B

Nicola Ferrigno
Mauro Laureti
Stefano Fanali
Guido Grippaudo
A long-term follow-up study of nonsubmerged ITI implants in the

treatment of totally edentulous jaws
Part 1: Ten-year life table analysis of a prospective
multicenter study with 1286 implants
Authors affiliations
Nicola Ferrigno, Stefano Fanali, Specialization
Course in Clinical Implantology and Biomaterials,
School of Dental Medicine, University of Chieti
G. DAnnunzio.
Nicola Ferrigno, Mauro Laureti, Guido
Grippaudo, Specialization Course in Oral
Implantology, School of Dental Medicine,
University of Rome La Sapienza, Rome, Italy
Nicola Ferrigno, Mauro Laureti, ITI member
Correspondence to:
Professor Nicola Ferrigno
Via Prenestina, 228
00176 Roma
Italy
Tel: 39 6 275 7397
Fax: 39 6 275 7397
e-mail: nicolaferrigno/implantologiaorale.it or
ferrigno.n/tiscalinet.it
Date:
Accepted 31 May 2001

To cite this article:
Ferrigno N, Laureti M, Fanali S, Grippaudo G. A

long-term follow-up study of non-submerged ITI
implants in the treatment of totally edentulous jaws
Clin. Oral Impl. Res, 13, 2002; 260273
Copyright C Blackwell Munksgaard 2002
ISSN 0905-7161
260
Key words: ITI implants, non-submerged implants, osseointegration, long-term study, life
table analysis, success rates, survival rates
Abstract: In this prospective multicenter study, non-submerged ITI implants were followed in
order to evaluate their long-term prognosis in fully edentulous jaws. A total of 1286
implants were inserted in 233 consecutive patients and, after a healing period of three to six
months, the successfully integrated implants were restored with 163 overdentures and 95 fixed
full-arch bridges. This prospective study not only calculated the 10-year cumulative survival
and success rates for the 1286 implants by life table analysis, but also evaluated the actual
survival and success rates for 498 implants after at least five years of functional loading. In
addition, cumulative success rates were calculated for implant subgroups according to implant
length and location. Additional analyses were performed to evaluate the estimated and
actual survival and success rates of the implants in relation to various prosthetic rehabilitation
techniques. The 10-year cumulative survival and success rates were 95.9% and 92.7%,
respectively. The actual 5-year survival and success rates of the first 498 implants that were
inserted were 97.7% and 95.0%, respectively. The analysis of implant subgroups showed
slightly more favourable cumulative success rates for 12 mm long implants (93%), in
comparison to 10 mm and 8 mm long implants (91.6% and 89.6%, respectively). The
cumulative success rate for mandibular implants (approximately 94%) was also more
favourable than that for maxillary implants (approximately 91%). Patients who were loaded
with both maxillary and mandibular prostheses maintained success rates well above 90%; while
only implants that were inserted to support maxillary overdentures that were retained by
Dolder bars showed a success rate below 90%.
One of the most ambitious goals in the

practice of oral implantology is the resolution of total edentulism and the adequate
restoration of both masticatory and aesthetic function. The therapeutic possibilities that are generally considered in these
cases consist either of the use of an implant-supported fixed full-arch prosthesis
or the application of a complete denture
that is supported or simply retained by implants, and known as an overdenture. The
discovery that commercially pure titanium
implants can obtain a functional ankylosis
with bone was first studied by the two research groups of Brnemark et al. (1969,
1977) and Schroeder et al. (1976, 1978).
This direct bone-to-implant contact is
often called osseointegration. Initially,
osseointegrated dental implants were utilized only for the treatment of the fully
edentulous mandible, in which a fixed fullarch prosthesis with distal cantilevers,
which was known as the Toronto bridge,
was supported by four or more implants
that were inserted in the intraforaminal
zone. The first long-term results of osseo-
Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws
integrated implants were based on a retrospective clinical study of completely edentulous patients who were treated with
Brnemark implants (Adell et al. 1981,
1990). In this latter publication, the 15-year
implant survival rates were 86% in the
mandible and 78% in the maxilla. Many
other prospective studies later reported
more favourable results, both in fully and
partially edentulous patients. Osseointegrated implants as anchors for various prosthetic reconstructions therefore became a
predictable treatment alternative (van
Steenberghe et al. 1990; Zarb & Schmitt
1990, 1993a, 1993b; Lekholm et al. 1994).
One of the more dogmatic aspects of the
clinical guidelines for these implants was
that implants had to be inserted in a submerged position in order to avoid functional load during the healing period and to
achieve osseointegration.
The development of non-submerged ITI
(International Team for Oral Implantology)
implants began in 1974. Professor Schroeder and his research group demonstrated
that, by following the same basic clinical
guidelines as for a submerged approach,
the placement of non-submerged oral titanium implants was just as predictable in
achieving successful osseointegration
(Schroeder et al. 1976, 1978, 1981). This
finding has since been documented in
many other comparative, experimental
studies (Gotfredsen et al. 1991; Abrahamsson et al. 1996; Ericsson et al. 1996; Weber
et al. 1996). Over the years, ITI implants
have been modified and improved, but the
basic non-submerged ITI philosophy has
not changed and good results have been reported for partially and fully edentulous patients in follow-up studies over both five
years (Buser et al. 1992; Mericske-Stern
et al. 1994; Weber et al. 2000) and eight to
ten years (Buser et al. 1997, 1999b). However, only a few of these latter studies have
directly correlated implant survival and
success rates with the various prosthetic
reconstruction techniques that are available to treat fully edentulous jaws.
The purpose of the present study was to
evaluate the cumulative survival and success rates of 1286 ITI implants (Institute
Straumann, Waldenburg, Switzerland) that
were inserted over a period of ten years. All
the implants were positioned in patients
who had a completely edentulous mandible or maxilla, and were used to support
overdentures and fixed full-arch bridges.
The life table analysis of Cutler & Ederer

(1958) was used to calculate 10-year survival and success rates. Furthermore, the
actual survival and success rates were
evaluated for 498 ITI implants after at least
five years of functional loading. Specific
cumulative success rates were also calculated for the various implant lengths and
locations that were used on the study. Additional analyses were performed to evaluate the estimated and actual survival and
success rates of the implants in relation to
various prosthetic rehabilitation techniques.
Material and methods

The present study was carried out at two
university study centers, which were
located at the Specialization Course in
Oral Implantology, University of Rome La
Sapienza, and the Specialization Course in
Clinical Implantology and Biomaterials,
University of Chieti G. Dannunzio, Italy.
Additional data were obtained from the
four private practices of the contributing
authors.
Between January 1990 and July 1999, a
total of 233 patients (93 men and 140
women), who were aged between 35 and
79years (average: 59.4years), were consecutively enrolled in this prospective multicenter study and treated either with implant-supported overdentures or with fixed
full-arch bridges. At presentation, 143 patients had complete edentulism of the
mandible, 64 patients had complete edentulism of the maxilla, and 26 patients were
completely edentulous and were treated for
both jaws. The medical history of each patient was assessed for current and previous
diseases and medications, and only healthy
patients were included in the study. In addition, patients who had any of the following conditions were excluded: (1) poor oral
hygiene; (2) severe intermaxillary skeletal
discrepancy; (3) bruxism; (4) heavy cigarette use (more than 15 cigarettes per day);
(5) drug or alcohol abuse; (6) previous insertion and loss of implants; (7) previous
radiotherapy to the head and neck region
for malignancy; (8) treatment with antiblastic chemotherapy; (9) chronic renal or
liver disease; (10) uncontrolled diabetes;
(11) hemophilia, bleeding disorder or cumarin therapy; (12) metabolic bone disorder;
(13) immunocompromised state, including
261 |
HIV; and (14) mucosal disease, such as lichen planus.

A total of 1286 ITI implants were inserted in 233 patients. The prosthetic rehabilitation techniques that were recommended to the patients are listed in
Table1.
Of the 26 patients who received prosthetic restorations of both jaws, ten were
treated with maxillary and mandibular
fixed full-arch bridges, six were treated
with Dolder bars in both arches, and ten
received a milled bar in the maxilla and
ball anchors in the mandible.
Based on these different indications, 618
implants (48.1%) were inserted in the maxilla and 668 (51.9%) implants were inserted
in the mandible. Of the 1286 implants that
were placed, 798 were inserted in the anterior region (62.0%) and 488 (38.0%) were
inserted in the posterior region of the maxilla or mandible (Table2).
It was always possible to insert eight implants for each arch in order to achieve
upper and lower full-arch bridges. In the
maxilla, the preferred arrangement was
with the implants in positions 1121, 13
23, 1525 and 1626. For functional and
aesthetic reasons, all the maxillary fullarch bridges were manufactured with two
separate hemi-arches that were divided between 11 and 21. In the mandible, the implants were inserted in positions 3343,
3444, 3545 and 3646, thus ending the
rehabilitation (as for the rest of the superior
arch) at the first molar.
Milled bars were only used to rehabilitate patients in the superior arch. To obtain
this particular type of overdenture, six implants were inserted for each patient in positions 1222, 1424 and 1626. Milled-bar
implant-supported overdentures, which are
fabricated by spark erosion technology or
electric discharge machining and are additionally spark-eroded to contain two lateral slant locks between implants in position 1416 and 2426, are characterized by
a stability that is similar to that of a fixed
prostheses; they can also be removed for
hygiene procedures (Davidoff 1993; Miller
1993; Hum 1994; Smith 1995; Toljanic
et al. 1997; Ercoli et al. 1998; Clepper
1999).
Patients who were treated with overdentures that were retained by Dolder bars received four implants that were positioned
as follows: in the lower arch, 34-32-42-44;
in the superior arch, 14-12-22-24. Overden-
Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273
Table 1. Prosthetic rehabilitation projects that were proposed to 233 patients
Table 5. Implant lengths
Prosthetic
rehabilitation
No. of
implants
Maxilla
HC
23
89
112
Full-arch bridge (8 implants)
55
40
760
HS
64
135
276
479
Milled bar (6 implants)
19
114
S3.3
46
169
215
Dolder bar (4 implants)
16
45
244
Ball anchors (2 implants)

Total
0
90
84
169
168
1286
S4.1
Total
4
8
29
93
144
348
303
837
480
1286
Mandible
6mm 8mm 10mm 12mm Total
HC, hollow-cylinder implants; HS, hollow-screw implants; S3.3, diameter-reduced solid-screw implants;
S4.1, standard solid-screw implants
Table 2. Distribution of implants

Anterior*
Posterior
Maxilla
290
328
Mandible
508
Total (N)
798
Total (%)
(62.0)
Total (N)
Total (%)
618
(48.1)
160
668
(51.9)
488
1286
(100)
(38.0)
(100)
*Anterior mandible: implant position between 34 and 44; anterior maxilla: implant position between 13 and 23
Table 3. Localization of 1286 inserted implants (WHO)

16
15
14
13
12
11
21
22
23
24
25
26
74
55
35
55
35
55
55
35
55
35
55
74
46
40
45
40
44
85
43
124
42
45
41
31
32
45
33
124
34
85
35
40
36
40
Table 4. Number and type of ITI. Dental Implant inserted during the present study
HC, hollow-cylinder implants; HS, hollow-screw implants; S3.3, diameter-reduced solid-screw implants;
S4.1, standard solid-screw implants
tures with ball anchors were only used for

the treatment of the edentulous mandible.
In these cases, implants were inserted in
position 3343. The precise locations of the
implants that were inserted are shown in
Table3.
Four different implant types of the ITI
Dental Implant System (Institute Straumann, Waldenburg, Switzerland) were utilized in the present study: i) hollow-cylinder
implants (HC), ii) hollow-screw implants
262 |
(HS), iii) standard solid-screw implants

(S4.1), and iv) diameter-reduced solid-screw
implants (S3.3). Most of the inserted implants had a TPS (titanium plasma-sprayed)
surface, and only 28 implants with a SLA
(sand-blasted, large grit, acid-etched) surface
were used during the last year of the study.
The numbers of implants that were inserted
during the study are shown in Table4.
The most frequently inserted implants
were 12mm long (837 implants), followed
by 10mm (348 implants), 8mm (93 implants) and 6mm (8 implants). Implants of
lengths 14mm and 16mm were never
used. Table5 shows the implant lengths in
relation to the different implant types.
A total of 772 implants were inserted in
standard sites that had sufficient keratinized mucosa at the alveolar crest and a good
bone volume (Table6). In 88 implant sites
that showed sufficient bone volume, an
initial gingival graft from the palate was
performed to reinstall keratinized mucosa
at the alveolar crest. A total of 234 implants were inserted with simultaneous sinus floor augmentation (one-step procedure) because of a deficient posterior alveolar ridge and increased pneumatization
of the maxillary sinus; of these 234 implants, 168 were inserted with the osteotome technique and 66 with the lateral window technique. Only autogenous bone in
particulate form was used as graft material;
this was harvested during the preparation
of the implant recipient sites or from other
intraoral sites. No implants were inserted
after a previous sinus floor augmentation
with bone grafting (two-step procedure)
(Tatum 1986; Misch 1987; Block & Kent
1993; Summers 1994).
A total of 192 implant sites that exhibited localized horizontal bone defects
were treated with barrier membranes, according to the principle of Guided Bone Regeneration (GBR) with a simultaneous approach; no implants were inserted with a
GBR-staged approach (Buser et al. 1990b,
1996). During the first half of the study
period, only 28 implant sites that had localized horizontal bone defects were treated,
and all with non-resorbable expanded polytetrafluoroethylene (e-PTFE) membranes
(Gore-TexA, W. L. Gore & Associates, Flagstaff, AZ, USA). During the second half of
the study period, only seven compromised
sites were treated with non-resorbable ePTFE membranes; the other 157 localized
horizontal bone defects were treated with
Table 6. Classification of implant recipient sites

Type of implant recipient site
Standard site
772
(sufficient bone, sufficient keratinized mucosa)

Sites with soft tissue problems
88
(sufficient bone keratinized mucosa graft)

Maxillary sites with deficient posterior alveolar ridge
168
(sinus floor augmentation implant position, osteotome technique, 1-step procedure)

66
(sinus floor augmentation implant position, window technique, 1-step procedure)

(sinus floor augmentation, no implant, 2-step procedure)

Sites with horizontal bone defect: implant position membrane
(simultaneous approach of GBR)
Sites with horizontal bone defect: bone grafting membrane no implant
192
0
(staged approach of GBR)

Total
1286
GBR, guided bone regeneration
resorbable membranes. Of these, 48 were

polylactic/polyglicolic bioresorbable membranes (ResolutA, W. L. Gore & Associates),
65 were degradable bi-layer collagen membranes (Bio-GuideA, Geistlich, Wolhusen,
Switzerland) and 44 were poly-D L-lactide
resorbable membranes (GuidorA AB, Huddinge, Sweden). Again, only autogenous
bone in particulate form was used as graft
material below the membranes; this was
harvested during the preparation of the implant recipient sites or from other intraoral
donor sites.
months for all implants that were inserted

in standard sites of the posterior maxilla.
A healing period of three months was
maintained for all implants that were inserted in the mandible using a standard
technique, as was six months for all implants that were positioned with the GBR
technique or sinus lifting.
During the last year of the study period,
the waiting time before the prosthetic
phase was reduced to six or eight weeks
for implants with an SLA surface that were
inserted with a standard technique.
Postoperative treatment
Annual examination
After surgery, all patients received i) oral

antibiotics for five days (or eight days if the
implants were inserted in a non-standard
site), (ii) non-steroidal analgesics for 3
5days, and (iii) detailed instructions about
oral hygiene (mouth rinses with 0.2%
chlorhexidine for two weeks). Sutures were
removed 815days after surgery.
Follow-up visits were scheduled for

2weeks and 1, 3, 6 and 12months during
the first postoperative year, and annually
thereafter. At each annual recall, patients
underwent a clinical and radiographic
evaluation to check: (a) peri-implant soft
tissue condition, (b) mobility of the implant, and (c) marginal bone loss.
The annual evaluation of the peri-implant soft tissue condition included the assessment of several clinical parameters,
using the following indices.
Healing period
During the first half of the study period, a

healing period of six months was observed
for all implants that were inserted in the
maxilla and for implants that were inserted
either with a simultaneous application of
GBR or with sinus floor elevation. For all
implants that were inserted in the mandible using a standard technique, the waiting time before the prosthetic phase was
three months.
Beginning in March 1995, it was decided
to reduce the period of osseointegration to
three months for all implants that were inserted with a standard technique in the anterior region of the upper jaw, and to four
O Modified plaque index (mPI) was determined on the mesial, distal, buccal and lingual/palatal surface of the implants (Mombelli et al. 1987; Mombelli & Lang 1994).
O Modified bleeding index (mBI) was assessed at the same surfaces as for mPI
(Mombelli et al. 1987; Mombelli & Lang
1994).
O Probing depth (PD) was measured to the
nearest mm with a Hu-Friedy PGF-GFS
periodontal probe (Hu-Friedy, Chicago, IL,
USA), at the same surfaces as for mPI
263 |
(Mombelli et al. 1987; Buser et al. 1990a;

Mombelli & Lang 1994).
O The distance between the implant
shoulder and the mucosal margin (DIM)
was measured to the nearest mm. In the
presence of a subgingival implant shoulder,
the measurement was recorded as a negative value. Measurements were taken with
the same Hu-Friedy probe at the same surfaces as PD (Buser et al. 1990a).
O Attachment level (AL) was computed
for each site by adding PD and DIM (Buser
et al. 1990a).
O The width of keratinized mucosa (KM)
was measured in mm, at the midfacial and
midoral aspects of implants in the mandible and at the midfacial aspect of implants in the maxilla (Buser et al. 1990a).
O Suppuration was evaluated as the presence or absence of suppuration.
The annual evaluation of the mobility of
the implant involved the removal of the
bars and the screw-retained full-arch
bridges. Each implant was evaluated individually. Implant mobility was tested
manually using the handles of two dental
mirrors (Smith & Zarb 1989; Buser et al.
1990a).
The evaluation of marginal bone loss began with the first radiographic evaluation
at the end of the osseointegration period.
In patients who were treated with full-arch
bridges and milled bars, a panoramic radiograph was taken, whereas periapical radiographs were generally used for patients
who were treated with Dolder bar and ball
anchors. The radiographs were analyzed for
the presence of continuous peri-implant radiolucencies, and for the location of alveolar bone levels around the implants.
Measurements were taken on the mesial
and distal implant sites by means of a
transparent millimeter ruler. Two distances were measured: i) the distance between the implant shoulder and the first
visible bone contact (DIB; Buser et al.
1990a), and (ii) the distance between the
most coronal bone-implant contact on the
radiograph and the apex of the implant.
The measurements were made to the nearest 0.5mm (Table8a). In order to correct dimensional distortion, the apparent dimension of each implant was measured on the
radiograph and was compared to the real
implant length (Brnemark et al. 1977; Adell et al. 1981; Ferrigno et al. 1994).
If a patient could not be followed at con-
Table 7. Criteria of success

1)
Life table analysis
Absence of persistent subjective complaints,

such as pain, foreign body sensation and/or
dysaesthesia
2)
Absence of a recurrent peri-implant infection

with suppuration
3)
Absence of mobility
4)
Absence of a continuous radiolucency around

the implant
Table 8a. Results for 1282 implants during the

study period
Parameters Min.
Max.
Mean
SD
mPI
0.18
0.48
mBI
0.28
0.60
PD
2.74
0.84
3
1
3
6
0.14
2.60
1.04
0.94
DIM
AL
KM
DIB
0.5
1.8
11
7.4
2.95
2.05
3.40
1.00
MPI, modified plaque index; mBI, modified bleeding

index; PD, probing depth; DIM, distance between implant shoulder and mucosal margin; AL, attachment
level (PD DIM); KM, width of keratinized mucosa;
DIB, distance between implant shoulder and first visible bone contact; SD, standard deviation
Table 8b. Implant classification at each annual

examination
1)
2)
3)
4)
5)
6)
Successful implant according to the criteria of

success
Implant failure due to recurrent peri-implant
infection
Implant failure due to implant mobility
Implant failure due to implant fracture
Implant failure due to progressive bone loss
without clinical signs of peri-implant infection
Implant exhibiting peri-implant infection with
suppuration, which requires antimicrobial
therapy
secutive annual examinations, the corresponding implants were classified as dropout implants.
The statistical analysis was based on the

life table analysis technique that was described by Cutler & Ederer (1958). In order
to obtain at least one year of examination
data for all the 1286 implants that were inserted, the data analysis was undertaken at
the end of July 2000.
O Cumulative survival rate. An implant
was classified as a survival implant when
it was still in service, but did not fulfil the
success criteria. This analysis calculated
the annual survival rate and the cumulative survival rate for the entire ten-year
period. Implant losses were all failure categories, except for implants that exhibited a
suppurative peri-implant infection at the
last annual examination.
O Cumulative success rate. An implant
was classified as a successful implant
when it fulfilled the criteria of success.
This analysis calculated the annual success
rate and the cumulative success rate for
the entire ten-year period. This analysis
was more stringent than the survival rate
analysis, as all implants that exhibited a
suppurative peri-implant infection at the
last annual control were also included in
the group of failures.
Cumulative survival and success rates were
also correlated to implant length and location, as well as to the different prosthetic rehabilitation techniques that were used in
the study. Moreover, an additional analysis
was performed for the first 498 implants
that were inserted between January 1990
and November 1994, in order to evaluate
the survival and success rates after at least
five years of functional loading.
Criteria of success and implant classification
The implants were examined for successful tissue integration utilizing predefined
criteria of success (Buser et al. 1990a)
(Table7).
First, a distinction was made between
implants that would not have obtained osseointegration (these were defined as early
failed implants) and those that would have
obtained success in the osseointegration
phase (these were defined as successfully
integrated implants).
Based on the clinical and radiographic
examinations (Table8a), each implant was
classified according to the list that is
shown in Table8b (Buser et al. 1997).
264 |
Results
Results during the healing period
At the end of the healing period, four implants that were inserted in two patients
presented implant mobility and had to be
removed; these implants were classified as

early failures. Both patients had planned
to receive an overdenture, but one of them,
after the failure of the two implants that
were inserted for ball anchors, renounced
implant therapy, while the second patient,
who should have received a Dolder bar,
opted for a ball anchor-retained prosthesis.
In addition, three implants presented a
light suppuration due to the mobility of
the cover screws; this minor problem was
resolved with oral antibiotics for five days,
local application of a 0.5% chlorhexidine
dental gel for one week, and the positioning of new cover screws. These implants were not considered as early failures (Table10). The early failure rate was
0.3%. Therefore, 1282 implants were considered suitable for the prosthetic rehabilitation and were restored with 258 prostheses, as listed in Table9.
Results of the 10-year life table analysis
During the follow-up period, eight patients

with 30 inserted implants were unfortunately lost to follow-up; all these implants
were successfully integrated, as documented at the last annual examination of
these patients.
During the follow-up period, a total of 12
implants were classified as late failures.
Two of these implants failed due to implant mobility, three implants fractured
(one HC 15 implant, one HC implant and
one HS implant), five implants showed untreatable recurrent peri-implant infection,
and two implants failed due to progressive
bone loss without clinical signs of peri-implant infection (Table10). These 12 implants were surgically removed.
A further 18 implants that presented
with peri-implant infection with suppuration in the peri-implant sulcus and radiographic evidence of bone resorption at the
last annual examination were treated with
mechanical debridement (carbon fiber curettes plus rubber cups and polishing paste;
Hawe Neos, Switzerland), antiseptic treatment (local application of a 0.5% chlorhex-
Table 9. Prosthetic rehabilitations performed on 1282 implants

Prosthetic rehabilitation
Maxilla
Mandible
No. of implants
Full-arch bridge (8 implants)

Milled bar (6 implants)
Dolder bar (4 implants)
Ball anchors (2 implants)
Total
55
19
16
0
90
40
0
44
84
168
760
114
240
168
1282
Table 10. Failures during the healing and follow up periods

Time
(mths)
Recurrent
infection
Implant
mobility
Implant
fracture
Progressive
bone loss
06
612
1324
2536
3748
1
3
3
4
4
7
4960
6172
7384
8596
97108
109120
1
0
1
0
Total
16
18
34
Table 11a. Life table analysis of 1286 implants for implant survival
Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Survival
rate in
period (%)
Cumulative
survival
rate (%)
01
12
23
34
45
56
67
78
89
910
1286
1112
936
762
574
416
286
154
76
24
0
6
4
6
4
8
0
2
0
0
1286
1109
934
759
572
412
286
153
76
24
4
1
1
3
3
1
1
1
1
0
99.7
99.9
99.9
99.6
99.5
99.7
99.6
99.3
98.7
100.0
99.7
99.6
99.5
99.1
98.6
98.3
97.9
97.2
95.9
95.9
Success
rate in
period (%)
Cumulative
success
rate (%)
Implants
at start of
interval
Drop-outs
during
interva
Implants
under
risk
Failures
during
interval
01
12
23
34
45
56
67
1286
1112
936
762
574
416
286
0
6
4
6
4
8
0
1286
1109
934
759
572
412
286
4
5
4
7
5
3
3
99.7
99.5
99.6
99.1
99.1
99.3
99.0
99.7
99.2
98.8
97.9
97.0
96.3
95.3
78
89
910
154
76
24
2
0
0
153
76
24
2
1
0
98.7
98.7
100.0
94.0
92.7
92.7
idine dental gel for 15days) plus oral antibiotics (ornidazole, TiberalA, Roche,
2500mg daily or metronidazole, FlagilA,
Rhone-Poulenc, 3350mg daily for ten
days) (Mombelli & Lang 1992, 1998; Lang
et al. 2000). Implant infection was successfully controlled for all the 18 implants, and
six of them were also treated with a surgical revision approach to reshape the periimplant soft tissues and/or bony architecture by means of resective surgical techniques (Behneke & Behneke 1996; Buser &
Maeglin 1996; Mombelli & Lang 1998;
Lang et al. 2000).
4
0
sis was done utilizing the criteria for implant success. Only eight 6mm long implants were inserted during the study
period, but these had a 100% cumulative
success rate.
This analysis was done to compare the success rate of implants that were inserted in
the anterior and posterior parts of the
mouth. Implants that were inserted in the
anterior and posterior maxilla demonstrated cumulative success rates of 93.4%
and 89.5%, respectively (Tables 13a and b).
In the mandible, the analysis revealed 10year cumulative success rates of 94.7% for
implants in the anterior mandible and
92.4% for implants in the posterior mandible (Tables13c and d).
Implant success rate in relation to prosthetic
rehabilitation technique and prosthesis survival
rate
Life table analysis of 1286 implants
The life table analyses for the 1286 implants that were inserted are shown in
Tables11a and 11b. These tables show a
cumulative survival rate at ten years of
95.9% and a cumulative success rate of
92.7%.
Analysis of various implant lengths
When the life table analysis was correlated

to implant length (Tables12a-d), the cumulative success rates were 89.6% for 8mm
long implants, 91.6% for 10mm implants
and 93.0% for 12mm implants. This analy-
265 |
Total
Analysis of various implant locations
Table 11b. Life table analysis of 1256 implants for implant success
Time
interval
(years)
Infection at
last exam.
Subtotal
This analysis was performed (utilizing the

criteria for implant success) to evaluate the
implant success rate in relation to the different prosthetic rehabilitation techniques
that were used, in order to establish
whether implant failure was related to the
bone stress distribution of the specific prosthetic restoration. The analysis also
allowed the survival rates for the different
prosthetic rehabilitation techniques to be
evaluated in relation to implant failure, i.e.
whether it was possible to maintain or
modify the prostheses after implant failure.
This possibility was, of course, only considered for failures that involved one or
two implants (Tables14 and 15).
Results of the 5-year life table analysis
This analysis was undertaken on 498 implants that were inserted, between January
Table 12a. Cumulative success rates for 6mm long implants

Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
100
100
12
100
100
23
100
100
34
45
4
0
0
0
4
0
0
0
100
100
56
67
78
89
910
Table 12b. Cumulative success rates for 8mm long implants

Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
93
79
71
62
47
24
20
14
9
2
0
2
0
2
0
2
0
0
0
0
93
78
71
61
47
23
20
14
9
2
1
1
0
1
1
1
0
0
0
0
98.9
98.7
100
98.4
97.9
95.7
100
100
100
100
98.9
97.6
97.6
96.0
93.9
89.6
89.6
89.6
89.6
89.6
Table 12c. Cumulative success rates for 10mm long implants

Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
348
297
250
172
103
69
48
14
14
14
0
2
2
2
2
2
0
0
0
0
348
296
249
171
102
68
48
14
14
14
1
2
0
3
2
1
1
0
0
0
99.7
99.3
100
98.2
98.0
98.5
97.9
100
100
100
99.7
99.0
99.0
97.2
95.2
93.7
91.6
91.6
91.6
91.6
Discussion
Table 12d. Cumulative success rates for 12mm long implants

Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
837
730
609
524
424
323
218
126
53
8
0
2
2
2
2
4
0
2
0
0
837
729
608
523
423
321
218
125
53
8
2
3
4
3
2
1
2
2
1
0
99.9
99.6
99.3
99.4
99.5
99.7
99.1
98.4
98.1
100
99.9
99.5
98.8
98.2
97.7
97.4
96.5
94.9
93.0
93.0
266 |
1990 and November 1994, in 98 patients

with fully edentulous jaws. The aim was to
evaluate implant survival and success rates
after at least five years of functional loading. When the data analysis was undertaken at the end of July 2000, this implant
group had, in fact, been at risk after the
prosthetic rehabilitation for a period of five
to ten years.
During the observation period, four patients with 20 successfully integrated implants were lost to follow-up for several
reasons (one patient with a maxillary fixed
full-arch bridge, one patient with a maxillary milled bar, one patient with a lower
Dolder bar and one patient with ball anchors; 20 drop-out implants, which corresponded to 4.0%). Therefore, a total of 478
implants were included in the 5-year life
table analysis. The prosthetic rehabilitations that were supported by the 478 implants are shown in Table16.
There were no early failures during the
healing period, but 11 implants were removed or lost during the follow-up period
for various reasons, and 13 implants
showed a peri-implant infection with suppuration that was treated as previously described (Table17). On the basis of the
above-mentioned criteria for implant survival and success, the 5-year survival rate
of implants was 97.7% (11 losses out of
478 implants) and the success rate was
95.0% (24 failures out of 478 implants). An
additional statistical analysis was performed to evaluate the actual 5-year implant success rates in relation to the different prosthetic rehabilitation techniques.
The lowest success rate (88.9%) was for
implants that supported a maxillary Dolder bar (Table17).
The present prospective study was carried

out with a consecutive inclusion of 233 patients who presented with fully edentulous
jaws at two different academic institutions,
and at four private offices. Prospective follow-up examinations were performed for
each patient at annual intervals, in order to
evaluate the long-term prognosis of the
1286 ITI implants that were inserted over
a 10-year period. Life table analysis was
performed according to the method that
was described by Cutler & Ederer (1958),
and allowed evaluation of cumulative sur-
Table 13a. Cumulative success rates for implants in the anterior maxilla
Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
290
290
100
100
12
250
250
99.6
99.6
23
212
212
99.5
99.1
34
45
170
124
2
0
169
124
1
3
99.4
97.6
98.5
96.1
56
90
88
98.9
95.0
67
62
62
98.4
93.4
78
34
34
100
93.4
89
16
16
100
93.4
910
100
93.4
Table 13b. Cumulative success rates for implants in the posterior maxilla
Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
328
286
246
200
150
110
78
44
22
4
0
0
0
4
0
4
0
0
0
0
328
286
246
198
150
108
78
44
22
4
0
2
2
3
1
0
0
1
1
0
100
99.3
99.2
98.5
99.3
100
100
97.7
95.5
100
100
99.3
98.5
97.0
96.3
96.3
96.3
94.0
89.5
89.5
Table 13c. Cumulative success rates for implants in the anterior mandible
Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
508
448
370
296
232
168
110
60
30
12
0
6
4
0
4
0
0
2
0
0
508
445
368
296
230
168
110
59
30
12
4
1
0
2
1
1
1
1
0
0
99.2
99.8
100
99.3
99.6
99.4
99.1
98.3
100
100
99.2
99.0
99.0
98.3
97.9
97.3
96.4
94.7
94.7
94.7
Table 13d. Cumulative success rates for implants in the posterior mandible
Time
interval
(years)
Implants
at start of
interval
Drop-outs
during
interval
Implants
under
risk
Failures
during
interval
Success
rate in
period (%)
Cumulative
success
rate (%)
01
12
23
34
45
56
67
78
89
910
160
128
108
96
68
48
36
16
8
4
0
0
0
0
0
0
0
0
0
0
160
128
108
96
68
48
36
16
8
4
0
1
1
1
0
1
1
0
0
0
100
99.2
99.1
99.0
100
97.9
97.2
100
100
100
100
99.2
98.3
97.3
97.3
95.2
92.4
92.4
92.4
92.4
267 |
vival and success rates for the 1286 implants according to predefined criteria of
success (Buser et al. 1990a). During the 10year study period, the results for all 1286
implants showed a cumulative survival
rate of 95.9% and a cumulative success
rate of 92.7%. The analogous values after
five years were 98.6% and 97.0%, respectively. These results were slightly better
than those for the first 498 implants that
were inserted that, after at least five years
of functional loading, presented a cumulative survival rate of 97.7% and a cumulative success rate of 95.0%.
In a previous publication, Buser et al.
(1997) evaluated the long-term prognosis of
2359 ITI implants in fully and partially
edentulous patients, over a period of up to
eight years. Using the same life table analysis technique of Cutler & Ederer (1958),
these authors estimated 5-year cumulative
survival and success rates of 97.9% and
96.6%, respectively. The corresponding
values for the first 536 implants that were
inserted, with a actual follow-up period of
five years, showed a survival rate of 98.2%
and a success rate of 97.3%. The authors
concluded that the comparison between the
actual 5-year survival and success rates and
the estimated cumulative survival and success rates indicated that the life table analysis technique of Cutler & Ederer (1958) was
an appropriate and rather conservative statistical method with which to estimate the
long-term prognosis of dental implants. The
current authors agree with this assertion, although a wider gap was seen in the present
study between the actual 5-year and the estimated survival and success rates, especially for the success rate analysis. These
statistical differences may be the consequence of three different conditions. Firstly,
at the time of the data analysis (at the end
of July 2000), the first 498 implants that had
been inserted had been at risk for longer
than five years, as only implants with a
functional loading of at least five years were
included. Secondly, during the first period of
the present study, only hollow implants
were used to treat completely edentulous
jaws. At the 1997 ITI Consensus Conference and the more recent 2000 ITI World
Congress, it was clearly shown that this
type of implants is not as safe as the fullbody screw. Thirdly, the surgeons confidence in performing the surgical techniques, such as GBR and sinus lifting, improved over the course of the study.
Table 14. Implant success rate in relation to prosthetic rehabilitation in the maxilla, and prosthesis
survival rates
Full-arch bridge
Milled bar
Time interval
(years)
Implants
under risk
at start of
interval
Failures
during
interval
Implants
under risk
at start of
interval
Failures
during
interval
Implants
under risk
at start of
interval
Failures
during
interval
01
440
114
64
12
368
108
60
23
304
102
52
34
45
232
152
1
3
87
78
1
0
48
44
2
1
56
100
60
36
67
64
48
28
78
32
30
16
89
18
12
910
Cumulative
92.1
Dolber bar
92.2
86.9
implant
success rate (%)
Survival rates
of the prosthetic
rehabilitations
Full arch bridge

(53/55)
96.4%
Milled bar
(18/19)
94.7%
Dolder bar
(14/16)
87.5%
Table 15. Implant success rates in relation to prosthetic rehabilitation in the mandible, and
prosthesis survival rates
Time
interval
(years)
Full-arch
bridge
Implants
under risk Failures
at start of during
interval
interval
Milled bar
Implants
under risk Failures
at start of during
interval
interva
Dolder bar
Implants
under risk Failures
at start of during
interval
interval
01
12
23
34
45
56
67
78
89
910
320
256
216
192
136
96
72
32
16
8
168
157
126
96
80
56
34
19
14
4
176
160
134
104
82
64
40
24
8
4
Cumulative
success rates
of implants (%)
0
1
1
1
0
1
1
0
0
0
96.2
Survival rates
of the prosthetic
rehabilitations
93.7
Full arch bridge

(40/40)
100%
Maxilla
No. of
Mandible implants
Full-arch
bridge
Milled bar
Dolder bar
16
14
240
9
9
18
54
108
Ball anchors
Total
34
38
70
76
478
268 |
0
0
0
1
1
0
0
1
0
0
93.9
Ball anchors
(83/84)
98.8%
Table 16. Prosthetic rehabilitations of 478 implants (498 implants were inserted, with 20
drop-outs, leaving 478 implants)
Prosthetic
rehabilitation
0
1
0
1
0
1
1
0
0
0
Dolder bar
(43/44)
97.7%
In a recent publication, Weber et al.

(2000) reported the results for 112 ITI implants that had been inserted in 46 patients, analyzed using life table analysis,
loaded with either single-tooth replacements or short span fixed partial dentures,
and in function for a period of five to six
years. An overall 6-year cumulative success rate of 95.5% and a corresponding
value of 99.1% over five years were reported. This 5-year implant success rate
(99.1%) is slightly better than that reported
by Buser et al. (1997) (97.3%) and quite
better still relative to the result of the present study (95.0%). These differences are
probably be related to the different prosthetic rehabilitation options that were
used, the numbers of patients and implants
that were included in the follow-up
studies, and the status of the implant recipient sites.
In regards to the types of prosthesis that
were used, it is interesting to note the correlation of the highest 5-year actual success
rate of 99.1% (Weber et al. 2000) with the
complete absence of implants inserted in
fully edentulous patients; the 5-year actual
success rate reduced to 97.3% (Buser et al.
1997) when probably 50% of the 536 implants were used to support restorations of
fully edentulous jaws (details of the types
of prosthetic restoration were not provided,
but a value of 50% can be deduced because
1180 out of 2359 implants (50%) were used
to support restorations of fully edentulous
jaws: 13 fixed full-arch prostheses and 391
overdentures). In the present study, the actual 5-year success rate later reduced to
95.0%, but all the implants were inserted
in completely edentulous jaws and with a
very different ratio of full-arch prostheses
to overdentures (31 fixed full-arch prostheses and 77 overdentures).
In regards to the status of the implant
recipient sites, experimental and clinical
studies have demonstrated that surgical
techniques as GBR and sinus floor augmentation can increase the bone width and
height of the atrophic ridge, and enable the
placement of implants in a new sufficient
bone volume (Tatum 1986; Misch 1987;
Becker & Becker 1990; Buser et al. 1990b;
Nyman et al. 1990; Block & Kent 1993;
Summers 1994). These techniques have become more predictable over the last ten
years, but still present greater risks in comparison to standard situations (Buser et al.
1993; Simion et al. 1994; Buser et al. 1996;
Simion et al. 1997; Jensen et al. 1998). In
the present study, only 60% of the implants (772/1286) were inserted in standard
sites, which may explain the low implant
success rate in comparison with the study
of Buser et al. (1997), in which 84.8% of
the implants (2001/2359) were inserted in
standard sites (Weber et al. (2000) did not
consider the status of the implant recipient
sites).
In regards to the numbers of patients and
implants that were involved in the followup studies, it has to be considered that cur-
Table 17. Survival and success rates of 478 implants (498 implants were inserted, with 20 dropouts, leaving 478 implants) after at least five years of functional loading
Prosthetic
rehabilitation
Recurrent Implant
infection mobility
Implant
fracture
Progressive
bone loss
Subtotal
Removed implants
Periimplant
infection
Total
Treated impl.
Maxilla
Full-arch bridge
(95.3%)*
Milled bar* (94.4%) 1
Dolder bar* (88.9%)
Mandible
Full-arch bridge
(96.4%)*
Dolder bar
11
13
24
(95.8%)*
Ball anchors
(94.7%)*
Total
Actual 5-year implant survival rate (467/478): 97.7%

Actual 5-year implant success rate (454/478): 95.0%
*Actual 5-year implant success rate related to the specific prosthesis
rent long-term studies on dental implants

must be carried out under specific scientifically accepted conditions, in order to
obtain comparable data. Albrektsson &
Zarb (1993) defined such conditions and required the inclusion of at least 50 consecutive patients at a minimum of two centers,
a distinction between implant survival and
implant success based on predefined criteria of success, the inclusion of drop-out
implants in the analysis, and a prospective
long-term documentation over at least five
years. The present study fulfils all these requirements, both in the prospective 10year analysis and the actual 5-year analysis.
In the present study, failures that occurred during the healing and follow-up
periods were divided into different types,
based on predefined criteria of success
(Buser et al. 1990a). A total of 16 implants
out of the 1286 implants that were inserted
were either lost or had to be surgically removed due to several reasons. At the last
annual examination, a further 18 implants
exhibited peri-implant infection with suppuration in the peri-implant sulcus.
During the healing period (three to six
months), only four implants (0.31%) did
not fulfil the criteria for successful tissue
integration and were classified as early
failures. These four implants, which
showed no clinical signs of peri-implant infection, were lost due to implant mobility
that was probably caused by bone necrosis
due to overheating of the peri-implant
bone during the preparation of the implant
bed. The recipient sites of these four early
failure implants were all located in the anterior mandible of two patients who were
in class V of the classification system that
was proposed by Cawood & Howell (1991).
The extremely reduced percentage of failures during the healing period was consistent with the results from previous studies
(Buser et al. 1990a; Mericske-Stern et al.
1994; Buser et al. 1997; Weber et al. 2000).
It was probably due to the careful patient
selection, the good quality of the ITI surgical instruments, and the use of TPS and
SLA surfaces, which achieve a stronger
bone anchorage in comparison to smooth
and other rough titanium surfaces (Wilke
et al. 1990; Buser et al. 1991, 1998, 1999a;
Cochran 1999).
During the follow-up period, two implants were lost due to implant mobility
and two more implants had to be surgically
removed due to evident progressive bone
loss. None of these implants showed clinical signs of peri-implant infection with
suppuration, so their failure was probably
due to occlusal overload. Five implants
showed recurrent and untreatable peri-implant infection with suppuration and had
to be surgically removed. Finally, three hollow-body implants (one HC 15 implant,
one HC implant and one HS implants) fractured. These failures typically occurred
after advanced bone loss below the first
line of perforations, and can most likely be
attributed to metal fatigue at the weakest
point of these hollow implants after the inversion of the crown-to-implant ratio (Buser et al. 1997; Weber et al. 2000). In ad-
269 |
dition, at the last annual examination, 18

implants exhibited a peri-implant infection
with suppuration in the peri-implant sulcus and were treated with antimicrobial
therapy (Mombelli & Lang 1992; Lang
et al. 2000) which, for six implants, was
combined with a surgical revision (Behneke & Behneke 1996; Buser & Maeglin
1996). These implants were considered
biologic failures, although suitable therapy was able to arrest the peri-implant infection and the implants became successful again. The 18 implants that were classified as biologic failures represented 1.4%
of the entire study group of 1286 implants.
This means that, despite the rather high
average patient age and the type of prosthetic rehabilitation, TPS and SLA surface
implants had a low risk of developing a
peri-implant infection after reaching a
stable osseointegration.
The 16 implants that were lost or removed were included in the calculation of
the cumulative survival rate and the actual
5-year survival rate. From the clinical point
of view, these represent the real success
that doctors and patients can expect from
implant therapy. The 18 implants that
were classified as biologic failures provided successful clinical function, but in
the strict evaluation of the implant cumulative success rate they were considered as
failures, in order to provide a more complete trend of the entire group of inserted
implants at an early stage.
In the present study, which used predefined criteria of success, several additional
analyses were performed in which implants were classified into different subgroups.
The direct comparison of the various implant lengths was only carried out for 8, 10
and 12mm implants because the number of
6mm implants (eight) was too small to
allow a direct comparison with the longer
implants. Nevertheless, all these very short
implants were followed for one to four
years, and showed a cumulative success rate
of 100%. This result is consistent with the
first multicenter report on 6mm ITI implants (Bruggenkate et al. 1998). The analysis of various implant lengths demonstrated
a trend for better results with increasing implant length, as 12mm and 10mm long implants had a 10-year cumulative success
rate of 93.0% and 91.6%, respectively. The
corresponding value for the 8mm long implants was 89.6%. Although the analysis
showed that 12mm implants had a better

result, the performance of the 8mm implant can be considered satisfactory, as
these implants were mainly inserted in the
posterior segment of both jaws, where the
bone quality and the vertical bone height
are often not as good as in the anterior part
of the jaw. These results involving short implants are consistent with those of other
studies (Buser et al. 1997; Bruggenkate et al.
1998) and are most likely due to the TPS and
SLA rough surfaces of the ITI implants,
which obtain a stronger bone anchorage
when compared to smooth titanium surfaces (Wilke et al. 1990; Buser et al. 1991,
1999a; Cochran 1999).
Concerning the analysis of various implant locations, although there was a trend
for better results in favor of the mandible,
the observed differences were minimal and
not statistically significant. Nor were there
any statistically significant differences observed between the implant cumulative
success rates of the anterior and the posterior parts of the jaws. These findings are
consistent with the meta-analysis results
of Cochran (1999) for rough-surfaced implants, but are in contrast with other longterm studies on ITI implants (Buser et al.
1997; Weber et al. 2000) and Brnemark
implants (Adell et al. 1981, 1990; Jemt
et al. 1996), where implants that were positioned in the maxilla appeared to have a
less favorable prognosis when compared to
mandibular implants. The reason for these
very surprising results is most likely the
type of prosthetic restorations that are used
in the treatment of the edentulous upper
jaw, as well as the surface characteristics
of the implant. Except for overdentures
that are supported by four implants with a
Dolder bar, all the other restorations were
realized with a minimum number of six
implants that were fixed together, thus
probably providing an adequate bone stress
distribution. In addition, the insertion of
most implants with sinus floor elevation
and autogenous bone graft, even when the
vertical bone height would have allowed
the use of a standard shorter implant, appeared to be a very good choice in the posterior maxilla. For example, a 12mm long
implant (rather than a 10mm or shorter
implant) was inserted with the osteotome
technique where the available vertical
bone dimension was 11mm. This was
done not only to gain one more millimetre
of implant osseointegration, but also to
270 |
achieve two favorable conditions: a smaller

crown-to-implant ratio and, above all, a bicortical implant contact with the implant
threads inserted in both crestal and sinus
floor cortical bone (Tatum 1986; Misch
1987; Summers 1994; Komarnyckyj &
London 1998).
The evaluation of implant cumulative
success rates according to prosthetic rehabilitation technique was undertaken on
the hypothesis that a long-term statistical
study on dental implants in the treatment of
edentulous jaws could be strongly influenced by the type of prosthesis used and the
size of the load that was incurred by the implants. In other words, the inadequate rehabilitation of fully edentulous patients
could cause implant failures, with a consequent reduction of the implant success
rates, while instead these implant failures
should mostly be attributed to a wrong
choice of prosthesis. In the present study,
the edentulous maxilla was mainly treated
with fixed full-arch bridges, each supported
by eight implants. It was decided to insert
implants in locations 1121, 1323, 1525
and 1626 because they appeared to be the
more appropriate choice empirically for the
occlusal force bone stress distribution (Rieger et al. 1989a, 1989b; Adell et al. 1990;
Jemt 1991). The 10-year cumulative success
rate of implants that support this type of restoration was 92.1% (Table14) and the corresponding value for the actual 5-year analysis
was 95.3% (Table17). These results seem to
demonstrate that a maxillary fixed full-arch
prosthesis that is supported by eight implants in that particular distribution allows
good long-term success rates for loaded implants.
Similar conclusions can be made for
overdentures that have a milled bar that is
supported by six implants inserted in locations 1222, 1424 and 1626. In fact, the
10-year cumulative and the 5-year actual
implant success rates were 92.2% and
94.4%, respectively. The least predictable
prosthetic rehabilitations of the upper jaw
were overdentures that had a Dolder bar
that was supported by four implants. These
rehabilitations were unable to offer longterm success to the implants which supported them, and showed 10-year cumulative and 5-year actual implant success rates
of 86.9% and 88.9%, respectively.
These results are nevertheless rather
better than the results which have been
published in previous studies, where very
high failure rates (over 20%) were reported

for maxillary overdentures (Engquist et al.
1988; Jemt 1991; Jemt et al. 1992; Jemt
1993; Hutton et al. 1995; Jemt et al. 1996).
A critical analysis of these latter studies revealed that the indication for overdentures
was often given in an emergency situation
(Palmqvist et al. 1994, 1996), which meant
that the overdentures were a substitute for
failing fixed prostheses or were a second
choice when the placement of implants to
support fixed full-arch prostheses was not
possible or when a fixed restoration was
planned, but the loss of implants made such
a placement impossible (Jemt 1991; Jemt
et al. 1996). Otherwise, for maxillary overdentures as the first-choice treatment in the
rehabilitation of edentulous ridges, an increased implant survival was observed, and
the marginal bone that surrounded the implants was found to be maintained at the
same level as with fixed full-arch prostheses, even in ridges with advanced atrophy (Palmqvist et al. 1996). Nevertheless,
recent studies (Hutton et al. 1995; Bergendal & Engquist 1998) have reported a cumulative implant survival rate of about 75%
even in maxillary overdentures planned as a
first solution. In the present study, none of
the maxillary overdentures were used for
emergency situations, but were chosen because they would provide better and easier
resolution of problems related to asymmetrical anatomic and morphologic structure of the maxilla, facial and lip support,
high lip-line (gummy smile), tooth length,
phonetics, soft tissue management and
economical demand. From the point of view
of implant success, however, it appears that
only milled bar-supported overdentures can
be proposed to patients as a valid alternative
to a fixed full-arch bridge . On the other
hand, maxillary overdentures that are retained by four implants, which are connected with Dolder bar, offer the least expensive solution to resolve the complete edentulism of the upper jaw, and the results of
the present study can be considered quite
satisfying if compared to the results that
have been published to date (Engquist et al.
1988; Jemt 1991; Jemt et al. 1992; Jemt
1993; Hutton et al. 1995; Jemt et al. 1996;
Bergendal & Engquist 1998). This is probably the consequence of three different conditions: the selection of patients, the symmetrical distribution of the implants over
the arch, and the use of TPS and SLAsurfaces, which achieve a stronger bone anchorage
in comparison to smooth and other rough titanium surfaces (Wilke et al. 1990; Buser
et al. 1991, 1998, 1999a; Cochran 1999).
Nevertheless, the overall results for implants that supported restorations in the
fully edentulous maxilla demonstrated that
the cumulative and actual implant success
rates can be significantly influenced by the
type of prosthetic rehabilitation (Tables14
and 17). Indeed, during the study period, a
total of 618 implants were loaded to realize
90 upper prostheses; of these 90 prostheses,
only 16 were Dolder bar overdentures (16/
9017.77%), supported by 64 implants (64/
61810.35%), but six out of 18 implants
that were considered as failures (6/18
33.33%) were found to belong to Dolder
bars (Table14). Similar considerations can
be made for the actual 5-year implant success rates in relation to the different prosthetic rehabilitation techniques. It was revealed that, while only 36 of 218 implants
(36/ 21816.51%) were used to support
maxillary Dolder bar overdentures, four of
the 13 implants that were considered as failures (4/1330.76%) were used to support a
Dolder bar (Table17). From a purely speculative point of view, the direct consequence
of these considerations is that, if a greater
number of Dolder bars had been used in the
present study to rehabilitate the edentulous
upper jaw, the implant success rate in the
maxilla would have been markedly reduced.
In regards to the edentulous mandible,
it can be concluded from this study that
implant-retained overdentures are an established treatment modality with implant
success rates that are very similar to the
results obtained with fixed implant-supported prostheses.
Based on the results of the present multicenter study, it can be concluded that i)
non-submerged ITI implants maintain survival and success rates well above 90% for
a 10-year observation period in edentulous
arches, and ii) non-submerged ITI implants
as anchors for various prosthetic reconstructions in edentulous arches represent a
predictable treatment alternative.
Resume
Dans cette etude multicentrique prospective, des implants ITI non-enfouis ont ete suivis pour evaluer leur
pronostic a` long terme dans des mchoires comple`tement
edentees. Chez 233 patients, 1286 implants ont ete inse-
res. Apre`s une periode de guerison de trois a` six mois,

les implants bien osteontegres ont ete restaures avec 163
prothe`ses amovibles et 95 prothe`ses fixees comple`tes.
Cette etude prospective calcule non seulement les taux
de survie cumulatifs et de succe`s sur dix ans mais egalement evalue les taux de succe`s et de survie presents pour
498 implants apre`s au moins cinq annees de mise en
fonction. De plus, les taux de succe`s cumulatifs ont ete
calcules pour des sous-groupes dimplants divises par longueur dimplant et lieu de placement. Des analyses additionnelles ont ete effectuees pour evaluer les taux de succe`s et de survie estimes et reels des implants en relation
avec les rehabilitations prothetiques variees. Les taux de
survie et de succe`s cumulatifs de dix ans etaient respectivement de 96 et 93%. Les taux de survie et de succe`s
sur cinq ans des 498 premiers implants inseres etaient
respectivement de 98 et 95%. Lanalyse des sous-groupes
dimplants a montre des taux de succe`s cumulatifs un
peu plus favorables pour les implants de 12 mm de longueur (93%) compares a` ceux de 8 et 10 mm (respectivement 92 et 90%) et des taux de succe`s cumulatifs plus
importants pour les implants mandibulaires (94%) que
pour les maxillaires (91%). Les patients avec des prothe`ses superieures et inferieures maintenaient des taux de
succe`s bien superieurs a` 90%; seul les implants inseres
aux prothe`ses maxillaires retenues par des barres de Dolder affichaient un taux de succe`s sous les 90%.
Zusammenfassung
In dieser an mehreren Zentren durchgefhrten Langzeitstudie, wurden transmukse ITI-Implantate nachuntersucht, um ihre Langzeitprognose in zahnlosen Kiefern zu
bestimmen. Bei total 223 Patienten wurden fortlaufend
1286 Implantate eingesetzt, und nach einer Heilphase von
3 bis 6 Monaten die erfolgreich integrierten Implantate mit
163 Hybridprothesen und 95 totalen Brcken versorgt.
Diese prospektive Studie berechnete nicht nur die kumulative 10-Jahresberlebensrate und Erfolgsrate fr 1286 Implantate mit einer berlebenstabellenanalyse, sondern untersuchte auch die aktuelle berlebens- und Erfolgsrate fr
498 Implantate mindestens fnf Jahre nach der funktionellen Belastung. Zustzlich wurden auch die Erfolgsraten fr
Implantatuntergruppen mit Kriterien wie Implantatlnge
oder Implantatlokalisation berechnet. Man unternahm
auch Analysen, um die aktuelle berlebens- und Erfolgsrate der Implantate in Abhngigkeit der verschiedenen prothetischen Rekonstruktionen zu bestimmen. Die 10-jhrige kumulative berlebens- und Erfolgsrate lag bei 95.9%
beziehungsweise 92.7%. Die aktuelle 5-jhrige berlebens- und Erfolgsrate der ersten 498 eingesetzten Implantate betrug 97.7% beziehungsweise 95.0%. Die Analyse
von Untergruppen der Implantate zeigte eine leicht gnstigere kumulative Erfolgsrate fr die 12 mm langen Implantate (93%) verglichen mit den 10 mm und 8 mm langen
Implantaten (91.6% beziehungsweise 89.6%). Im Weiteren
zeigte sich eine leicht bessere kumulative Erfolgsrate fr
die Unterkieferimplantate (91%). Patienten, die sowohl
Ober- wie Unterkieferprothesen erhalten hatten, zeigten
evaluar su pronostico a largo plazo en mandibulas totalmente edentulas. Se insertaron consecutivamente 1286
implantes en 233 pacientes y tras un periodo de cicatrizacion entre 3 y 6 meses los implantes integrados con exito
se restauraron con 163 sobredentaduras y 95 puentes de
arco completo. Este estudio prospectivo no solo calculo
los ndices acumulativos de aupervivencia y de exito de
10 anos para 1286 implantes por medio de un analisis de
tabla de vida, si no que tambien evaluo los indices actuales de supervivencia y de exito para 498 implantes tras 5
anos de carga functional. Ademas tambien se calcularon
los ndices acumulativos de exito para subgrupos de implantes divididos por longitud de implants situacion del
implante. Se Ilevaron a cabo analisis adicionales para evaluar los ndices actuales de supervivencia y de exito estimados de los implantes en relacion con las diferentes rehabilitaciones prosteticas. Los indices acumulativos de
supervivencia y de exito de 10 anos fueron del 95.9% y
92.7% respectivamente. Los ndices actuales de supervivencia y de exito de 5 anos de los primeros 498 implantes
insertados fue del 97.7% y 95.0% respectivamente. El
analisis de los subgupos de implantes mostro unos ndices acumulativos de exito ligeramente mas favorable para
los implantes de 12 mm de longitud (93%) comparados
con los implantes 10 mm y 8 mm de longitud (91.6% y
89.6%, respectivamente) y unos ndices acumulativos de
exito bastante mas favorables para los implantes mandibulares (94%) cuando se compararon con los implantes
maxilares (91%). Los pacientes con protesis maxilares
y mandibulares mantuvieron unos ndicesde exito bien
por encima del 90%; solo los implantes insertados para
soportar sobredentaduras maxilares retenidas por barras
Dolder, mostraron un ndice de exito por debajo del 90%.
Erfolgsraten von weit ber 90%; einzig die Implantate, die

mit dem Zweck gesetzt worden waren, eine Oberkieferhybridprothesen mit Doldersteg zu fixieren, zeigten eine Erfolgsrate von unter 90%.
Resumen
En el presente estudio multicentrico prospectivo se realizo un seguimiento de implantes ITI no sumergidos para
271 |
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Nicola Ferrigno

A long-term follow-up study of nonsubmerged ITI implants in the

Accepted 31 May 2001

Ferrigno N, Laureti M, Fanali S, Grippaudo G. A

One of the most ambitious goals in the

Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws

The life table analysis of Cutler & Ederer

Material and methods

HIV; and (14) mucosal disease, such as lichen planus.

Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273

Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws

Table 1. Prosthetic rehabilitation projects that were proposed to 233 patients

Table 5. Implant lengths

Full-arch bridge (8 implants)

Milled bar (6 implants)

Dolder bar (4 implants)

Ball anchors (2 implants)

6mm 8mm 10mm 12mm Total

Table 2. Distribution of implants

Table 3. Localization of 1286 inserted implants (WHO)

tures with ball anchors were only used for

(HS), iii) standard solid-screw implants

Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273

Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws

Table 6. Classification of implant recipient sites

(sufficient bone, sufficient keratinized mucosa)

(sufficient bone keratinized mucosa graft)

(sinus floor augmentation implant position, osteotome technique, 1-step procedure)

(sinus floor augmentation implant position, window technique, 1-step procedure)

(sinus floor augmentation, no implant, 2-step procedure)

(staged approach of GBR)

GBR, guided bone regeneration

resorbable membranes. Of these, 48 were

months for all implants that were inserted

After surgery, all patients received i) oral

Follow-up visits were scheduled for

During the first half of the study period, a

(Mombelli et al. 1987; Buser et al. 1990a;

Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273

Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws

Table 7. Criteria of success

Life table analysis

Absence of persistent subjective complaints,

Absence of a recurrent peri-implant infection

Absence of a continuous radiolucency around

Table 8a. Results for 1282 implants during the

MPI, modified plaque index; mBI, modified bleeding

Table 8b. Implant classification at each annual

Successful implant according to the criteria of

The statistical analysis was based on the

Criteria of success and implant classification

removed; these implants were classified as

During the follow-up period, eight patients

Table 9. Prosthetic rehabilitations performed on 1282 implants

Full-arch bridge (8 implants)

Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273

Ferrigno et al . Non-submerged ITI implants in totally edentulous jaws

Table 10. Failures during the healing and follow up periods

Life table analysis of 1286 implants

When the life table analysis was correlated

Analysis of various implant locations

This analysis was performed (utilizing the

Clin. Oral Impl. Res. , Clinical Oral Implants Research / 260273