Journal of
Clinical Medicine
Article
Evaluation of Prosthetic Marginal Fit and Implant Survival
Rates for Conventional and Digital Workflows in Full-Arch
Immediate Loading Rehabilitations: A Retrospective
Clinical Study
Nicola De Angelis 1,2,3, * , Paolo Pesce 4 , Marco De Lorenzi 5 and Maria Menini 4
Citation: De Angelis, N.; Pesce, P.; De
Lorenzi, M.; Menini, M. Evaluation of
Prosthetic Marginal Fit and Implant
Survival Rates for Conventional and
Digital Workflows in Full-Arch
Immediate Loading Rehabilitations:
A Retrospective Clinical Study. J. Clin.
Med. 2023, 12, 3452. https://doi.org/
10.3390/jcm12103452
Academic Editors: Francisco Mesa
and Daniele De Santis
Received: 6 April 2023
Revised: 1 May 2023
Accepted: 11 May 2023
Published: 13 May 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
J. Clin. Med. 2023, 12, 3452. https://doi.org/10.3390/jcm12103452
1 Department of Surgical Sciences (DISC), Unit of Endo and Restorative Dentistry, University of Genova,
Largo R. Benzi 10, 16132 Genova, Italy
2 Dental Department, University Technology MARA, Sungai Buloh 40450, Malaysia
3 Dental Department, University Trisakti, Jakarta 11440, Indonesia
4 Department of Surgical Sciences (DISC), Unit of Prosthodontics and Implant Prosthodontics, University of
Genova, Largo R. Benzi 10, 16132 Genova, Italy; paolo.pesce@unige.it (P.P.); maria.menini@unige.it (M.M.)
5 Private Practice, 15011 Acqui Terme, Italy; drmarcodelo@gmail.com
* Correspondence: nicolaantonio.deangelis@edu.unige.it; Tel.: +39-3474188180
Abstract: Digital impression provides several advantages in implant prosthodontics; however, its use
in full-arch rehabilitations, especially immediately after surgery, has yet to be validated. The aim of
this study was to retrospectively analyse the fit of immediate full-arch prostheses, fabricated using
conventional or digital impressions. Patients requiring a full-arch immediate loading rehabilitation
were divided into three groups: T1 (digital impression taken immediately after surgery), T2 (Preop-
erative digital impression, guided surgery—prefabricated temporary bridge) and C (conventional
impression taken immediately after surgery). Immediate temporary prostheses were delivered within
24 h after surgery. X-rays were obtained at the time of prosthesis delivery and at the 2-year follow-up.
Primary outcomes were cumulative survival rate (CSR) and prosthesis fit. Secondary outcomes were
marginal bone level (MBL) and patient satisfaction. One hundred and fifty patients were treated from
2018 to 2020, with 50 in each group. Seven implants failed during the observation period. The CSR
was 99% for T1, 98% for T2 and 99.5% for C. A statistically significant difference in prosthesis fit was
found among T1 and T2 vs. C. A statistically significant difference was found in the MBL between T1
and C. The outcomes of the present study suggest that digital impression is a viable alternative to
conventional protocols for the realisation of full-arch immediate loading prostheses.
Keywords: dental implants; immediate loading; digital impression; full arch rehabilitation; temporary
fixed bridge; guided surgery
1. Introduction
Full-arch immediate loading rehabilitation is considered a predictable technique to
rehabilitate completely edentulous patients or patients with a terminal dentition. Long-term
studies validated this procedure [1–4], and a reduced number of implants was demonstrated
to be sufficient as long as they are properly spread out for well spread for load distribution
and sufficiently long to improve primary stability.
Immediate loading of dental implants is well accepted by patients since it reduces dis-
comfort during the osseointegration period, avoids the need of a second surgical operation
to uncover the implants, avoids the use of removable immediate temporary prostheses
and reduces the number of doctor visits [5]. This approach allows patients to maintain
function and aesthetic throughout the treatment, allowing them to maintain their usual
daily activities and resulting in less social and work impact with important psychological
https://www.mdpi.com/journal/jcm
J. Clin. Med. 2023, 12, 3452 2 of 12

benefits for the patient [6,7]. Conventional protocols for full-arch immediate loading re-
habilitations require an analogic impression and occlusal registration immediately after
implant placement. Rigid materials such as plaster demonstrated ideal results but were not
scientifically evaluated for their trueness and accuracy and lead to optimal results for the
fabrication of passive-fitting immediate frameworks [8].
More recently, digital impression gained popularity; however, its accuracy in full-arch
immediate loading rehabilitations was not demonstrated [8–10]. While digital impres-
sion showed favourable outcomes, especially in the case of partial rehabilitations, clinical
evidence is poor regarding trueness and accuracy in full-arch implant-supported rehabil-
itations [10] and it was mainly investigated in in vitro studies. In addition, impression
in immediate loading presents peculiar challenges, since a completely edentulous arch is
scanned when the flaps were just stitched and were still bleeding.
An alternative is the use of completely digital workflows that might fasten and simplify
the clinical procedures while avoiding the need for taking an impression immediately
after surgery. With a guided surgery approach, the immediate temporary prosthesis can
be fabricated before surgery and delivered immediately after implant insertion, thereby
decreasing patient discomfort.
Thus, the aim of the present study is to compare the fit and clinical outcomes of
full-arch immediate loading prostheses fabricated using three different and currently used
methods: conventional impression taken immediately after surgery, digital impression
taken immediately after surgery and guided surgery and delivery of a prefabricated tem-
porary bridge.

2. Materials and Methods

2.1. Study Design
The study was designed as a retrospective clinical study according to Strobe guidelines
for cohort studies [11]. The participants were consecutively recruited from the patients
visiting the private clinic of the principal investigator (N.D.A.) and divided into 3 groups
(Test 1, Test 2 and Control) and followed up by the investigators, monitoring the outcomes
for 2 consecutive years. All patients were asked to sign an informed consent with a full
explanation of the procedure according to the Helsinki declaration for human rights. The
procedures included in the present investigation did not include any experimental material
or techniques. All the procedures were performed in accordance with the instruction of the
regional ethical committee. All patients were informed that they were allowed to withdraw
from the study at any time.

2.2. Inclusion and Exclusion Criteria

Any patient with a terminal natural dentition and requiring an implant-supported
full-arch rehabilitation, being at least 18 years old with no restriction of race, gender and
nationality was included in the study.
Exclusion criteria were:
• General contraindications to implant surgery;
• Immunosuppressed or immunocompromised patients;
• Irradiation in the head or neck area;
• Uncontrolled diabetes;
• Pregnant or lactating;
• Untreated periodontitis;
• Poor oral hygiene and motivation;
• Substance abuse;
• Heavy smokers (more than 10 cigarettes/day);
• Psychiatric disorders or unrealistic expectations;
• Acute infection in the site intended for implant placement;
• Unable to commit to 2-year follow-up post-loading;
• Under treatment or had previous treatment with intravenous amino-bisphosphonates;
 • Psychiatric disorders or unrealistic expectations;
• Acute infection in the site intended for implant placement;
• Unable to commit to 2-year follow-up post-loading;
• Under treatment or had previous treatment with intravenous amino-bisphospho
J. Clin. Med. 2023, 12, 3452 nates; 3 of 12
• Participation in other clinical trials interfering with the present protocol;
• Sites, judged by the investigator, with a bone volume insufficient to guarantee at leas
• 1.5 mm all around
Participation the implant.
in other clinical trials interfering with the present protocol;
• Sites, judged by the investigator, with a bone volume insufficient to guarantee at least
1.5 mm all around
2.3. Outcomes the implant.
of the Procedure
Outcomes
2.3. Outcomes of theofProcedure
the protocol were divided into main and secondary. Main outcome wa
related to the of
Outcomes implant cumulative
the protocol survival
were divided intorate
main(CSR). Secondary
and secondary. outcomes
Main outcomewere
was fit of th
temporary
related to theprosthetic framework
implant cumulative over the
survival rateimplant connections/abutments,
(CSR). Secondary outcomes were evaluated
fit of im
mediately
the temporaryafter prosthesis
prosthetic delivery;
framework overperi-implant marginal bone level evaluated
the implant connections/abutments, evaluatedover tw
years after the
immediately rehabilitation;
after and patient
prosthesis delivery; satisfaction.
peri-implant marginal bone level evaluated over
two years after the rehabilitation; and patient satisfaction.
2.4. Clinical Procedure
2.4. Clinical Procedure
Before surgery, all the patients underwent professional oral hygiene and were care
Before surgery, all the patients underwent professional oral hygiene and were carefully
fully instructed
instructed on maintenance
on the oral the oral maintenance before
before and after and after
surgery. surgery.
A digital A digital
impression, impression
clinical
photos and cone beam computed tomography (CBCT) were taken on the same day. Thethe sam
clinical photos and cone beam computed tomography (CBCT) were taken on
day. The
CBCT and CBCT
standardand standard triangulated
triangulated language (STL) language
model of(STL) model
the arch of the
selected forarch selected fo
surgery
were uploaded
surgery weretouploaded
software fortosurgical planning
software (SWISSMEDA
for surgical AG OBERMÜHLE
planning (SWISSMEDA 8 6340
AG OBER
BAAR, SWITZERLAND provided by MS Company) and matched
MÜHLE 8 6340 BAAR, SWITZERLAND provided by MS Company) and matched to together to select the
best implant
gether size and
to select the length and plan
best implant theand
size implant position
length (Figure
and plan the1).implant position (Figure 1)

Figure1.1.Planning
Figure Planning of aofcase
a case
withwith SWISSMEDA
SWISSMEDA AG OBERMÜHLE
AG OBERMÜHLE 8 6340SWITZERLAND
8 6340 BAAR, BAAR, SWITZERLAND
software.Implant
software. Implant size
size andand length
length can becanchanged
be changed
as wellasaswell as implant
implant positionposition and angulation.
and angulation. After Afte
completing
completing thethe planning,
planning, the the order
order of theofsurgical
the surgical stent
stent can be can be managed
managed by site.
by the web the web site.

All
Allthethe
surgical and and
surgical prosthodontic procedures
prosthodontic were executed
procedures were by the sameby
executed experienced
the same experi
clinician (N.D.A.) in a private dental clinic. Surgeries were performed
enced clinician (N.D.A.) in a private dental clinic. Surgeries were performedunder local anaesthe-
under loca
sia (Articaine 40 mg/mL with Epinefrine 1:100,000). Extractions were carried out without
anaesthesia (Articaine 40 mg/mL with Epinefrine 1:100,000). Extractions were carried ou
flap elevation, and at least one tooth was left in order to match the preoperative impressions
without flap elevation, and at least one tooth was left in order to match the preoperativ
and the postsurgical ones and reproduce the occlusion.
impressions and the
A full thickness flappostsurgical ones
was raised from and to
molar reproduce
molar, andthe
flapocclusion.
elevation was extended
on the buccal sides of the maxilla and the mandible, isolating and and
A full thickness flap was raised from molar to molar, flap elevation
preserving was extende
the anatomical
on the buccal
structures. sidesostectomy
Minimal of the maxilla and the mandible,
was performed isolating
when necessary and preserving
to compensate the anatom
for bone
discrepancies
ical structures.(Figure 2).
Minimal ostectomy was performed when necessary to compensate fo
bone discrepancies (Figure 2).
 J. Clin. Med. 2023, 12, 3452 4 of 12
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2023,2023, 12, 3452
12, 3452 4 of 412of 12

(a) (a) (b) (b)

Figure
Figure 2. (a)2.Intraoral
(a) Intraoral
Intraoral pictures
pictures of a of a mandibular
mandibular case case
afterafter
teethteeth extraction
extraction and and
flap flap elevation;
(b) a(b) a
elevation;
elevation;
minimal
minimal ostectomy
ostectomy
minimal was was
ostectomy was performed
performed in
in order
in order
performed to
to compensate
to compensate
order for bone
for bone
compensate for bone discrepancies.
discrepancies.
discrepancies.

After
After flap flap
After flapelevation,
elevation,
elevation, the
theoperator
operator
the operator performed
performed
performed thethe
the site sitesite
preparation
withwith
preparation
preparation or without
orwith the the
or without
without
printed
the surgical
printed guide
surgical with
guide the
with sequence
the of drills
sequence of according
drills to the
according implant
to the
printed surgical guide with the sequence of drills according to the implant system (Strau- system
implant (Strau-
system
mann ® Holding
® Holding AG, Basel, Switzerland—BLT SLActive surface) as described in Figure 3.
mann Holding AG, Basel, Switzerland—BLT SLActive surface) as described in Figure 3. in
(Straumann
® AG, Basel, Switzerland—BLT SLActive surface) as described
Figure
The 3. The
operator operator
was was
strictly strictly
forced toforced
followto follow
the the
provided provided
protocolprotocol
for the
The operator was strictly forced to follow the provided protocol for the creation of the for the creation
creation of the
of the osteotomies.
osteotomies.
osteotomies.

(a) (a)

(b) (b)
Figure
Figure 3. Intraoral
3. Intraoral picture
picture of aofof a patient
patient T2of
of of T2 group: (a) surgical stent design before printing; (b)
Figure 3. Intraoral picture a patient T2group:
group:(a)
(a)surgical
surgical stent
stent design before
design before printing;
printing; (b)place-
(b)
placement
placement of ofsurgical
the the surgical
guide.guide.
ment of the surgical guide.

Implant
Implant
Implantsitessites for
for participants
for participants
sites belonging
belonging
participants to T1
belonging to T1
T1 and
toand C
C were
C were
and undersized,
undersized,
were if
if needed,
if needed,
undersized, in in
needed, in
orderorder
order to
to reach reach the maximum
the maximum
to reach the maximum primary
primary
primary stability
stability by drilling
by drilling
stability bone,
bone,
by drilling skipping
skipping
bone, the
the last
skipping last dedicated
the dedicated
last dedicated
drilldrill
drill in
in soft soft
in soft bone
bonebone class
classclass 4. Implant
4. Implant
4. Implant placement
placement followed
followed
placement the the
followed the Columbus
Columbus Bridge
Columbus Bridge Protocol
Protocol
Bridge Protocol
described
described
described in
in 2011 2011 by
by Tealdo
in 2011 Tealdo T.
T. etT.
by Tealdo et al.
al.et[12]. [12]. The
The two
al. [12]. two
The distaldistal implants
implants
two distal were
werewere
implants mesio-distally
mesio-distally
mesio-distally tilted
tilted
tilted
and and
had had
and had aa minimum
a minimumminimum length
length of 12of
length 12
12 mm
ofmm (Figure
(Figure
mm 4).
4). 4).
(Figure
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J. J. Clin.
Clin. Med.
Med. 2023,
2023, 12,12, 3452
3452 5 5ofof1212

Figure4.4.Intraoral
Figure Intraoralpicture
pictureofofimplant
implantplacement.
placement.
Figure4.4.Intraoral
Figure Intraoralpicture
pictureofofimplant
implantplacement.
placement.
Afterimplant
After implantplacement,
placement, thethe multi-unit
multi-unit abutments
abutments were
were connected
connected to the
to the implants
implants at
25atNcmAfter
After
25 Ncm implant
implant
according
according placement,
placement,
to following
to the the
the
the following multi-unit
multi-unit abutments
abutments
pattern:
pattern: were
were connected
connected toto the
the implants
implants
at
• •
at 25Ncm
25 Ncm
0°
◦ or according
according
17°
◦ on thetotothe
thefollowing
anterior following
0 or 17 on the anterior implants;
pattern:
pattern:
implants;
•••• 0° 0°◦ or
or
30°
30 on
on 17°
17° on
on
the
the theanterior
the anterior
posterior
posterior implants;
implants;
tilted
tilted implant(Figure
implant (Figure5).
5).
• • 30° 30°ononthe
theposterior
posteriortilted
tiltedimplant
implant(Figure
(Figure5).5).

Figure 5. Abutment connection.

Figure
Figure 5.5.Abutment
Figure5. Abutmentconnection.
Abutment connection.
connection.
Flaps were sutured with interrupted resorbable sutures (4/0 Vicryl ® Ethicon,
Flaps
Flaps were
were sutured
sutured with interrupted resorbable sutures ® Ethicon,
(4/0 Vicryl ® Ethicon,
Flaps
Somerville, were NJ,sutured
USA). Inwith
with interrupted
interrupted
patients belonging resorbable
resorbable tosutures
the T1sutures
(4/0 (4/0
Vicryl
group, scanVicryl Ethicon,
®Somerville,
abutments were
Somerville,
NJ, USA).
Somerville,
connected to In NJ,
NJ,the USA).
patients
USA). In
belonging patients
In patients
multi-unit to
abutments belonging
the T1
belonging group, to the
scan
to the T1
and a full-arch T1 group,
abutments
group,
digital scan
were abutments
connected
was takento
scan abutments
impression were
the
were
using
connected
multi-unit
connected
Trios 3 Shape tothe
the
toabutmentsmulti-unit
multi-unit
(København abutments
and aabutments
full-arch
K, and
Capitaldigital
and a afull-arch
Region, full-arch
impression digital impression
wasimpression
1060, digital
Denmark). taken usingwas
In patients was
Triostaken
taken using
3 Shape
using
belonging to
(København
Trios
the C3 3group,
Trios Shape
Shape K, Capital
(København
(København
pick-up Region,
transfers 1060,connected
K,K,Capital
Capital
were Denmark).
Region,1060,
Region, 1060,
on InDenmark).
the patients
Denmark).
platforms belonging
InInpatients
of to belonging
patients
the abutmentsthe C and
group,
belonging toto
tied
pick-up
the
the CCgroup,
together transfers
group,
with pick-up
pick-up were connected
transfers
transfers
interdental floss as aon
were
were the platforms
connected
connected
frame foron onthe ofplatforms
the abutments
theplatforms
cyanoacrilate ofofthe and(Periacryl
theabutments
solidarisation tied and
abutments together
andtied
tied
High
with interdental floss as a frame for cyanoacrilate solidarisation (Periacryl High Viscosity ®
together
together with
with interdental
interdental floss
floss as
as a a frame
frame for
for cyanoacrilate
cyanoacrilate
Viscosity GluStich, Delta, BC, Canada) or by using flowable light curing composite
® solidarisation
solidarisation (Periacryl
(Periacryl High
High
GluStich, ®
(Bulkfill® Delta,
Viscosity
Viscosity ®
®GluStich,
Kyoto,BC,Japan).
GluStich, Canada)
Delta, or
BC, by
Delta,Impressions
BC, usingwere
Canada)
Canada) flowable
ororbytaken light
byusing
using curing
flowable
flowable
with composite
standard light
light (Bulkfill
curing
curing
plastic open Kyoto,
composite
composite
trays and
Japan).
(Bulkfill
(Bulkfill Impressions
® ® Kyoto,Japan).
Kyoto,
polyvinilsiloxane were
Japan). taken
(PVS) Impressions
material with
Impressions standard
weretaken
were
(Flexitime plastic
taken
Regular with
with open
standard
and trays
standard
Heavyplasticand
body polyvinilsiloxane
plastic opentrays
® open
Kulzer, trays and
and
D-63450
(PVS) material
polyvinilsiloxane
polyvinilsiloxane
Hanau, Germany) (Flexitime
(PVS)
(PVS) Regular
material
material
(Figure and Heavy
(Flexitime
6). (Flexitime body®and
Regular
Regular Kulzer,
andHeavy D-63450
Heavy body
body ®Hanau,
Kulzer,Germany)
® Kulzer, D-63450
D-63450
(Figure
Hanau, 6).
Hanau,Germany)
Germany)(Figure (Figure6).6).

(a) (b) (c)

(a)
(a) (b)
(b) (c)(c)
Figure 6. (a,b) Pick-up transfers tied together and PVS impression; (c) stl file of the digital
Figure
Figure 6.6.(a,b)
impression.
Figure 6. (a,b)
(a,b) Pick-up
Pick-up
Pick-up transfers
transfers
transfers tiedtogether
tiedtied together
together and
and
and PVS PVSimpression;
PVS impression;
impression; (c)(c)
(c) stl file ofstlstlfile
the fileofofimpression.
digital thedigital
the digital
impression.
impression.
InIngroups
groupsT1 T1andandC,C,after
afterthetheimpressions
impressionswere weretaken,
taken,any anyremaining
remainingteeth teethwerewere
InIngroups
extracted,
extracted,groups
and T1T1and
andpatients andC,
patients C,
were after
after
were theimpressions
dismissed
the
dismissedimpressions
and
andscheduledweretaken,
were
scheduled taken,
for
forthe
the any remaining
delivery
any delivery ofofthe
remaining the teeth
temporary
teeth were
were
temporary
bridge
bridgewithin
extracted,
extracted, and
and
within 24 h after
patients
patients
24 surgery
were
were
h after from from
dismissed
dismissed
surgery theand
surgical
and intervention
scheduled
scheduled
the surgical forthe
for for
the all groups,
delivery
delivery
intervention while
ofthe
forofall the patients
temporary
temporary
groups, while
belonging
bridge
bridge to
within
within the24 T2
24h hgroup
after
after received
surgery
surgery the
from immediate
from the
the temporary
surgical
surgical prosthesis
intervention
intervention
patients belonging to the T2 group received the immediate temporary prosthesis for
for immediately
all
all groups,
groups, after
while
while
surgery,
patients
patients that
immediately was
belonging
belonging
afterobtained
totothe
surgery, thedirectly
T2T2group
that wasfrom
group the laboratory
received
received
obtained according
theimmediate
the
directly immediate
from totemporary
the surgical
temporary
the laboratory plantoand
prosthesis
prosthesis
according the
the preoperative
immediately
immediately
surgical plan after impression.
after
and surgery,
surgery, In
that T2,
thatwas
the preoperative the prosthesis
wasobtained
obtained was
directly
directly
impression. delivered
from
from
In the
T2,thethe together
laboratory
laboratory
prosthesis with the
according
according surgical
totothe
was delivered the
guide
surgical
surgical
togetherbefore
plan
plan
with surgery.
and
the the Inpreoperative
andsurgical
the all the groups,
preoperative
guide before temporary
impression.
impression.
surgery. InIn bridges
InT2,
all the were
T2,groups,
the
the made
prosthesis
prosthesis of was
temporary printed
was acrylic
delivered
delivered
bridges were
resin
togetherandwith
together endowed
with the with aguide
thesurgical
surgical titanium
guidebefore milled
before bar, with
surgery.
surgery. no
InInallall cantilevered
the
the extensions
groups,temporary
groups, temporary (Figure
bridges
bridges 7).
were
were
J. Clin. Med. 2023, 12, 3452 6 of 12

J. Clin. Med. 2023, 12, 3452 6 of 12

made of printed acrylic resin and endowed with a titanium milled bar, with no
cantilevered extensions (Figure 7).

(a) (b)

(c) (d)
Figure 7.
Figure 7. (a–d)
(a–d) A
A resin
resin model
model was
was created
created for
for all
all patients
patients in
in all
all groups, and the
groups, and the titanium
titanium milled
milled bar
bar
was inserted and cemented into the acrylic teeth structure.
was inserted and cemented into the acrylic teeth structure.

After delivery
After delivery ofof the
the fixed
fixed prosthesis,
prosthesis, occlusion
occlusion waswas carefully
carefully checked
checked andand corrected.
corrected.
All interferences
interferences were eliminated. A digital ortopanoramic X-ray
were eliminated. A digital ortopanoramic X-ray was retrieved immediatelywas retrieved
immediately after the delivery of the temporary bridge (time/month 1—t1).
after the delivery of the temporary bridge (time/month 1—t1). Patients were instructed Patients were
instructed not to brush for the first two weeks after surgery and to observe
not to brush for the first two weeks after surgery and to observe a soft diet for 30 days. a soft diet for
30 days. Antibiotic
Antibiotic therapy was therapy was administered
administered to all participants
to all participants through thethrough the use of
use of Amoxicillin
Amoxicillin
875 875 mg+Acid
mg+ Clavulanic Clavulanic
125 mgAcid 125 mg
twice/day fortwice/day
6 days (infor 6 days
case (in case
of allergy of allergy
Azithromicin
Azithromicin
500 mg/day for 500 mg/day
6 days) for 6and
[13,14] days) [13,14]toand
NSAID NSAID
control paintoaccording
control pain according
to their needs. toFortheir
the
needs.
oral For the
hygiene oral hygiene
maintenance, maintenance,
Chlorexidine Chlorexidine
0.20% 0.20%towas
was prescribed prescribed
be used at least to be used
during the
at least
first during
30 days the
after first 30Appointments
surgery. days after surgery.
were Appointments were scheduled
scheduled according according
to the following to
pattern:
10
thedays: suturepattern:
following removal, 1015 days:
days: check-up,
suture 90 days:
removal, temporary
15 days: bridges
check-up, unscrewed
90 days: temporaryand
implant stability check,
bridges unscrewed andprofessional oral hygiene
implant stability session (thenoral
check, professional repeated
hygieneevery 3 months),
session (then
120 days: every
repeated final digital impression,
3 months), 130 final
120 days: days:digital
final prosthesis
impression,delivery and final
130 days: X-ray,prosthesis
730 days
(2 years—time/months
delivery and X-ray, 730 2-t2):
days (2check-up and X-ray. 2-t2): check-up and X-ray.
years—time/months

2.5. Outcomes Evaluation

2.5. Outcomes Evaluation
The
The implant
implantcumulative
cumulativesurvival rate rate
survival (CSR)(CSR)
was evaluated in all theingroups.
was evaluated Postopera-
all the groups.
tive panoramic X-rays, obtained for all patients included in the
Postoperative panoramic X-rays, obtained for all patients included investigation, were corrected
in the investigation,
and ® (Ottawa, Canada) with a
wereequalised
correctedby theequalised
and software by
CorelDRAW
the softwareGraphics Suite 2023
CorelDRAW Graphics Suite 2023® (Ottawa,
linear
Canada) operation, expressed
with a linear by theexpressed
operation, followingby equation:
the following equation:
𝑓𝑒𝑞
f eq ( a) 𝑎= =
Hi𝐻𝑖 𝑎 K. −
( a)·( 𝐾 1−) 1: MN
: 𝑀𝑁
where M
where M and
andNNare arethe selected
the selecteddimensions
dimensions of the image
of the withwith
image pixelspixels
in theininterval [0;K −
the interval
1] and then further magnified to a maximum of 300 dpi by Adobe
[0; K − 1] and then further magnified to a maximum of 300 dpi by Adobe Photoshop®Photoshop ® software

(San Jose,(San
software CA, Jose,
USA),CA, andUSA),
the barand
connection on the platform
the bar connection on theof platform
the abutmentof thewas resized
abutment
and processed by ImageJ ® software (Rasband,
® W.S., ImageJ, U. S. National
was resized and processed by ImageJ software (Rasband, W.S., ImageJ, U. S. National Institutes of
Health, Bethesda, MD, USA), which allows the measures through the Analyse
Institutes of Health, Bethesda, MD, USA), which allows the measures through the Analyse function.
As described in Figure 8, by the use of Image J, the distance between the prosthesis
function.
(upperAsline) and theinabutment
described Figure 8, platform
by the use (lower line) J,
of Image wasthecalculated using number
distance between of pixels
the prosthesis
and expressed
(upper line) andinthe
a abutment
linear function.
platformSince there
(lower was
line) was nocalculated
presence using
of irregular
numberpeaks, no
of pixels
and expressed in a linear function. Since there was no presence of irregular peaks, no
further mathematical analysis was needed. Secondary outcomes were the marginal bone
 J. Clin. Med. 2023, 12, 3452 7
J. J.Clin.
Clin.Med.
Med.2023,
2023,12,
12,3452
3452 7 of 1212
7 of

further mathematical analysis was needed. Secondary outcomes were the marginal
further mathematical
level and analysis Marginal
patient satisfaction. was needed.
boneSecondary
level was outcomes
evaluated were the marginal
at time/months bone
1 (t1) and
level and patient satisfaction. Marginal bone level was evaluated at time/months 1 (t1
at time/months
level 2 (t2), calculating
and patient satisfaction. the distance
Marginal between
bone level the implant
was evaluated platform and
at time/months the and
1 (t1) most
at time/months 2 (t2), calculating the distance between the implant platform and the
atapical position2of(t2),
time/months thecalculating
bone on thethe
mesial and between
distance distal side ofimplant
the each implant.
platformAs and
a reference
the most for
apical position of the bone on the mesial and distal side of each implant. As a refe
calculation,
apical the
position ofdistance
the bonebetween the implant
on the mesial platform
and distal and
side of the implant.
each first thread
As (0.5 mm), as
a reference
well
for calculation,
as the distance between
the distancewas
the threads,
between
used
the implant
(0.5 mm)
platform
(Figure
and the first thread (0.5
9). thread (0.5 mm),
for calculation, the distance between the implant platform and the first
as well as the distance between the threads, was used (0.5 mm) (Figure 9).
as well as the distance between the threads, was used (0.5 mm) (Figure 9).

(a)
(a)

(b)
(b)
Figurewere
(a,b)X-rays
X-rays 8. (a,b) X-raysinwere
cropped ordercropped in order to have onlybar/abutment,
the connectionequalised
bar/abutment, equ
Figure8.8.(a,b)
Figure were cropped in order totohave
haveonly
only theconnection
the connection bar/abutment, equalised
and magnified. The red arrow indicates the gap between the bar and the abutment, whic
andmagnified.
and magnified.The The redarrow
red arrowindicates
indicatesthe
thegapgapbetween
betweenthe thebar
barand
andthe
theabutment,
abutment,whichwhichwaswas
measured. They were then imported on ImageJ which allowed us to measure the distance in
measured.They
measured. Theywere
werethen
thenimported
importedononImageJ
ImageJwhich
whichallowed
allowedusustotomeasure
measurethethedistance
distanceininpixels
pixels
between one point and another. Measures were then converted to millimetres using the so
between
betweenone onepoint and
point and another.
another. Measures
Measures were
were then
then converted
converted totomillimetres
millimetres using
usingthe software
the software
(https://www.convertire-unita.info/convertire+Pixel+in+mm.php, accessed on 20 April 2023).
(https://www.convertire-unita.info/convertire+Pixel+in+mm.php,
(https://www.convertire-unita.info/convertire+Pixel+in+mm.php, accessed on 20
accessed onApril 2023).
20 April 2023).

Figure
Schematic 9. Schematicof
representation representation
theimplants
implantsusedof theinimplants
used thestudy used
study inindications
with the study with indications
distance of the di
Figure9.9.Schematic
Figure representation of the in the with indications ofofthe
thedistance
betweenthe between
theplatform
platformand the
andthe platform
thefirst and
firstthread, the first
thread,asaswell thread,
wellasasthe as
thedistancewell as the
distancebetween distance
betweenthe between
thethreads.
threads. the threads.
between
J. Clin. Med. 2023, 12, 3452 8 of 12

At time/months 2 (t2), all the patients included in the study were requested to fill out
a 4-question questionnaire, including the following questions:
1. How would you rate intraoperative discomfort?
2. How do you rate the discomfort during impression?
3. How do you rate the immediate delivery of the temporary prosthesis?
4. Overall judgment on the procedure
The responses were delivered using a visual analogue scale (VAS) and categorised as
follows:
0 = nothing to report;
1–3 = minimal response;
4–6 = medium response;
6–10 = high response (very stressful).

2.6. Statistical Analysis

For the analysis, a sample composed of 150 observations was considered. Given a
theoretical prevalence rate of 95%, the sample size analysis returned a minimum sample of
73 observations (considering a confidence interval of 95% and 5% margin of error). Three
computer-generated restricted random lists were created. The implant was the statistical
unit of the analyses. An intention-to-treat (ITT) analysis was used. R software (R Software
Inc., San Francisco, CA, USA) was used for all tests. Differences in the proportion of
patients with implant failures and complications (dichotomous outcomes) were compared
between the groups, using the Fisher extract probability test. Differences of means at
the implant level for continuous outcomes (gap bar/abutment and bone levels) between
groups were compared by t tests. The Mann–Whitney U test was conducted to compare
the medians of the three groups for patient satisfaction. Group distributions were tested
to determine normality of the samples. Normality Jarque–Bera test was performed on
all three samples, and the null hypothesis was not rejected. Since the samples were not
normally distributed, the Mann–Whitney U test was applied since it is a nonparametric
test that allows two groups or conditions to be compared without making the assumption
that values are normally distributed. All statistical comparisons were conducted at the 0.05
level of significance.

3. Results
One hundred and fifty patients, whose mean age was 55, were treated from 2018 to
2020, 50 for each group, 75 were males and 75 females. Seven implants failed during the
observation period. Two implants failed in T1 before the final prosthetic delivery, 4 implants
failed in T2 one year after final loading and 1 implant failed in C 6 months after the final
prosthetic delivery. Implant failures were not connected to gender, neither or age. The final
CSR was 99.0% for group T1, 98.0% for group T2 and 99.5% for group C. The Kaplan–Meier
survival log is reported in Figure 10.
All the prostheses were considered clinically acceptable and immediately delivered
without the need to take additional impressions. The mean gap between the bar and the
abutment was 0.21 ± 0.10 mm, 0.28 ± 0.20 mm and 0.42 ± 0.20 mm for T1, T2 and C
groups, respectively, with a statistically significant difference among T1 and C (p = 0.003)
and between T2 and C (p = 0.002).
The marginal bone level mean differences are reported in Table 1. A statistically
significant difference was present among T1 and C both at time/months 1 (p = 0.011) and
at time/months 2 (p = 0.050). No statistically significant differences were found between
T2 and control.
J. Clin. Med. 2023, 12, 3452 9 of 12
J. Clin. Med. 2023, 12, 3452 9 of 12

Figure 10. No statistically significant differences were present among the groups (p = 0.370).
Figure 10. No statistically significant differences were present among the groups (p = 0.370).

1. List
TableAll the of questions for
prostheses patient
were satisfaction
considered questionnaire.
clinically * 0 = nothing
acceptable to report; 1–3delivered
and immediately = minimal
response; 4–6 = medium response; 6–10 = high response to stress.
without the need to take additional impressions. The mean gap between the bar and the
abutment was 0.21 ± 0.10 mm, 0.28 ± 0.20 mm and 0.42 ± Rate
Question 0.20 (Score
mm for T1,10)T2* Mean
0 to and CValue
groups,
respectively, with a statistically significant difference among T1 and C (p = 0.003) and
How did you experience the intraoperative
between T2 and C (p = 0.002).
discomfort? (length of the procedure, 3 (U = 1.5)
The marginal bone discomfort)
physical level mean differences are reported in Table 1. A statistically
significant
How dodifference was
you evaluate present
the among
impression T1 and C both at time/months
technique? 1 (p = 0.011) and
5 (U = 2.5)
at time/months 2 (p = 0.050).
How do you evaluate No statistically
the immediate delivery ofsignificant
the differences0 were
(U = 0)
found between
T2 and control. temporary dentition?
Overall judgment on the procedure 3 (U = 1.5)
Table 1. List of questions for patient satisfaction questionnaire. * 0 = nothing to report; 1–3 = minimal
response;
At 4–6
the =two-year
medium response;
follow-up6–10visit
= high response
(t2), to stress.
the mean MBL was 0.35 ± 0.10 mm and
0.23 ± 0.80 mm in T1 for the maxilla and mandible,
Question Rate (Score respectively;
0 to 10) * Mean ± 0.22 mm and
0.37 Value
0.26 ± 0.14 mm in T2 in maxilla and mandible, respectively; and 0.4 ± 0.20 mm and
How did you experience the
0.3 ± 0.12 mm in group C for maxilla and mandible, respectively.
intraoperative discomfort? (length
All groups of patients were equally satisfied by function 3 (U = 1.5)(Mann–Whitney U test
of the procedure, physical
p = 0.880) and the aesthetics of their implant-supported rehabilitation (Mann–Whitney U
discomfort)
test). All patients declared that they would undergo the same procedure again, and the
mostHow do you
accepted partevaluate the
of the treatment (with the lowest mean and= U
5 (U value) was related to the
2.5)
impression technique?
immediate temporary dentition delivery, as displayed in Table 1.
How do you evaluate the
4. Discussion
immediate delivery of the 0 (U = 0)
temporary
The results ofdentition?
the present study suggest that, even if all the herein described procedures
led to a clinically
Overall judgmentacceptable
on the fit of the prostheses, with optimal clinical outcomes at the
2-year follow-up,
procedurea statistically significant difference was3found (U = 1.5)
in the fit of the prostheses
made following the three different techniques analysed.
Historically,
At the two-year a full-arch
follow-up prosthesis supported
visit (t2), the mean MBL by two
was distal
0.35 ± tilted
0.10 mmimplants and
and 0.23 two
± 0.80
upright anterior implants were implanted free hand with the help of
mm in T1 for the maxilla and mandible, respectively; 0.37 ± 0.22 mm and 0.26 ± 0.14 mm some devices useful in
planning the tilting of the implant [15], and standard analogic impression
in T2 in maxilla and mandible, respectively; and 0.4 ± 0.20 mm and 0.3 ± 0.12 mm in group techniques were
Cemployed.
for maxilla This
andallowed
mandible,us torespectively.
obtain an optimal implant and prosthesis cumulative survival
rate All
andgroups
marginal of patients werethe
bone loss in medium
equally term by
satisfied [2,4,15,16].
function The results were confirmed
(Mann–Whitney U test p =
0.880) and the aesthetics of their implant-supported rehabilitation (Mann–Whitney Urate
over a 10-year period by Pera et al., who reported an implant cumulative survival of
test).
93.25% and a mean bone loss of 2.11 mm [1].
All patients declared that they would undergo the same procedure again, and the most
Seven
accepted implant
part of thefailures
treatmentwere(with
observed throughout
the lowest meanthe andduration
U value) of was
the study; however,
related to the
two implants were lost in the T1 group before
immediate temporary dentition delivery, as displayed in Table 1.the final prosthetic delivery, which may
be suggestive of a related non-osseointegration problem, while the other failures were
J. Clin. Med. 2023, 12, 3452 10 of 12

observed after the final prosthetic delivery, which means at least 6 months after the im-
plant placement. It is difficult to establish the exact causes of these complications, but
a retrospective study published in the Journal of Clinical and Experimental Dentistry in
2020 evaluated the implant survival and success rates for All-on-4 procedures in a group
of 104 patients. The authors found that the implant survival rate was 97.2%, while the
success rate was 93.3%. In the present study, the final CSR was 99% for group T1, 98% for
group T2 and 99.5% for group C, which is in agreement with the data reported by the other
authors [17].
Moreover, a systematic review and meta-analysis published in the Journal of Clinical
Periodontology in 2020 evaluated the implant survival and success rates of All-on-4 proce-
dures in patients with severe bone loss. The authors found that the implant survival rate
was 98.9%, while the success rate was 97.7% [18].
Similar outcomes were found in the present research. After a follow-up of 2 years in the
T1 group, the CSR was 99% and the mean bone loss was 0.35 ± 0.1 mm and 0.23 ± 0.8 mm
in the maxilla and mandible, respectively. This supports the statement that new digital
technologies and procedures might help to simplify clinical workflows, maintaining the
same accuracy of conventional protocols.
Impressions were taken with Trios 3 Shape intraoral scanner (Shape København K,
Capital Region, 1060, Denmark) by using the continuous scanning technique, which saves
time and reduces patient discomfort as it eliminates the need to pause and reposition
the scanner multiple times. The accuracy of the Trios 3 Shape scanner is attributed to
its high-resolution camera and advanced software algorithms, which can capture and
process high-quality images quickly. The scanner also has a real-time feedback feature that
allows the operator to adjust the scanning technique to ensure that the images captured are
accurate. In terms of capturing accuracy, the Trios 3 Shape scanner was found to be highly
accurate, with studies reporting accuracy levels of up to 99.7% [19].
Digital impression was proven to be a reliable method to impress single or partial
implant rehabilitations; on the contrary, data on full-arch implant impressions are more
contradictory [20,21]. Recent studies reported an increasing precision in the full-arch im-
pression accuracy. Papaspyridakos et al., evaluating retrospectively digital vs. conventional
full-arch implant impressions, reported that the 3D implant deviations found between
the two groups (88 ± 24 µm) lie within the clinically acceptable threshold [22]. Similar
results were reported in the present research, even if it must be highlighted that a higher
discrepancy between the bar and the abutment was registered in the group treated with
the guided surgery, when compared to digital impressions taken after surgery.
It should also be noted that the conventional impression in the present study was
a polyvinylsiloxane impression with implant splinting with cyanolacrylate or composite
material and showed the worst fit of all the prostheses compared to T1 and T2. The plaster
impression used in other studies on full-arch immediate loading [1,3,8] was not evaluated
in the present investigation.
Although compelling human evidence does not exist for clinical effects on peri-implant
bone during the healing phase, a prosthesis misfit might induce noxious biomechanical
stresses on the implants and prosthesis components and might favour screw loosening.
For this reason, a very precise impression technique must be applied, aimed at achieving
a clinically acceptable passive fit within 24 h after surgery. This is particularly important
especially when using a screw-retained prosthesis, while a minimum misfit might be
compensated in cemented prostheses due to the cement space. However, screw-retention
is considered the best option by the authors for full-arch implant-supported restorations,
since it facilitates the detection and management of possible complications, prosthesis
relining and avoids the risk of cement-induced periimplantitis [5–23]. It is relevant to
notice that the prosthetic framework is connected to the abutments, which are screwed
onto the implants at the time of surgery; therefore, the possibility of complication and/or
deformation of the internal connection of the implants, as described by Pandey C. in 2022,
is not relevant when this technique is used [24].
J. Clin. Med. 2023, 12, 3452 11 of 12

Some limits of the present research must be acknowledged. Foremost, the fit was
evaluated on panoramic x-ray, and this could have affected the outcome measures. The
mean gap between the prosthesis and the abutment was quite high in the present study
(0.21 ± 0.1 mm, 0.28 ± 0.2 mm and 0.42 ± 0.2 mm for T1, T2 and C groups, respectively).
In a previous in vitro study on full-arch implant supported prostheses, the mean gap was
lower than 30 µm, as measured by a stereomicroscope [10]. The different instruments
applied for scanning and measurement, as well as the additional variables inherent with
the clinical environment, might have affected the outcomes. Secondary, the number of
included patients is quite high, but a bias might arise connected to the operator skills,
since all surgeries and prosthodontics were performed by the same operator. It must be
considered that a learning curve for both the clinician and the dental technician is essential
to obtain the same outcomes.

5. Conclusions
The outcomes of the present investigation bring about promising steps to the clinical
management of full-arch immediate rehabilitation protocols by merging a consolidated
knowledge on the long-term survival of four dental implants, supporting a fixed full-
arch prosthesis with the innovative digital impression technique and guided surgery
approach, which shortens the operative times, increases the precision of the framework
and is addressed to a future view of sustainable and eco-friendly systems.

Author Contributions: Conceptualization, N.D.A. and M.D.L.; methodology, N.D.A. and P.P.; soft-
ware, N.D.A.; validation, M.M. and P.P.; formal analysis, M.D.L.; investigation, N.D.A.; resources,
N.D.A.; data curation, N.D.A.; writing—original draft preparation, N.D.A. and M.D.L.; writing—
review and editing, M.M.; visualization, P.P.; supervision, M.M.; project administration, M.M. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki.
Informed Consent Statement: Informed consent was obtained from all participants involved in the
study.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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