Treatment outcomes of fixed or removable implant-supported prostheses in

the edentulous maxilla. Part II: Clinical findings

Nicola U. Zitzmann, Dr med dent,a and Carlo P. Marinello, Dr med dent, MSb
University of Basel, Basel, Switzerland
Statement of problem. There is a widespread belief that maxillary overdenture prostheses are associated
with a higher frequency of complications and require more maintenance than fixed implant prostheses.
Purpose. This prospective clinical study compared the treatment outcomes of fixed and removable
implant-supported restorations in the edentulous maxilla with the main emphasis on the clinician’s point of
view.
Material and methods. Ten patients were treated with fixed screw-retained implant prostheses (group 1),
and 10 patients were treated with removable implant-supported overdentures (group 2) in the edentulous
maxilla. Recall was scheduled at 6-month intervals to investigate the prosthodontic treatment outcomes,
including implant survival, prosthesis time until retreatment, and maintenance issues. Clinical parameters
gingival index (GI), plaque index (PI), the clinical attachment level, and radiographic marginal bone levels
measured, along with any biologic and mechanical complications were recorded.
Results. Patients were followed over a mean period of 39 months (SD=7; group 1) and 27 months
(SD=10; group 2) after implant placement. Cumulative implant survival was 97.6% for group 1 and 94.4%
for group 2 after an 18-month observation period. The mean time until retreatment after prostheses inser-
tion was 23.4 months for group 1 and 19.8 months for group 2 (n.s.). In both groups, the increase over
time in the radiographically investigated bone level was found to be significant. The indices given for the
mucosal health and oral hygiene status (GI and PI) were highly correlated in both groups at each recall
appointment, but no significant differences were found between groups 1 and 2.
Conclusion. In groups 1 and 2, comparable prosthodontic treatment outcomes were achieved. The
majority of mechanical complications could be managed chairside during recall visits and did not require
additional appointments, so that the time and costs involved in providing maintenance were kept down.
(J Prosthet Dent 2000;83:434-42.)

CLINICAL IMPLICATIONS
For the maxillary fixed and removable implant prostheses, in this study, that the
period until retreatment is required was similar provided that both superstructures are
implant-supported and recall intervals are scheduled every 6 months.

W hen assessing the outcomes of oral implant

therapy, it is important to consider both the clinicians’
and the patients’ appraisals.1 For the clinician, implant
survival, prosthesis longevity, and the frequency of
complications are the most significant parameters. It
has been pointed out that giving the proportion of
failed implants is not an adequate way of describing the
success of implant prosthesis treatment. A better sur-
vival measure is the period until any intervention is
required, which was described as “time to retreat-
ment.”2 This parameter provides the means to take
other biologic or mechanical complications that may
aAssistant
Professor, Clinic of Fixed and Removable Prosthodontics
and TMJ Disorders.
bProfessor and Chair, Clinic of Fixed and Removable Prosthodontics
and TMJ Disorders.
occur during maintenance into account. On the other
hand, the social and psychological impact of the treat-
ment and its cost-effectiveness, benefit, and utility are
what patients tend to be interested in, so that their
assessments focus on the effect of the treatment on
esthetics, function, comfort, and, not least, on his/her
personal well-being and self-confidence.3
In the first part of this study, the authors reported
patients’ assessments and the social and psychologic
impact of 2 prostheses designs applied to reconstruct
the edentulous maxilla. They showed that both the
fixed screw-retained implant prosthesis and the remov-
able implant-supported overdenture provided the
patient with a high degree of satisfaction and had a pos-
itive effect on his/her well-being and quality of life.
Several authors have reported on higher implant failure
rates with overdenture prostheses in the maxilla and

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Table I. Distribution of implant length according to each tooth position

Tooth area/
implant length 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Sum

Group 1
8/5 1 1 2
8.50 2 2
10 2 1 2 2 2 1 10
10/5 2 1 3
13 1 5 3 5 2 2 4 2 7 3 2 36
15 1 1 2 6 3 2 2 3 6 3 1 30
18 1 1
Sum 0 2 1 6 10 9 9 4 4 9 10 10 6 3 1 0 84
Group 2
10 1 1 1 2 1 1 7
10/5 1 1 1 1 4
11.50 1 1 1 2 5
12/5 1 1
13 1 1 2 3 4 1 1 2 3 5 4 2 1 30
13/5 1 1 1 3
15 2 4 2 3 2 1 3 2 19
18 1 1 2
Sum 3 1 3 5 9 8 5 4 1 5 8 9 5 2 0 3 71
/5 indicates wide diameter implants.

MATERIAL AND METHODS

more complications when compared with repairs with
fixed reconstructions.4-6 However, these reports refer
to compromised study groups that included patients
with severely resorbed maxillae who were restored with
combined implant- and soft tissue–supported overden-
ture prostheses retained at 2 to 6 implants. On the
other hand, it has been assumed that implant survival
rates could be similar for maxillary fixed or removable
implant prostheses provided that the selected cases
were matched for bone quality and quantity.7,8
Because implant mobility is a final sign of loss in
osseointegration, is irreversible, and indicates implant
failure, it has been proposed that other parameters
should be used during recall to detect any peri-
implant disease. According to Mombelli and Lang,9
periodontal parameters can be applied to peri-implant
tissues to monitor their condition in a manner similar
to that used with periodontal tissues. With regard to
mechanical complications, Kaptein et al10 observed
retrospectively a higher rate of maintenance for maxil-
lary fixed implant prostheses. They found, however,
that the number of overdenture fractures increased
over time.
It was the aim of this clinical study: (1) to investigate
the longevity outcome of fixed and removable implant-
supported prostheses in the edentulous maxilla; (2) to
analyze biologic and mechanical complications; and (3)
to investigate the effort involved in maintenance care.
Findings were evaluated by comparing cases with simi-
lar starting points that were treated with either fixed or
removable implant-supported maxillary prostheses.
Patient selection and surgical procedure
Twenty patients who required implant treatment in
the edentulous maxilla were included in the study.
According to the indication criteria described in part 1,
10 patients were included in group 1 and treated with
a fixed detachable implant prosthesis, retained at 8 to
10 implants. One patient, who agreed to receive a
shortened dental arch, was provided with 6 implants 13
to 15 mm in length. In group 2, 10 patients were treat-
ed with removable bar-retained, implant-borne over-
denture prostheses. Six to 8 implants were placed; in 1
patient (no. 16), the implant number was restricted to
5 because of the advanced bone resorption; another
patient (no. 17) received 10 implants because of antic-
ipated complications with poor bone quality, the
patient’s smoking habit, and the periodontal involve-
ment of the mandibular dentition. In partially edentu-
lous patients, the residual teeth were extracted approx-
imately 6 weeks before or during implant placement.
Guided bone augmentation procedures with grafting
material (Bio-Oss, Osteohealth Co, Shirley, N.Y.) and
barrier membranes (Bio-Gide, Osteohealth Co; or
Gore-Tex, Implant Innovation, West Palm Beach, Fla.)
were used to cover exposed implant surfaces in 15
patients, affecting 34 implants. Bone quality and quan-
tity were preoperatively and intraoperatively assessed,
according to the classification by Lekholm and Zarb11
and using the modification by Zitzmann and Schärer12
to describe the bone quantity in the area of the maxil-
lary sinus. Self-tapping screw-type implants (Bråne-

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THE JOURNAL OF PROSTHETIC DENTISTRY
mark, Nobel Biocare, Gothenburg, Sweden) with a
3.75-mm diameter were used. Distribution of implant
lengths in the corresponding tooth positions is shown
in Table I.
Wide diameter implants (5 mm) were placed in the
posterior region when a type IV bone quality was pre-
sent and/or a 3.75-mm diameter implant was not pri-
marily stable. The surgical and prosthetic treatment was
performed either by the authors or under their direc-
tion as part of the clinical postgraduate program at the
Universities of Basel and Zurich, Switzerland. After a
healing period of about 6 months (6.2 ± 0.3), the reen-
try was performed, healing abutments placed, and final
abutments selected.
Prosthetic treatment sequence
Fixed implant prostheses were veneered with acrylic
or porcelain and screwed onto EsthetiCone or angulat-
ed abutments.13 Removable overdenture prosthesis was
made so as to fit the prefabricated or individually milled
bar in a precise way that facilitated retention and load
distribution.14 The individually waxed bar was
designed to contact the underlying soft tissue without
pressure, thereby allowing for adequate oral hygiene
access for interproximal brushes mesiodistally to the
abutments. In 3 patients, prefabricated bar elements
(Dolder, Hader) were used with no soft tissue con-
tact.14 The extensions of the buccal and palatal pros-
thesis flanges were determined during setup try-in rel-
ative to the smile line, the need for facial support, and
speech requirements. Prefabricated acrylic denture
teeth were individually stained and the prostheses com-
pleted with acrylic resin.
Postinsertion maintenance
Patients were checked 2 to 3 weeks after insertion of
the final restoration and then recalled every 6 months
(6.3 ± 0.4). All implants were monitored according to
the criteria defined by Albrektsson et al,15 who claimed
that the success criteria for individual implant sites were
implant stability, the absence of peri-implant radiolu-
cency, and clinical symptoms, such as pain, infection,
neuropathies, and paresthesia. The restriction to less
than 0.2-mm annual vertical bone loss after the first
year of loading was not applied as a success criterion, so
that the term “implant survival,” rather than “implant
success,” is used.7 Because a widely approved implant
system (Brånemark) was used, prostheses were general-
ly not removed for individual mobility testing during
recall visits unless something unexpected had occurred.
Prosthesis failure was defined as the renewal of the
implant superstructure. Prosthesis longevity was evalu-
ated in months from prosthesis placement until any
additional treatment was required and described as
“time until retreatment.”1,2 This outcome measure was
used to determine maintenance, adjustment, and repair
436
ZITZMANN AND MARINELLO
for both prosthesis designs. The time until retreatment
was related to causes that were biologic or mechanical
and comprised the following unexpected events and
complications:
For fixed implant prostheses: implant loss, implant
fracture, fracture or loosening of a gold- and/or abut-
ment-screw, discoloration, and chipping and/or frac-
ture of the veneering.
For removable overdenture prostheses: implant
loss, implant fracture, fracture or loosening of a gold-
and/or abutment-screw, bar and/or clip fracture,
discoloration, chipping and/or fracture of acrylic
resin, clip or attachment activation or change, and any
relining.
Implant failures after prosthesis placement were
recorded as retreatment even when no additional pros-
thesis adjustment was required. Soft tissue complica-
tions, such as mucosal hyperplasia, were also included
in the criteria, if any additional intervention was
required.
During recall appointments the following clinical
parameters were evaluated at every implant-abutment
in the maxilla:
1. Plaque Index (PI) was measured according to Sil-
ness and Löe,16 grade 0 to 3 on the facial aspect.
2. Clinical signs of inflammation of the periimplant
mucosa were graded using the criteria of the Gingival
Index (GI) (Löe and Silness),17 20 seconds after prob-
ing, with grade 0 to 3 on the facial, oral, and mesial
aspects.
3. Clinical pocket-probing depth (PD) was mea-
sured with a periodontal probe (CP-12, Hu-Friedy,
Chicago) at 4 sites (buccal, oral, mesial, and distal).
4. The distance between the mucosal margin and the
top margin of the abutment was recorded as a recession
(REC, 4 sites). Positive values represent supramucosal
margins, negative values indicate the submucosal mar-
gins of the superstructure.
5. Soft tissue complications, such as redness,
swelling, hyperplasia, pain during palpation, or exuda-
tion during palpation were recorded as present or not
for every implant site.
The PI and GI were calculated per patient on a per-
centage base, including all maxillary implants, irrespec-
tive of the status of the mandible. The sum of the
recorded plaque-values (PI) was divided by the number
of maxillary implants and the sum of the mucosal-val-
ues (GI) was divided by the number of recorded sites
(3 per abutment) of all maxillary implants. According
to Quirynen et al,18 the attachment level (AL) was
defined as the sum of PD and REC minus the abut-
ment length, and was calculated for the mesial and dis-
tal aspect. Positive values indicate that the tip of the
probe was located below the abutment-fixture junction
(AFJ), whereas negative values show a tip location
above the AFJ (Fig. 1).
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ZITZMANN AND MARINELLO
Fig. 1. Probing on mesial aspect of bar-splinted abutment
(patient no. 20, group 2).
Fig. 2. Radiographs (30-month observations) for evaluation
of peri-implant translucency at any site, and MBL measure-
ments at implant region 14 (patient no. 5, group 1).
Periapical radiographs of all sites were made with the
appropriate Rinn holder (Rinn XCP, IL) using the long-
cone parallel technique (Oralix 65 S, Gendex Dental
System, Hamburg, Germany), so that implant threads
were clearly visible (Fig. 2). When a deviation from a
proper parallel implant projection was observed, the
radiograph was redone during the same visit. The mea-
sured distance between the tips of the implant threads,
which is always 0.6 mm in reality, was used as the basis
for assessing and calibrating the radiograph. The mar-
ginal bone level (MBL) was estimated to the nearest
0.3 mm (half interthread distance) with the AFJ as the
baseline reference because implants had been initially
placed with the implant shoulder (AFJ) located at the
height of the bone crest (Fig. 3). For the measurements
of the marginal bone level (MBL) and comparison with
the clinically calculated AL, the implant in the left or
right first premolar region was selected as representative
because it revealed the most accurate radiographs. If one
side was affected by other clinical factors such as bone
augmentation procedures, the contralateral side was
chosen. If both sides fulfilled the requirements, the left
or right side was randomly chosen for the evaluation of
the marginal bone level. Of the 2 values measured on the
APRIL 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Schematic drawing of AL calculation and MBL mea-
surements.
mesial and distal aspect, the greater distance was used as
a representative value for every patient.
For the investigation of the MBL, the radiographs
taken at the 6-month (reentry), 12-month (first recall
visit), 18-month (1 year of prosthetic loading), and
30-month observation (2 years of prosthetic loading)
were used. The measurements were performed by one
of the authors (N.U.Z.) and were redone after 1 week
to check intraobserver reliability.
Statistical evaluation
The analyses were carried out with STATA version
6.0 (Stata Corp, Texas) statistical software. Cumulative
implant survival rates were estimated at 6-month time
intervals starting from implant placement. Log-rank
tests were applied to assess whether the rates for
implant survival and the rates of mechanical and bio-
logic complications were significantly different for the
2 groups (fixed and removable). The estimation of
mean values of time until retreatment in groups 1 and
2, and standard error (SE) of the means were based on
Kaplan-Meier.
The first objective of the evaluation of the clinical
parameters was to assess whether the average GI, PI,
437
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 4. Mean values for GI and PI in groups 1 and 2 during recall.
AL, and MBL increased significantly with time after
implant placement. Second, there was the question as
to whether the parameters under examination differed
significantly between the 2 groups. To evaluate both
objectives, cross-sectional time-series Gaussian models
were obtained using the Stata package. The dependent
variables were GI, PI, AL, and MBL, and explanatory
variables were time and group. The analysis was adjust-
ed according to sex when this variable appeared to
modify the magnitude of the treatment effect slightly,
but not its significance. Correlations arising from the
longitudinal nature of the data were accounted for by
assuming an exchangeable type correlation matrix for
the within-patient observations. The generalized esti-
mating equation approach was used to evaluate the
parameters of the model. Before analyzing the data, the
GI, PI, AL, and MBL values were transformed to nor-
mality using the Box-Cox transformation. The close to
normality transformation was the square transforma-
tion. The third objective was to assess the degree of
correlation between GI and PI at different follow-up
times after prosthesis placement and, additionally, to
assess the degree of correlation between the clinically
investigated AL and the radiographically estimated
MBL. For these objectives, Spearman’s rank correla-
tion was used.
To show how strong the intraobserver agreement
was for the repeated MBL measurements, the Wilcox-
on paired test was used.
RESULTS
Implant and prosthesis survival and time until
retreatment
A total of 155 implants were placed in 20 maxillary
jaws, 84 implants in group 1 and 71 implants in group 2
(Table I). The average observation time was 39.2
months (SD=7.0; group 1) and 27.5 months (SD=9.9;
438
ZITZMANN AND MARINELLO
group 2) from the first surgical intervention. The
cumulative implant survival rate was 97.6% (group 1)
and 94.4% (group 2) after an 18-month observation
period (Log-rank test: χ21=1.2, P=.28). In none of the
cases was reoperation needed to place additional
implants. During reentry, 6 months after implant place-
ment, 2 patients in group 1 lost one implant each (nos.
5 and 7). Both sites revealed complications during the
healing period, due to exposed ePTFE-membranes
(Gore-Tex). Another patient (no. 15, group 2) with a
type IV bone quality and a severely resorbed alveolar
ridge (bone quantity D) lost 2 implants at reentry.
After prosthesis installation, 1 patient (no. 17, group 2)
lost 2 implants, one after 3 months and the other after
5 months. It was not necessary to adjust the prosthesis.
Prosthesis survival was 100% for both prosthesis
designs during the entire observation period. The
mean time until retreatment was 23.4 months
(SE=2.87) for group 1 (affecting 6 patients) and 19.8
months (SE=2.68) for group 2 (affecting 5 patients, 2
of them twice). The time until retreatment was not sta-
tistically associated with whether the treatment was
fixed or removable (log-rank test: χ21=0.2, P=.653).
Clinical and radiologic examination
Mean values for the GI and PI are shown in Table II
and Fig. 4. At the examination 2 to 3 weeks after pros-
thesis insertion, the PI was 28% (SD=12) for group 1
and 36% (SD=25) for group 2. The GI was 35%
(SD=11) for group 1 and 38% (SD=17) for group 2.
Slight suppuration on probing and/or pressure
occurred on 3 sites at the 12- and 18-month observa-
tion and were measured with a GI grade 3. Mucosal
hyperplasia was observed in 2 patients (group 2) at the
12-month recall and was repeatedly found during the
following observations. Oral hygiene was reinstructed,
chlorohexidine rinsing solution prescribed, but no
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ZITZMANN AND MARINELLO THE JOURNAL OF PROSTHETIC DENTISTRY

Table II. Mean values (and SD) of Gingival Index and Plaque Index, attachment level, and marginal bone level
6-mo observation 12-mo observation 18/mo observation 30-mo observation
(prosthesis insertion) (6-mo recall) (12-mo recall) (24-mo recall)
Time/
group 1 2 1 2 1 2 1 2

GI (%) 35 (11) 38 (17) 32 (15) 38 (18) 33 (19) 56 (24) 29 (12) 54 (26)

PI (%) 28 (12) 36 (25) 30 (21) 43 (23) 27 (22) 48 (27) 25 (17) 40 (26)
AL (mm) 0.8 (0.63) 0.2 (0.42) 0.7 (0.67) 0.5 (0.71) 0.9 (0.74) 0.71 (0.76) 1.11 (0.78) 0.8 (0.84)
MBL (mm) 1.69 (0.79) 1.64 (0.64) 2.25 (0.36) 2.07 (0.46) 2.43 (0.38) 2.38 (0.28) 2.47 (0.38) 2.56 (0.25)
GI = Gingival Index; PI = Plaque Index; AL = attachment level; MBL = marginal bone level.

Table III. Parameter estimates of the linear regression model

additional treatment required. In group 2, higher mean
on Gingival Index, Plaque Index, attachment level, and
percentages of GI and PI were found than in group 1. marginal bone level
The average values did not change significantly with
Outcome Parameter Coefficients SE Wald test P value
time (between recall visits) or between groups 1 and 2
(Table III). GI and PI were highly correlated in both GI Constant –1.062 0.13 –8.148 <.0001
groups at every follow-up visit (Table IV). Time 0.001 0.003 0.425 .671
The mean AL and MBL calculated for group 1 and Group (2) 0.216 0.185 1.17 .242
group 2 are presented in Table II and Fig. 5. The AL PI Constant –0.669 0.171 –3.9 <.0001
was 0.8 mm (SD=0.6) for group 1 and 0.2 mm Sex –0.219 0.154 –1.422 .155
(SD=0.4) for group 2 at the first examination after Time –0.0007 0.004 –0.187 .852
Group (2) 0.068 0.15 0.454 .65
prosthesis insertion. The MBL was initially 1.69 mm
AL Constant –0.425 0.23 –1.846 .065
for group 1 and 1.64 mm for group 2. At the 2-year
Sex 0.32 0.24 1.333 .182
recall, 2.47 mm and 2.56 mm were measured for group Time 0.016 0.006 2.48 .013
1 and 2. The intraobserver variation in the measure- Group (2) –0.289 0.252 –1.148 .251
ments of MBL was not statistically significant and the MBL Constant 0.858 0.477 1.797 .072
difference between the first and second measurements Sex 0.735 0.481 1.53 .126
was on average 0.005 (Wilcoxon paired test, P=.73). Time 0.046 0.007 6.608 <.0001
The mean AL and MBL values were found to increase Group (2) 0.061 0.474 0.13 .897
significantly with time (Wald test = 2.48, P=.013, and Abbreviations are explained in Table II footnote.
Wald test = 6.61, P<.0001, respectively). No significant
differences were evaluated between the 2 groups for
any parameter AL and MBL (Wald test = –1.148, cases in group 1 approximately 1 year after placement
P=.251, and Wald test = 0.13, P=.897, respectively; and were repaired with resin material. The patients had
Table III). In group 1, no significant correlation was not sought supplementary recall visits for repair or even
found between the clinical AL and the MBL (Table IV). noticed the fracture of the veneering. In all cases, repair
At 12 months, a strong correlation was found between was performed chairside during the recall visits, which
AL and MBL in group 2 (rho = 0.69, P=.026). required approximately 15 minutes of additional treat-
ment time. The patients were not charged for these.
Adjustment and repair
In group 2, no gold screws were lost, but an abut-
No fractured implants or gold screws were observed ment screw fracture was observed during the first recall
in groups 1 or 2. In 1 patient (no. 2, group 1) who visit in 1 patient (no. 18). The fracture affected the
wore a fixed cantilevered implant prosthesis, redness most distal implant that was adjacent to a retentive
and slight swelling around the right distal implant was attachment included into the posterior bar extension.
associated with abutment screw loosening. However, The abutment was easily removed with the screwdriver
there was no evidence for this complication or any asso- after placing a new slot at the broken surface. No frac-
ciated bone loss in the periapical radiograph. The fixed ture or chipping of the acrylic veneering was observed
implant prosthesis was removed and the abutment in group 2, but 2 patients (nos. 12 and 13) showed
screw of the EsthetiCone Abutment cleaned and severe discoloration of the individually stained denture
retightened with the torque-control device (20 Ncm). teeth after 2 years in function. Because cleaning and
The superstructure was then checked for passive fit and polishing of the prosthesis was required, this problem
replaced. Porcelain chipping was observed twice in was measured as retreatment in both cases. During the
group 1 and was repaired with composite filling mate- first year of loading, neither relining of the overdenture
rial (Herculite, Kerr, West Collins, Orange, Calif.). prostheses nor activation of the clips or attachments
Fractures of acrylic resin veneering occurred in 3 of 5 was necessary. After the second year, 1 Ceka attach-

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THE JOURNAL OF PROSTHETIC DENTISTRY ZITZMANN AND MARINELLO

Fig. 5. Mean values for attachment level and marginal bone level in groups 1 and 2 during
recall.

Table IV. Spearman’s correlation between Gingival and Plaque Indexes and attachment and marginal bone levels
6-mo observation 12-mo observation 18-mo observation 30-mo observation
(prosthesis insertion) (6-mo recall) (12-mo recall) (24-mo recall)
Time/
group 1 2 1 2 1 2 1 2

GI/PI rho 0.67 0.79 0.71 0.77 0.896 0.75 0.79 0.9
P value .035 .0065 .0217 .0096 .0005 .0522 .0108 .0374
AL/MBL rho 0.57 0.31 0.57 0.69 0.2 0.546 –0.197 0.11
P value .085 .38 .087 .026 .576 .205 .612 .86
Abbreviations are explained in Table I footnote.

ment (Ceka, Antwerp, Belgium; patient no. 13) and 1
clip (Vario soft, Bredent, Senden, Germany; patient no.
11) were lost and then replaced by the examiner.
DISCUSSION
The aim of this prospective study was to investigate
the maxillary fixed and removable implant-supported
prostheses with regard to the postinsertion mainte-
nance, which is required and the period that elapsed
until retreatment was first necessary. Clinical parame-
ters were applied to monitor implant survival and to
compare the 2 groups. The results of our study demon-
strated high implant survival rates for patients provided
with either fixed or removable implant-supported pros-
theses in the edentulous maxilla. Several factors may be
responsible for these results: (1) 7-mm implants, which
appear to have caused most failures in other studies,7,8
were not used; (2) when compared with reports and
studies in the literature, a relatively large number of
implants were inserted for both prosthesis designs to
ensure better load and force distribution7; (3) all
implants were rigidly joined with fixed screw-retained
implant prostheses or bar splints.20,21
Recently, a large variety of different factors, both sur-
gical and prosthetic have been discussed as possibly influ-
encing the long-term success of oral implants. Patients’
individual features, occlusal loads, parafunctioning, the
bacterial environment in the mouth, and smoking habits
may also affect the biologic system. Various suggestions
have been made about the appropriate number of
implants needed to restore the edentulous maxilla, but
no definite conclusions have been reached. For fixed
maxillary implant prostheses screwed onto 6 to 8
implants, a continuous prosthesis stability of 89% after an
observation time of 5 to 9 years has been established as
standard for longevity outcomes according to Adell et
al.19 However, this measure did not capture the addi-
tional surgical interventions that had to be performed to
replace implants in 21% of the patients. Brånemark et al22
recommended the insertion of maxillary fixed implant
prostheses on 4 and 6 implants as they found that
implant survival rates were 78% and 80% 10 years after
placement. However, these authors had to admit that the
risk of implant failure was significantly higher when only
4 instead of 6 implants were used. In more than 60%
(8/13) of the prostheses screwed onto 4 implants,
implant failure occurred and required retreatment, even
though the prosthesis itself did not have to be remade.
For removable overdentures, it has been suggested
that implant length and number, and prosthesis support
(solely implant borne or implant and tissue supported)
may play a role in implant and prosthesis survival. Jemt et

440 VOLUME 83 NUMBER 4

ZITZMANN AND MARINELLO
al4 reported about 16% implant failure in overdenture
prostheses (with 2-6 implants) at the first annual check-
up; 84% of the implants that failed were 7 mm in length;
6% failures were found before or at reentry and were
therefore not related to the prosthesis design. Bergendal
and Engquist6 reported that, when an overdenture was
retained at 2 to 5 bar-splinted implants, the implant sur-
vival rate was 89.3% after 1 year and 80.4% after 2 years.
The loss of 30% of the initially placed implants required
reoperation in 17% of the patients. Naert et al20 report-
ed an implant survival rate of 87.5% 1 year after insertion
of a bar-retained overdenture on 4 splinted implants. The
results from our study indicate that similar implant
survival rates are achievable with fixed or removable
implant-supported prostheses when the cases are approx-
imately matched in terms of implant number, implant
length, and splinting.
With regard to the clinical parameters applied, the
results of this study suggested a weak correlation
between clinical AL and radiographically evaluated
bone level (MBL). A tendency to closer correlation in
group 2 may be ascribed to the better accessibility with
the bar reconstruction compared with the fixed implant
prostheses. The tip of the probe was located above the
calculated bone level. This finding is in agreement with
results from experimental animal studies.23,24 It has
been reported that probing depth measured in the peri-
implant mucosa depends on the degree of penetrability
of the soft tissues by the probe and is influenced by sev-
eral factors such as accessibility and probing pressure
that are similar to the conditions around natural
teeth.24,25 In our study, probing around implants did
not allow us to draw any conclusions about the MBL.
However, it can be assumed that bleeding or suppura-
tion on probing helps to detect sites where a change in
the peri-implant microbiota may indicate the develop-
ment of peri-implant diseases.9
With regard to the sensitivity of the radiographs, it
must be taken into account that the accuracy of bone
level measurements is compromised if there is even just
a small deviation from strict parallelism between the
implant axis and the film plane.26,27 However, in our
investigation similar bone levels were found in group 1
(1.69 mm) and group 2 (1.64 mm) during prosthesis
placement (Table II). These values correspond to a
bone resorption up to the first thread after the healing
period. A significant increase over time was observed,
which was most pronounced during the first 6 months
after prosthesis insertion. These values appear to be rel-
atively high when compared with the standards previ-
ously established for implant success. Adell et al19
reported a mean bone loss of 1.5 mm after the first year
of loading with fixed implant prostheses. However,
these authors used the apical implant shoulder margin
as a reference point. To be able to compare these val-
ues, 0.8 mm should be added to the results to com-
APRIL 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
pensate for the implant shoulder height. For removable
overdenture prostheses, the reports in the literature
vary between 2 mm after a 1-year loading period when
a bar-retained overdenture is placed on 4 implants and
3.2 mm when an overdenture is retained with 2 ball
attachments. In all these studies, the authors used the
abutment-fixture junction as a reference point.20,21
In contrast to reports in the literature in which high
incidences of mucosal hyperplasia were observed in
patients wearing removable appliances,4,5,20 this prob-
lem occurred only in 2 patients in the current study
group. Both patients were provided with conventional
bar systems (Dolder and Hader), which were not ini-
tially in contact with the underlying mucosa. It might
be assumed that the individually waxed bar design,
which allows soft tissue contact and superfloss to pass
beneath, would be favorable as almost no dead spaces
that could cause epithelial proliferation occur. Howev-
er, time may play a role in developing mucosal hyper-
plasia, and thus, a longer observation period is required
to confirm an improvement in the mucosal tissues sur-
rounding the individually designed bar. Higher PIs in
group 2 than in group 1 (ns) indicate that it is difficult
for some patients to clean the bars.
In our investigation, no significant differences were
found between groups 1 and 2 with regard to the fre-
quency of complications and the time until retreatment.
In group 1, fractures of the porcelain or acrylic veneering
were responsible for the majority of retreatments. It was
possible to deal with these chairside within the frame of
the recall visits and no additional costs arose for the
patient. However, it may not always be possible to fit this
service into the daily schedule of a general practitioner, so
that extra appointments will be required, which increase
maintenance costs. In group 2, the applied attachment
systems hardly ever needed maintenance or repair. This
might be due to the implant-supported prosthesis design,
which has a frictional overcasting that means no prosthe-
sis rotation is possible, so that there may be less wear on
the clips. This observation is in accordance with the find-
ings of Smedberg et al,28 who used a similar milled bar
design for overdenture prostheses, and reported that only
a few attachment adjustments were needed (Ceka) in 3 of
20 patients during 2 years of observation. Otherwise,
when patients were provided with a hinging overdenture
prosthesis, the most frequent prosthetic complication was
having to replace and reactivate the attachments (Revax
Ceka).20 Reinforcement of the removable prostheses may
be another aspect of maintenance. Kaptein et al10
observed at least 1 complication per overdenture (100%),
most of which were prostheses fractures, after a mean
lifetime of 40 months, when no metal framework was
used. Jemt et al4 found a high incidence of clip activation
(17%) and clip fractures (22%) with removable prostheses
during the first year of loading. The mechanical problems
with fixed implant prostheses included chipping or frac-
441
THE JOURNAL OF PROSTHETIC DENTISTRY
turing of the veneering, loosening or fracturing of gold
screws or abutment screws, and even fracture of the pros-
thesis framework.29 Almost half of the fixed implant
prostheses were affected by some biologic or mechanical
complication during the first year.30 When assessing the
time, effort, and costs involved in maintaining fixed or
removable prostheses, one must consider that the chair-
side effort that is required to replace a clip or activate an
attachment is negligible in comparison with that needed
to renew the veneering, replace an abutment screw, or
even repair a fractured framework in collaboration with
the technician.
CONCLUSIONS
This study suggested that similar treatment out-
comes are obtainable in patients restored with fixed and
removable implant-supported prostheses. No signifi-
cant differences between the 2 groups were found in
the time until retreatment, a measure that represents
the outcome of prosthetic rehabilitation better than
implant survival or prosthesis success. The period until
any intervention is required included implant failures
that occurred after prostheses insertion, and any bio-
logic or mechanical complications. The majority of
prostheses adjustments were managed chairside during
the recall visits. Finally, it is likely that having the recall
scheduled every 6 months helped to prevent more
severe biologic and/or mechanical problems occurring.
We thank Prof Dr Peter Schärer, Head of the Department of Fixed
and Removable Prosthodontics and Dental Material Sciences, Univer-
sity of Zurich, for enabling us to perform patient recall visits at the
Department after we had left. We would also like to gratefully acknowl-
edge the statistical assistance of Dr Penelope Vounatsou, Department of
Public Health and Epidemiology, Swiss Tropical Institute.
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Reprint requests to:
DR N. U. ZITZMANN
UNIVERSITY OF BASEL
HEBELSTRAßE 3
CH-4056 BASEL
SWITZERLAND
FAX: (41)61-267-26-60
E-MAIL: zitzmann@ubaclu.unibas.ch
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2000/$12.00 + 0. 10/1/104911
doi:10.1067/mpr.2000.104911
VOLUME 83 NUMBER 4