a distal angulation andimmediately adjacent to the anterior wall of themaxillary sinus ____.a. permits use of shorter implantsb. permits use of longer implantsc. results in the implants engaging less boned. creates an anterior shift of the implant platform


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immediate fixed restoration of implants in the atrophic ... · of implants in the atrophic...

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