Survival Rate and Bone Resorption in Immediate Loading of

Atrophic Maxillary Arches Using Normal and Long Implants:

A Pilot Observational Study
Paolo Pesce, DDS, PhD1/Francesco Pera, DDS, PhD2/Diego Bruno, DDS2/Maria Menini, DDS, PhD3

Purpose: To estimate implant survival and peri-implant bone resorption around long vs normal-
length implants in full-arch immediate loading rehabilitation of maxillary arches of low bone
quality (D4). Materials and Methods: A total of 45 patients received two mesial normal-
length (10 to 15 mm) or longer (18 to 20 mm) implants and two long (18 to 20 mm) distally
tilted implants. Differences in bone resorption at 24 months were assessed using the Mann-
Whitney U Test. Results: At the 24-month follow-up, no significant differences were found in
survival (global cumulative survival rate: 98.9%) or bone resorption (mean: 1.1 mm) between
long and normal implants (P = .053). Conclusion: At 24 months, the use of long implants
provides favorable survival and bone maintenance results in the immediate loading rehabilitation
of low-quality maxillary arches. Int J Prosthodont 2018;31:580–583. doi: 10.11607/ijp.5756

Implant rehabilitation with full-arch immediate load-

ing is a widespread procedure for treating patients
with an edentulous maxilla or with seriously compro-
mised teeth in the maxilla.1–3 Low bone quality could
represent a limit to implant rehabilitation; for this
reason, long implants (possibly tilted in the posterior
zone to avoid a sinus lifting procedure) could be used
to increase the primary stability, to obtain a potential
bicortical stability, and to bypass the dental alveolus
of postextraction sites.
The aim of the present preliminary report was to
estimate the survival rate and peri-implant bone re-
sorption over time of long implants (18 to 20 mm) and
normal-length implants (10 to 15 mm) in full-arch im-
mediate loading rehabilitation of edentulous maxillary
arches of low bone quality.
Materials and Methods
The present preliminary report was conducted in ac-
cordance with the Helsinki Declaration and was ap-
proved by the local Scientific Ethical Committee of the
1Research
Fellow, Department of Surgical Sciences, Implant and Prosthetic
Dentistry Unit, University of Genoa, Genoa, Italy.
2Lecturer, Department of Surgical Sciences, Implant and Prosthetic
University of Genoa. Between May and September
2014, a convenience sample of 45 patients referred
to the Division of Implant and Prosthetic Dentistry of
Genoa University was enrolled. Patients were in good
medical condition with unfavorable prognoses for their
residual maxillary dentitions. The unfavorable progno-
ses were attributed to periodontal disease (n = 18),
endodontic failures (n = 9), dental caries (n = 11), or a
combination of these factors. Before implant insertion,
patients underwent scaling, root planing, oral hygiene
instruction, or any periodontal treatment necessary to
provide an oral environment more favorable to wound
healing. Inclusion and exclusion criteria are reported
in Table 1.
A cone beam scan (GXCB-500 Gendex Dental
System) was used to select implant sites, plan im-
plant insertion, and analyze bone quality of the se-
lected sites.4 All patients were treated by the same
clinicians (T.T., F.P., P.P.) according to the Columbus
Bridge Protocol, as described in previously published
papers.3,5 At least four external hexagon implants with
a 4-mm diameter were inserted: two 10- to 15-mm
implants (Full Osseotite NT implants, Biomet 3i) or
longer implants (18 to 20 mm) in the anterior maxilla,
and two 18- to 20-mm (Biomet 3i) tilted implants in
the posterior maxilla (Figs 1 and 2).

Dentistry Unit, University of Genoa, Genoa, Italy. Assessment

3Assistant Professor, Department of Surgical Sciences, Implant and

Prosthetic Dentistry Unit, University of Genoa, Genoa, Italy.

Correspondence to: Dr Paolo Pesce, Department of Surgical Sciences
(DISC) Implant and Prosthetic Dentistry Unit (PAD. 4),
Ospedale S. Martino, L. Rosanna Benzi 10, 16132 Genova, Italy.
Fax: + 39 0103537402. Email: paolo.pesce@unige.it
©2018 by Quintessence Publishing Co Inc.
Intraoral periapical films were accomplished to as-
sess interproximal bone levels at prosthesis place-
ment (T0) and at the 24-month follow-up appointment
(T1). Radiographs were obtained using the parallel
long-cone technique. The implant-abutment inter-
face was used as a reference point for bone level

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 Pesce et al

Fig 1  Radiographic examination

before treatment and 24 months after
treatment with the final prosthesis. A
rigid carbon fiber framework was used.

Fig 2  Intraoral photograph before

treatment and 24 months after treat-
ment with the final prosthesis.

measurements, as shown in Fig 3. Two examiners (P.P.

and D.B.) performed the clinical measurements after
a calibration exercise, demonstrating 95.7% concor-
dance within ± 0.5 mm for measurements.

Statistical Analyses

Differences in the absolute changes of bone resorp-

tion (T1 – T0) between side (mesial vs distal), length
(normal vs long), and position (all anterior vs all poste-
rior) of implants were assessed by performing Mann-
Whitney U Test. P ≤ .05 was considered statistically Fig 3  Bone resorption reference points: yellow line = implant-
significant. abutment connection, which is distally located at the bone level; red
line = distance between the implant-abutment connection and the
bone level mesial to the implant.
Results

A total of 45 patients (26 men, 19 women) with a mean

age of 64 years (range: 41 to 91) were included, and
186 dental implants (143 long implants, 43 normal im-
plants) were inserted and evaluated over a 24-month
period.
Of the 186 implants, 95 were anterior and 91 pos-
terior. All posterior implants were long (100.0%), while
43 of the anterior ones (45.3%) were normal and 52
were long (54.7%). A statistically significant relation-
ship was found between site (anterior or posterior)
and type of implants (long or normal).
After 1 month, two patients lost one distal long
implant (18 mm) each. At 24 months, the cumulative
survival rate (CSR) was 100% for normal implants
and 98.5% for long implants. The global CSR was
98.9%.
No significant differences in bone loss over time
were found between the two implant sides (mesial
vs distal) (P = .68) (Table 2), nor between long and
Table 1   S
 ubject and Study Site Inclusion and
Exclusion Criteria
Subject inclusion criteria:
  Unfavorable prognosis for maxillary dentition
  Demanding an immediate, fixed implant prosthesis
  Age > 18 years
  No relevant medical conditions
  Nonsmoking; smokers were advised to give up smoking
Study site inclusion criteria:
  Low bone quality (quality 4 on the Norton and Gamble scale4)
Specific subject and site exclusion criteria:
  Requiring bone grafting prior to implant placement
normal implants (P = .053) (Table 3). A statistically
significant difference (P = .011) between anterior
and posterior implant sites was found (Table 4), with
greater bone resorption next to the anterior implants
compared to the posterior ones (Δ = 0.1 mm).

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Survival Rate and Bone Resorption of Normal vs Long Implants in the Atrophic Maxilla

Table 2   C
 omparison of Bone Level Changes (mm) Table 3   C
 omparison of Bone Level Changes (mm)
Between Mesial and Distal Implant Sides Between Normal and Long Implants
Side Implant length
Total Mesial Distal P Long Normal P
Bone level T0 Bone level T0
 Mean –0.2 0.1 –0.6   Mean –0.2 –0.3
  Standard deviation 1.4 1.4 1.3   Standard deviation 1.5 1.1
  Median –0.4 0.0 –0.7   Median –0.5 0.0
  Minimum –5.1 –3.5 –5.1   Minimum –5.1 –3.2
  Maximum 4.0 4.0 4.0   Maximum 4.0 2.1
Bone level T1 Bone level T1
  Mean –1.1 –0.8 –1.4   Mean –1.0 –1.3
  Standard deviation 1.5 1.5 1.5   Standard deviation 1.6 1.1
.68 .053
  Median –1.3 –1.0 –1.6   Median –1.2 –1.6
  Minimum –6.0 –3.9 –6.0   Minimum –6.0 –3.6
  Maximum 4.0 3.7 4.0   Maximum 4.0 1.5
Δ Δ
 Mean –0.8 –0.9 –0.8  Mean –0.7 –1.1
  Standard deviation 1.1 1.2 1.0   Standard deviation 1.1 1.2
 Median –0.4 –0.4 –0.4  Median –0.3 –0.7
 Minimum –5.5 –5.5 –4.5  Minimum –5.5 –3.8
 Maximum 0.5 0.5 0.5  Maximum 0.5 0.3
T0 = prosthesis placement; T1 = 24-month follow-up; Δ = difference. T0 = prosthesis placement; T1 = 24-month follow-up; Δ = difference.

Table 4   C
 omparison of Bone Level Changes (mm) CSRs and bone maintenance in full-arch immediate
Between Anterior and Posterior Implants loading rehabilitations after 24 months of follow-up.
Site Overall bone resorption at T1 was 0.8 mm (0.7 mm for
Anterior Posterior P long implants and 1.2 mm for normal implants). A sta-
Bone resorption T0 tistically significant difference in bone resorption was
  Mean –0.5 0.0 found between anterior and posterior implants, but
  Standard deviation 1.6 1.2 the difference in mean bone resorption was 0.1 mm.
  Median –0.7 0.0 Such a small difference might be considered statisti-
  Minimum –5.1 –3.5 cally but not clinically significant.
  Maximum 4.0 4.0 Compared to a 15-mm implant, implants of 20- and
Bone resorption T1 18-mm length present an increase in surface area
  Mean –1.3 –0.8 of approximately 33% and 20%, respectively, thus
  Standard deviation 1.6 1.5 increasing bone-implant contact and primary sta-
.011 bility, especially in soft bone. Moreover, in cases of
  Median –1.5 –1.1
  Minimum –6.0 –3.9 immediate loading in postextraction sites, long im-
  Maximum 3.0 4.0 plants could facilitate an increase in primary stability,
Δ bypassing postextraction sites, the apex reaches the
 Mean –0.9 –0.8 denser residual bone of the premaxilla and allows po-
  Standard deviation 1.0 1.1 tential bicortical stabilization.
 Median –0.5 0.0 Some limits of the present research must be ac-
 Minimum –5.5 –4.5 knowledged. This study was not a randomized clini-
 Maximum 0.5 0.5 cal trial, and long implants were mainly tilted and
T0 = prosthesis placement; T1 = 24-month follow-up; Δ = difference.
inserted in the posterior maxilla; therefore, other
variables different from implant length may have af-
fected the results. The limited 24-month follow-up
Discussion assessment qualifies this report as a preliminary one.
Consequently, further comprehensive, long-term re-
Based on the present study results, long implants search outcomes are needed to confirm the merits of
placed in low-quality bone demonstrated favorable the present observations.

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 Pesce et al

Conclusions References

At 24 months, the use of long implants provides favor-  
able survival and bone maintenance results in the im-
mediate loading rehabilitation of low-quality maxillary
 
arches.
Acknowledgments  
The authors declare no conflicts of interest.
 
 
1. Menini M, Signori A, Tealdo T, et al. Tilted implants in the im-
mediate loading rehabilitation of the maxilla: A systematic re-
view. J Dent Res 2012;91:821–827.
2. Del Fabbro M, Ceresoli V. The fate of marginal bone around ax-
ial vs. tilted implants: A systematic review. Eur J Oral Implantol
2014;7(suppl):S171–S189.
3. Tealdo T, Menini M, Bevilacqua M, et al. Immediate versus
delayed loading of dental implants in edentulous patients’
maxillae: A 6-year prospective study. Int J Prosthodont 2014;
27:207–214.
4. Norton MR, Gamble C. Bone classification: An objective scale
of bone density using the computerized tomography scan. Clin
Oral Implants Res 2001;12:79–84.
5. Pera F, Pesce P, Solimano F, Tealdo T, Pera P, Menini M. Carbon
fibre versus metal framework in full-arch immediate loading
rehabilitations of the maxilla—A cohort clinical study. J Oral
Rehabil 2017;44:392–397.

Literature Abstract

Accuracy of Single Crowns Fabricated from Ultrasound Digital Impressions

This in vitro study aimed to evaluate marginal and internal fit of single crowns produced from high-frequency, ultrasound-based digital
impressions of teeth prepared with finish lines covered by porcine gingiva in comparison with those obtained using optical scanners with
uncovered finish lines. A total of 10 human teeth were prepared, and 40 zirconia crowns were fabricated from stereolithography (STL) data
sets obtained from four dental scanners (n = 10 each): extraoral CS2 (Straumann), intraoral Lava COS (3M), intraoral Trios (3Shape), and
extraoral ultrasound scanner. The accuracy of the crowns was compared by evaluating marginal and internal fit by means of the replica
technique with measurements in four areas (P1: occlusal surface; P2: transition between occlusal and axial surfaces; P3: middle of axial
wall; and P4: marginal gap). Restoration margins were classified according to their mismatch as regular, underextended, or overextended.
Kruskal-Wallis one-way analysis of variance and Mann-Whitney U test were used to evaluate the differences between groups at P < .05.
The median value of marginal gap (P4) for ultrasound (113.87 μm) differed statistically from that of CS2 (39.74 μm), Lava COS (41.98 μm),
and Trios (42.07 μm). There were no statistical differences between ultrasound and Lava COS for internal misfit (P1–P3); however, there
were statistical differences when compared with the other two scanners (Trios and CS2) at P1 and P2. The ultrasound scanner was able to
make digital impressions of prepared teeth through porcine gingiva (P4), but with less accuracy of fit than conventional optical scanners
without coverage of the finish lines. Where no gingiva was available (P1–P3), the ultrasound accuracy of fit was similar to that of at least
one optical scanner (Lava COS).

Praça L, Pekam FC, Rego RO, Radermacher K, Wolfart S, Marotti J. Dent Mater 2018. Epub ahead of print. References: 42.
Reprints: Juliana Mariotti, jmarotti@ukaachen.de —Carlo Marinello, Switzerland

Volume 31, Number 6, 2018 583

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