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 189

Peri-implant Outcome of Immediately Loaded

Implants with a Full-Arch Implant Fixed Denture:
A 5-Year Prospective Case Series

Filip Martens, DDS1 Early and immediate loading in ful-

Stefan Vandeweghe, DDS, PhD2 ly edentulous arches results in out-
Hilde Browaeys, MD, DDS, MSc3 comes similar to those for classical
Hugo De Bruyn, DDS, MSc, PhD4 one- or two-stage delayed proto-
cols.1 Several prospective studies
report survival rates ranging from
This prospective study evaluated clinical results of immediately loaded Biomet
3i implants with different surface topographies. Thirty-three periodontally 91.3% to 100% for immediate load-
compromised patients received 163 implants (130 in the maxilla and 33 in the ing in the mandible. Survival rates
mandible; 132 NanoTite and 31 Osseotite). After a mean loading period of in the maxilla range from 88.5% to
57 months, the survival rate was 96.3%. Mean crestal bone loss was 1.6 mm. 100%; poorer reported outcomes
No difference in bone loss was detected between the two surfaces. Only 6% may be due to poor bone qual-
of the implants had peri-implantitis based on total bone loss above 2 mm
ity.2–5 By and large, these protocol
from the day of surgery in conjunction with probing depths of > 4 mm. (Int J
Periodontics Restorative Dent 2014;34:189–197. doi: 10.11607/prd.1938) modifications have significantly re-
duced treatment time, improving
patient satisfaction.6 With regard to
surface topography, an improved
1Faculty Member, Department of Periodontology and Oral Implantology,
survival rate has been reported
Dental School, Faculty of Medicine and Health Sciences, University of Ghent, for moderately rough surfaced im-
De Pintelaan, Ghent, Belgium. plants compared with machined
2Faculty Member, Department of Periodontology and Oral Implantology,
surfaces, especially in challenging
Dental School, Faculty of Medicine and Health Sciences, University of Ghent,
De Pintelaan, Ghent, Belgium and Department of Prosthodontics, Faculty of Odontology, conditions such as poor bone qual-
Malmö University; Carl Gustavsvag, Malmö, Sweden. ity.7,8 Furthermore, the introduc-
3Maxillofacial Surgeon, Department of Periodontology and Oral Implantology,
tion of nanotechnology to implant
Dental School, Faculty of Medicine and Health Sciences, University of Ghent,
surfaces has enhanced the implant
De Pintelaan, Ghent, Belgium and Department of Maxillofacial Surgery,
Academic Hospital Sint-Dimpna, Geel, Belgium. osteoconductivity.9 Clinical stud-
4Professor and Chairman, Department of Periodontology and Oral Implantology,
ies, although limited in number
Dental School, Faculty of Medicine and Health Sciences, University of Ghent, and follow-up time, indicate that
De Pintelaan, Ghent, Belgium and Department of Prosthodontics, Faculty of Odontology,
Malmö University; Carl Gustavsvag, Malmö, Sweden.
nanosurfaced implants may be
more successful, especially when
Correspondence to: Prof Hugo De Bruyn, Department of Periodontology and Oral immediately loaded. Theoretically,
Implantology, University Hospital Ghent-P8, De Pintelaan 185, B-9000 Ghent, Belgium;
the bioactive topographic feature,
fax: +3293323551; email: hugo.debruyn@ugent.be.
which enhances the initial osseoin-
©2014 by Quintessence Publishing Co Inc. tegration cascade, should enhance

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190

based on clinical and radiographic

* = Lost during follow-up inspection, which included pan-
33 patients (P) † = failure
oramic radiograms and/or three-
dimensional radiographic evalua-
163 implants (I) tion using computed tomography
(CT) or cone beam CT. Included
patients had to have enough bone
Mandible Maxilla
Baseline P = 25
to insert at least four implants with
P=8
I = 33 I = 130 a minimum diameter of 4 mm
8* and minimum length of 10 mm.
2*
6† All implants placed were Biomet
26 mo P=8 I = 33 P = 23 I = 116 3i implants with an Osseotite or
NanoTite surface. In some pa-
6* tients, Osseotite and NanoTite im-
1* 5* 1*
3†
plants were placed alternately to
57 mo P=7 I = 28 P = 22 I = 107 allow comparison of both surfaces
within the same patient. A sche-
matic overview of the study design
27 NanoTite 1 Osseotite 77 NanoTite 30 Osseotite is displayed in Fig 1.

Fig 1    Flowchart of the study design.

Treatment protocol and follow-up

bone-to-implant contact and thus
implant success.10,11
The aim of the current pro-
spective study was to evaluate
results for immediately loaded
full-arch provisional partial den-
tures placed on dual acid-etched
titanium implants with NanoTite
and Osseotite surfaces (Biomet 3i).
Clinical outcome in terms of im-
plant survival, crestal bone remod-
eling, and peri-implant health were
assessed for up to 6 years in peri-
odontally compromised patients.
Method and materials
Patient selection
The study population consisted of
33 patients consecutively treated
with immediately loaded implants
to rehabilitate the maxilla and/or
mandible. Patients with a history
of radiation therapy, use of medi-
cation for cancer prevention, or
irregular compliance with dental
care or maintenance were exclud-
ed, but smokers were included.
All patients were classified as peri-
odontally compromised based on
tooth loss at a young age and/or
ongoing periodontal disease in
remaining teeth. All patients were
enrolled in a periodontal treat-
ment protocol prior to implant
surgery, including nonsurgical or
surgical periodontal infection con-
trol, with selective extractions of
hopeless teeth at least 2 months
prior to implant placement. Oral
hygiene instructions were given at
each visit. Surgical planning was
Implants were placed by two expe-
rienced surgeons (HDB, HB) after
crestal incisions were made and
full-thickness flaps were raised. The
drilling protocol was adapted to
the bone quality to enhance initial
implant stability. All implants were
placed subcrestally or crestally, tak-
ing into consideration the biologic
width in relation to soft tissue thick-
ness. Impressions and bite regis-
trations were taken in conjunction
with the implant placement, in
accordance with a previously de-
scribed treatment protocol.12,13 All
implants were loaded by a trained
prosthodontist (SVDW) with a 10-
to 12-unit screw-retained metal-
reinforced acrylic resin provisional
partial denture manufactured by
the dental technician within 72
hours of surgery. Minor occlusal

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 191

a b

c d e

f g h

Fig 2    Case presentation of an immedi-

ate loading treatment in the maxilla. (a and
b) Extensive tooth loss and caries, (c) the
surgical guide made by the dental technician
shows the tooth positions and contains space
for bite-registration material, (d) healing abut-
ments immediately after impression making,
(e) impression analogs are connected to the
impression coping by the surgeon and sent
to the lab to create a working cast, (f) bite
registration was performed with the guide i j
plate, (g and h) provisional partial denture
made by the dental technician, (i and j)
radiographs 6 months after placement of the
provisional construction.

adjustments were made to achieve Patients were enrolled in a recall the referring clinician provided a
spreading of the occlusal load and program to ensure good oral hy- definitive restoration.
establish bilaterally protected artic- giene and to evaluate the provi- Digital periapical radiographs
ulation with group function (Fig 2). sional restoration. After 6 months, were taken after implant insertion

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192

a b c
Fig 3    Apical radiographs at (a) 6 months, (b) 2 years, and (c) 5 years after immediate loading. Red arrows indicate the bone level.

Table 1 Implant length in relation to arch
Implant length (mm)
Arch 10.0 11.0
Mandible 0 1
Maxilla 5 0
Total 5 1
(baseline) and during two follow-
up visits to visualize the crestal
marginal bone-to-implant con-
tact (Fig 3). These radiographs
were analyzed by the same clini-
cian (FM). Twenty randomly se-
lected radiographs were measured
twice by two clinicians to analyze
intra- and interexaminer reliabil-
ity. Plaque and bleeding on prob-
ing were evaluated at four places
around each implant using the
Mombelli index.14 The presence
of plaque was tested by running
the side of the probe around the
implant surface at the peri-implant
sulcus. Bleeding was evaluated by
gently sliding a periodontal probe
through the sulcus. A mean pocket
depth was calculated per implant.
11.5 13.0 15.0 Total
6 20 6 33
9 60 56 130
15 80 62 163
Statistical analysis
Pairwise analysis of crestal bone
changes and clinical parameters
was performed with the Wilcoxon
rank sum test. Correlations be-
tween clinical and radiographic
measurements were calculated us-
ing the Spearman rank correlation
coefficient. The intra- and interex-
aminer reproducibly of the radio-
graphic analysis was calculated by
means of the Spearman correlation
coefficient and Wilcoxon signed-
rank test. All tests were performed
using SPSS (version 19.0; SPSS,
IBM) and were evaluated at a .05
significance level.
Results
Implant survival
In total, 33 patients (16 women and
17 men) receiving 163 implants
were evaluated. The mean age was
66 years (range, 39 to 89 years; SD,
12.8 years). Twenty-five patients re-
ceived 130 implants in the maxilla,
and 8 received 33 implants in the
mandible. One patient received im-
plants in both arches (Table 1 and
Fig 4). All implants were long (10
to 15 mm) and were 4 mm in diam-
eter. Only one implant was 3.25 mm
wide and 5 were 5 mm wide. Dur-
ing provisionalization, 6 implants
were lost in 4 patients, bringing the
1-year survival rate to 157 of 163
(96.3%). At the first investigation
interval of 26 months (range, 7 to
48 months; SD, 13.6 months), no
further failures had occurred, al-
though 2 patients with 8 implants
were lost from recall. At the second
follow-up, after a mean period of
57 months (range, 34 to 77 months;
SD, 12.4 months), 1 patient had lost
3 implants, and 2 patients with a
total of 11 implants were lost from
follow-up. Hence, a total of 9 of
163 implants had failed (5.5%). The
dropout rate was 4 of 33 patients
(12%), of which 3 were unaccount-
ed for and 1 deceased. All failures

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 193

30

20
Total (n)

Total (n)
4

10
2

0 0
18 16 14 12 22 24 26 28 45 43 41 31 33 35
Implant position Implant position

Fig 4    Locations of 163 implants in 33 patients, according to FDI tooth position.

4.0 4.0
Crestal bone loss (mm)

3.0 3.0
Bone loss (mm)

2.0 2.0

1.0 1.0

0 0
26-mo follow-up 57-mo follow-up NanoTite Osseotite

Fig 5    Crestal bone loss at the two recall intervals. Red arrows Fig 6    Crestal bone loss with two different implant topographies.
indicate the median.

occurred in the maxilla, bringing the 1.40 mm (range, 0.39 to 2.29 mm;
failure rate there to 6.9%. Implant SD: 0.46 mm) with the implant and
survival in the mandible was 100%. the patient as the statistical unit, re-
spectively (Figs 5 and 6). There was
no statistically significant difference
Peri-implant bone and health (P = .23) in mean bone loss after
26 months (1.5 mm; SD, 0.69 mm;
After a mean follow-up period of range, 0 to 3.2 mm) (Figs 7). Mean
57 months, mean total crestal bone crestal bone loss for the Osseotite
loss calculated from the day of implants was 1.7 mm (n = 31; SD,
surgery was 1.6 mm (n = 135; SD, 0.80 mm; range, 0.30 to 3.15 mm)
0.77 mm; range, 0 to 3.35 mm) and and for the NanoTite implants,
1.5 mm (n = 104; SD, 0.76 mm;
range, 0.00 to 3.35 mm). This differ-
ence was not statistically significant
(P = .632). In the maxilla, the mean
crestal bone loss was 1.5 mm; in
the mandible, 1.6 mm. This differ-
ence was not significant (P = .708).
There was no significant difference
(P = .59) in bone loss between im-
plants placed in bone of poor qual-
ity (1.5 mm) and those placed in
bone of good quality (1.4 mm).

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194

The bone loss around 22 Os-

seotite (1.56 mm) and NanoTite
100
(1.40 mm) implants was pairwise
compared within 11 patients who
had both implants in equal num-
ber, and the difference was not
80
statistically significant (P = .68)
(Fig 7). The Spearman correlation
coefficient for bone-level assess-
ment showed a high intra- and
Cumulative percent

60 interexaminer reliability (κ = 0.87

and 0.91, respectively). The differ-
ences in mean bone level did not
exceed 0.3 mm (corresponding to
40 half a thread), and the Wilcoxon
rank sum test could not detect a
significant difference (P = .214).
The mean overall and in-
20 terproximal probing depth was
Time interval 3.4 mm (SD, 0.70 mm; range, 1.5
26-mo follow-up
to 6.0 mm) and 3.6 mm (range, 2.0
57-mo follow-up
to 6.0 mm; SD, 0.76 mm), respec-
0 tively. Only 5.4% of the implants
had a mean interproximal probing
depth of more than 5 mm. Exces-
0
0.38
0.73
0.83
1.05
1.13
1.23
1.35
1.43
1.53
1.63
1.70
1.80
1.85
1.93
2.05
2.15
2.30
2.55
2.60
2.85
3.05
3.20

sive bleeding was present around 5

Marginal bone loss
implants, with spontaneous bleed-
Fig 7    Cumulative percentage of implants and their corresponding bone loss as measured
ing evident around 2 (Table 2).
during the follow-up examinations. As indicated, 50% of patients had > 1.53 mm of bone
loss after 57 months. There was no correlation be-
tween interproximal probing pock-
et depth (PPD) and marginal bone
Table 2 Plaque and bleeding scores
level (P = .63), according to the
Score Variable n (%) Spearman correlation test. The re-
lation between radiographic bone
  Bleeding
0 No bleeding 43 (29.4) loss and PPD is shown in Table 3. In
1 Isolated bleeding spot visible 41 (28.0) total, 94.6% of the implants had a
2 Blood forms a confluent red line mean interproximal probing depth
on the margin 57 (39.0)
≤ 5 mm, and 80.7% had mean mar-
3 Heavy or profuse bleeding 5 (3.4)
ginal bone loss up to the second
Plaque/calculus thread. Deeper (> 5 mm) as well as
0 Not detected 30 (20.5)
shallower (< 4 mm) pockets were
1 Plaque only recognized by
running a probe 72 (49.3) present in all bone loss groups,
2 Plaque can be seen by the naked suggestive of the low correlation
eye 42 (28.7) coefficient between these param-
3 Abundance of soft matter 2 (1.3)
eters. Despite this stable bone

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 195

Table 3 Cross table of individual implants presented according to the marginal bone loss and
the mean interproximal PPD*

Mean marginal bone level after 5 y (%)

Within the 1st Between the 1st and Between the 2nd Surpassing the
thread 2nd thread and 3rd thread third thread
(≤ 1.5 mm) (1.51–2.1 mm) (2.11–2.7 mm) (> 2.7 mm) Total (%)
Mean interproximal PPD (mm)
≤ 3.0 25 17 7 1 50 (38.4)
3.1–4.0 30 16 7 2 55 (42.3)
4.1–5.0 7 5 5 1 18 (13.8)
> 5.0 1 4 1 1 7 (5.4)
Total 63 (48.5) 42 (32.3) 20 (15.4) 5 (3.8) 129 (100)
PPD = probing pocket depth.
*Implants in green represent a low disease risk. Implants in yellow (19.2%) can be considered at risk for disease and should
be monitored more closely. Implants in red (3.8%) showed bone loss past the third thread at the 57-month interval. These
may be at risk for peri-implantitis. Due to probing difficulties or some unreadable radiographs, not all pockets could be
related to a corresponding bone loss value. In total, 130 implants were evaluated.

condition, bleeding was present
around 80% of the implants.
Discussion
The aim of the present prospec-
tive study was to evaluate survival,
crestal bone level changes, and
peri-implant health of NanoTite
and Osseotite dental implants
used for complete rehabilitation
of the maxilla and/or mandible
using an immediate loading pro-
tocol. Immediate loading is sup-
ported by numerous reports with
satisfactory outcomes,2,12,13,15 and
the present study shows a high
clinical cumulative survival rate
of 94.4% after a mean of 5 years.
Implant survival was 100% in the
mandible, in line with other pub-
lished prospective clinical stud-
ies.4,16 Cumulative survival in the
maxilla was 93.7% after 57 months.
This outcome is consistent with re-
cent literature.17 It should be noted
that the included patients had a
history of periodontal disease and
tooth loss at a young age, and
such a history has been associated
with a threefold higher implant
failure rate.18,19 Other studies have
reported comparable survival rates
of immediately loaded maxillary
Biomet 3i implants.20,21 Immediate-
ly loaded dual acid-etched Biomet
3i implants placed in 26 patients
(8 to 10 implants each) experienced
no failures after 12 to 74 months of
follow-up.16 The lower number of
implants per patient in the pres-
ent study (4 to 6 implants) may
have resulted in a more unevenly
distributed occlusal load and high-
er micromotion on each individual
implant, another potential contrib-
uting factor to increased failure
risk. Clinical studies of less than 5
implants per arch have been clearly
associated with higher failure rates
compared with clinical studies with
5 to 8 implants per arch.17 In this
study, the bone volume in 11 non-
smoking patients only allowed for
placement of 4 implants per arch.
Four of 44 implants (9.1%) failed in
this group, including 3 after more
than 2 years of loading. Five of 74
implants (6.7%) failed in patients
who received 6 implants per arch.
This clinical difference points to
the importance of sufficient oc-
clusal load spreading, especially
in immediately loaded maxillary
restorations.

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196
The surface of Biomet 3i im-
plants has a roughness (Sa value,
0.5 µm) that has been shown to be
relatively smooth compared with
competing implants.22 This may be
helpful in maintaining peri-implant
health especially in periodontally
involved patients. Use of this sur-
face up to the abutment level has
been demonstrated not to increase
the risk of peri-implantitis.23 The
present study confirms this; crestal
bone levels did not change after
the initial biologic width and re-
modeling were established. No
changes in peri-implant health
were observed between the first
and second follow-up visits.
Although some studies have
proven that nanotechnology im-
proves osteoconductivity, this
advantage only comes into consid-
eration during initial bone healing
in compromised cases. Hence, the
lack of a difference in crestal bone
loss between full Osseotite or full
NanoTite surfaced implants ap-
pears logical and is in agreement
with earlier studies.20,24
Bone loss of less than 1.5 mm
during the first year after loading
and 0.2 mm annually thereafter
has been defined as a criteria for
implant success.25 In this study,
this would allow for a total crestal
bone loss of 1.94 to 2.60 mm, as
the range for follow-up was 34 to
77 months. Observed crestal bone
loss was below these threshold val-
ues for 75% of the evaluated im-
plants. This bone loss was based on
baseline measurements recorded
on the day of surgery. However, re-
cent clinical studies have revealed
that initial bone remodeling takes
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from 3 to 6 months after single-
stage implant placement. Hence,
a waiting period between abut-
ment placement and loading, as
is often the case in delayed load-
ing studies, excludes a large por-
tion of the total crestal bone loss.
A comparison of immediate load-
ing with early/immediate loading
is therefore scientifically biased.26,27
A few studies have reported bone
loss of 0.8 to 0.9 mm with Biomet
3i implants,20,21,24,28 less than the
1.6 mm found in the present study.
An explanation may be found in
the limited follow-up time of some
of those studies.
No correlation was found be-
tween probing depth and bone
loss, pointing to the low predic-
tive value of probing to detect
ongoing disease. A total of 48.5%
and 80.7% of implants showed
bone loss not exceeding the first
or second implant thread, respec-
tively (Table 3). Only 19% of im-
plants had bone loss of more than
2.1 mm. When bone loss of more
than 2.1 mm and pocket depths
of more than 5 mm are considered
together (the diagnostic criteria for
peri-implantitis),29 only 1.5% of the
implants fall into this category.
Conclusion
This study makes it clear that con-
cerns about high peri-implantitis
prevalences are unfounded. This
confirms other reports and clearly
indicates that a combination of
bone loss and probing depth must
be considered. Use of the NanoTite
or Osseotite surface, rough to the
top, does not appear to be prone
to peri-implant disease.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
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Volume 34, Number 2, 2014