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B
Fig. 2. A, Three-dimensional reconstruction of edentulous
maxilla CT. B, Biomodel derived from 3-dimensional CT
information transfer.
gical template after a simulated operating procedure. ed because of the higher incidence of maxillary peri-
The biomodel also can be used to develop the provi- implantitis in smokers.27 Additional studies are needed
sional restoration used in single-stage surgery and to determine whether the adverse effects of smoking
immediate loading protocols, as illustrated in Figure 3. on peri-implant tissues are reversible if the patient
At the practical level, CT data can be transferred to a stops smoking, as has been shown with the reduction
biomodel manufacturing facility by either electronic of periodontal disease in former smokers compared
transfer or a rewritable optical disc (DEC-702 Optical with active smokers.28
Disk; Pioneer Communication of America Inc, Upper Many female patients are concerned that osteo-
Saddle River, NJ); this process is not dependent on porosis will preclude them from considering dental
proprietary software programs. implant treatment because of a lack of bone density
and perceived loss of confidence with respect to
Identification of high-risk categories
risk. Although osteoporosis has been considered a
A number of risk factors associated with high fail- risk factor, particularly for postmenopausal women,
ure rates have been identified through clinical no clinical studies on this matter have been pub-
experience.15 Poor-quality bone, bone grafts, irradi- lished. One literature review suggests there is no
ation, immunosuppressive medications, and selected scientific background to confirm osteoporosis as a
disease states are universally recognized as risk fac- risk factor for oral implants. 29 Currently, such
tors. Furthermore, factors such as bruxism, patients are advised that treatment is indeed possi-
alcoholism, tobacco smoking, and osteoporosis have ble, but prolonged healing periods and careful
been identified as relative contraindications whereby conservative prosthetic management are desirable.
treatment results may be compromised. Success and A similar recommendation can be applied to dia-
survival rates associated with some of these condi- betes in light of the recent consensus that
tions may be controlled by the application of altered placement of implants in patients with metabolical-
protocols. Definitive cause-and-effect relationships ly controlled diabetes mellitus does not result in a
have not been reported in multicenter trials. Clinical greater risk of failures than in the general popula-
judgment, prudence, and informed consent are tion.30 However, the duration of diabetes may be
desirable before treatment is routinely applied in associated with implant failure, and longer implants
high-risk patients,4 who generally are planned for 8 experience fewer failures.31
implants.
Clinical and technical considerations
Bruxism, smoking, and osteoporosis require more
detailed consideration because they are relatively com- An anticipated maxillary complete-arch implant
mon in patients seeking implant treatment. Bruxism prosthesis with extensive bone grafting presents a
and parafunction were defined as contraindications in long-term, complicated, and extensive challenge for
early research on osseointegration.1 In the edentulous both patient and prosthodontist. Detailed planning
jaw, bruxism has been implicated in higher failure rates and treatment are mandatory if the patients function-
and increased incidence of screw loosening as well as al and esthetic requirements are to be fulfilled. As with
prosthetic fractures16 and increased loss of bone asso- conventional prosthodontics in the esthetic zone, the
ciated with poor plaque control.l7 It is generally agreed provisional restoration is paramount to a successful
that excessive loading or undue stress may induce bone outcome.
loss and that secondary bone quality and quantity fac-
Interim restorative phase
tors may contribute to this outcome.15 Bruxism
should be managed in implant candidates in the same Interim restorations may be utilized for 1 year or
manner as in general prosthodontic patients, with longer.32 Implants of questionable stability can be
careful attention to the design of the occlusal scheme monitored during this period with resonance frequen-
and the nocturnal utilization of an occlusal splint as cy analysis (Ostell, Gothenburg, Sweden).33 This
required.8 instrumentation measures the stability of the implant
Smoking is increasingly incriminated in a number of to which it is attached. A transducer is screwed onto an
health issues and is often discussed in relation to implant or abutment; when the measure key on the
implants. Several studies have shown that smoking can instrument is activated, an electronic signal is sent to
be associated with higher failure rates, complications, the transducer. The response is displayed on the
and altered soft tissue conditions.18-24 In general, instrument graphically and given a numerical value
patient profiles can be significantly correlated to called the implant stability quotient (ISQ). The ISQ is
implant loss with bruxing and smoking in maxillary scaled from 0 to 100 and is a measure of implant sta-
bone graft patients.25 While a nonsmoking period that bility derived from the resonance frequency value
covers the treatment phase has been recommended,26 obtained from the transducer. An increase in the ISQ
complete cessation of smoking also has been suggest- is representative of improved interfacial osteogenesis,
Fig. 4. Choice of impression registration protocol is dependent on design criteria and labora-
tory sequencing. (Henry PJ. Tooth loss and implant replacement. Aust Dent J 2000;45:150-72.
Reproduced with permission from the Australian Dental Journal.)
and experience has shown that over 3 to 6 months, illustrated in Figure 4. Implant-level impressions and
many implants give improved readings from 35 to 40 soft tissue casts give the laboratory the most flexibili-
to in excess of 60 units. Such technology is prognostic ty in developing proper contours and emergence
and may give credence to the clinical concept of func- profiles. Abutment-level impressions are indicated
tional remodeling. Furthermore, resonance frequency when definitive abutments have been selected and
analysis with periodic radiographic marginal bone connected to the implants. This may be prior to or
height assessment is used as part of long-term mainte- subsequent to the outcome of the provisional phase of
nance protocols.34,35 treatment.
Impression registration Framework technology
An impression procedure is carried out at Stage 1 A number of protocols and technological patterns
surgery if an interim restoration is planned for inser- are available for framework design and fabrication. The
tion at Stage 2 surgery. In some situations, this casting of complex frameworks and problems associat-
procedure facilitates soft tissue healing after Stage 2 ed with distortion by various veneering materials can
surgery and simplifies postoperative restorative man- result in management problems at both the clinical
agement. At the Stage 2 surgical procedure, and technical levels. Historically, these dilemmas have
impression transfer copings can be linked directly to been addressed with various technologies, including
the surgical template with autopolymerizing or light- spark erosion, laser-welding, and the use of adhesive
polymerizing resin.36,37 The registration is retrofitted systems to locate abutments within the framework to
to a duplicate of the original, interchangeably achieve a passive fit.38
mounted study cast with the use of a split cast sys- Recently, computer-numeric-controlled (CNC)
tem.8 frameworks milled from a solid block of titanium have
Restorative procedures can be finalized any time become available. These frameworks provide an alter-
after Stage 2 surgery as dictated by soft tissue healing native to conventional castings and have demonstrated
and whether provisional restorations are employed. comparable accuracy of fit as well as similar clinical and
The first stage in the restorative phase is fabrication of radiological performance at follow-up.39,40 The proto-
the master cast. This cast is derived from an impres- col for framework production is industrial (All-in-One;
sion made at Stage 2 surgery or after resolution of the Nobel Biocare AB), which eliminates many of the fac-
soft tissue healing several weeks later. Impressions tors related to the manual handling of conventional
may be at the implant level or at the abutment level.8 castings. Manufacturing costs are similar to those for
A number of different impression techniques may be conventionally cast frameworks. The framework can be
utilized depending on the complexity of the situation designed to suit any implant-supported complete den-
and the anticipated design of the final restoration, as ture work authorization, including metal-ceramic
B C
Fig. 5. A, Panoramic radiograph shows deficient maxillary bone status and extrusion of
mandibular anterior segments. B, Maxillary provisional prosthesis at implant level supported
by 8 implants and maxillary bone graft. Mandibular arch was treated with single-stage surgery
with immediate loading and CNC-milled, 1-piece titanium framework. C, Final maxillary
restoration with CNC-milled titanium framework.
prostheses and hybrid designs used to support and improvement from 40-45 to 60+ in the following 12-
retain denture teeth. Specific low-fusing porcelains can month provisional phase of treatment (Fig. 5, B).
be applied directly to the framework, resulting in min- Final reconstruction of the maxillary arch was accom-
imal distortion because of the high melting point of plished with an All-in-One framework (Nobel Biocare
titanium. The framework is also suitable for other AB) with directly bonded composite tooth and gingi-
applications such as the bonding of gold alloy metal- val sections.
ceramic sections with intermediary composite bonding
Single-stage surgery and immediate loading
systems.
in the maxilla
The application of contemporary technology is
illustrated in Figure 5, in which the classic conse- Single-stage surgery with immediate loading is an
quences of combination syndrome are evident: accepted treatment approach in the mandible and has
extrusion of the anterior mandibular teeth and gross resulted in high success rates in selected patients. This
resorption of the anterior maxillary residual ridge. procedure has been widely documented for prosthesis
The 50-year-old patient was considered high risk due design on 4 or more implants.3,4 A recent protocol has
to a history of smoking, alcoholism, and bruxism. made use of preformed components placed on 3
After the patient underwent counseling and stopped implants, with the entire treatment completed in 7 to
smoking for 3 months, a treatment plan involving 8 hours.41 Unfortunately, results from similar con-
maxillary bone grafting and implants was implement- trolled, prospective studies in the maxilla have not
ed. After placement of the provisional prosthesis at been forthcoming. Nevertheless, limited reports are
Stage 2 surgery, the implants were monitored with accumulating and indicate that in certain circum-
resonance frequency analysis and demonstrated ISQ stances, successful results can be achieved.42 There is a
clear tendency to utilize a larger number of implants edentulous patients treated with mandibular fixed tissue-integrated pros-
theses. J Prosthet Dent 1988;59:59-63.
because prognosis is doubtful and risk assessment is 18. Consensus report. Implant therapy I. Ann Periodontol 1996;1:792-5.
not based on long-term data or established, evidence- 19. Jones JK, Triplett RG. The relationship of cigarette smoking to impaired
based guidelines. Single-stage surgery with immediate intraoral wound healing: a review of evidence and implications for
patient care. J Oral Maxillofac Surg 1992;50:237-9.
loading in the edentulous maxilla must be considered 20. Gorman LM, Lambert PM, Morris HF, Ochi S, Winkler S. The effect of
experimental and should be performed with consider- smoking on implant survival at second-stage surgery: DICRG interim
able caution in select situations only. report No. 5. Dental Implant Clinical Research Group. Implant Dent
1994;3:165-8.
SUMMARY 21. De Bruyn H, Collaert B. The effect of smoking on early implant failure.
Clin Oral Implants Res 1994;5:260-4.
Rehabilitation of the edentulous maxilla continues 22. Bain CA. Smoking and implant failurebenefits of a smoking cessation
protocol. Int J Oral Maxillofac Implants 1996;11:756-9.
to be comparatively more challenging than rehabilita- 23. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study
tion of the edentulous mandible. Although of mandibular fixed prostheses supported by osseointegrated implants.
single-stage surgery with immediate loading concepts Clinical results and marginal bone loss. Clin Oral Implants Res
1996;7:329-36.
are well established in the mandible, they should be 24. Lemons JE, Laskin DM, Roberts WE, Tarnow DP, Shipman C Jr,
considered experimental in the maxilla until long- Paczkowski C, et al. Changes in patient screening for a clinical study of
term, evidence-based data and guidelines are dental implants after increased awareness of tobacco use as a risk factor.
J Oral Maxillofac Surg 1997;55(12 Suppl 5):72-5.
established. Recent advances in diagnostic imaging 25. Brnemark PI, Grndahl K, Worthington P. Osseointegration and auto-
modalities, bone grafting protocols, and prognostic genous bone grafts: reconstruction of the edentulous atrophic maxilla.
technology able to monitor the functional responses of Chicago: Quintessence; 2001. p. 111-34.
26. Bain CA, Moy PK. The association between the failure of dental implants
implants are encouraging. The implant option for the and cigarette smoking. Int J Oral Maxillofac Implants 1993;8:609-15.
edentulous maxilla is increasingly becoming the treat- 27. Haas R, Haimbck W, Mailath G, Watzek G. The relationship of smok-
ment of choice for many patients. ing on the peri-implant tissue: a retrospective study. J Prosthet Dent
1996;76:592-6.
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Evidence for cigarette smoking as a major risk factor for periodontitis. J
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al. Osseointegrated implants in the treatment of the edentulous jaw. 29. Dao TT, Anderson JD, Zarb GA. Is osteoporosis a risk factor for osseoin-
Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl tegration of dental implants? Int J Oral Maxillofac Implants
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2. Brnemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of 30. Consensus Report. Implant therapy II. Ann Periodontol 1996;1:816-20.
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3. Henry PJ. Future therapeutic directions for management of the edentu- a prospective study. Int J Oral Maxillofac Implants 2000;15:811-8.
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4. Henry PJ. Clinical experiences with dental implants. Adv Dent Res restorations. Quintessence Dent Tech 1991;14:110-23.
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Prosthet Dent 2000;83:58-65. mandibles. A clinical resonance frequency analysis study. Int J Oral
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Chicago: Quintessence; 2001. p. 31-63. occlusal records in osseointegrated implant rehabilitation. J Prosthet
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11. Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A. partial dentures fabricated from implant level impressions made at stage
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MW, et al. Stereolithographic biomodelling in cranio-maxillofacial 1999;12:209-15.
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Reprint requests to: Copyright 2002 by The Editorial Council of The Journal of Prosthetic
DR PATRICK J. HENRY Dentistry.
THE BRNEMARK CENTER 0022-3913/2002/$35.00 + 0. 10/1/122775
64 HAVELOCK ST
WEST PERTH, WA 6005
AUSTRALIA
FAX: (61)8-9322-1119
E-MAIL: patrick1@iinet.net.au doi:10.1067/mpr.2002.122775
Purpose. Studies that evaluate the effect of surface characteristics of dental implants on bone cell
behavior have not used actual implants in the test system. This study used as-manufactured
implants with smooth titanium, titanium dioxide-blasted, titanium plasma-sprayed, and hydroxy-
apatite plasma-sprayed surfaces for comparison. This study was performed to investigate bone cell
migration, proliferation, and differentiation on different implants.
Material and methods. Smooth surface (Astra Tech), titanium oxide-blasted surface (Astra
Tech), titanium plasma-sprayed surface (ITI/Straumann and IMZ Friatec AG), and hydroxyap-
atite-coated (IMZ Friatec AG) implants were used in their manufactured states. These implants
were exposed to neonatal rat osteoblast cell suspensions for a 20-minute period. Scanning elec-
tron microscopy was used to classify and to stage the attachment of cells to implants.
Results. Cells spread more rapidly on the titanium plasma-sprayed implants. Full spreading of cells
occurred on smooth titanium implants; these cells were closely adherent to the implant surface.
In contrast, there was no adaptation of cells to the irregularities of the titanium dioxide-blasted
implant surface. Cell adherence with hydroxyapatite-coated implants occurred only on the smooth
areas.
Conclusion. The method used in this study allowed evaluation of rat osteoblast cell adherence to
actual implant surfaces rather than simulations of such surfaces. 32 References.SE Eckert