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This document describes a retrospective study that evaluated the outcomes of using narrow diameter titanium-zirconium implants to support maxillary overdentures in patients with atrophic maxillae. Ten patients who received a total of 40 implants were evaluated after 12-16 months. No implants were lost, and only one implant showed bone loss greater than 1.5mm, resulting in an implant success rate of 97.5% and survival rate of 100%. Probing depths and bleeding on probing were low, and prosthesis stability was good. The results suggest narrow diameter titanium-zirconium implants can successfully support maxillary overdentures in patients with atrophic maxillae.
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6 . Rehabilitation of an Edentulous Atrophic Maxilla With Four Unsplinted Narrow Diameter Titaniumzirconium Implants Supporting an Overdenture
This document describes a retrospective study that evaluated the outcomes of using narrow diameter titanium-zirconium implants to support maxillary overdentures in patients with atrophic maxillae. Ten patients who received a total of 40 implants were evaluated after 12-16 months. No implants were lost, and only one implant showed bone loss greater than 1.5mm, resulting in an implant success rate of 97.5% and survival rate of 100%. Probing depths and bleeding on probing were low, and prosthesis stability was good. The results suggest narrow diameter titanium-zirconium implants can successfully support maxillary overdentures in patients with atrophic maxillae.
This document describes a retrospective study that evaluated the outcomes of using narrow diameter titanium-zirconium implants to support maxillary overdentures in patients with atrophic maxillae. Ten patients who received a total of 40 implants were evaluated after 12-16 months. No implants were lost, and only one implant showed bone loss greater than 1.5mm, resulting in an implant success rate of 97.5% and survival rate of 100%. Probing depths and bleeding on probing were low, and prosthesis stability was good. The results suggest narrow diameter titanium-zirconium implants can successfully support maxillary overdentures in patients with atrophic maxillae.
PROSTHODONTICS (wide platform for molars, narrow platform for lateral and mandibular incisors, and standard platform for other teeth). 3 For over- denture treatments, prosthetic issues are overcome by the design of the restoration, and the choice regarding implant dimen- sion is related mainly to the amount of residual alveolar bone and the mechanical properties of the xture. Some studies suggest that 1.5 mm of residual bone should be present on the buccal and lingual/palatal aspects of the implant after its insertion. 4,5 Therefore, when less than 6 mm of bone width is present, it can be assumed that there is insufcient bone volume to place an implant with a standard diameter of 4 mm. In edentulous maxillae, horizontal bone resorption is frequently seen mesial to the maxillary sinus and under the nasal oor and may interfere with the placement of standard diameter implants. 6 Treatment alternatives include bone augmentation or the insertion of reduced diameter implants. Dental implants are a viable treatment option for replacing teeth in edentulous jaws. Fixed or removable implant-support- ed restorations may be provided to patients with different prosthetic designs and surgi- cal protocols. 1 In the maxilla, a removable full-arch implant-supported restoration (overdenture) is usually supported by four or more implants. 2 This approach has shown good results when standard diameter implants are used. 1 Implant width and length is generally chosen depending on the prosthetic needs 1 Head, Department of Periodontology and Prosthodontics, Eastman Dental Hospital, Rome, Italy. 2 Assistant Researcher, Department of Periodontology and Prosthodontics, Eastman Dental Hospital, Rome, Italy. 3 ITI Scholar, Department of Periodontology and Prosthodontics, Eastman Dental Hospital, Rome, Italy. Correspondence: Dr Luca Cordaro, Via Guido DArezzo 2, 00198 Roma, Italy. Email: lucacordaro@usa.net Rehabilitation of an edentulous atrophic maxilla with four unsplinted narrow diameter titanium- zirconium implants supporting an overdenture Luca Cordaro, MD, DDS, PhD 1 /Ferruccio Torsello, DDS, PhD 2 / Vincenzo Mirisola di Torresanto, DDS 2 /Marinka Baricevic, DDS 3 The edentulous maxilla is often affected by bone resorption, sometimes making it difcult to plaoo standard diamotor implants. Narrow diamotor implants mado o titanium-ziroonium (Ti-Zr) alloy, which has superior mechanical properties compared with titanium, have been proposed for these difcult situations. This retrospective clinical observation reports the outcome of the use of reduced diameter implants made of Ti-Zr alloy supporting maxillary overdentures retained with locator abutments. The charts of all patients who received max- illary overdentures supported by four unsplinted implants from January 2009 to June 2010 at tno Dopartmont o Poriodontology and Prostnodontios, Eastman Dontal Hospital, Pomo, Italy, were reviewed. All patients treated with four narrow diameter Ti-Zr implants were selected for the present case series. Ten patients were found, six of whom received aug- mentation procedures. After 12 to 16 months of follow-up, no implants were lost, and only one implant showed bone resorption greater than 1.5 mm. Implants showed a success rate of 97.5% and a survival rate of 100%. All prostheses were successfully in function. The present case series showed promising results regarding the use of narrow diameter implants made of Ti-Zr supporting maxillary overdentures retained with locator abutments. (Quintessence Int 2013;44:3743) Key words: edentulous maxilla, narrow implants, overdenture, titanium-zirconium 38 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Cordaro at al Bono augmontation may bo porormod using different techniques such as guided bono rogonoration (GBP) or autogonous bone blocks. 7 These techniques increase the surgical complexity and morbidity of the procedure compared with standard implant placement. The use of narrow diameter implants may decrease the need for bone augmenta- tion in edentulous maxillae when an over- denture treatment is planned. Poduood diamotor implants may snow inferior mechanical strength of the xture at the level of the prosthetic connection, when an internal connection is used. 8,9 For this reason, implants made of a titanium zirco- nium (Ti-Zr) alloy have been introduced to minimize the incidence of mechanical fail- ures. As a general principle, it is clear that a decrease in the need for surgical recon- struction of the alveolus simplies implant treatment and extends their indications. In clinical practice, the question of whether the use of reduced diameter implants affects the outcome of the restoration should be investigated. Different authors have reported good short-term outcomes using Ti-Zr implants in partially edentulous patients 10 or edentulous mandibles. 11 Studies are needed to establish the clinical indications and limitations of narrow diameter implants. 3 This retrospective clini- cal observation reports the outcomes of the use of reduced diameter implants made of Ti-Zr alloy supporting maxillary overden- tures retained with locator abutments. METHOD AND MATERIALS In this retrospective study, the charts of the patients consecutively treated with maxil- lary overdentures at the Department of Periodontology and Prosthodontics, Eastman Dontal Hospital, Pomo, taly, rom January 2009 to June 2010 were reviewed. Patients were either edentulous in the maxil- lary arch at presentation or the treatment plan involved extraction of the few remain- ing teeth in the maxillary arch. The prosthetic treatment plan consisted of an implant-supported maxillary overden- ture in accordance to the criteria proposed by Ziztmann and Marinello. 12 The treatment plan included inserting four maxillary implants with the transmucosal technique. 1 Only patients who were treated with nar- row diameter implants made of Ti-Zr alloy (Poxolid) witn a onomioally aotivo mioro- roughened surface (3.3 mm Standard SLActive, Institut Straumann) were includ- ed. The implants used were 10 or 12 mm in length. All patients showed some degree of maxillary atrophy. Horizontal defects were present at the time of implant placement, with a residual ridge width of 6 mm or less. Ten cases were found to have been treated following the same surgical ration- ale. The mean age was 76 years, and there were four women and six men. Surgical techniques In three cases, advanced horizontal resorp- tion was seen with a residual bone width of less than 3 mm, but with more than 12 mm of bone height. In these cases, augmenta- tion was performed with mandibular bone blocks and implant surgery took place after 4 months of healing. The alveolar bone width for all patients at the moment of implant placement (including nal width after bone reconstruction) was between 5 and 6 mm; therefore, narrow diameter implants were chosen. Three cases demonstrated some minor bono dooot ator implant insortion. GBP was performed by means of a synthetic biphasic calcium phosphate graft material (BonoCoramio, nstitut Straumann) oovorod by oollagon mombrano (Bio-Gido, Goistlion). In four cases, the implants could be placed without any need for augmentation. Prosthetic phase Loading of the implants was performed 8 weeks after insertion. Impressions were taken with the aid of pickup transfers, a master cast was created, occlusal registra- tions were taken, and a wax-up was pre- pared and tried in. An overdenture retained by four locator abutments (Zest Anchors) was delivered to the patient. Panoramic radiographs were taken at the time of the delivery of the denitive prosthesis. VOLUME 44 NUMBEP 1 JANUAPY 2013 39 QUI NTESSENCE I NTERNATI ONAL Cordaro at al Table 1 Summary of the retrospective evaluation Case type No. of cases No. of implants (inserted and sur- vived) Probing depth (mean SD) BoP (% of BOP + implants) Marginal bone loss (mean SD) Implant stability (+ or ) Prosthesis stability (VS, S, U) Implants with more than 1.5 mm bone loss No augmontation 4 16/16 3.11 0.8 12.5 0.4 0.3 16 + 2, 1, 1 Simultanoous GBP 3 12/12 2.45 0.7 8.3 0.8 0.6 12 + 1, 2, 1 Blook grats 3 12/12 2.39 1.0 8.33 0.5 0.6 12 + 1, 1, 1 Overall 10 40 2.69 0.8 10.0 0.55 0.5 40 + 4, 4, 2 GBP, guidod bono rogonoration, SD, standard doviation, BoP, blooding on probing, vS, vory stablo, S, stablo, U, unstablo. Follow-up evaluation Patients were evaluated in May 2011. The mean follow-up time was 13.5 months (range, 12 to 16 months). A panoramic radiograph was taken, and probing was performed around implants at four points per implant (the mean value for each implant was calculated). Implants were checked for stability by their acoustic and visual response to a gentle percussion test and also by pushing each implant between two instru- ment handles and observing any move- ment. 13 Prosthesis stability was assessed as very stable (no movement upon mastication and need for two hands for the patient to remove the prosthesis), stable (slight move- ments visible upon eccentric mandibular movements, one hand may remove prosthe- sis), or unstable (the prosthesis may be displaced by the patient without the use of nands). Blooding on probing (BoP) and probing depth were recorded. Mean prob- ing depth for each group, as well as for the entire study population, were calculated. The percentage of implants that showed BoP was also oaloulatod. Bono lovols woro compared with the baseline situation (radio- graphs taken immediately after implant loading) on panoramic radiographs; implant length was used to calibrate the measure- ments. Marginal bone levels were recorded at the mesial and distal sites on each implant, and a mean value was calculated for each implant at baseline and follow-up. RESULTS In total, 40 Ti-Zr narrow diameter implants were evaluated. The results of this study are reported in Table 1. All implants were in place after at least 1 year of function; only one implant demonstrated more than 1.5 mm marginal bone loss (without signs of inammation), giving a 100% survival rate and a 97.5% success rate according to the oritoria publisnod by Busor ot al. 14 Marginal bone stability was excellent in all groups (mean, 0.55 0.5 mm marginal bone resorption), as were soft tissue parameters, with only 3 of 40 implants snowing BoP. Tno moan probing doptn was 2.69 0.8 mm. The Plaque Index mea- sured at the four sites on each implant showed 70 sites showing 0 score (no plaque), 64 showing score 1, and 14 and 12 sites showing scores of 2 and 3, respec- tivoly. No statistioal oomparison botwoon the different treatment modalities (no bone grats, GBP, or bono blooks) was por- formed because of the small size of the subgroups, which did not allow for valid statistical analysis. Overdenture stability was considered at the follow-up examination (May 2011) as very stable in four cases, stable in four cases, and unstable in two cases. In the unstable cases, stability was improved (to very stable) by changing the plastic inserts 40 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Cordaro at al Fig 2 Details of the GBR procedures. (a and b) Fenestration around implant and very thin buccal bone were evident in both sides. (c and d) This situation was addressed with GBR using a particulated bone substitute and a collagen mem- brane. Standard diameter implants could not be placed without a block graft. Thus, it can be safely afrmed that 3.3-mm Ti-Zr implants reduced the inva- siveness of the procedure for this patient. Fig 1 (a) Initial photograph of a patient treated for maxillary edentulism. (b) After the refection of a mucoperiosteal fap, horizontal alveolar atrophy was evi- dent. Four 3.3-mm Ti-Zr implants were placed with the GBR procedure. (c and d) The fnal photograph and the panoramic radiographs showed good soft tissue healing and proper implant placement. of the locator attachments; these patients did not show up at the 6-month control. DISCUSSION Limited data are available on the long-term outcomes of reduced diameter implants in dioront indioations. Narrow implants navo been used for different indications, such as limited tooth-to-tooth spacing, 15,16 partially edentulous patients, 10,17 and edentulous mandibles, 18 with acceptable survival rates reported so far. Previous studies also reported on nar- row implants used to restore edentulous maxillae. Veltri et al 19 documented 12 cases in which narrow implants were used to sup- port a xed rehabilitation. A mean of 6 implants per patient were inserted in narrow ridges and followed for up to 1 year with a 100% survival rate. 19 Payne et al 20 used a a c c b b d d VOLUME 44 NUMBEP 1 JANUAPY 2013 41 QUI NTESSENCE I NTERNATI ONAL Cordaro at al Fig 3 (a) Initial and (b) fnal clinical situa- tions of a patient treated with two man- dibular ramus grafts to correct a severe horizontal alveolar atrophy to place 4 3.3- mm Ti-Zr implants supporting an overden- ture. (c and d) Panoramic radiographs show the initial situation and the correct implant placement. three narrow implants to support maxillary overdentures in a group of 39 patients with 81% success and 84.6% survival rate after 1 year. Hallman 21 published the results of a case series in which edentulous and par- tially edentulous maxillae were restored with the aid of narrow nonsubmerged implants. Fixed dental prostheses, overdentures, and single crowns were delivered to the patients and evaluated. A survival rate of 99.4% and success rate of 94.6% was reported after at least 1 year of function. 21 Although the majority of the included patients were eden- tulous, it is not possible to extrapolate the data related to this subgroup of patients in the Hallman study. One of the potential drawbacks of the reduced diameter titanium implants is their lower mechanical strength, with the related risk of fracture, especially at the implant- abutment interface (where the presence of the connecting screw reduces the width of the residual metal implant structure). 8,9
Consoquontly, dioront titanium alloys navo been used by some manufacturers to increase the fatigue strength compared with grade 4 commercially pure titanium. Pooontly, a Ti-Zr alloy (13% to 17% zirooni- um) with a superior resistance to fatigue has been introduced and used to manufac- ture implants with a diameter of 3.3 mm. 22,23
In a pilot study, Ti-Zr implants were shown to be safe and effective in partially edentulous patients when splinted to stan- dard diameter implants. 10 In a randomized controlled trial, Ti-Zr implants were compared with titanium grade IV implants in a sample of patients treated with mandibular overdentures retained by two implants. One year after loading, survival and success rates of 98.9% and 96.6%, respectively, were shown by the test implants, with no statistical dif- ference with the control group. 11 Patients included in our sample were also treated with surgical approaches that included staged mandibular block grafting or simultanoous GBP proooduros. Tno authors opinion is that the use of narrow implants in these cases was instrumental in making implant placement possible or sim- pler in the given clinical situation, as evi- donood by tno oasos snown. n GBP oasos, simultaneous insertion and augmentation could be performed without bone harvest- ing (Figs 1 and 2). In block grafts cases, the mandibular ramus could be used instead of extraoral grafting, thus reducing morbidity for the patient (Figs 3 and 4). It should be noted that horizontal augmentation of extremely narrow maxillary arches by means of mandibular ramus block grafts a c b d 42 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Cordaro at al Fig 4 Photographs of the surgical phases. (a and b) The maxillary horizontal atrophy was severe, and (c and d) two block grafts were harvested from the mandibular angles and secured to the alveolar process by means of lag screws. (e and f) After 4 months of healing, the implants were placed. It is evident that 3.3-mm implants could be placed. Standard diameter implants would have required additional grafting at the moment of placement or extraoral block grafts during the frst surgical phase. Thus, it can be safely afrmed that 3.3-mm Ti-Zr implants reduced the invasiveness of the procedure for this patient. may still result in a 6-mm wide arch after graft healing. In this condition, a narrow diameter implant is needed. The short-term follow-up observation limits the results of this clinical observation. However, it should be noted that the results are worth reporting because of the consis- tency of the prosthetic treatment objective proposed and delivered to the patients with the aid of narrow diameter implants. It may be concluded that Ti-Zr implants are a promising option for restoration of the edentulous maxilla since they show excel- lent survival and success rates and enable less invasive surgery. CONCLUSION This case series, based on 10 patients, showed promising results for the use of 4 unsplinted Ti-Zr implants to support maxil- lary overdentures. 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