Single mandibular first molar implants

with flapless guided surgery and

immediate function: Preliminary clinical
and radiographic results of a
prospective study
Walter Rao, MD, DDS,a and Riccardo Benzi, MD, DDSb
Statement of problem. Implant therapy is widely accepted and increasingly used by clinicians as part of fixed pros-
thodontics, and there is a need to develop standardized protocols for its use. The first mandibular molars are the most
frequently lost teeth and, even if not indispensable, have an important role for the comfort of patients.

Purpose. The purpose of this study was to develop and document a standardized method for mandibular single molar
replacement performed with flapless surgery and premanufactured individualized abutments and crowns for immedi-
ate function.

Material and methods. Forty-six patients received 51 implants in the first mandibular molar region. All implants were
placed with guided flapless surgery and were immediately loaded with premanufactured definitive abutments and
acrylic resin provisional restorations. Definitive restorations were inserted after 3 months. Clinical and radiographic
analyses were used to evaluate the treatment outcomes. Data were reported using descriptive statistics.

Results. All implants inserted were stable and successful in function after 1 year, providing a 100% survival rate. Three
implants reached clinical stability after an initial adverse event requiring delayed loading, thus, the survival rate for
immediate function was 94%.

Conclusions. The 100% survival rate suggests that safe replacement of single mandibular first molars with an immedi-
ate prosthesis is possible with flapless surgery and premanufactured individualized abutments and crowns. (J Prosthet
Dent 2007; 97: S3-S14.)

Clinical Implications
The outcome with proposed clinical protocol demonstrates that
single implant replacement of the mandibular first molar can be
performed safely and predictably and much like a conventional
prosthodontic procedure.

Dental implants have been widely
used to support fixed dental pros-
theses, and the dental profession is
confident regarding their use.1-4 Sin-
gle-tooth restorations with implant-
supported crowns have been shown
in several studies to be both predict-
able and successful long-term clini-
cal solutions.5-15 The 2-stage surgical
procedure for implant placement is
the most documented approach, but
comparable results have been report-
ed with a 1-stage surgical approach16
and, recently, immediate function has
gained acceptance.17-20 Predictable
results for immediate function are be-
lieved to depend on good initial im-
plant stability, controlled load condi-
tions, and an osseoconductive implant
surface.21,22 The extended treatment
time for submerged implants, the fact
that the patient must use removable
prostheses or be without teeth dur-
ing implant healing, pain, difficulty
with mastication with a transitional
removable prosthesis,23 and the need
for a second surgery to uncover the
implants are examples of disadvan-
tages related to conventional implant
treatment. These problems may cause
physiological, psychological, and so-
ciological challenges for patients.24
The flapless surgical technique is a

The study was supported by Nobel Biocare AB.

Private practice, Pavia, Italy.

a

Private practice, Vigevano, Italy.

b

Rao and Benzi

s4
further simplification which has been
shown to be safe and effective.25-26
Since the first mandibular molars are
the most frequently lost teeth and play
an important role in patient comfort,
their implant replacement should be
selected for a safe and standardized
approach. Promising results with im-
mediate function for single mandibu-
lar molar replacement are available,20
but there is a need for a well-defined
planning procedure to obtain these
benefits and secure a predictable out-
come. One method is to use a bone
mapping technique,19 offering a way
to create a prefabricated position-
ing device using an easy and low cost
procedure not requiring sophisticated
radiological analyses.
The objective of this study was to
define a simple, safe, and reproduc-
ible surgical and prosthetic proto-
col for immediate function of single
mandibular first molar replacement
when well-preserved hard and soft
tissues are present. This report pres-
ents the treatment modality as well
as the interim clinical results. The re-
search hypothesis was that it is pos-
sible to premanufacture all implant
and prosthetic components for a
single mandibular first molar replace-
ment, perform the treatment in 1 visit
with immediate function, and obtain
a survival rate equivalent to that re-
ported for other implant procedures
for the same indication.
MATERIAL AND METHODS
This prospective study was de-
signed to place, consecutively, 100
implants at 2 private practices in
Pavia and Vigevano, Italy, starting in
June 2002. This report presents the
follow-up of the first 51 implants
placed, the last of which was placed
in December 2004. Forty-six pa-
tients (25 women and 21 men) with
a mean age of 42 years (range 22 to
66 years) had 23 implants placed in
the left side and 28 in the right. In 4
of these patients, both the right and
the left first mandibular molars were
missing and, therefore, bilateral im-
The Journal of Prosthetic Dentistry
plants were simultaneously placed.
The implants were all threaded, had
an oxidized surface, a tapered body,
and a 1.5-mm-high collar (Replace
Select Tapered TiUnite; Nobel Bio-
care AB, Goteborg, Sweden). Implant
diameters and lengths are presented
in Table I.
The following inclusion criteria
were used: (1) healthy patients lack-
ing the first mandibular molar, (2) a
minimum of 11 mm of bone above
the mandibular nerve, (3) available
mesio-distal interradicular space be-
tween 8 and 12 mm, (4) bone ridge
width of a minimum 6.3 mm, (5)
normal quantity and quality of kera-
tinized tissues, (6) good oral hygiene,
and (7) absence of interarch discrep-
ancies, such as reverse anteropos-
terior and/or mediolateral curves,
reverse articulation, and maxillary
first molar extrusion interfering with
the prosthesis. In addition to exclu-
sion criteria universally accepted in
implant surgery,27 the following exclu-
sion criteria were used: (1) Implant
Stability Quotient (ISQ) lower then
65,28 (2) insertion torque less than 30
Ncm, (3) signs of active periodontal
disease with bone loss, (4) periapical
lesions on adjacent teeth, (5) surgical
extractions or regenerative therapy, if
performed within the 6 months pre-
ceding the insertion of the implant,
(6) heavy smokers (more than 10
cigarettes per day), and (7) bruxism
and/or parafunctional habits. All pa-
tients signed a consent form purpose-
ly designed by the Ethics Committee
of the Local Health and Social Agency
Table I. Implant diameters and lengths
Diameter x Length (mm)
4.3 x 10
4.3 x 13
5.0 x 10
5.0 x 13
6.0 x 10
6.0 x 13
Volume 97 Issue 6
in Pavia, Italy.
The medical history of the in-
cluded patients was collected to-
gether with radiographs (periapical
complete mouth series) and clinical
photographs. A site analysis was per-
formed to visualize the implant posi-
tion for safe guided flapless surgery.
An impression was made with a poly-
ether material (Impregum; 3M ESPE,
St. Paul, Minn) and poured in poly-
urethane resin (ExactoForm; Bredent,
Senden/Witzighausen, Germany) to
form a diagnostic cast. As previously
described in the literature19 the 3-di-
mensional cast was mounted in an
articulator (Sam 2P; SAM Prazision-
stechnik GmbH, Munich, Germany)
and an acrylic resin (Palapres; Herae-
us Kulzer, Hanau, Germany) template
with a series of calibrated holes was
fabricated (Fig. 1). Twenty-one holes
were made on 7 lines with 3 holes
placed approximately 2 mm apart.
One of the lines was positioned over
the center of the ridge crest, 3 lines
were positioned towards the buccal
vestibule, and 3 lines were placed
lingually. The bone volume was mea-
sured (bone mapping) under local an-
esthesia by passing an endodontic file
through the soft tissue. All recorded
measurements were transferred to
the cast (Fig. 2) where the volume of
the soft tissues was removed and re-
placed with a silicone (Gingifast rigid;
Zhermack GmbH, Ohlmul, Germany)
replica. Proper selection of implant di-
mension was made based on the anal-
ysis of the “hard-and-soft-tissue cast”
together with measurements made on
Number
8
25
9
7
1
1
Rao and Benzi
June 2007
1 Mapping template on cast.
2 Transfer of mapped values to cast.
a centered intraoral radiograph of the
edentulous space. A diagnostic waxing
of the missing teeth was completed,
the ideal prosthetic axis was defined,
and an implant analogue was inserted
in the selected position. The mapping
template was transformed into a sur-
gical guide19 where a titanium sleeve
(CA.MI; Impianti, Milan, Italy) with
a 2-mm internal diameter guided the
pilot drill (Nobel Biocare AB). A wax-
ing of the abutment was made, and
the immediate definitive abutment
was produced using the CAD-CAM
Procera technique (Nobel Biocare
AB)(Fig. 3). A provisional acrylic resin
restoration was fabricated to fit the
abutment (Fig. 4).
The surgical site was kept clean
following antiseptic procedures and
special attention was given to the
oral hygiene of the patients. The pa-
Rao and Benzi
tients were instructed to begin us-
ing 0.20% chlorhexidine digluconate
mouth rinse (Ghimas, Bologna, Italy)
the day before the treatment. No an-
tibiotics or sedatives were prescribed.
An anti-inflammatory drug (275 mg)
(Sodic Naprosene Synflex; Recordati
SpA, Milano, Italy) was administered
1 hour prior to surgery and for 3 fol-
lowing days. Surgery was performed
using the following protocol as ap-
plied in periodontal surgery. Surfaces
and instruments used were sterile,
and the oral environment was highly
controlled from a hygienic point of
view (low plaque index). The facial
skin of the patient was cleaned with
a clorhexidine solution (Ghimas) but
not covered with sterile drapes. Non-
sterile gloves were used. The rationale
for the protocol was to perform a safe
but relaxing procedure, reducing any
s5
source of stress for the patients. The
implant placement was performed
under local anesthesia with a flap-
less approach. No punching was per-
formed, and burs were used to cut
both the mucosa and the bone. The
standard (2 mm) pilot drills (Nobel
Biocare AB) were safely guided by the
surgical template (Fig. 5) to a depth
of 8 mm, which is in agreement with
other studies on immediately loaded
single molars20 and on short im-
plants,29-30 suggesting that bicortical
anchorage is not mandatory in situa-
tions with good bone density. A radio-
graph was made to verify the intraop-
erator depth and the relative position
of the roots of the adjacent teeth (Fig.
6). The drilling sequence followed the
recommendation of the manufacturer
(Nobel Biocare AB). The bone quality
was manually assessed and classified
into 3 categories according to Trisi
and Rao, D for dense bone (type 1),
N for normal bone (type 2-3), and S
for soft bone (type 4).27,31 The bone
density of the patients was primarily
of type N bone (90%); in 2 clinical
situations the bone density was classi-
fied as D (5%), and in 2 situations as S
(5%). To ensure correct placement of
the implant in the preplanned apico-
crestal position, a perio probe (PCP
12; Hu-Freidy, Chicago, Ill) was used
to assess the thickness of the soft tis-
sue and to verify the accuracy of the
bone mapping. Radiographs were
made of the final drill left in place, in-
dicating implant level seating (Fig. 7).
Insertion torque was measured with a
drill unit (OsseoCare; Nobel Biocare
AB) (Fig. 8).
After insertion of the individual-
ized CAD-CAM abutment, but be-
fore tightening the abutment screw
and before trial insertion of the pro-
visional crown, a template was used
to verify that the abutment position
clinically reproduced what was previ-
ously planned (Fig. 9). Once an opti-
mal position was reached, as verified
through a periapical radiograph and
the acrylic resin template seated on
the definitive abutment and the ad-
jacent teeth, the abutment screw was
s6 Volume 97 Issue 6

3 Waxing (left) and individualized abutment (right).

4 Provisional restoration on abutment. Upper left: buccal view of provisional restoration on cast. Upper
right: buccal view of provisional restoration completely seated on cast. Lower left: lingual view of provisional
restoration on cast. Lower right: lingual view of provisional restoration completely seated on cast.

5 Pilot bur engaged in surgical template and flapless approach. Upper left: surgical guide positioned. Upper
right: standard (2 mm) pilot drills in final position. Lower left: surgical pin inserted for radiograph. Lower right:
transmucosal flapless approach.
The Journal of Prosthetic Dentistry Rao and Benzi
June 2007 s7

6 Axial correction after making radiograph. Left: surgical pin in position

for radiographic evaluation. Right: standard (2 mm) pilot drill in position
for radiographic evaluation.

50 6.00 12.00

40

30
Ncm

20

10

2 4 6 8 10 12 14 16 18 20 22
Turns
7 Final bur in position for final radiographic
8 Tapered root form of implants provides progressive inser-
evaluation.
tion torque curve and peak torque is reached at last 3 turns.

9 Template used to verify abutment position.

Rao and Benzi

s8
fastened with a torque of 35 Ncm, and
the acrylic resin provisional prosthesis
was evaluated intraorally. If necessary,
minor adjustments were performed
before cementation of the crown to
ensure an accurate fit. Maximal oc-
clusal contact in the intercuspation
position with equal load distribution
among adjacent teeth and the pro-
visional crown was established and
lateral contacts were eliminated by
evaluating points of contact (Fig. 10).
After 2 weeks of a soft diet, the pa-
tients were clinically evaluated and in-
structed to progressively increase the
masticatory loads towards a normal
masticatory pattern after 1 month of
loading. After 3 months of uneventful
healing, the provisional restoration
was removed, implant stability as-
sessed, and the definitive crown (All-
Ceram Procera; Nobel Biocare AB)
cemented (Fig. 11).
All patients were recalled 3, 6, 12,
and 24 months posttreatment. Ra-
diographs were made at time of treat-
ment, and at 3-, 12- and 24-months
recall. Implant stability evaluations
Volume 97 Issue 6
were made after 12 months using a
resonance frequency device (Osstell;
Integration Diagnostic, Goteborg,
Sweden) measurements (Fig. 12). Ra-
diographs (Fig. 13) were made per-
pendicularly with a long-cone parallel
technique using a radiograph holder
(Rinn centrator bite; Dentsply Rinn,
Elgin, Ill) individualized for each site
with an acrylic resin template (Fig.
14). Bone level measurements were
performed by an independent radi-
ologist at Goteborg University. The
lower corner of the straight cylindri-

10 Implant placement and insertion of provisional restoration. Upper

left: edentulous first mandibular molar area. Upper right: final bur in situ.
Lower left: implant in situ. Lower right: provisional crown cemented.

11 Definitive restoration.

The Journal of Prosthetic Dentistry Rao and Benzi

June 2007
12 ISQ value measurement device in place.
13 Radiograph at 12-month recall.
14 Individualized radiograph centering device.
Rao and Benzi
s9
cal portion (collar) of the implant was
used as a reference point. The implant
has an unthreaded collar of 1.5 mm
and a thread pitch of 0.7 mm. The
thread starts evolving below the col-
lar and reaches its full depth after 2
turns. Measurements were made me-
sially and distally, rendering a mean
value per position. The levels and fre-
quency were compared to reported
values for other dental implants.21-
22,32-36
Implant stability was measured
with the resonance frequency analysis
device37-39 (Osstell; Integration Diag-
nostic) (Fig. 12). No specific discrimi-
nation ISQ value is given by the manu-
facturer, and the value of 65 used in
the study was based on experiences
reported from other clinical studies.28,
37-39
In the situation of questionable
implant stability during the early heal-
ing phase (1-3 weeks), additional ISQ
measurements were performed as a
loosening implant may recover after a
few months with load relief.40-41
Implant survival was based on
clinical stability of the implant, and
comfortable mastication and esthet-
ics for the patient. In addition, the
criteria for absence of infection, pe-
riimplant disease, and radiolucency
around the implants, according to
Albrektsson,42 were used. The degree
of esthetic and functional satisfac-
tion was assessed, independently and
subjectively by patient and dentist, at
every follow-up visit. Responses were
provided in an unassisted manner on
a 4-point Likert scale43 as “Excellent”,
“Good”, “Acceptable”, or “Unaccept-
able”. Function was described to the
patients prior to the evaluation as the
way the prostheses functioned when
speaking and eating. Additionally, the
dentist evaluated the occlusion. The
data are described using descriptive
statistics.
RESULTS
All patients have been followed
for at least 1 year, except for 1 patient
who moved after implant insertion
and was lost to follow-up. Twenty-
seven patients (53%) have been fol-
s10
lowed for 2 years and 12 (24%) for
3 years. All implants were stable and
successful in function at all visits, ren-
dering a 100% survival rate (Table II).
The implant stability during the first
12 months after placement is present-
ed in Table III. A progressive reduction
of the ISQ value during the first weeks
was observed for 3 implants, Table
IV. These implants were subsequently
nonloaded for 2 months, a period
long enough for the implants to regain
an ISQ superior to the discrimination
value of 65 at the first scheduled fol-
low-up visit at 3 months.
The prefabricated provisional
restorations showed a good fit with
the abutments. In 51% of the situa-
tions the restorations were cemented
without any adjustment. The remain-
ing 49% needed minor adjustments,
such as light modification of the in-
clination of the intaglio surface of
the provisional crown using a bur at
low speed, followed by minimal re-
lining. Five instances of screw loos-
ening of the customized abutments
were observed during the use of the
provisional prostheses. Two of these
patients previously presented with
a reduction of ISQ value during the
first month. After definitive cementa-
tion, complete fracture of the ceramic
crown occurred in 2 patients during
the decementation necessary for the
ISQ measurement. This study-related
Volume 97 Issue 6
problem was solved by changing the
alumina core to zirconia.
Readable radiographs at baseline
and 12 months were available for 46
implants (90%) and at 24-months fol-
low-up for 25 implants (93%) (Table
V) (Fig. 15). The baseline (standard
deviation) was positioned 0.0 mm
(1.30) relative to the lower corner of
the implant collar, which corresponds
to a vertical positioning of the im-
plant collar at the bone margin. After
12 months, the bone level (standard
deviation) was –1.12 mm (1.06) and
after 24 months it was –0.89 mm
(0.92). The bone level frequency is
shown in Table VI. Two of the im-
plants that lost stability during the

Table II. Life table analysis

Not Due Cumulative
Time (Months) Implants Failed Withdrawn for Recall Survival Rate (%)

Implant insertion to 3 51 0 1 0 100

3 to 12 50 0 0 0 100

12 to 24 50 0 0 23 100

24 to 36 27 0 0 15 100

Greater than 36 12

Table III. Implant stability during first 12 months (ISQ)

Placement 3 Months 6 Months 12 Months

Average 71.9 68.9 72.5 74.1

Minimum 65.0 52.0 64.0 64.0

Maximum 80.0 78.0 80.0 80.0

Table IV. Stability measurements for 3 implants that lost stability during first month (ISQ)

Patient Placement 1 Month 3 Months 6 Months 12 Months

Number 1 74 54 66 66 74

Number 2 73 52 65 70 73

Number 3 75 41 69 74 74

The Journal of Prosthetic Dentistry Rao and Benzi

June 2007 s11

Table V. Marginal bone level (mm)

Average of Mesial and
Mesial Distal Distal Bone Levels

Placement Mean 0.10 –0.10 0.00

SD 1.39 1.34 1.30

n 46 46 46

3 Months Mean –0.63 –0.86 –0.75

SD 1.41 1.44 1.40

n 47 47 47

1 Year Mean –1.06 –1.17 –1.12

SD 1.07 1.16 1.06

n 46 46 46

2 Years Mean –0.80 –0.97 –0.89

SD 1.02 0.92 0.92

n 25 25 25

3 Years Mean –0.81 –1.02 –0.92

SD 1.05 0.90 0.96

n 9 9 9

n=46

0.0
Marginal Bone Level

0.5 n=47
n=9
n=25

n=46
1.0

1.5
0 12 24 36
Follow-up Time (months)
15 Mean marginal bone level at placement and after 3, 12, 24,
and 36 months.

Rao and Benzi

s12 Volume 97 Issue 6

Table VI. Marginal bone level frequency distribution (mm)

Placement 3 Months 1 Year 2 Years 3 Years
Mean 0.00 0.00 –1.12 –0.89 –0.92

SD 1.30 1.40 1.06 0.92 0.96

Number 46 47 46 25 9

mm n % n % n % n % n %

2.1 to 3.0 1 2 0 0 0 0 0 0 0 0

1.1 to 2.0 9 20 5 11 0 0 0 0 0 0

0.1 to 1.0 17 37 8 17 7 15 5 20 2 22

0 0 0 1 2 2 4 1 4 0 0

–1.0 to –0.1 7 15 14 30 14 30 8 32 2 22

–2.0 to –1.1 9 20 11 23 18 39 7 28 4 44

–3.0 to –2.1 2 4 5 11 3 7 4 16 1 11

–4.0 to –3.1 1 2 2 4 1 2 0 0 0 0

–5.0 to –4.1 0 0 1 2 1 2 0 0 0 0

first months were associated with an
increase in marginal bone radiolucen-
cy at the 3-month recall, but regained
bone density before the 1- and 2-year
recall visits, respectively. The esthetic
and functional results were judged
good by 2 patients and excellent by
all 44 remaining patients. A general
impression of satisfaction of the pa-
tients was observed, as they expressed
amazement over the absence of symp-
toms such as bleeding, postoperative
pain, and swelling.
DISCUSSION
The results support the research
hypothesis that it is possible to pre-
manufacture all implant and pros-
thetic components for a single man-
dibular molar replacement, perform
the treatment in 1 appointment with
immediate function, and reach a
survival rate equivalent to what is re-
ported for other implant procedures
for the same indication. Within the
limited number of observed patients,
a safe and predictable protocol was
defined. Even though the rationale for
The Journal of Prosthetic Dentistry
immediately loading a single mandib-
ular first molar was based on patient
comfort, it is important to note that
the esthetic and functional outcomes
of the therapy were high, based on the
assessment of both the dentists and
the patients, and all patients consid-
ered the procedure as good or excel-
lent. Many patients indicated that
the treatment was more comparable
to a restorative procedure than to a
surgical procedure, due to the ab-
sence of symptoms such as postop-
erative pain, swelling, or discomfort.
Moreover, patients were enthusiastic
to leave the practice on the day of
treatment with a tooth in the previ-
ously edentulous area. Although the
interim results of this study show ex-
cellent results, it is important to em-
phasize that the clinical outcome may
be dependent on accurate patient
selection, pretreatment planning and
diagnostic procedures and that the
flapless technique is simple but not
always indicated. Within the limita-
tions of this study, and as indicated in
the study of immediately loaded sin-
gle molars by Calandriello et al20 and
short implants by Pierrisnard et al29
and Renouard et al,30 the results sug-
gests that bicortical anchorage is not
needed in situations with good bone
density. It is believed that the centered
placement of the implant axis relative
to the prosthesis and limitation of the
distance to the alveolar nerve of at
least 1 mm are important factors to
consider. The decision whether or not
to load immediately was made based
on 3 clinical pieces of information:
manual sensation, minimum torque
insertion value (Ncm), and minimum
ISQ value. Insertion torques ranging
from 30 to 50 Ncm appeared to be
an effective criterion for good prima-
ry anchorage and possible immedi-
ate loading. No correlation between
torque and ISQ value was found; how-
ever, ISQ measurement constitutes
an effective indicator of the possibil-
ity to apply immediate loading when
used in combination with the previ-
ously mentioned means of evaluating
the implant site. The bone level and
its frequency distribution compare
well to results from other threaded
implants and indicate that the bone
Rao and Benzi
June 2007
stabilizes at the position of the first
implant thread.
Fourteen of the enrolled patients
were excluded after bone mapping,
due to insufficient bone quantity,
that is less than 6.3 mm between the
lingual and buccal vestibular sides,
allowing the placement of a 4.3-mm-
diameter implant with a minimum of
1 mm of bone on each side of the im-
plant. Mapping disclosed insufficient
bone volume, which is a risk in patient
selection for the flapless technique.
However, the limits for bone volume
were arbitrarily set, and it may be that
initial stability is a more important
criterion for immediate function than
the bone volume per se, and these pa-
tients may have been candidates for
the treatment.
Three implants (6%) lost stability
during the first months of healing.
They were, subsequently, not loaded
for 2 months and then successfully
reloaded and are surviving. Overload-
ing, as indicated by loosening of the
abutment screw and cement loosen-
ing of the provisional crowns, was
a possible reason for 2 of the situa-
tions, while no apparent reason was
found to explain the decreased stabil-
ity of the third implant. Two of these
implants also showed marginal bone
radiolucency that later disappeared.
These observations indicate that the
bone remodelling capacity is great
in the early healing phase, and that
it is important to evaluate patients
treated with the immediate function
protocol during the first weeks after
placement to avoid unnecessary fail-
ures. Similar observations, that a few
implants may lose stability, but regain
it if properly attended, are reported in
clinical studies by Glauser et al39 and
Siepenkothen et al.40
CONCLUSIONS
Within the limitations presented
in this study, the suggested immediate
function protocol demonstrates that
replacement of single mandibular first
molars is possible in a safe and simple
standardized manner, if careful pre-
Rao and Benzi
treatment planning, flapless surgery
and premanufactured individualized
abutments and crowns are used. The
almost complete absence of symp-
toms, together with the 100% survival
rate and patient satisfaction, are in-
dicators of the viability of this treat-
ment concept.
REFERENCES
1. Branemark PI, Hansson BO, Adell R, Breine
U, Lindstrom J, Hallen O, et al. Osseoin-
tegratated implants in the treatment of
the edentulous jaw. Experience from a
10-year period. Scand J Plast Reconstr Surg
1977;16:1-132.
2. Adell R, Lekholm U, Rockler B, Branemark
PI. A 15-year study of osseointegrated
implants in the treatment of the edentulous
jaw. Int J Oral Surg 1981;10:387-416.
3. Albrektsson T. On long-term maintenance
of the osseointegrated response. Austr
Prosthondontic J 1993;7 Suppl:15-24.
4. Astrand P, Almfeldt I, Brunell G, Hamp
SE, Hellem S, Karlsson U. Non-submerged
implants in the treatment of the edentulous
jaw. A 2-year longitudinal study. Clin Oral
Impl Res 1996; 7:337-44.
5. Jemt T, Lekholm U, Grondahl K. 3-year
follow-up study of early single implant res-
torations ad modum Branemark. Int J Peri-
odontics Restorative Dent 1990;10:340-9.
6. Henry PJ, Laney WR, Jemt T, Harris D,
Krogh PH, Polizzi G, et al. Osseointegrated
implants for single-tooth replacement: a
prospective 5-year multicenter study. Int J
Oral Maxillofac Implants 1996;11:450-5.
7. Jemt T, Pettersson P. A 3-year follow-up
study on single implant treatment. J Dent
1993;21:203-8.
8. Schmitt A, Zarb GA. The longitudinal clini-
cal effectiveness of osseointegrated dental
implants for single-tooth replacement. Int J
Prosthodont 1993;6:197-202.
9. Ekfeldt A, Carlsson GE, Borjesson G. Clini-
cal evaluation of single-tooth restorations
supported by osseointegrated implants: a
retrospective study. Int J Oral Maxillofac
Implants 1994;9:179-83.
10.Becker W, Becker BE. Replacement of
maxillary and mandibular molars with
single endosseous implant restorations:
a retrospective study. J Prosthet Dent
1995;74:51-5.
11.Engquist B, Nilson H, Astrand P. Single-
tooth replacement by osseointegrated
Branemark implants. A retrospective
study of 82 implants. Clin Oral Impl Res
1995;6:238-45.
12.Balshi TJ, Hernandez R, Pryszlak MC, Rang-
ert B. A comparative study of one versus
two implants replacing a single molar. Int J
Oral Maxillofac Implants 1996;11:372-8.
13.Palmer RM, Smith BJ, Palmer PJ, Floyd
PD. A prospective study of Astra single
tooth implants. Clin Oral Implants Res
1997;8:173-9.
14.Andersson B, Odman P, Lindvall AM,
Branemark PI. Cemented single crowns on
s13
osseointegrated implants after 5 years: re-
sults from a prospective study on CeraOne.
Int J Prosthodont 1998;11:212-8.
15.Scheller H, Urgell JP, Kultje C, Klineberg I,
Goldberg PV, Stevenson Moore P, et al. A
5-year multicenter study on implant sup-
ported single crown restoration. Int J Oral
Maxillofac Implants 1998;13:212-18.
16.Buser D, Mericske-Stern R., Bernard JP,
Behneke A, Behneke N, Hirt HP, et al.
Long-term evaluation of non-submerged ITI
implants. Part 1: 8-year life table analysis
of a prospective multicenter study with
2359 implants. Clin Oral Implants Res
1997;8:161-72.
17.Calandriello R., Tomatis M, Rangert B.
Immediate functional loading of Branemark
System implants with enhanced initial
stability: a prospective 1 to 2 – year clinical
and radiographic study. Clin Implant Dent
Relat Res 2003;5 Suppl 1:10-20.
18.Vanden Bogaerde L, Pedretti G, Dellacasa
P, Mozzati M, Rangert B. Early function of
splinted implants in maxillas and poste-
rior mandibles using Branemark system
machined-surface implants: an 18-month
prospective clinical multicenter study.
Clin Implant Dent Relat Res 2003;5 Suppl
1:21-8.
19.Rocci A, Martignoni M, Gottlow J. Immedi-
ate loading of Branemark System TiUnite
and machined-surface implants in the pos-
terior mandible: a randomized open-ended
clinical trial. Clin Implant Dent Relat Res
2003;5 Suppl 1:57-63.
20.Calandriello R, Tomatis M, Vallone R,
Rangert B, Gottlow J. Immediate occlu-
sal loading of single lower molars using
Branemark System Wide-Platform TiUnite
implants: an interim report of a prospective
open-ended clinical multicenter study. Clin
Implant Dent Relat Res 2003;5 Suppl:74-
80.
21.Vanden Bogaerde L, Rangert B, Wendelhag
I. Immediate/early function of Branemark
System TiUnite implants in fresh extraction
sockets in maxillae and posterior man-
dibles: an 18-month prospective clinical
study. Clin Implant Dent Relat Res 2005;7
Suppl 1:S121-30.
22.Vanden Bogaerde L, Pedretti G, Dellacasa
P, Mozzati M, Rangert B, Wendelhag I. Ear-
ly function of splinted implants in maxillas
and posterior mandibles, using Branemark
System TiUnite implants: an 18-month
prospective clinical multicenter study. Clin
Implant Dent Relat Res 2004;6:121-9.
23.Schnitman PA, Wohrle PS, Rubenstein JE.
Immediate fixed interim prostheses sup-
ported by two-stage threaded implants:
methodology and results. J Oral Implantol
1990;16:96-105.
24.Salama H, Rose LF, Salama M, Betts NJ.
Immediate loading of bilaterally splinted ti-
tanium root-form implants in fixed prosth-
odontics - a technique reexamined: two
case reports. Int J Periodontics Restorative
Dent 1995;15:344-61.
25.Becker W, Goldstein M, Becker BE, Senne-
rby L. Minimally invasive flapless implant
surgery: a prospective multicenter study.
Clin Implant Dent Relat Res 2005;7 Suppl
1:S21-7.
26.Hahn J. Single-stage, immediate load-
s14
ing, and flapless surgery. J Oral Implantol
2000;26:193-8. Maxillofac Implants 1994;9:49-54.
27.Lekholm U, Zarb GA. Patient selection and
preparation. In: Branemark PI, Zarb GA,
Albrektsson T. Tissue-integrated prostheses.
Chicago: Quintessence; 1985. p. 199-209.
28.Glauser R, Lundgren AK, Gottlow J, Senne-
rby L, Portmann M, Ruhstaller P, et al.
Immediate occlusal loading of Branemark
TiUnite implants placed predominantly in
soft bone: 1-year results of a prospective
clinical study. Clin Implant Dent Relat Res
2003;5:S47-56.
29.Pierrisnard L, Renouard F, Renault P,
Barquins M. Influence of implant length
and bicortical anchorage on implant stress
distribution. Clin Implant Dent Relat Res
2003;5:254-62.
30.Renouard F, Nisand D. Short implants in
the severely resorbed maxilla: a 2-year ret-
rospective clinical study. Clin Implant Dent
Relat Res 2005;7 Suppl 1:S104-10.
31.Trisi P, Rao W. Bone classification: clinical-
histomorphometric comparison. Clin Oral
Implants Res 1999;10:1-7.
32.Glauser R, Ruhstaller P, Windisch S, Zem-
bic A, Lundgren A, Gottlow J, et al. Immedi-
ate occlusal loading of Branemark System
TiUnite implants placed predominantly in
soft bone: 4-year results of a prospective
clinical study. Clin Implant Dent Relat Res
2005;7 Suppl 1:S52-9.
33.Laney WR, Jemt T, Harris D, Henry PJ,
Krogh PH, Polizzi G, et al. Osseointe-
grated implants for single-tooth replace-
ment: progress report from a multicenter
The Journal of Prosthetic Dentistry
prospective study after 3 years. Int J Oral
34.Widmark G, Friberg B, Johansson B,
Sindet-Pedersen S, Taylor A. Mk III: a third
generation of the self-tapping Branemark
System implant, including the new Stargrip
design. A 1-year prospective four-cen-
ter study. Clin Implant Dent Relat Res
2003;5:273-9.
35.Astrand P, Billstrom C, Feldmann H,
Fischer K, Henricsson V, Johansson B,
et al. Tapered implants in jaws with soft
bone quality: a clinical and radiographic
1-year study of the Branemark System Mark
IV fixture. Clin Implants Dent Relat Res
2003;5:213-8.
36.Jung YC, Han CH, Lee KW. A 1-year
radiographic evaluation of marginal bone
around dental implants. Int J Oral Maxil-
lofac Implants 1996;11:811-8.
37.Heo SJ, Sennerby L, Odersjo M, Grans-
trom G, Tjellstrom A, Meredith N. Stability
measurements of craniofacial implants
by means of resonance frequency analy-
sis. A clinical pilot study. J Laryngol Otol
1998;112:537-42.
38.Meredith N, Book K, Friberg B, Jemt T,
Sennerby L. Resonance frequency mea-
surements of implant stability in vivo. A
cross- sectional and longitudinal study of
resonance frequency measurements on
implants in the edentulous and partially
dentate maxilla. Clin Oral Implants Res
1997;8:226-33.
39.Glauser R, Sennerby L, Meredith N, Ree
A, Lundgren A, Gottlow J et al. Resonance
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frequency analysis of implants subjected
to immediate or early functional occlusal
loading. Successful vs. failing implants. Clin
Oral Implants Res 2004;15:428-34.
40.Siepenkothen T. Clinical performance and
radiographic evaluation of a novel single-
piece implant in a private practice over a
mean of 17 months. J Prosthet Dent 2007;
97: S69-S78.
41.Friberg B, Sennerby L, Linden B, Grondahl
K, Lekholm U. Stability measurements
of one-stage Branemark implants during
healing in mandibles. A clinical resonance
frequency analysis study. Int J Oral Maxil-
lofac Surg 1999;28:266-72.
42.Albrektsson T, Zarb G, Worthington P,
Eriksson AR. The long-term efficacy of
currently used dental implants: a review
and proposed criteria of success. Int J Oral
Maxillofac Implants 1986;1:11-25.
43.Allen PF, McMillan AS, Walshaw D. Patient
expectations of oral implant-retained
prostheses in a UK dental hospital. Br Dent
J 1999;186:80-4.
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