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Immediate Nonfunctional Loading of Two Different Nobel Biocare Implant Designs

Permanent Link: http://ufdc.ufl.edu/UFE0022160/00001

Material Information

Title: Immediate Nonfunctional Loading of Two Different Nobel Biocare Implant Designs
Physical Description: 1 online resource (89 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cases, dental, immediate, implants, load, nobel
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The general objective of this study is to compare two different Nobel Biocare dental implant systems. The primary objective is to compare success rate and marginal bone loss between the two systems. The secondary objective is the evaluation of soft tissue healing and papilla height in both systems. The last objective is to provide a case series for 9 cases and their follow-ups for up to 6 months. Nine patients were randomized according to the company to receive either the Nobel Replace select tapered (control) or the Nobel Replace Tapered Groovy (test). Specific inclusion and exclusion selection criteria were followed. The implants were placed surgically, temporized with a crown and followed up according to the company's protocol. The patients were followed up at 3 months and 6 months. At 4 months, the final crowns were placed. Clinical photographs and x-rays were collected at all these appointments. The results of the cases collected were variable. The majority of the implants examined at 6 months survived. A couple of implants failed due to instability and mobility and had to be excluded from the study. General considerations and some surgical input are presented in the conclusion based on the experience gained from participation in the research.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Aukhil, Ikramuddin.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022160:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022160/00001

Material Information

Title: Immediate Nonfunctional Loading of Two Different Nobel Biocare Implant Designs
Physical Description: 1 online resource (89 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: cases, dental, immediate, implants, load, nobel
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The general objective of this study is to compare two different Nobel Biocare dental implant systems. The primary objective is to compare success rate and marginal bone loss between the two systems. The secondary objective is the evaluation of soft tissue healing and papilla height in both systems. The last objective is to provide a case series for 9 cases and their follow-ups for up to 6 months. Nine patients were randomized according to the company to receive either the Nobel Replace select tapered (control) or the Nobel Replace Tapered Groovy (test). Specific inclusion and exclusion selection criteria were followed. The implants were placed surgically, temporized with a crown and followed up according to the company's protocol. The patients were followed up at 3 months and 6 months. At 4 months, the final crowns were placed. Clinical photographs and x-rays were collected at all these appointments. The results of the cases collected were variable. The majority of the implants examined at 6 months survived. A couple of implants failed due to instability and mobility and had to be excluded from the study. General considerations and some surgical input are presented in the conclusion based on the experience gained from participation in the research.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Aukhil, Ikramuddin.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022160:00001


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IMMEDIATE NONFUNCTIONAL LOADI NG OF TWO DIFFERENT NOBEL BIOCARE IMPLANT DESIGNS By RANA KHAJAH A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008 1

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TABLE OF CONTENTS Page LIST OF TABLES ...........................................................................................................................6LIST OF FIGURES .........................................................................................................................7ABSTRACT ...................................................................................................................... .............10 CHAPTER 1 HISTORY OF BRNEMARK DE NTAL IMPLANT SYSTEM ..........................................11Events in 1950s and 1960s .....................................................................................................11Events in the 1970s ........................................................................................................... ......12Events in the 1980s ........................................................................................................... ......12Events in the 1990s ........................................................................................................... ......131992 .................................................................................................................................131996 to 1998 ....................................................................................................................131997 .................................................................................................................................131999 .................................................................................................................................14Events in 2000 ........................................................................................................................14Events in 2000 to 2002 ...........................................................................................................15Events in 2003 ........................................................................................................................15Events in 2004 ........................................................................................................................16Events in 2005 ........................................................................................................................16Events in 2006 ........................................................................................................................162 IMMEDIATE LOAD BACKGROUND ................................................................................17Traditional Delayed Loading ..................................................................................................1 7Immediate Load Definitions ...................................................................................................1 7Immediate Load of Mandibular Full Edentulous Cases .........................................................17Immediate Load of Maxilla Full Edentulous Cases ...............................................................18Immediate Load of Single-Implant Cases ..............................................................................19Osseointegration (Bone to implant contact =BIC) in Immediate Load Implants ....................19Soft Tissue Attachment in Immediate Load Implants ............................................................20Immediate Load Success Factors ............................................................................................20Occlusal Load Control .....................................................................................................20Primary Implant Stability ................................................................................................21Implant Surface Area and Design ....................................................................................22 2

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3 STUDY OBJECTIVES, MATERIALS, AND METHODS ...................................................23General Study Objectives ...................................................................................................... .23Materials and Methods ...........................................................................................................23Success and Failure Criteria .................................................................................................. .23Subjects ...................................................................................................................... .............24Eligibility ................................................................................................................... ......25Inclusion Criteria .............................................................................................................25Exclusion Criteria ............................................................................................................25Components .................................................................................................................... ........26Sequence of Treatment ......................................................................................................... ..26Pretreatment Examination ...............................................................................................26Implant Insertion ............................................................................................................. 26Follow-ups .................................................................................................................... ...27Registrations ................................................................................................................. ..........27Clinical Registrations ......................................................................................................27Adverse Events ................................................................................................................27Radiographic Examination .....................................................................................................2 84 RESULTS ....................................................................................................................... ........32Case Number 1 .......................................................................................................................32Demographic ................................................................................................................... 32Medical History ...............................................................................................................32Intraoral Examination ......................................................................................................32Preoperative Diagnostic Workup ....................................................................................33Surgical Implant Placement .............................................................................................33Temporary Prosthesis Fabrication ...................................................................................33Postoperative Instructions and Medications ....................................................................34Two-Week Follow-up Visit .............................................................................................34Three-Month Follow-up Visit .........................................................................................34Final Prosthesis Delivery .................................................................................................35Six-Month Follow-up Visit .............................................................................................35Case Number 2 .......................................................................................................................35Demographics .................................................................................................................. 35Medical History ...............................................................................................................35Intraoral Examination ......................................................................................................35Preoperative Diagnostic Workup ....................................................................................36Surgical Implant Placement .............................................................................................36Temporary Prosthesis Fabrication ...................................................................................36Postoperative Instructions and Medications ....................................................................37Two-Week Follow-up Visit .............................................................................................37Three-Month Follow-up Visit .........................................................................................37Permanent Prosthesis Delivery ........................................................................................38Six-Month Follow-up Visit .............................................................................................38Case Number 3 .......................................................................................................................38Demographics .................................................................................................................. 38 3

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Medical History ...............................................................................................................38Intraoral Exam .................................................................................................................38Preoperative Diagnostic Workup ....................................................................................38Surgical Implant Placement .............................................................................................39Temporary Prosthesis Fabrication ...................................................................................39Postoperative Instructions and Medications ....................................................................40Two-Week Follow-up .....................................................................................................40Three-Month Follow-up Visit .........................................................................................40Final Prosthesis Delivery .................................................................................................40Six-Month Follow-up ......................................................................................................41Case Number 4 .......................................................................................................................41Demographics .................................................................................................................. 41Medical History ...............................................................................................................41Intraoral Exam .................................................................................................................41Preoperative Diagnostic Workup ....................................................................................41Surgical Implant Placement .............................................................................................42Temporary Prosthesis Fabrication ...................................................................................42Postoperative Instructions and Medications ....................................................................43Two-Week Follow-up Visit .............................................................................................43Three-Month Follow-up Visit .........................................................................................43Final Prosthesis Delivery .................................................................................................44Six-Month Follow-up Visit .............................................................................................44Case Number 5 .......................................................................................................................44Demographics .................................................................................................................. 44Medical History ...............................................................................................................44Intraoral Exam .................................................................................................................44Preoperative Diagnostic Workup ....................................................................................45Surgical Implant Placement .............................................................................................45Temporary Prosthesis Fabrication ...................................................................................45Postoperative Instructions and Medications ....................................................................46Two-Week Follow-up Visit .............................................................................................46Three-Month Follow-up Visit .........................................................................................46Final Prosthesis Delivery .................................................................................................47Six-Month Follow-up Visit .............................................................................................47Case Number 6 .......................................................................................................................47Demographics .................................................................................................................. 47Medical History ...............................................................................................................47Intraoral Exam .................................................................................................................47Preoperative Diagnostic Workup ....................................................................................48Surgical Implant Placement .............................................................................................48Temporary Prosthesis Fabrication ...................................................................................48Postoperative Instructions and Medications ....................................................................49Two-Week Follow-up Visit .............................................................................................49Three-Month Follow-up Visit .........................................................................................49Final Prosthesis Delivery .................................................................................................50Six-Month Follow-up Visit .............................................................................................50 4

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Case Number 7 .......................................................................................................................50Demographics .................................................................................................................. 50Medical History ...............................................................................................................50Intraoral Exam .................................................................................................................50Preoperative Diagnostic Workup ....................................................................................51Surgical Implant Placement .............................................................................................51Temporary Prosthesis Fabrication ...................................................................................51Postoperative Instructio n and Medications .....................................................................52Two-Week Follow-up Visit .............................................................................................52Three-Month Follow-up Visit .........................................................................................52Final Prosthesis Delivery .................................................................................................53Six-Month Follow-up Visit .............................................................................................53Case Number 8 .......................................................................................................................53Demographics .................................................................................................................. 53Medical History ...............................................................................................................53Intraoral Exam .................................................................................................................54Preoperative Diagnostic Workup ....................................................................................54Surgical Implant Placement .............................................................................................54Temporary Prosthesis Fabrication ...................................................................................55Postoperative Instructions and Medications ....................................................................55Two-Week Follow-up Visit .............................................................................................55Three-Month Follow-up Visit .........................................................................................55Case Number 9 .......................................................................................................................56Demographics .................................................................................................................. 56Medical History ...............................................................................................................56Intraoral Exam .................................................................................................................56Preoperative Diagnostic Workup ....................................................................................56Surgical Implant Placement .............................................................................................56Temporary Prosthesis Delivery .......................................................................................57Postoperative Instructions and Medications ....................................................................57Two-Week Follow-up Visit .............................................................................................57Three-Month Follow-up Visit .........................................................................................58Final Prosthesis Delivery .................................................................................................585 DISCUSSION .................................................................................................................... .....796 CONCLUSION .................................................................................................................... ...81LIST OF REFERENCES ...............................................................................................................82BIOGRAPHICAL SKETCH .........................................................................................................89 5

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LIST OF TABLES Table page 3-1 Sequence of treatment and data colle cted at different time intervals ................................. 293-2 Detailed description of cl assification, clinical observation, and surgical assessment ........ 30 6

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LIST OF FIGURES Figure page 4-1 Case #1, implant placement................................................................................................ 594-2 Case #1, implant placement................................................................................................ 594-3 Case #1, 3-month follow-up ............................................................................................... 594-4 Case #1, 3-month follow-up ............................................................................................... 604-5 Case #1, 6-month follow-up ............................................................................................... 604-6 Case #1, 6-month follow-up ............................................................................................... 604-7 Case #2, implant placement................................................................................................ 614-8 Case #2, implant placement................................................................................................ 614-9 Case #2, implant placement................................................................................................ 614-10 Case #2, implant placement................................................................................................ 624-11 Case #2, 3-month follow-up ............................................................................................... 624-12 Case #2, 3-month follow-up ............................................................................................... 624-13 Case #2, 3-month follow-up ............................................................................................... 634-14 Case #2, 3-month follow-up ............................................................................................... 634-15 Case #2, 6-month follow-up ............................................................................................... 634-16 Case #2, 6-month follow-up ............................................................................................... 644-17 Case #2, 6-month follow-up ............................................................................................... 644-18 Case #2, 6-month follow-up ............................................................................................... 644-19 Case #3, implant placement................................................................................................ 654-20 Case #3, implant placement................................................................................................ 654-21 Case #3, 3-month follow-up ............................................................................................... 654-22 Case #3, 3-month follow-up ............................................................................................... 664-23 Case #3, 6-month follow-up ............................................................................................... 66 7

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4-24 Case #3, 6-month follow-up ............................................................................................... 664-25 Case #4, implant placement................................................................................................ 674-26 Case #4, implant placement................................................................................................ 674-27 Case #4, 3-month follow-up ............................................................................................... 674-28 Case #4, 3-month follow-up ............................................................................................... 684-29 Case #4, 6-month follow-up ............................................................................................... 684-30 Case #4, 6-month follow-up ............................................................................................... 684-31 Case #5, implant placement................................................................................................ 694-32 Case #5, implant placement................................................................................................ 694-33 Case #5, 3-month follow-up ............................................................................................... 694-34 Case #5, 6-month follow-up ............................................................................................... 704-35 Case #5, 6-month follow-up ............................................................................................... 704-36 Case #6, implant placement................................................................................................ 704-37 Case #6, implant placement................................................................................................ 714-38 Case #6, 3-month follow-up ............................................................................................... 714-39 Case #6, 3-month follow-up ............................................................................................... 714-40 Case #6, 6-month follow-up ............................................................................................... 724-41 Case #6, 6-month follow-up ............................................................................................... 724-42 Case #7, implant placement................................................................................................ 724-43 Case #7, implant placement................................................................................................ 734-44 Case #7, implant placement................................................................................................ 734-45 Case #7, implant placement................................................................................................ 734-46 Case #7, 3-month follow-up ............................................................................................... 744-47 Case #7, 3-month follow-up ............................................................................................... 744-48 Case #7, 3-month follow-up ............................................................................................... 74 8

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4-49 Case #7, 3-month follow-up ............................................................................................... 754-50 Case #7, 6-month follow-up ............................................................................................... 754-51 Case #7, 6-month follow-up ............................................................................................... 754-52 Case #8, implant placement................................................................................................ 764-53 Case #8, implant placement................................................................................................ 764-54 Case #8, implant placement................................................................................................ 764-55 Case #8, implant placement................................................................................................ 774-56 Case #9, implant placement................................................................................................ 774-57 Case #9, implant placement................................................................................................ 774-58 Case #9, 3-month follow-up ............................................................................................... 784-59 Case #9, 3-month follow-up ............................................................................................... 78 9

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10 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science IMMEDIATE NONFUNCTIONAL LOADI NG OF TWO DIFFERENT NOBEL BIOCARE IMPLANT DESIGNS By Rana Khajah May 2008 Chair: Ikramuddin Aukhil Major: Dental Sciences The general objective of this study is to co mpare two different Nobel Biocare dental implant systems. The primary objective is to compare success rate and marginal bone loss between the two systems. The secondary objective is the evaluation of soft tissue healing and papilla height in both systems. Th e last objective is to provide a case series for 9 cases and their follow-ups for up to 6 months. Nine patients were randomized according to the company to receive either the Nobel Replace select tapered (control) or the Nobel Replace Tapered Groovy (test). Specific inclusion and exclusion selection criteria were followed. The implants were placed surgically, temporized with a crow n and followed up according to the companys protocol. The patients were followed up at 3 mont hs and 6 months. At 4 m onths, the final crowns were placed. Clinical photographs and x-rays were collected at all these appointments. The results of the cases collected were variable. The majority of the implants examined at 6 months survived. A couple of implants failed due to inst ability and mobility and had to be excluded from the study. General considerations and some surgi cal input are presented in the conclusion based on the experience gained from participation in the research.

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CHAPTER 1 HISTORY OF BRNEMARK DENTAL IMPLANT SYSTEM Events in 1950s and 1960s In the 1950s research was conducted at Camb ridge University in England to study bone blood flow in vivo.1,2 These workers devised a method of c onstructing a chamber of titanium that was then embedded into the soft tissue of th e ears of rabbits. In 1952 the Swedish orthopedic surgeon, P. I. Brnemark, was interested in studying bone healing, so he adopted the Cambridge designed rabbit ear chamber to stu dy blood flow in the rabbit femur bone.3,4 Following several months of study, Brnemarks technician, Victor Kiukka, attempted to retrieve these chambers from the sacrificed rabbits and found that he was unable to remove them. The implants were anchored to the bone. Dr Brnemark observed th at bone had grown into such close proximity with the titanium that it effectively adhered to the metal, and he called the phenomenon osseointegration. Osseointegration was defined by Brnemark as a direct structural and functional connection between ordered, living bone and the surface of a load carrying implant.5,2 Brnemark carried out many further studies into this phenomenon, using both animal and human subjects, which all confirmed this unique property of titanium. The osseoinegration was shown to be predictable and did not cause any soft tissue inflammation or fibrous encapsualtion.6,5,7 Although he had originally considered that the first work should centre on knee and hip surgery, Brnemark finally decided that due to the high rate of edentulous patients in the general Swedish population, the mouth wa s the area more accessible and in need for continued clinical observations.5,1,2 In 1965 Brnemark placed the first titanium dental implants into a human volunteer who was a Swede named Gsta Larsson.1 11

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Events in the 1970s Over the next 14 years, Brnemark and his co workers published the first studies on the use of titanium in dental implantology. 5 As a result, in 1978, the placem ent of implants and their restorations was approved for clinical use by the Swedish health authorities.1 During the same year, 1978 Brnemark, entered into a commercial pa rtnership with the Swedish defense company, Bofors AB, for the development and marketing of his dental implants.1 With Bofors as the parent company, Nobe lpharma AB (later to be renamed Nobel Biocare-1996) was founded in 1981 to focus on dental implantology. A new parent company Nobel Biocare Holdi ng AG, with the head office in Zurich, Switzerland, was founded in 2000. Nobel Biocare has a world market share of approximately 35 percent for dental implants. The first commercial implants to be sold were called Biotes, but these were renamed to reflect the inventor. The initial implants design had machined titanium surface, threaded pitch and external hex joint to the abutment. Events in the 1980s A great moment follows for Brnemark: he makes an internati onal breakthrough in 1982 by presenting his results at an international congress in Toront o (Canada). One year later, 1983, Matts Andersson invents and develops the Proc era method for the high-precision, repeatable production of crowns. Procera is a CAD-CAM system that allows producing crowns with high strengths approaching th ose of a PFM, yet provide the esthetics of all-ceramic restorations. In 1988, the Procera method is ready for global introduction, with full training and support programs. 12

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Events in the 1990s 1992 The original Brnemark standard implant design was replaced with MKII, MKIII,MKIV. The MKII is a self-tappi ng, straight-walled, and machined su rface root form implant. The MKII was launched in 1992. In a 5-year prospective study in 1997, Friberg et al. revealed an equivalent success rate of the standard and the MKII Brnemark designs.8 The third generation of the MK system, the MKIII, is a self-ta pping, straight-walled, machined surface, and root form with a modified internal star grip. In 2003,Widmark et al. evaluated MKIII design for one year and conclude d that it had a high success rate of 97% to 100% and the internal grip mechanism was effective too.9 The MK IV system is a tapered, machined surface with double he lix, and self-tapping implant. The implant was launched for use in so ft bone. In 2003, Friberg et al. evaluated the MKIV in a one-year follow up.10 Friberg et al. found in that st udy that the system needed more torque for insertion and that the primary stability was higher than that of the standard Brnemark implants.10 1996 to 1998 Nobelpharma is renamed Nobel Biocare in 1996. In 1998, after the takeover of the American company SteriOss, Nobe l Biocare renamed their implants to Replace Select. At that time, Nobel Biocare becomes the undisputed leader in the field of implants and reconstructive dentistry. 1997 The Nobel Biocare implant system, Replace Select, was introduced in 1997. The Replace Select fixture can either be straight or tapered and the system is available in two surface treatments HA and TiUnite. The system has been e ffectively used in healed or fresh extraction 13

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sites and in immediate load cases. In a well de signed study by Kan et al. in 2003, a 12-month follow-up on Replace Select Tapered implants (T iUnite) was conducted. The results of the immediate implant placement and immediat e provisionalization included high patient satisfaction, minimal proximal bone loss (.2 mm-. 6 mm), and minimal proximal tissue height loss (.39mm-.8 mm). (11) In a 36-month followup study on Replace Select Tapered implants (HA coated), the mean marginal bone loss was up to 1mm and the osseointegration was successful in 100% of the implants.12 1999 In the end of this decade Brnemark and coworkers presented a new concept called teeth in a day. This technique utilizes prefabricated, stan dardized components allo wing the entire implant treatment to be finished in one working day. Nobel Biocare presented the concept as Nobel Novum and Brnemark et al. presente d the first results in a report 1999.13,14,15,16 Events in 2000 During the nineties most of the implant companies on the market offered implants with an enlarged treated surfac e. Nobel Biocare responded to this new customer demand with the newly introduced Replace Select system. After extens ive research, the new surface treatment that enhanced the Nobel Biocare implant system, TiUn ite, was available in the market in the year 2000. This surface treatment, with the increased layer of titanium oxide, a llowed practitioners to have the option of using Brnemark MKIII and MK IV in either a machined or TiUnite surface. The higher initial implant stability that can be achieved with the use of MK III (TiUnite) and MK IV (TiUnite) allowed some c linicians to use them in immedi ate loading situations with a success range of 97.1% to 100%.17,18 14

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Events in 2000 to 2002 In the year of 2000 to 2002, the immediate functi on and load of implants started increasing as a response to the new line of implants in the market. The concept of teet h in an hour has been employed too. Teeth in an hour is a presurgical tr eatment protocol planning utilizing a computer generated soft ware that will evaluate a patient CT scan, generate a surgical stent, and fabricate the final restoration too. Multiple investigator s examined that concept and used it in the rehabilitation of edentulous cases of the maxilla or the mandible.15,16,19 Events in 2003 In 2003, Nobel Perfect design was presented. This system provides the esthetic option of a scalloped design. Nobel Perfect pr ovides an esthetic crown and gingival tissue contour because the scallop is claimed to maintain proximal bone height. In one study, Mcal lister et al. found that the one piece Nobel Perfect implan t maintained higher proximal ti ssue height than the two piece implant of the same design.20 With both oneand two-piece Nobel Perfect, the papilla height according to the Jemt classification was 3 in 78% to 89% and 2 in 11% to 22%.20 They concluded from that study that th e proximal tissue height can be pr edictably maintained with this implant system. The Jemt classification for papilla will be discussed in the materials and methods section. Kan et al. completed a 12month follow-up on 31 Nobel Perfect implants placed in healed and extraction sites.21 He found that the soft tissu e height was preserved in a majority of the cases, but the proximal bone heig ht was preserved in only 41% of the implants. Nawzari et al. in 2006 evaluated 17 N obel Perfect implants for 18 months.22 Nawzari et al. found that the proximal bone loss was excessive and greate r than that expected with the flat platform design. 15

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Events in 2004 One year later, In 2004 Nobel Biocare launch ed another line of implants, Nobel Direct. This is a one-piece system that enhances esth etics and allows implant placement into narrow edentulous spaces. Multiple studies evaluated that design for up to 3 years.23,24,25 Those investigators observed high mainte nance of marginal bone and soft tissue height and survival rate of about 97%. This system has been subjecte d of safety concerns since it reportedly causes a greater amount of bone loss than ea rlier types of dental implants Alberktsson et al. observed high failure rate of 10.9% and excessive bone loss to the 5th thread at the one-year evaluation.26 Events in 2005 In 2005, the design of Nobel Replace was introd uced. That system includes the design of the Nobel Replace Tapered Groovy. The TiUnite surface treatment is extended to the implant platform level and it includes additional mini th reads in the grooves to increase stability and decrease cervical bone loss. This line was tested in the following case series in an attempt to compare it to the traditional Replace Select Ta pered Implants in immediate implant loading. Events in 2006 The Teeth in a Day concept has been modified to allow the cl inician to plan and perform implant treatment with guided computerized te chnology. This new concept, Nobel Guide, was presented to the market during the Nobel Biocare World Meeting in Las Vegas 2006. 16

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CHAPTER 2 IMMEDIATE LOAD BACKGROUND Traditional Delayed Loading Traditionally, implant placement protocol repl acing hopeless teeth was divided into three stages (extraction and bone healing, implant healing phase, and finally implant crown restoration). This is a process that is consider ed lengthy, as it may take up to 6 or 7 months before patients can get their final restoration.6 The long approach was i ndicated to avoid implant micromovement that leads to fibrous encapsulation and implant failure.27,28 The terminology of delayed loading was defined by Aparicio as attach ing the prosthesis 3 to 6 months after implant healing.29 The initial healing pe riod of implants for 3 to 6 months is based on Branemark clinical experience (Branemark 1985). Some other studies proved that leaving Branemark implants exposed in a one stage protocol doesnt decrease the success rate.30,31,32 Immediate Load Definitions Immediate loading is defined in a review by Apar icio et al. as attaching the prosthesis to the implant no later than 72 hours after implant placement.29 In the same review, early loading was defined as attaching the prosthesis to the implants earlier than the conventional 3 to 6 months healing period.29 Immediate loading can further be divided into immediate occlusal and immediate nonocclusal loading.29,23 Immediate occlusal loading is accomplished with the implant prosthesis in full inte r-occlusal contacts with the opposing dentition. It should also be noted that during nonocclusal loading implants are still subjected to forces from the tongue, oral musculature, and food. Immediate Load of Mandibular Full Edentulous Cases As a result of predictable success rate in c onventional delayed load of implants placed in the anterior mandible, immediate loading started with the treatment of edentulous mandibles and 17

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reports from several investigat ors proved >90% success rate.34,35,36,37,38,39 Four or five implants were placed in the anterior mandible. The implan ts were splinted and the denture prosthesis is attached to the implants. The occlusal forces we re divided by multiple implants rather than one or two. Some researchers report that using greater number of implants is necessary to allow immediate load on some and leaving the rest for complete healing.37,40 Studies have proven that placing less number of implants is as predictable and may be more favorable than placing a lot of implants.16 In an attempt to simplify and reduce the co st of treatment of edentulous mandibular cases, the Brnemark Novum system was introdu ced. The system requires three implants and necessitate special jaw bone morphology.41 The Brnemark Novum was a complicated system to use; and if one implant is lost, then the pros thetic failure mounted to 15% with unfavorable results.42 This lead to the conclusion that four implants is the minimum number needed for mandibular full edentulous prosthesis. Immediate Load of Maxilla Full Edentulous Cases Immediate occlusal loading in the edentul ous maxilla is also a treatment reported by multiple investigators.17,43,44 The survival rate from the previ ous studies reported survival rate ranges of >90%. One study by Degidi et al. report ed lower implant survival rate for edentulous maxillary cases. The survival rate on the implants followed up for 7 years was 83.3%.45 The majority of studies report the need for a high number of implants to treat the edentulous maxilla (8 to 12 implants).37,40,46 Other reports indicate the need fo r less number of implants (5 to 8 implants).47,43 The maxillary bone quality is inferior to the mandible.48 Careful surgical techniques by condensing the surrounding bone around the implants can insure obtaining primary stability for immediate loading.44 Also, due to the poor bone quality of the maxilla, some reports indicate the need for rough surface treatme nt to enhance and accalerate bone contact to 18

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the implant.37,43 Still, Houriuchi et al. report high succe ss rate in immediate loaded Branemark machined surface implants in the anterior maxilla.40 The success and ability to immediately load and restore fully edentulous maxillary and mandibular cases encouraged the next step of tr ying to apply that concep t to single and partial edentulous patients. The clini cal part of my thesis involve d immediate nonfunctional load on single or partial ed entulous cases. Immediate Load of Single-Implant Cases A single tooth replacement by dental implant is a predictable and successful procedure over the years when used in a two-stage or one-stage approach.50,51,52 Nowadays, implant treatment can be completed in a short time peri od. Implants can be pl aced immediately after extraction.53 Achieving primary stability during surg ical placement encouraged immediate loading.30,54,55,56,11 The survival rate in immediate loaded single implant cases can range from 90% to 100%.54,55,56,11 A lower survival rate of 81.2% was reported by Ericsson et al.57 Patients do not remain edentulous for a long time any more and this is especially appealing to patients that are missing any of their ante rior teeth. Some of the factors that are essential to ensure success in immediate load will be di scussed and they are critical in single or part ial edentulous situations. Osseointegration (Bone to implant cont act=BIC) in Immediate Load Implants Several animal experimental studies ha ve proven that immediate implant placement results in a similar degree of osseointegration to the traditional staged implants and no fibrous encapsulation was observed.58,59 Degidi et al. and Romanos et al. confirmed these results in humans. Degidi et al. found that immediate loaded implants that were retrieved showed compact bone with less marrow in the mandible than the maxilla.60 Degidi et al. repor ted that the BIC was 60 to 65%. Romanos et al. retrieved immediately placed Ankylos implants in one smoker.61 He 19

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found that the BIC was 45% and that there was mo re bone in the threads on maxillary implants than the mandible. Soft Tissue Attachment in I mmediate Load Implants Several studies have documented a high success rate for immediate single implant restorations that ra nged from 90% to 100%.62,63 We have to determine that success is not achieving osseointegration or survival only. Suc cess should include careful monitoring of the soft tissue maintenance and rec ontouring around immediate prosthesis. Siar et al. reported in a monkey study that the soft tissue dimensions of the transmucosal attach ment is the same for immediate versus delayed load implants evaluated at 3 months.59 Bengazzi and Wennstrm reported that the majority of the soft tissue recession (about .5mm) around implants can be seen at 6 months and is stabilized for the rest of the 2-year follow up.64 Cornellini et al. and Kan et al. reported increased papilla hei ght at 12-month follow up in im mediate temporization versus conventional loading. Papilla sc ores at the 12 month were 2 or 3 according to Jemt classification.65,11 Both authors have also reported high pa tient satisfaction with esthetic results. Immediate Load Success Factors Occlusal Load Control The success of immediate implant loading depe nds partly on controlli ng occlusal factors.29 In the consensus by Aparicio et al., the treatm ent planning included the presence of adequate number of implants to allow load distribution, optimum occlusal stability on the adjacent teeth, reducing the implant occlusal contacts, optimum implant position for direct axial loading and multiple occlusal evaluations after immediate tem porization. Nkene et al. reported in a pig model that there was no difference in BIC in immediate versus delayed load at 4 months. Nkene et al. also found that implants failed when the occlusal forces were not controlled, even though the insertion torque value was 50Ncm.58 Ericsson et al. and Nikellis et al. evaluated the success of 20

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immediate load implants under the presence of fu ll arch occlusal stability with canine guidance or group function, and they report hi gh success rate from 86% to 100%.57,66 Degidi et al., Piatelli et al., and Lorenzoni et al. placed the patients on soft diets and dispensed night guards to overcome the occlusal factors for th e entire length of healing period.67,68 The Degidi and Piatelli group also found a high success rate for both imme diate functional loading (IFL) and immediate nonfunctional load (INFL), but the IFL had sligh tly more failure chances in the posterior mandible and anterior maxilla. Also, it was reported that the lower the number of implants placed in relation to the number of prosthetic units, the higher the chances of failure in the immediate load.67 Calandriello et al. and Glauser et al maintained only light centric contacts on the temporary crowns and eliminated lateral ex cursive contacts to prevent any increase in micromotion.69,17 Primary Implant Stability One of the main factors that may ensure the success of immediate implants is the primary stability of implants to prevent excess micromovement. It is known that the stability of implants is more difficult to achieve in softer than denser bone. Rocci et al. and Glauser et al. reported that when immediate implants are placed in type IV bone more failures should be anticipated.70,71 Implant success dropped to 82% when placed in soft bone.71 Proussaefs et al., Ca landriello et al., and Cannizaro et al. achieved 100% survival rate of immediate implants when they excluded type IV bone in the maxillary premolar and the mandibular posterior regions.12,69,63 Loungo et al. achieved 98% success rate even in soft bone after splinting the implants.72 Different implant stability measures were used by the investigators. To ensure optimum stability, studies including Calndriello et al Glauser et al, and Cornellini et al. used resonance frequency analysis (RFA) value of 58 and more as an indication of primary stability.69,71,62 Resonance frequency analysis is a technique in which a transducer is attached to the implant fixture or the 21

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abutment to measure the implant stability in re lation to the stiffness in the bone and amplifying as the height of bone increases.73 Other investigators including Nikellus et al. (2004) and Kan et al. (2003) used the torque value of 32 Ncm.66,11 Periotest was also us ed by Abboud et al. and Proussaefs et al. to insure a value of <0 for stability.74,12 Periotest is an electronic instrument used originally to measure the c linical stability of teeth and recently used to measure the clinical stability of implants. The peri otest device involves a metal tip with an accelerometer that contacts and strikes the tooth or implants to induce mobility.75,76 All of these tests claim to decrease the chances of fibrous encapsulation by maintaining the micromotion with in the 100 micron to ensure complete osseointegration.27 Implant Surface Area and Design Immediate implant restoration is made possibl e due to the enhancement of implant to bone contact with the use of different implant surface treatments and implant surface topography.77,78 The TiUnite surface of nobel implants enhances primary stability to the surrounding bone more than the machined surface and al low immediate temporary placement.70,17 Rocci et al. reported 10% higher failure rate for immediately loaded machined than treated surface implants.70 Also, the new line of tapered groovy features a sma ller groove in the exis ting grooves. This is anticipated to enhance bone to grow rapidly and along the grooves and allow faster osseointegration. The groove is also expected to improve the retention of the marginal bone crest. The increased retention of bone decreases the annually anticipate bone loss .2 mm (Alberktsson), and thus esp ecially critical for the anterior esthetic region. 22

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CHAPTER 3 STUDY OBJECTIVES, MATERIALS, AND METHODS General Study Objectives The study objectives are as follows: PRIMARY OBJECTIVE: To compare the success rate and marginal bone level around immediately provisionalized Nobel Replace Tapered Groovy implant to Nobel Replace Select Tapered. SECONDARY OBJECTIVE: Evaluation of soft tissue response and papilla height to both implant systems. THIRD OBJECTIVE: Case series presentation of 9 cases and their 6 months follow-ups as the thesis presentation Materials and Methods This is an open controlled and prospectiv e investigation. Random block assignment were performed using a computer generated program a nd provided to the gradua te periodontics at the UF Investigator by Nobel Biocar e. The Investigator registered the patients in which subjects were consecutively included according to the inclusion and exclusion criteria. Nobel Replace Tapered Groovy will be tested. The Replace Select Tapered was used as control. Single stage procedure was used with immediate provisionalization. The subjects included in the following seri es were followed for 6 months after receiving their provisional. Prosthetic re storations and possible drop-outs and withdrawals, as well as possible adverse events, were carefully monito red during the entire investigation period. Success and Failure Criteria The success criterion that is used in this investigation is a modification of the success criteria suggested by van Steenberghe (1997). This investigations success criterion has been determined as follows: 23

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A successful implant is an implant which o Does not cause allergic, toxi c, or gross infectious reactions either locally or systematically. o Offers anchorage to a functional prosthesis. o Does not show any signs of fracture or bending. o Does not show any mobility when indivi dually tested by tapping or rocking with a hand instrument. o Does not show any signs of radiolucency on an intraoral radiogr aph using a paralleling technique strictly perpendicular to the implant-bone interface. A surviving implant is when the implant remains in the jaw and is stable, and when the subjects treatment is functiona lly successful even though all the individual success criteria are not fulfilled. A successful prosthesis is a prosthetic rec onstruction that is stab le and in good function This investigations failure criteria have been determined as follows: A failed implant is an implant that has o been removed, o fractured beyond repair, or o cannot be classified as a su ccessful or surviving implant. Subjects Fifteen subjects were included in the study, but nine subjects are going to be presented in the following case series. All subjects scheduled for implant supported restorations were asked to participate in the investigation in a consecutive order, provided they fulfilled the criteria as stated below. Half of the subjects received the Nobe l Replace Tapered Groovy implant while the rest of the subjects will constitute the control group and receive the Replace Select Tapered. The subjects were assigned to bei ng either test or controls based on the randomization method. Indications studied included single teeth replacements. 24

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Eligibility All subjects were patients of the dental surgeon for whom the surgeon has previously determined that implants are an appropriate choice. Inclusion Criteria The subjects should have a healed osseous arch itecture enough to receiv e an implant with a diameter of at least 3.5mm and a sufficient amount of bone for placing implants with a length of at least 10mm. The subjects as well as the implant site(s) should fulfill the criteria for immediate provisionalization. The implant site(s) should be free from infection and/or extraction remnants. No apical disorder or inflammation at the implant site. Good gingival/periodontal/periapica l status of adjacent teeth. Favorable and stable occlusal relationship. Exclusion Criteria Alcohol or drug abuse as noted in pati ent records or in patient history. Health conditions do not perm it the surgical procedure. Reason to believe that the treatment might ha ve a negative effect on the subjects total situation (psychiatric problems), as noted in patient records or in patient history. The subject is not able to give her/his informed consent to participate. The need of bone augmentation less than 6 mont hs prior to implant installation to obtain a prosthetically correct implantation transversally or if Bio-Oss has been used. However, an augmentation procedure to cover exposed thre ads or interproximal/buccal grafting due to deficient sites is not an exclusion criteria. Any disorders in the planned implant area such as previous tumors, chronic bone disease, or previous irradiation Resorption of residual ridge, devoid of th ree-dimensional bony architecture in interproximal peak. Severe bruxism or other destructive habits. Extraction sites 25

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Ongoing infections, endodontic or periodontal problems in teeth adjacent to the implant. Implant bridges connected to a natural tooth or teeth. Subjects with any uncontrolled systemic c ontraindications to surgery (bisphosphonates). Components The implants will be either Nobel Replace Tapered Groovy or Replace Select Tapered. The Nobel Replace Tapered Groovy implant has a groove on the thread and the collar with TiUnite all the way up and is available in diameter s of 3.5, 4.3, and 5mm with lengths of 10, 13, and 16mm. The Replace Select Tapered has a TiUnite surface ending with a turned collar of 1.5mm and is available in diameters of 3.5, 4.3, a nd 5mm with lengths of 10, 13, and 16mm. All implants had authority clearance (i.e., FDA approval, CE-marking etc.). Sequence of Treatment All subjects scheduled for implant supported rest orations were asked to participate in the investigation in a consecutive order, provided th ey fulfill the inclusion and exclusion criteria. Subject inclusion >implant pl acement, abutment connection, immediate provisionaliz ation >3 month + 2 weeks > 6 + 1 month. Pretreatment Examination Patient data, medical history and pretreatment examination will be recorded for each patient according to the case record form. The case record forms will follow the company guidelines Implant Insertion Preoperative and postoperative medications were performed according to the routines of the clinic. The clinical procedures were performed according to the Nobel Replace Tapered Groovy or the Replace Select Tapered Implant placement manual. A one-stage procedure with immediate provisionalization was used. Thus, the implants were clinically stable as judged by 26

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the clinician and torqued to 35 Ncm and were provisionalized within 24 hours from implant installation. On the day of surgery, temporar y abutments were connected and the patients received a provisional crown/bri dge. The provisional restoration wa s out of occlusal contact. The bone level covered 0.75 mm of the collar on the vertically positio ned implant. Accordingly, the lower half of the collar, having grooves was below the bone crest, while the upper half of the collar was above the bone crest. The patients were provid ed with home-care maintenance instructions and scheduled for postoperative check-ups on an i ndividual basis. The permanent prosthesis was delivered within 4 mo nths after immediate provisionalization. Follow-ups Follow-ups were performed at 3 months + 2 weeks, 6 months + 1 week counted from the day of immediate provisionalization. (i.e., implant insertion). The 3 + 2 weeks follow-up is considered routine follow-up intervals; the 6 + 1-month follow up is for the study purpose. At each visit a clinical evaluation was made and case record form(s) completed and radiographs were taken. Registrations Clinical Registrations The data collected from the pati ents will be illustrated in two ta bles to explain the sequence of treatment and guidelines for clinical assessm ent. Table 3-1 shows th e sequence of treatment and data collected at different time intervals. Table 3-2 lists a deta iled description of classification, clinical observat ion, and surgical assessment. Adverse Events An adverse event is defined as any undesira ble clinical occurrence in a subject whether it is considered to be device related or not. If the a dverse event is regarded as device related it is stated as an adverse device effect. 27

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Radiographic Examination Intra-oral radiographs from the pretreatment examination implant insertion, 3 months + 2 weeks, prosthesis insertion, and 6 + 1 month follow-up visits were taken for evaluation. These radiographs were taken perpendicularly with a long-cone parallel technique and showed the implant/abutment connections, and at l east 2 mm on each side of the implant. 28

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Table 3-1. Sequence of treatment and data collected at different time intervals Pretreatment Implant insertion 3 month follow up 6 month follow up Permanent prosthetic delivery Medical history X Radiographic examinations X X X X Clinical photographs X X X X Flap design X Implant diameter and length X Type of implant site X Planned Implant position X Bone quality and quantity X Implant stability X X X Bone grafting X Soft tissue grafting X Papilla size X X X X Status of peri-implant mucosa X X X X Plaque X X X X 29

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Table 3-2. Detailed description of classificati on, clinical observation, and surgical assessment Medical history: Taken at the examination phase Radiographic examinations: Taken at base line, implant placement, prosthesis placement, 6months and 12 month evaluation Clinical photographs: 1:1 right angle view of surgical site with, if applicable, adjacent teeth in picture. The photographs are to be kept at the clinic. Use digital images. Flap design: The used flap design is described as: 0 = No flap, if the insertion is made in an extraction site without any incisions. 1 = Flap with/without the us e of releasing incisions. 2 = If the incision is made by the use of a punch Implant diameter & length: Diameter 3.5mm, 4.3mm, 5 mm/ length 10,13 mm Type of implant site: Is recorded as: H = Healed site, i.e. healed mucosa or B = Healed sites with bone augm entation > 6 months prior to implant placement. Bone quality & quantity: Quality Type I-IV, Quantitiy of resorption A, B, C, D Implant stability: Stable, not stable Bone grafting: Bone grafting due to deficient sites is noted as yes with stated material, or no Soft tissue grafting: Soft tissue grafting is noted as yes or no Papilla size: An assessment of the soft tissue contour adjacent to the implant is made using the papilla index presented by Jemt Index score 0 No papilla is present, and there is no indication of a curvature of the soft tissu e contour adjacent to the implant restoration. Index score 1 Less than half of the height of the papilla is present. A convex curvature of th e soft tissue contour adjacent to the implant crown and the adjacent tooth is observed. Index score 2 half or more of the height of the papilla is present, but does not extend a ll the way up to contact point between the teeth. The papilla is not completely in harmony with the adjacent papilla between the permanent teeth. Index score 3 The papillae fill up the entire proximal space and are in good harmony with the adjacent papillae. Optimal soft tissue contour. 30

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Table 3-2. Continued. Index score 4 The papillae are hyperpla stic and covers too much of the implant restoration and/or the adjacent tooth. The soft tissue contour is more or less irregular. Status of peri-implant mucosa: The registration is made acco rding to a modi fied version of Le & Silness gingival index. Status of peri-implant mucosa is registered as: 0 = Normal peri-implant mucosa 1 = Bleeding on superficial probing 2 = Discoloration and spontaneous bleeding Plaque: The amount of plaque is register ed bucally and lingually at the implant(s) using a modified version of Silness & Le plaque index. Measurements are registered as: 0 = No visible plaque 1 = Visible plaque 31

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CHAPTER 4 RESULTS The results of the cases will be presented in a case series format. The case series will begin with specific case disc ussion (including: demographics medical history, intra-oral examination, preop diagnostic workup, surgical implant placement, temporary prosthesis fabrication, postop instructions and medications, 2 week follow-up visit, 3 month follow-up visit, final prosthesis delivery, 6-mont h follow-up visit), intraoral photogr aph presentation of that case, periapical x-rays display related to the same case, and finally the cases collected data in a result table. Case Number 1 Demographic A 58-year-old Caucasian female presented for examination to participate in the implant study. The patient is a staff member in the dental school sterilization department at the University of Florida. The patient chief complaint was Im missing a tooth, and I need an implant Medical History The patients medical history was clear for surgery and the patient was not taking any medications. Patient is healthy and had insignificant medical history. Intraoral Examination The patients intraoral exam revealed mi ssing tooth #20 with the presence of opposing tooth #13. Adequate interocclusal space with adequate bone quantity for a regular neck implant was present. 32

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Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were taken. The periapical x-rays were free of anomaly or pathology. Alginate impre ssions were taken for study models fabrication. The patient was requested to sign the IRB a pproved informed consent. According to a randomized preassigned implant type, the patien t received the Replace Select Tapered. The patient was scheduled for su rgical implant placement. Surgical Implant Placement Normal preoperative vital signs were record ed. After local anesthet ic was administered, midcrestal and sulcular incision around the adjace nt tooth was performed. A full thickness flap was reflected. Some buccal plate resorption wa s observed. The ostetomy was prepared with 2.0 mm pilot drill to 6 mm length. A periapical x-ray was taken with a di rection indicator to confirm angulation. Upon drilling, the bone quality was determined to be type IV. The osteotomy was widened with subsequent twis t drills but undersiz ed to allow for bone condensation and to ensure primary stability. Manual implant placement was completed with a torque value of 35-45 Ncm. A polished implant collar was placed about .5 mm to .75 mm into bone. A healing abutment was placed and a final periapical x-ray was ta ken. Single interrupted sutures were placed around the mesial and distal of the implant. 4.0 chromic gut suture was used. Temporary Prosthesis Fabrication The prosthetic procedure was completed on the same surgical day in the Graduate Prosthodontic Clinic. Temporary plastic abutment, and premade clear vacuform were used to make the temporary crown using jet acrylic material. The screw retained temporary crown was contoured and polished and reduced occlusally about 1-2 mm. The temporary screw was tightened to 15 Ncm. Polyvinyl siloxane impre ssion material was used to cover the occlusal 33

PAGE 34

screw access. Intraoral p hotographs were taken at that time (Figures 4-1 and 4-2). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for her 2-week follow-up. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft to oth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Ibuprofen (600 mg) over the count er for pain control. Two-Week Follow-up Visit The patient returned after 2 weeks for the follow-up. The clinical exam revealed the presence of moderate plaque, but no sign of infection. The patient reported no complaint or problem with the implant. Oral hygiene instru ctions were reinforce d, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3-month followup. The patient reported being satisfied with the implants and had no problems. A periapical x-ray was taken and revealed some proximal bone loss but no sign of failure. In traoral photographs were taken (Figures 4-3 and 4-4). Minimal plaque and bleeding were presen t upon probing. The papilla size was charted and recorded in the result table. The implant was stable with manual testing. The temporary crown taken was off and the impression for the final crown was made usi ng the open tray techniqu e. The temporary crown was screwed back in. 34

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Final Prosthesis Delivery The patient returned at 4 months for the fi nal crown delivery. The permanent prosthetic abutment was torqued in to 32 Ncm and the fi nal crown was cemented with zinc phosphate cement. A periapical x-ray and intraoral photos were taken. Six-Month Follow-up Visit At the 6-month follow-up, the patient reporte d being satisfied with the final crown. The new periapical x-ray sh owed more crestal bone loss but no si gn of failure. Intraoral photographs were taken (Figures 4-5 and 46). No plaque was present an d minimal bleeding was detected upon probing. The Implant was stable when tested manually. The papilla size was charted and recorded in the result table. At this time, the patient is scheduled for her 12-month follow-up visit. Case Number 2 Demographics A 48-year-old Caucasian female presented fo r examination and to participate in the implant study. The patient is a s ecretary at the dental school Or al Surgery department at the University of Florida. The patient chief complain t was I need to get some dental implants Medical History Medical history review revealed borderline diabetes that was c ontrolled by diet and exercise. The patient was allergic to Penicilli n. The patients medical history was clear for surgery. The patient was not taking any medications. Intraoral Examination An intraoral exam revealed missing tooth #12 and #28 with th e presence of opposing teeth. Adequate interocclusal sp ace was present with adequate bone quantity to allow placement of a regular neck implant for both sites. 35

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Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were taken. The periapical x-rays were free of anomaly or pathology. Alginate impression s were taken for fabrication of study models. The patient signed the IRB approved informed c onsent. According to a preassigned randomized implant type, the patient receiv ed the Replace Tapered Groovy implant system. The patient was scheduled for surgical implant placement Surgical Implant Placement Normal preoperative vital si gns were noted, and a local an esthetic was administered. Midcrestal and sulcular incision were done ar ound the adjacent teeth. A full thickness flap reflection was accomplished. Some buccal plate resorption was observed. The osteotomy was prepared with 2.0 mm pilot drill to 6 mm depth. Periapical x-rays were taken with direction indicators to confirm angulati on. Upon drilling, the bone quality was determined to be type III. The osteotomy was widened with subsequent tw ist drills but undersized to allow for bone condensation and to ensure primary stability. Manual implants placement was completed with a torque value of 35-45 Ncm. The implant plat form was placed at the bone level. Healing abutments were placed and periapical x-rays were taken. Two single interrupted sutures were placed around the implants .4.0 chromic gut suture was used. Temporary Prosthesis Fabrication The prosthetic procedure was completed on the same surgical day in the Graduate Prosthodontic Clinic. Temporary plastic abutments and premade clear vacuforms were used to make the temporary crowns using jet acrylic ma terial. The screw retained temporary crowns were contoured, polished, and reduced occlusally about 1-2 mm. The temporary screws were tightened to 15 Ncm. Polyvinyl siloxane impre ssion material was used to cover the occlusal 36

PAGE 37

screw access. Intraoral p hotographs were taken at that time (Figures 4-7, 4-8, 4-9, and 4-10). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for her follow up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft to oth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Clindamy cin antibiotic (300 mg) Qid for 7 days and instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the follo w-up. The clinical exam revealed the presence of moderate plaque but no sign of infection. Th e patient reported no comp laint or problem with the implants. Oral hygiene instruct ions were reinforced, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3-month followup. The patient reported being satisfied with the implants and had no problems. Periapical xrays were taken and revealed some proximal bone loss but no sign of failure. Intraoral photographs were ta ken (Figures 4-11, 4-12, 4-13, and 4-14). Minimal plaque and bleeding was pres ent upon probing. Papilla size was charted and recorded in the results table. The implants we re stable with manual testing. The temporary crowns were taken off and impressions for the final crowns were done using the open tray technique. The temporary crowns were screwed back in. 37

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Permanent Prosthesis Delivery The patient returned at 4 months for fina l crowns delivery. The permanent prosthetic abutments were torqued in to 32 Ncm and the fi nal crowns were cemented with Duralon cement. Periapical x-rays and intraoral photographs were taken. Six-Month Follow-up Visit At the 6-month follow-up, the patient reported being satisfied with the final crowns. The new periapical x-rays showed more crestal bone loss but no sign of failure. Intraoral photographs were taken. Minimal plaque and bleeding was present upon probing. The implants were stable when tested manually. Papilla size was charted and r ecorded in the result table. At this time the patient is scheduled for her 12-month follo w-up (Figures 4-15, 4-16, 4-17, and 4-18). Case Number 3 Demographics A 69-year-old Caucasian male presented for examina tion and to participate in the implant study. The patient is a self-employed. The patient chief complaint was I was told I can get a dental implant to repl ace my missing tooth. Medical History The patients medical history was clear fo r surgery. Patient was taking no medications. Intraoral Exam Intraoral examination revealed missing t ooth #19 with the presence of opposing tooth. Adequate interocclusal space was present with ad equate bone quantity to permit placement of a wide-neck implant. Preoperative Diagnostic Workup Intra-oral digital photographs a nd periapical x-ray were taken. Periapical x-ray was free of anomaly or pathology. Alginate impressions were taken for fa brication of study models. The 38

PAGE 39

patient signed the IRB approved informed c onsent. According to preassigned randomized implant type, the patient rece ived the Replace Tapered Groovy. The patient was scheduled for surgical implant placement. Surgical Implant Placement Normal preoperative vital signs were noted. Local anesthetic was administered. Midcrestal and sulcular incisions were completed around the adjacent teeth. A full thickness flap was reflected. Some buccal plate resorption was obser ved. The osteotomy was prepared with 2.0mm pilot drill to 6mm depth. A periapical x-ray wa s taken with a directi on indicator to confirm angulation. Upon drilling, the bone quality was type I. the osteotomy was widened with subsequent twist drills to the final twist drill. No dense bone dr ills were used to allow for bone condensation and to ensure primary stability. Manual implant placement was completed with a torque value of 35-45 Ncm. The implant platform was placed at the bone level. A healing abutment was placed and a final periapical x-ray was taken. Two mesial and distal single interrupted sutures were placed around the im plant.4.0 chromic gut sutures were used. Temporary Prosthesis Fabrication The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premad e clear vacuform were used to make the temporary crown using jet acrylic material. The screw retained temporary crown was contoured, polished, and reduced occlusally about 1-2 mm. The temporary screw was tightened to 15 Ncm. Polyvinyl siloxane impression material was used to cover the occlusal screw access. An intraoral photograph was taken at that time (Figures 4-19 and 4-20). The procedure was completed for that day. 39

PAGE 40

Postoperative Instructions and Medications The patient was scheduled for her follow-up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft tooth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the fo llow-up. The clinical exam revealed minimal plaque present but no sign of infection. The patie nt reported no complaint or problem with the procedure. Oral hygiene instruct ions were reinforced, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3-month follow-up. The patient report being satisfied with the implants. Also, the patient report that he is constantly cleani ng due to food particles getting trapped between the crown and the two adjacent t eeth. A periapical x-ray was taken and revealed some proximal bone loss but no sign of failure. In traoral photographs were taken (Figures 4-21 and 4-22). No plaque or bleeding was presen t upon probing. Papilla si ze was charted and recorded in the results table. The implant was stable with manual testing. The temporary crown was taken off and impression for the final crow n was done using the open tray technique. The temporary crown was screwed back in. Final Prosthesis Delivery The patient returned at 4 months for the fi nal crown delivery. The permanent prosthetic abutment was torqued in to 32 Ncm and the fi nal crown was cemented with Duralon cement. A periapical x-ray and intr aoral photos were taken. 40

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Six-Month Follow-up Visit At the 6-month follow-up, the patient reporte d being satisfied with the final crown. The new periapical x-ray sh owed more crestal bone loss but no si gn of failure. Intraoral photographs were taken (Figures 4-23 and 4-24). Plaque and bleeding was present upon probing. The implant was stable when tested manually. Papilla size was charted and recorded in the results table. At this time, the patient is scheduled for his 12-month follow-up. Case Number 4 Demographics A 50-year-old Caucasian female presented fo r examination and to participate in the implant study. The patient is a staff member at the VA hospital. The patient chief complaint was I just completed my orthodontic treatment, and Im ready to replace my missing front tooth Medical History Medical history was clear for surgery. The patient was taking no medications. The patient is healthy and had an insignificant medical history. Intraoral Exam Intraoral examination revealed missing tooth #10 with the presence of opposing tooth. The patient had just completed orthodontic treatmen t trying to create enough interproximal space for #10 implant site. Adequate interocclusal space was present and adequate bone quantity to permit placement of a narrow neck implant. Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were taken. The periapical x-rays were free of anomaly or pathology. A widened PDL on the adjacent teeth due to recent orthodontic treatment was observed. Orthodontic consult reve aled that this was a normal presentation and that the minor mobility on the adjacent teeth wa s within normal limits too. Alginate impressions 41

PAGE 42

were taken for study models fabrication. The patie nt signed the IRB approved informed consent. According to a preassigned randomized implant t ype, the patient received the Replace Select Tapered. The patient was scheduled for surgical implant placement. Surgical Implant Placement Normal preoperative vital si gns were noted. Local anesthe tic was administered. Papilla sparing incision was performed. Mesial and dist al releasing incisions were done too to the mucogingival line. Full thickness flap was reflect ed. Some buccal plate resorption was observed. The osteotomy was prepared with 2.0 mm pilot dr ill to 6 mm depth. A periapical x-ray was taken with a direction indicator to confirm angulation. Upon drilling, the bone quality was type II. The osteotomy was widened with subsequent twist drills to the final size drill, and no bone tap was used to allow for bone condensation and ensure primary stability. At the completion of the drilling, minor buccal plate perfor ation was encountered at the apical of the implant. Manual implant placement was completed with a torque value of 35-45 Ncm. Polished implant collar was placed about .5-.75 mm into bone. Nu-oss partic ulate graft material was packed around the perforation and Ace collagen membrane was used to contain the particul ate material. A healing abutment was placed and a final periapical x-ray was taken. Mesial and dist al single interrupted sutures were placed around the implants using 4.0 vicryl sutures. Closure of the mesial and distal release incision was done last. Temporary Prosthesis Fabrication The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premad e clear vacuform were used to make the temporary crown using jet acrylic material. The screw retained temporary crown was contoured, polished and reduced occlusally about 1-2 mm. The temporary crown screw was tightened to 15 Ncm. Polyvinyl siloxane impression material was used to c over the occlusal screw access. 42

PAGE 43

Intraoral photographs were ta ken at that time (Figures 425 and 4-26). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for follow up in 2 w eeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra soft t ooth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days a nd instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the follo w-up. The clinical exam revealed the absence of plaque and no sign of infecti on. The patient reported some discom fort with the apical part of the implant, and the patient was informed that this is due to the grafting that was done at that site and it should decrease over time. The sutures were removed. Oral hygiene instructions were reinforced, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3-month follow-up. The patient report being satisfied with the implants and had no problems. A periapical x -ray was taken and revealed some proximal bone loss but no sign of failure. Intraoral photographs we re taken. No plaque or bleeding was present upon probing. The papilla size was ch arted and recorded in the re sults table. The implant was stable with manual testing. The temporary crow n was taken off and impression for the final crown was completed using the ope n tray technique. The temporar y crown was screwed back in Figures 4-27 and 4-28). 43

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Final Prosthesis Delivery The patient returned at 4 months for the fi nal crown delivery. The permanent prosthetic abutment was torqued in to 32 Ncm. The final crown was cemented with zinc phosphate cement, and a final periapical x-ray was taken. Six-Month Follow-up Visit At the 6-month follow-up, the patient reporte d being satisfied with the final crown. The new periapical x-ray sh owed more crestal bone loss but no si gn of failure. Intraoral photographs were taken (Figures 4-29 and 4-30). No plaque and no bleeding were present upon probing. The implant was stable when tested manually. Papill a size was charted and recorded in the results table. At this time, the patient is scheduled for 12-month follow-up. Case Number 5 Demographics A 50-year-old Caucasian female presented fo r examination and to participate in the implant study. The patient is a housewife. The patient chief complaint was I have been missing my tooth for a while, and I need to get a dental implant Medical History The patients medical history was clear for su rgery. The patient was taking no medications. The patient is healthy and had an insignificant medical history. Intraoral Exam An intraoral examination revealed missing tooth #12 with the presence of opposing removable partial denture. Adequate interocclus al space and adequate bone quantity for a regular neck implant were present. 44

PAGE 45

Preoperative Diagnostic Workup Intraoral digital photographs and periapical x-rays were taken. Periap ical x-rays were free of anomaly or pathology. Algi nate impressions were taken fo r study models fabrication. The patient signed the IRB approved informed consent. According to a preassigned randomized implant type, the patient rece ived the Replace Tapered Groovy. The patient was scheduled for surgical implant placement Surgical Implant Placement The patient returned for implant placement. Normal preoperative vital signs were noted. Local anesthetic was administer ed. Midcrestal and sulcular in cisions were completed around the adjacent teeth. Full thickness flap was reflected. Some buccal plate resorption was observed. The osteotomy was prepared with 2.0 mm pilot drill to 6 mm depth. A periapical x-ray was taken with a direction indicator to confirm angulation. Upon drilling, th e bone quality was type III. The osteotomy was widened with subsequent twis t drills but undersiz ed to allow for bone condensation and to ensure primary implant stab ility. Manual implant placement with a torque value of 35-45 Ncm was obtained. The implant plat form was placed at the bone level. A healing abutment was placed and a final periapical x-ray was taken. Mesial and dist al single interrupted sutures were placed around the implant. A 4.0 vicryl suture was used. Temporary Prosthesis Fabrication The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premade clear vacuform was used to make the temporary crown using jet acrylic material. The screw retained temporary crown was contoured, polished, and reduced occlusally about 1-2 mm. The temporary crown screw was tightened to 15 Ncm. Polyvinyl siloxane im pression material was used to cover the occlusal screw access. 45

PAGE 46

Intra-oral photographs were take n at that time (Figures 4-31 a nd 4-32). The procedure completed for that day. Postoperative Instructions and Medications The patient was scheduled for a follow-up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft to oth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days a nd instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the fo llow-up. The clinical exam revealed minimal plaque present but no sign of infection. The patie nt reported no complaint or problem with the procedure. The sutures were removed. Oral hygiene instructions were rein forced, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3-month followup. The patient reported being satisfied with the implants and had no problems. A periapical x-ray was taken and revealed some proximal bone loss but no sign of failure. In traoral photographs were taken (Figure 4-33). Minimal plaque and bleeding were present upon probing. Papilla size was charted and recorded in the result table. The implant was stable with manual te sting. The temporary crown was taken off and impression for the final crown was done using the open tray technique The temporary crown was screwed back in. 46

PAGE 47

Final Prosthesis Delivery The patient returned at 4 months for the fi nal crown delivery. The permanent prosthetic abutment was torqued in to 32 Ncm and the fina l crown was cemented with Duralon cement and a periapical x-ray was taken. Six-Month Follow-up Visit At the 6-month follow-up, the patient reported being satisfied with the final crown. The periapical x-ray showed more cr estal bone loss but no sign of failu re. Intraoral photographs were taken (Figures 4-34 and 4-35). No plaque and minimal bleeding were present upon probing. The implant was stable when tested manually. Papill a size was charted and recorded in the results table. At that time the patient was scheduled for her 12 month follow-up. Case Number 6 Demographics A 72-year-old Caucasian male presented for examina tion to participate in the implant study. The patient is retired. The patient chief comp laint was I need to get some false teeth, but I dont want a denture. Medical History The patients medical history was clear fo r surgery. The patient was not taking any medications. The patient is healthy and had an insignificant medical history. Intraoral Exam An intraoral examination revealed missing teeth #19 and #20 with the presence of opposing teeth. Adequate interocclusal space was pr esent with adequate bone quantity to permit placement of a regular neck implant in #20 and a wide neck implant in #19. 47

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Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were ta ken. Periapical x -rays were free of anomaly or pathology. Algi nate impressions were taken fo r study models fabrication. The patient signed the IRB approved informed consent. According to a preassigned implant type, the patient received the Replace Select Tapered. The patient was scheduled for surgical implant placement. Surgical Implant Placement Normal preoperative vital signs were not ed. Local anesthetic was administered. Midcrestal and sulcular incisi on around the adjacent teeth was completed. Full thickness flap was reflected. Some buccal plate resorption observed. The osteotomy was prepared with 2.0mm pilot drill to 6mm depth. A periapical x-ray was taken with direction indicators to confirm angulation. Upon drilling, the bone quality was type II. The osteotomy was wi dened with subsequent twist drills to the final size drill, and no dense bone drill was used to allow for bone condensation and ensure primary stability. Manual implant placemen t was completed with a torque value of 3545 Ncm. Polished implant collar was placed a bout .5-.75 mm into bone. Healing abutments were placed and final periapical x-rays were taken. Mesi al and distal single interrupted suture placed around the implant. 4.0 vicryl suture was used. Temporary Prosthesis Fabrication The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutments and premade vacuform were used to make the temporary crowns using jet acrylic material. The screw re tained temporary crown was contoured, polished, reduced occlusally about 1-2 mm, and were splinted. The temporary crown screws were tightened to 15 Ncm. Polyvinyl siloxane impre ssion material was used to cover the occlusal 48

PAGE 49

screw access. Intraoral photogra phs were taken at that time (Figures 4-36 and 4-37). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for a follow up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra soft t ooth brush for tw2o weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3 month healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Ibuprofen (600 mg) over the counter for pain. Two-Week Follow-up Visit The patient returned at 2 weeks for the follo w-up. The clinical exam revealed the absence of plaque and no sign of infection. The sutures were removed. Oral hygiene instructions were reinforced, and the patient stopped using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3 month follow-up. The patient reported being satisfied with the implants and had no problems. The patient reported discomfort with taking the intraoral radiographs due to presence of bilateral lingual exosto sis. The patient was informed that the exostosis will be removed toward the 1-year foll ow-up on the implants to avoid interfering with the implant healing. Periapical x-rays were ta ken and revealed some proximal bone loss but no sign of failure. Intraoral photogra phs were taken. No plaque was detected and minimal bleeding was present upon probing. Papilla size was charte d and recorded in th e results table. The implants were stable with manual testing. Th e temporary crowns were taken off, and an impression for the final crown was done using th e open tray technique. The temporary crowns were screwed back in (Figures 4-38 and 4-39). 49

PAGE 50

Final Prosthesis Delivery The patient returned at 4 months for the fi nal crown delivery. The permanent prosthetic abutment was torqued in to 32 Ncm and the fi nal crown was cemented with Duralon cement. A final periapical x-ray was taken. Six-Month Follow-up Visit At the 6-month follow-up, the patient reporte d being satisfied with the final crown. The new periapical x-ray sh owed more crestal bone loss but no si gn of failure. Intraoral photographs were taken (Figures 4-40 and 4-41). No plaque was detected and minimal bleeding was present upon probing. The implants were stable when tested manually. Papilla size was charted and recorded in the results table. At that time the patient was scheduled for his12-month follow-up. Case Number 7 Demographics A 29year-old Caucasian male presented for examin ation to participate in the implant study. The patient is a martial art trainer. The pa tient reported occasiona l recreational cigarette smoking (1 to 2 cigarettes per day). The patient chief complaint was I need to get some dental implants Medical History Medical history was clear for surgery. Th e patient was not taking any medications. The patient is healthy and had an insignificant medical history. Intraoral Exam Intra-oral examination revealed missing toot h #19 and tooth #30 w ith the presence of opposing teeth. Adequate interocclusal space was pr esent with adequate bone quantity to permit the placement of a regular neck implant on #30 and a wide neck implant on #19. Also, the 50

PAGE 51

intraoral exam revealed minimal jaw opening du e to a previous accident that affected both temporomandibular joints. Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were taken. The periapical x-rays were free of anomaly or pathology. Alginate impression s were taken for study models fabrication. The patient signed the IRB approved informed consen t. According to preassigned implant type, the patient received the Replace Tapered Groovy. The pa tient was scheduled for surgical implant placement Surgical Implant Placement Normal preoperative vital si gns were noted. Local anesth etic was administered. Midcrestal and sulcular incisions were completed around the adjacent teeth. Full thickness flap was reflected. Some buccal plate resorption was observed. The osteotomies was prepared with 2.0 mm pilot drill to 6 mm depth, a nd periapical x-rays were take n with direction indicators to confirm angulation. Upon drilling, the bone quality was type III. The osteotomies were widened with subsequent twist drills bu t undersized to allow for bone condensation and ensure primary stability. Manual implant placement was completed with a torque value of 35-45 Ncm. The implant platform was placed at the bone level. Healing abutments were placed and final periapical x-rays were taken. Mesial and distal single interrup ted suture were placed around the implants.4.0 chromic gut suture was used. Temporary Prosthesis Fabrication The prosthetic procedure was complete d on the same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premade clear vacuform were used to make the temporary crown using Bis-GMA material. The screw reta ined temporary crowns were contoured, polished, and reduced occlusally a bout 1-2 mm. The tempor ary crown screw was 51

PAGE 52

tightened to 15 Ncm. Polyvinyl siloxane impre ssion material was used to cover the occlusal screw access. Intraoral p hotographs were taken at that time (Figures 4-42, 4-23, 4-44, and 4-45). The procedure was completed for that day. Postoperative Instruction and Medications The patient was scheduled for his follow-up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft tooth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the fo llow-up. The clinical exam revealed minimal plaque present, but no sign of infection. The pati ent reported no complaint or problem with the procedure. The patient also reported episode s of eating regular nonsoft diet. Oral hygiene instructions were reinforced a nd the patient was informed that eating regular diet can cause the implant to fail. The patient was requested to stop using the peridex mouth wash. Three-Month Follow-up Visit The patient returned for the 3 month follow-up. The patient report being satisfied with the implants, but he remembered having a sharp pain in #19 implant site for few days. The patient thought that the pain is normal a nd didnt seek an earlier followup. Periapical x-rays were taken and revealed some proximal bone loss on #30 and possible sign of excessive bone loss on #19. Intraoral photographs were taken. No plaque was detected and minima l bleeding was present upon probing. Papilla size was charted and recorded in the results table. Implant #30 was stable with manual testing. The temporary crown was ta ken off on #30, and the impression for the final crown was done using the open tray technique. The temporary crown on #30 was screwed back 52

PAGE 53

in. Implant #19 was painful to manual testing, but not mobile. The #19 implant was deemed not integrated and a healing abutment was placed. Th e #19 implant was left with no occlusal forces for few months to see if that would promote h ealing and better integration. The #19 implant was excluded from the study (Figures 4-46, 4-27, 4-28, and 4-49). Final Prosthesis Delivery The patient returned at 4 months for fina l crown delivery. The permanent prosthetic abutment on #30 was torqued in to 32 Ncm and th e final crown was cemented with Duralon and a final periapical x-ray was taken on #30. Six-Month Follow-up Visit At the 6-month follow-up, the patient reported being satisfied with the final crown on #30. The new periapical x-ray showed more crestal bone loss but no sign of failure. Intraoral photographs were taken (Figures 4-50 and 4-51). No plaque a nd minimal bleeding were present upon probing. The implant was stable when test ed manually. Papilla size was charted and recorded in the result table. At that time, the patient was scheduled for a 12-month follow-up. Case Number 8 Demographics A 70-year-old Caucasian male presented for examin ation to participate in the implant study. The patient is self employed. The patient chief complaint was I need to replace some missing teeth Medical History Medical history was significan t for a heart attack and sten t placed 5 years prior and borderline diabetes that was cont rolled with diet and exercise. The patient was on aspirin 81 mg daily. Medical consult was requested, and the pati ent was cleared for implant surgery from his physician. 53

PAGE 54

Intraoral Exam An intraoral examination revealed missing to oth #8 and #12 with the presence of opposing teeth. Adequate interocclusal space was present with adequate bone quantity to permit placement of regular platform implants on #8, and #12. Preoperative Diagnostic Workup Intraoral digital photog raphs and periapical x-rays were taken. The Periapical x-rays were free of anomaly or pathology. Alginate impression s were taken for study models fabrication. The patient signed the IRB approved informed consent. The patient was scheduled for surgical implant placement on #8 and #12. According to preassigned implant type, the patient received the Replace Tapered Groovy. The patient was sc heduled for surgical implant placement on #8 and #12. Surgical Implant Placement Normal preoperative vital signs were noted. Local anesthetic was administered. Midcrestal and sulcular incisions were completed around the adjacent teeth. A full thickness flap was reflected. Some buccal plate resorption was obser ved. The osteotomy was prepared with 2.0mm pilot drill to 6mm depth and periapical x-rays we re taken with direction indicators to confirm angulation. Upon drilling, the bone qua lity was type III in #8 and type IV in #12. The osteotomy was widened with subsequent tw ist drills but unders ized to allow for bone condensation and ensure primary stability. Manual implant placem ent completed with a torque value of 35-45 Ncm. The implant platform was placed at the bo ne level. Healing abutments were placed and final periapical x-rays were taken. Mesial a nd distal single interrupt ed sutures were placed around the implants; 4.0 chromic gut sutures were used. 54

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Temporary Prosthesis Fabrication The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premad e clear vacuform were used to make the temporary crown using Bis-GMA material. The screw retained temporary crown was contoured, polished and reduced occlusally about 1-2 mm. The temporary crown screw was tightened to 15 Ncm. Polyvinyl siloxane impressi on material was used to cover the occlusal screw access. Intraoral photographs were taken at that time (Fi gures 4-52, 4-53, 4-54, and 4-55). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for a follow-up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra-soft to oth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Tylenol (500 mg) over the counter for pain control. Two-Week Follow-up Visit The patient returned at 2 weeks for the follow-up. The clinical exam revealed heavy plaque present, but no sign of infection. The pati ent reported no complaint or problem with the procedure. The patient also reported episode s of eating regular nonsoft diet. Oral hygiene instructions were reinforced. The patient was informed that eating nonsoft diet can cause the implants to fail. The patient was requeste d to stop using the peridex mouth wash. Three-Month Follow-up Visit The patient missed multiple appointments for su bsequent follow-ups. He developed a heart attack and was requested by his physician not to con tinue any more surgical or dental work that could be stressful. The patient discontinued the study. 55

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Case Number 9 Demographics A 48-year-old Caucasian female presented for examination to participate in the implant study. The patient is self employe d. The patient chief complaint wa s I have some missing teeth for a while and I need to get dental implants Medical History Medical history was clear for surgery. Th e patient was not taking any medications. The patient is healthy and had an insignificant medical history. Intraoral Exam Intraoral examination revealed missing t ooth #3 with the presence of opposing tooth. Adequate interocclusal space was present with adequate bone quantity to allow placement of a regular neck implant. Preoperative Diagnostic Workup Intraoral digital phot ographs and periapical x-rays were taken. The periapical x-ray was free of anomaly or pathology. Alginate impression s were taken for study models fabrication. The patient signed the IRB approved informed consen t. According to preassigned implant type, the patient received the Replace Select Tapered. The patient was scheduled for surgical implant placement. Surgical Implant Placement Normal preoperative vital signs were noted. Local anesthetic was administered. Midcrestal and sulcular incisions around the adjacent teeth were performed. A full thickness flap was reflected. Some buccal plate resorption was obser ved. The osteotomy was prepared with 2.0 mm pilot drill to 6 mm depth. A periapical x-ray wa s taken with a directi on indicator to confirm angulation. Upon drilling, the bone quality was type IV. The osteotomy was widened with 56

PAGE 57

subsequent twist drills but undersized to al low for bone condensation and ensure primary stability. Manual implant placement was completed with a torque value of 35-45 Ncm. The polished implant collar was placed about .50-.75 mm into bone. A h ealing abutment was placed and a final periapical x-ray was taken. Mesial and distal single interrupted sutures were placed around the implant; 4.0 chromic gut sutures were used. Temporary Prosthesis Delivery The prosthetic procedure was completed on th e same day in the Graduate Prosthodontic Clinic. Temporary plastic abutment and premad e clear vacuform were used to make the temporary crown using Bis-GMA material. The screw retained temporary crown was contoured, polished, and reduced occlusally about 1-2 mm. The temporary crown screw was tightened to 15 Ncm. Polyvinyl siloxane impression material was used to c over the occlusal screw access. Intraoral photographs were ta ken at that time (Figures 456 and 4-57). The procedure was completed for that day. Postoperative Instructions and Medications The patient was scheduled for a follow-up in 2 weeks. The patient was instructed to rinse with peridex for 2 weeks, use an extra soft t ooth brush for 2 weeks and to floss gently. The patient was also instructed to st ay on a soft diet for the 3-m onth healing period. The patient was given a prescription for Amoxicillin antibiotic (500 mg) Tid for 7 days and instructed to take Ibuprofen (600 mg) over the c ounter for pain control. Two-Week Follow-up Visit The patient returned at two weeks for the follo w-up. The clinical exam revealed absence of plaque and no sign of infection. Oral hygiene in structions were reinforced, and the patient stopped using the peridex mouth wash. 57

PAGE 58

Three-Month Follow-up Visit The patient returned for the 3-month follow-up. The patient report being satisfied with the implants and had no problems. A periapical x -ray was taken and revealed some proximal bone but no sign of failure. Intraoral photographs were taken (Figures 4-58 and 4-59). No plaque or bleeding was present upon probing. Pa pilla size was charted and reco rded in the results table. The implant was stable with manual testing. Th e temporary crown was taken off and impression for the final crown was done using the open tray technique. The temporary crown was screwed back in. Final Prosthesis Delivery The patient returned at 4 months for fina l crown delivery. The permanent prosthetic abutment could not be torqued in to 32 Ncm due to implant rotation. The implant deemed nonintegrated and a temporary healing abutment was used. The implant would remain without occlusal contacts for few months to determin e if healing improved a nd resulted in better integration. The implant was excluded from the study. 58

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Figure 4-1. Case #1, implant placement Figure 4-2. Case #1, implant placement Figure 4-3. Case #1, 3-month follow-up 59

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Figure 4-4. Case #1, 3-month follow-up Figure 4-5. Case #1, 6-month follow-up Figure 4-6. Case #1, 6-month follow-up 60

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Figure 4-7. Case #2, implant placement Figure 4-8. Case #2, implant placement Figure 4-9. Case #2, implant placement 61

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Figure 4-10. Case #2, implant placement Figure 4-11. Case #2, 3-month follow-up Figure 4-12. Case #2, 3-month follow-up 62

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Figure 4-13. Case #2, 3-month follow-up Figure 4-14. Case #2, 3-month follow-up Figure 4-15. Case #2, 6-month follow-up 63

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Figure 4-16. Case #2, 6-month follow-up Figure 4-17. Case #2, 6-month follow-up Figure 4-18. Case #2, 6-month follow-up 64

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Figure 4-19. Case #3, implant placement Figure 4-20. Case #3, implant placement Figure 4-21. Case #3, 3-month follow-up 65

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Figure 4-22. Case #3, 3-month follow-up Figure 4-23. Case #3, 6-month follow-up Figure 4-24. Case #3, 6-month follow-up 66

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Figure 4-25. Case #4, implant placement Figure 4-26. Case #4, implant placement Figure 4-27. Case #4, 3-month follow-up 67

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Figure 4-28. Case #4, 3-month follow-up Figure 4-29. Case #4, 6-month follow-up Figure 4-30. Case #4, 6-month follow-up 68

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Figure 4-31. Case #5, implant placement Figure 4-32. Case #5, implant placement Figure 4-33. Case #5, 3-month follow-up 69

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Figure 4-34. Case #5, 6-month follow-up Figure 4-35. Case #5, 6-month follow-up Figure 4-36. Case #6, implant placement 70

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Figure 4-37. Case #6, implant placement Figure 4-38. Case #6, 3-month follow-up Figure 4-39. Case #6, 3-month follow-up 71

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Figure 4-40. Case #6, 6-month follow-up Figure 4-41. Case #6, 6-month follow-up Figure 4-42. Case #7, implant placement 72

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Figure 4-43. Case #7, implant placement Figure 4-44. Case #7, implant placement Figure 4-45. Case #7, implant placement 73

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Figure 4-46. Case #7, 3-month follow-up Figure 4-47. Case #7, 3-month follow-up Figure 4-48. Case #7, 3-month follow-up 74

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Figure 4-49. Case #7, 3-month follow-up Figure 4-50. Case #7, 6-month follow-up Figure 4-51. Case #7, 6-month follow-up 75

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Figure 4-52. Case #8, implant placement Figure 4-53. Case #8, implant placement Figure 4-54. Case #8, implant placement 76

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Figure 4-55. Case #8, implant placement Figure 4-56. Case #9, implant placement Figure 4-57. Case #9, implant placement 77

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Figure 4-58. Case #9, 3-month follow-up Figure 4-59. Case #9, 3-month follow-up 78

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CHAPTER 5 DISCUSSION This study is a part of a larger multicentre clin ical trial organized by Nobel Biocare. A total of 15 patients have been recruited and are at various stages of treatment from the University of Florida Center. The nine patients that were presented in the case series received 13 implants. A total of eight tapered groovy and five replace se lect implants were placed. The low number of patients and the short term follow-up of 6 months make it difficult to evaluate the healing of those implants. Nevertheless, the majority of the implants healed uneventfully. In evaluating the success and failure of impl ants using the criteria discussed prior, 11 implants were successful up to the six months evaluation. Two im plants failed in two patients. The failed implants were one test and one control. They both were placed with a 35 Ncm in type IV bone quality. Both implants were moving while removing the temporary crowns during impression making. The patients were feeling pa in when the temporary crowns were being removed. The failure in both cases could be rela ted to inadequate surgical techniques, and not condensing enough apical surrounding bone. The second reason for failure is lower bone density. Type IV bone quality is weak bone and possi bly immediate load on these implants is not favorable due to possible overload that leads to fibrous encapsulation. The third possible reason for failure is non compliant patient with the soft di et protocol. Even if the implants are stable at the surgical placement, there might be excess load with eating hard type food. Some of the other limitations of the study in cluded non-standardized x-rays and intraoral photographs. The nonstandardized technique may lead to inaccurate bone and soft tissue height measures. With those limitations in mind, in ev aluating radiographic bone height and papilla height they seem to be within the normal ranges. Bone loss was to the first thread on the implants in majority of cases for both systems. Papilla f ill was inadequate for both systems. More soft 79

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tissue height increase can be anticipated ove r the next few months. Some crowns were undercontoured and had inadequate interproximal contact height which mi ght have contributed to inadequate papilla fill. To improve study design, there probably should be more control over some variables. The first change will be to sta ndardize xrays and this may allow more accurate bone reading. Standardized xrays should be taken perpendicula r to the implants platform and the bone height should be interpreted by multiple investigators. The second change will be to standardize intraoral photos to allow accurate soft tissue hei ght papilla scoring. The th ird change will be to contour the temporary crowns to allow soft tissue papilla to fill. The temporary crowns should be slightly undercontoure d interproximally. Also the tem porary crowns should maintain interproximal contact to the ad jacent teeth to minimize lateral displacement. The temporary crowns should be completely out of occlusion and not maintain any cusps on them. The fourth variable to control will be a clos e follow-up for those patients on monthly basis for the first four months to ensure patients complia nce with soft diet and with main taining adequate oral hygiene. While the present data is just case seri es, Nobel Biocare would be assembling and analyzing data from all the remaining centers that are participants in this mutlicentre clinical trial. 80

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CHAPTER 6 CONCLUSION The previous nine cases that were presente d are a part of a mu lticenter study supported by Nobel Biocare. The shortcomings of the clinic al part presented as my thesis include the following: The short-term 6-month follow-up on only nine pa tients (5 test, 4 cont rol) does not provide enough data to compare the Replace Select ta pered to the Replace Tapered Groovy design. The materials and method section in the origin al protocol provided by Nobel Biocare did not require standardized x-rays or standard ized intraoral photographs. This results in nonreproducible radiographic bone leve l and soft tissue measurements. The nonstandardized technique makes inac curate the comparison of x-rays and photographs taken at di fferent follow-ups. The conclusions that I can summarize are ba sed on clinical observa tions and not based on any statistical analysis or interpretation: Careful presurgical implant site selection ba sed on available bone volume, and stable opposing occlusion is necessary. This will l ead to optimum implant position, help in directing the occlusal forces axially along the implant, and de crease the load on implants. The patients should be informed about a strict postsurgical soft di et during bone healing. Also, they should receive multiple examinations during bone healing to ensure normal healing. It is critical to perform careful surgical techniques to allow condensing the surrounding bone, to ensure obtaining high initial implant stability, and to allow immediate loading of the implants. 81

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LIST OF REFERENCES 1. Ring M. A thousand years of dental implants: A definitive historyPart 2. Compendium October 1995;16:1132-1139. 2. Branemark PI. Introduction to osseointegra tion. In: Branemark PI, Zarb G, Alberktsson T, eds. Tissue-Integrated Prosthesis: Osseointegration in Clinical Dentistry Chicago: Quintessence; 1985:11-70. 3. Branemark PI, Lindstrom J. A modified ra bbits ear. High power high resolution studies in regenerated and preformed tissues. Anat Rec 1963;145:533-540. 4. Costa O, Branemark PI. Vital microscopicev aluation of the microvessels of the cochlea. Adv. Microcirc 1970;3:96-107. 5. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen O. Osseointegrated implants in the treatment of the edentulous jaw: Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;11:1. 6. Branemark, P.I., Adell, R., Breine, U. Ha nsson, B.O., Lindstrom, J. & Ohlsson, A. Intraosseous anchorage of dental prosthesis. I. Experimental studies. Scand J Plast Reconst Surg 1969;3:81-100. 7. Branemark PI. Osseointegrati on and its experimental background. J Prosthet Dent 1983;50:399-410. 8. Friberg B, Nilson H, Olsson M, Palmquist C. MK II in 1992 self-tapping machined root form implant, MK II: The self-tapping Branem ark implant: 5-year results of a prospective 3center study. Clin Oral Implant Res 1997;8(4):279-285. 9. Widmark G, Friberg B, Johansson B, Sindet-Pedersen S, Taylor A. 1999 MK III selftapping machined root form and star grip inte rnal design/MKIII: A third generation of the self tapping Branemark System implant, incl uding the new Stargrip internal design. A 1-year prospective four-center study. Clin Oral Dent Relat Res 2003;5(4):273-279. 10. Friberg B, Jisander S, Windmark G, Lundgr en A, Ivanoff CJ, Sennerby L, Thoren C. One-year prospective threecenter study comparing the outco me of a soft bone implant (Prototype MK IV) and the standard Branemark implant. Clin Implant Dent Relat Res 2003;5(2):71-7. 11. Kan J, Rungcharassaeng K, Lozada J. Im mediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18:31-39. 12. Proussaefs P, Lozada J. Immediate load ing of hydroxyapatite-coated implants in the maxillary premolar area: Three-year results of a pilot study. J Prosthet Dent. 2004 Mar;91(3):228-33. 82

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13. Branemark PI, Engstrand P, Ohrnell LO, Grondahl K, Nilsson P, Hagberg K. Branemark Novum: A new treatment concept for rehabilitati on of the edentulous mandible. Preliminary results from a prospective clinical follow-up study. Clin Implant Dent Relat Res 1999;1:2 16. 14. Balshi TJ, Wolfinger GJ. Immediate load ing of Brnemark implants in edentulous mandibles. A preliminary report. Implant Dent 1997;6:83-88. 15. Balshi SF, Wolfinger GJ, Balshi TJ. A prospective study of immediate functional loading following the Teeth in a day protocol: A case se ries of 55 consecutive edentulous maxillas. Clin Impl Dent Rel Res 2005;7:24-31. 16. Wolfinger GJ, Balshi TJ, Rangert B. Im mediate functional loading of Brnemark System implants in edentulous mandibles: Clinical report of the results of developmental and simplified protocols. Int J Oral Maxillofac Implants 2003;18:250-257 (continuation of Balshi & Wolfinger 1997). 17. Glauser R, Ruhstaller P, Windisch S, Ze mbic A, Lundgren A, Gottlow J, Hammerle CH. Immediate occlusal loading of Branemark Syst em TiUnite implants placed predominantly in soft bone: 4-year results of a prospective clinical study. Clin Implant Dent Relat Res 2005;7(suppl 1):52-9. 18. Calandriello R, Tomatis M, Vallone R, Rangert B, Gottlow J. Immediate occlusal loading of single lower molars using Brnemark System wide-platform TiUnite Implants: An interim report of a prospective, open-ended, clinical multi-center study. Clin Implant Dent Relat Res 2003b;5(Suppl 1):74-80 19. Van Steenberghe D, Molly L, Jacobs R, Vandekerckhove B, Quirynen M, Naert I. The immediate rehabilitation by means of a ready-made final fixed prosthesis in the edentulous mandible: A 1-year follow-up study on 50 consecutive patients. Clin Oral Impl Re s 2004;15:360-365 20. McAllister BS. Scalloped implant desi gns enhance interproximal bone levels. Int J Periodontics Restorative Dent 2007; 27: 9-15. 21. Kan JYK, Rungcharassaeng K, Lieddelow G, Henry P, Goodacre CJ. Peri-implant tissue response following immediate provi sional restoration of scallope d implants in the esthetic zone: A one-year pilot prospective multi-center study. J Prosthet Dent 2007; 97 (suppl): 109-118. 22. Nowzari H, Chee W, Yi K, Pak M, Ho C hung W, Rich S. Scallope d dental implants: A retrospective analysis of radiographic and clinical outcomes of 17 NobelPerfect implants in 6 patients. Clin Implant Dent Relat Res 2006; 8:1-10. 23. Parel S M, Schow S R. Early clinical expe rience with a new one-piece implant system in single tooth sites. J Oral Maxillofac Surg 2005;63(Suppl2):2-10. 83

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24. Hahn J. One-piece root-form implants: A return to simplicity. J Oral Implantol 2005;2:77-84 25. Finne K, Rompen E, Toljanic J. Clinical evaluation of a prospective multi-centre study on one-piece implants. Part 1: Marginal bone level evaluation after one-year of follow-up. Int J Oral Maxiofac Implants 2007;22:226-234. 26. Alberktsson T, Gottlow J, Meirelles L, Os tman PO, Rocci A, Senerby L. Survival of NobelDirect implants: An analysis of 550 cons ecutively placed implants at 18 different clinical centers. Clin Implant Dent Relat Res 2007;9(2):65-70. 27. Brunski, J.B., Moccia, A.F. Jr, Pollack, S.R., Korostoff, E. & Trachtenberg, D.I. The influence of functional use of endosseous dent al implants on the tissue-implant interface. I. Histological aspects. J Dent Res 1979;58:1953-1969. 28. Bidez MW, Misch CE, Force transfer in impl ant dentistry: Basic concepts and principles. Implant Dent 1992;1(4):289-294. 29. Aparicio, C., Rangert, B., & Sennerby, L., I mmediate/early loading of dental implants: A report from the Sociedad Espanola de Impl antes World Congress consensus meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res 2003;5:57-60. 30. Becker W, Becker BE, Israelson H, Lucchini JP, Hendelsman M, Ammons W. One step surgical placement of Branem ark implants: A prospective mu lticenter clinical study. Int J Oral Maxillofac Implants 1997;12:454-62 31. Collaert B, De Bruyn H. Comparison of Br anemark fixture integration and short-term survival using one-stage or two-stage surgery in completely and partially edentulous mandibles. Clin Oral Implants Res 1998;9:131-135. 32. Friberg B, Sennerby L, Linden B, Grondahl K, Lekholm U. Stability measurements of onestage Branemark implants during healing in mandibles. A clinical resonance frequency analysis study. Int J Oral Maxillofac Surg 1999;28:266. 33. Cochran, DL, Morton, D, Weber, HP. Cons ensus statements and recommended clinical procedures regarding loading protoc ols for endosseous dental implants. Int J Oral Maxillofac Implants 2004;19:109-113. 34. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw implants for the reconstruction of the edentulous mandible. J Oral Maxillofac Res 1986;44(4):274-82. 35. Schnitman PA, Whorle PS, Rubenstein JE DaSilva JD, Wang NH. Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12(4):495-503. 84

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36. Balshi TJ, Wolfinger GJ. Immediate loading of Branemark implants in edentulous mandibles. A preliminary report. Implant Dent 1997;6:83-88. 37. Tarnow DP, Emitez S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches. Ten consecutive case reports with 1-to-5-year data. Tnt J Oral Maxillofac Implants 1997;12:319-324. 38. Branemark PI, Engstrand P, Ohrnell LO, Gr ondahl K, Nilsson P, Hageberg K, Dale C, Lekholm U. Branemark Novum. A new treatm ent concept for rehabilitation of the edentulous mandible preliminary results fr om a prospective clinical follow-up study. Clin Impl Dent Rel Res 1999;1:2-16. 39. Malo P, Rengert B, Nobre M. All-on-F our immediate function concept with Branemark System implants for completely edentulous mandibles. A retrospe ctive clinical study. Clin Implant Dent Relat Res 2003a;5(suppl 1):2-9. 40. Horiuchi K, Uchida H, Ya mamoto K and Sugimura M, Immediate loading of Branemark system implants following placement in ed entulous patients: A clinical report, Int J Oral Maxillofac Implants 2000;15: 824. 41. Lekholm U, Patient selection for Branemark Novum treatment. Appl Osseo Res 2001;2:36-40. 42. De Bruyn H, Kisch J, Collaert B, Linden U, Nilner K, Dvarsater L. Fixed mandibular restorations on three early-loaded re gular platform Branemark implants. Clin Implant Dent Relat Res 2001;3:176. 43. Jaffin RA, Kumar A, Berman CL. Immediate lo ading of dental implants in the completely edentulous maxilla: A clinical report. Int J Oral Maxillofac Implants 2004;19:721-730. 44. Ostman PO, Hellman M, Sennerby L. Direct implant loading in the edentulous maxilla using a bone densityadapted surg ical protocol and primary implant stability criteria for inclusion. Clin Impl Dent Rel Res 2005;7:60-69 (Suppl 1). 45. Degidi M, Piatelli A. 7-year follow-up of 93 immediately loaded titanium dental implants. J Oral Implant 2005;31:25-31. 46. Vanden Bogaerde L, Pedretti G, Dellacasa P, Mozzati M, Rangert B. Early function of splinted implants in maxillas and posterior mandibles using Branemark System, machinedsurface implants: An 18-month pros pective clinical multicenter study. Clin Implant Dent Relat Res 2003;5:21. 47. Fischer K and Stenberg T, Early loading of ITI implants supporting a maxillary full-arch prosthesis: 1-year data of a prospective, randomized study, Int J Oral Maxillofac Implants 2004;19:374. 85

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48. Misch CE. Contemporary Implant Dentistry. Bone De nsity: A Key Determinant for Clinical Success. Missouri: Mosby; 1993:109-113. 49. Jaffin RA, Kumar A, Berman CL Immediate loading of implants in partially and fully edentulous jaws: A series of 27 case reports, J Periodontol 2000; 71:833. 50. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of patients with missing teeth Preliminary study of 876 implants. Quintessenz 1990;41(12):1935-46. 51. Schmitt A, Zarb GA. The longitudinal clinic al effectiveness of osseointegrated dental implants for single tooth replacement. Int J Prosthodont 1993;6(2):197-202. 52. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, Belser UC, Lang NP. Long-term evaluation of non-submerged ITI im plants. Part 1: 8 year life table analysis of a prospective multi-canter study with 2359 implants. Clin Oral Implants Res 1997;8(3):161-72. 53. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical tr ial of endosseous screwshaped implants placed at the time of tooth extraction without augmentation. J Periodontol 1998;69:920-926. 54. Wohrle P. Single tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. Pract Periodontics Aesthet Dent 1998;9:1107-1114. 55. Hui E, Chow J, Li D, Liu J, Wat P, Law H. immediate provisional for single-tooth implant replacement with Branemark System: Preliminary report. Clin Implant Dent Relat Res 2001;3:79-86. 56. Cooper LF, Rahman A, Moriarty J, Ch affee N, Sacco D. Immediate mandibular rehabilitation with endosseous implants: Si multaneous extraction, implant placement, and loading. Int J Oral Maxillofac Implants 2002;17:517-525. 57. Ericsson I, Nilson H, Lindh T, Nilner K, Randaw K. Immediate functional loading of Branemark single tooth implants. An 18 months clinical pilot follow-up study. Clin Oral Impl Res 2000;11:26-33. 58. Nkene E., Lehner B., WEinzierl K, Thomas U, Neugebauer J, Steveling H, RadespielTroger M, Neukam FW. Bone contact, grow th, and density around immediately loaded implants in the mandible of mini pigs. Clin Oral Implant Res 2003;14:312-321. 59. Siar C.H., Toh CG, Swaminathan D, Ong AH, Yaacob H, Nentwig GH. Peri-implant soft tissue integration of immediately loaded implants in the posterior macaque mandible: A histomorphometric study. J Periodontol 2003;74:571-578. 86

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60. Degidi M, Scarano A, Patrone A, Piatelli A. Histological analysis of clinically retrieved immediately loaded titanium implants: A report of 11 cases. Clin Implant Dent RElat Res 2003;5:89-94. 61. Romanos GE, Johansson CB. Immediate loading with complete implant-supported restorations in an edentulous heavy smoke r: Histologic and histomorphometric analyses. I J Oral Maxillofac Implant 2005;20:282-290. 62. Cornelini R, Cangini F, Covani U, Barone A, Buser D. Immediate restoration of single tooth implants in mandibular molar sites: A 12-month preliminary report. I J Oral Maxillofac Implant 2004;19:855-860. 63. Cannizaro G, Leone M. Restoration of partia lly edentulous patients using dental implants with a microtextured surface: A prospective comparison of delayed and immediate full occlusal loading. I J Oral Maxillofac Implant 2003;18:512-522. 64. Bengazi F, Wennstrom JL, Lekholm U. Rece ssion of the soft tissue margin at oral implants. A 2-year longit udinal prospective study. Clin Oral Implant Res 1996;7:303-310. 65. Cornellini R, Cangini F, Covani U, Wilson TG. Immediate restoration of implants placed into fresh extraction sockets for single tooth replacement: A prospective clinical study. Int J Perio Rest Dent 2005;25:439-447. 66. Nikellis I, Levi A, Nicolopoulus C. Imme diate loading of 190 endosseous dental implants: A prospective observational study of 40 patie nt treatment with up to 2-year data. Int J Oral Maxillofac Implants 2004;19:116-123. 67. Degidi M, Piatelli A. Immediate functiona l and nonfunctional loading of dental implants: A 2to 60-month follow-up study of 646 titanium implants. J Periodontol 2003;74:225-241. 68. Lorenzoni M, Pertle C, Zhang K, Wimme r G, Wagscheider WA. Immediate loading of single-tooth implants in the anterior ma xilla. Preliminary results after one year. Clin Oral Implant Res 2003;14:180-187. 69. Calandriello, R. Tomatis M. Simplified treatment of the atrophic posterior maxilla via immediate/early function and tilted implant s: A prospective 1-year clinical study. Clin Implant Dent Relat Res 2005;7(suppl.1):S1-S12. 70. Rocci A, Martignoni M, Gottlow J. Immediat e loading of Branemark System TiUnite and machined-surface implants in the posterior mandible: A randomized open ended clinical trial. Clin Implant Dent Relat Res 2003b;5(suppl 1):57-63. 71. Glauser R, Ree A, Lundgren A, Gottlow J, Hammerle CH, Scharer P. Immediate occlusal loading of Branemark implants applied in va rious jawbone regions: A prospective, 1-year clinical study. Clin Implant Dent Relat Res 2001a;3:204-213. 87

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72. Luongo G, Di Raimondo R, Filippini P, Gu alini F, Paoleschi C. Early loading of sandblasted, acid etched implants in the poste rior maxilla and mandible: A 1-year followup report from a multicenter 3-year prospective study. Int J Oral Maxillofac Implants 2005;20(1):84-91. 73. Meredith N, Alleyne D, Cawly P. Resonance frequency analysis measurements of implant stability in vivo: A cross-sectional and longitudinal study of resonance frequency measurements on implants in the edentu lous and partially dentate maxilla. Clin Oral Implant Res 1997;8:226-233. 74. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. Int J Oral Maxi llofac Implants 2005;20(1):60-68. 75. Teerlinck J, Quirunen M, Da rius P, Van Steenberghe D. Pe riotest an objective clinical diagnosis of bone appos ition toward implants. Int J Oral Maxillofa Implants 1991;6:55-61 76. Olive J, Aparicio C. The periotest method as a measure of osseointegrated oral implants stability. Int J Oral and Maxillofac Implants 1990;5:390-400. 77. Goransson A, Wennerberg A. Bone formation at titanium implants prepared with iso-and anisotropic surfaces of sim ilar roughness: an in vivo study. Clin Implant Dent Relat Res 2005;7(1):17-23. 78. Kim YH, Koak JY, Chang IT, Wennerberg A, Heo SJ. A histomorphometr ic analysis of the effects of various surface treatm ent methods on osseointegration. Int J Oral Maxillofac Implants 2003;18(3):349-356. 88

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89 BIOGRAPHICAL SKETCH I was born in 1978 and grew up in Kuwait City, Kuwait. I graduated from Al-Rawdah High School in Kuwait City in 1995. In 1995, I enro lled at the University of MissouriKansas City as a dental student where I joined the 6-year combined program of Bachelor of Arts and Science and Dentistry. I worked for the public health system of Kuwait from 2002 to 2005 before I decided to go back to the USA to special ize in periodontics. I en rolled in the graduate periodontic program at the University of Florid a. After graduation, I w ill return to my home, Kuwait, and work for the public health system a nd the University of Kuwait. The past was only a short trip and the rest will be a long journey.