VOLUME 44 NUMBEP 1 JANUAPY 2013 37

QUI NTESSENCE I NTERNATI ONAL

PROSTHODONTICS
(wide platform for molars, narrow platform
for lateral and mandibular incisors, and
standard platform for other teeth).
3
For over-
denture treatments, prosthetic issues are
overcome by the design of the restoration,
and the choice regarding implant dimen-
sion is related mainly to the amount of
residual alveolar bone and the mechanical
properties of the xture.
Some studies suggest that 1.5 mm of
residual bone should be present on the
buccal and lingual/palatal aspects of the
implant after its insertion.
4,5
Therefore, when
less than 6 mm of bone width is present, it
can be assumed that there is insufcient
bone volume to place an implant with a
standard diameter of 4 mm.
In edentulous maxillae, horizontal bone
resorption is frequently seen mesial to the
maxillary sinus and under the nasal oor
and may interfere with the placement of
standard diameter implants.
6
Treatment
alternatives include bone augmentation or
the insertion of reduced diameter implants.
Dental implants are a viable treatment
option for replacing teeth in edentulous
jaws. Fixed or removable implant-support-
ed restorations may be provided to patients
with different prosthetic designs and surgi-
cal protocols.
1
In the maxilla, a removable full-arch
implant-supported restoration (overdenture)
is usually supported by four or more
implants.
2
This approach has shown good
results when standard diameter implants
are used.
1
Implant width and length is generally
chosen depending on the prosthetic needs
1
Head, Department of Periodontology and Prosthodontics,
Eastman Dental Hospital, Rome, Italy.
2
Assistant Researcher, Department of Periodontology and
Prosthodontics, Eastman Dental Hospital, Rome, Italy.
3
ITI Scholar, Department of Periodontology and Prosthodontics,
Eastman Dental Hospital, Rome, Italy.
Correspondence: Dr Luca Cordaro, Via Guido DArezzo 2, 00198
Roma, Italy. Email: lucacordaro@usa.net
Rehabilitation of an edentulous atrophic maxilla
with four unsplinted narrow diameter titanium-
zirconium implants supporting an overdenture
Luca Cordaro, MD, DDS, PhD
1
/Ferruccio Torsello, DDS, PhD
2
/
Vincenzo Mirisola di Torresanto, DDS
2
/Marinka Baricevic, DDS
3
The edentulous maxilla is often affected by bone resorption, sometimes making it difcult
to plaoo standard diamotor implants. Narrow diamotor implants mado o titanium-ziroonium
(Ti-Zr) alloy, which has superior mechanical properties compared with titanium, have been
proposed for these difcult situations. This retrospective clinical observation reports the
outcome of the use of reduced diameter implants made of Ti-Zr alloy supporting maxillary
overdentures retained with locator abutments. The charts of all patients who received max-
illary overdentures supported by four unsplinted implants from January 2009 to June 2010
at tno Dopartmont o Poriodontology and Prostnodontios, Eastman Dontal Hospital, Pomo,
Italy, were reviewed. All patients treated with four narrow diameter Ti-Zr implants were
selected for the present case series. Ten patients were found, six of whom received aug-
mentation procedures. After 12 to 16 months of follow-up, no implants were lost, and only
one implant showed bone resorption greater than 1.5 mm. Implants showed a success
rate of 97.5% and a survival rate of 100%. All prostheses were successfully in function.
The present case series showed promising results regarding the use of narrow diameter
implants made of Ti-Zr supporting maxillary overdentures retained with locator abutments.
(Quintessence Int 2013;44:3743)
Key words: edentulous maxilla, narrow implants, overdenture, titanium-zirconium
38 VOLUME 44 NUMBEP 1 JANUAPY 2013
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Bono augmontation may bo porormod
using different techniques such as guided
bono rogonoration (GBP) or autogonous
bone blocks.
7
These techniques increase
the surgical complexity and morbidity of the
procedure compared with standard implant
placement.
The use of narrow diameter implants
may decrease the need for bone augmenta-
tion in edentulous maxillae when an over-
denture treatment is planned.
Poduood diamotor implants may snow
inferior mechanical strength of the xture at
the level of the prosthetic connection, when
an internal connection is used.
8,9
For this
reason, implants made of a titanium zirco-
nium (Ti-Zr) alloy have been introduced to
minimize the incidence of mechanical fail-
ures.
As a general principle, it is clear that a
decrease in the need for surgical recon-
struction of the alveolus simplies implant
treatment and extends their indications. In
clinical practice, the question of whether the
use of reduced diameter implants affects
the outcome of the restoration should be
investigated.
Different authors have reported good
short-term outcomes using Ti-Zr implants in
partially edentulous patients
10
or edentulous
mandibles.
11
Studies are needed to establish the
clinical indications and limitations of narrow
diameter implants.
3
This retrospective clini-
cal observation reports the outcomes of the
use of reduced diameter implants made of
Ti-Zr alloy supporting maxillary overden-
tures retained with locator abutments.
METHOD AND MATERIALS
In this retrospective study, the charts of the
patients consecutively treated with maxil-
lary overdentures at the Department of
Periodontology and Prosthodontics,
Eastman Dontal Hospital, Pomo, taly, rom
January 2009 to June 2010 were reviewed.
Patients were either edentulous in the maxil-
lary arch at presentation or the treatment
plan involved extraction of the few remain-
ing teeth in the maxillary arch.
The prosthetic treatment plan consisted
of an implant-supported maxillary overden-
ture in accordance to the criteria proposed
by Ziztmann and Marinello.
12
The treatment
plan included inserting four maxillary
implants with the transmucosal technique.
1
Only patients who were treated with nar-
row diameter implants made of Ti-Zr alloy
(Poxolid) witn a onomioally aotivo mioro-
roughened surface (3.3 mm Standard
SLActive, Institut Straumann) were includ-
ed. The implants used were 10 or 12 mm in
length. All patients showed some degree of
maxillary atrophy. Horizontal defects were
present at the time of implant placement,
with a residual ridge width of 6 mm or less.
Ten cases were found to have been
treated following the same surgical ration-
ale. The mean age was 76 years, and there
were four women and six men.
Surgical techniques
In three cases, advanced horizontal resorp-
tion was seen with a residual bone width of
less than 3 mm, but with more than 12 mm
of bone height. In these cases, augmenta-
tion was performed with mandibular bone
blocks and implant surgery took place after
4 months of healing. The alveolar bone
width for all patients at the moment of
implant placement (including nal width
after bone reconstruction) was between 5
and 6 mm; therefore, narrow diameter
implants were chosen.
Three cases demonstrated some minor
bono dooot ator implant insortion. GBP
was performed by means of a synthetic
biphasic calcium phosphate graft material
(BonoCoramio, nstitut Straumann) oovorod
by oollagon mombrano (Bio-Gido, Goistlion).
In four cases, the implants could be
placed without any need for augmentation.
Prosthetic phase
Loading of the implants was performed 8
weeks after insertion. Impressions were
taken with the aid of pickup transfers, a
master cast was created, occlusal registra-
tions were taken, and a wax-up was pre-
pared and tried in. An overdenture retained
by four locator abutments (Zest Anchors)
was delivered to the patient. Panoramic
radiographs were taken at the time of the
delivery of the denitive prosthesis.
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Table 1 Summary of the retrospective evaluation
Case type
No. of
cases
No. of
implants
(inserted
and sur-
vived)
Probing depth
(mean SD)
BoP
(% of BOP +
implants)
Marginal bone
loss (mean
SD)
Implant
stability
(+ or )
Prosthesis
stability
(VS, S, U)
Implants
with more
than 1.5
mm bone
loss
No augmontation 4 16/16 3.11 0.8 12.5 0.4 0.3 16 + 2, 1, 1
Simultanoous GBP 3 12/12 2.45 0.7 8.3 0.8 0.6 12 + 1, 2, 1
Blook grats 3 12/12 2.39 1.0 8.33 0.5 0.6 12 + 1, 1, 1
Overall 10 40 2.69 0.8 10.0 0.55 0.5 40 + 4, 4, 2
GBP, guidod bono rogonoration, SD, standard doviation, BoP, blooding on probing, vS, vory stablo, S, stablo, U, unstablo.
Follow-up evaluation
Patients were evaluated in May 2011. The
mean follow-up time was 13.5 months
(range, 12 to 16 months). A panoramic
radiograph was taken, and probing was
performed around implants at four points
per implant (the mean value for each implant
was calculated). Implants were checked for
stability by their acoustic and visual response
to a gentle percussion test and also by
pushing each implant between two instru-
ment handles and observing any move-
ment.
13
Prosthesis stability was assessed as
very stable (no movement upon mastication
and need for two hands for the patient to
remove the prosthesis), stable (slight move-
ments visible upon eccentric mandibular
movements, one hand may remove prosthe-
sis), or unstable (the prosthesis may be
displaced by the patient without the use of
nands). Blooding on probing (BoP) and
probing depth were recorded. Mean prob-
ing depth for each group, as well as for the
entire study population, were calculated.
The percentage of implants that showed
BoP was also oaloulatod. Bono lovols woro
compared with the baseline situation (radio-
graphs taken immediately after implant
loading) on panoramic radiographs; implant
length was used to calibrate the measure-
ments. Marginal bone levels were recorded
at the mesial and distal sites on each
implant, and a mean value was calculated
for each implant at baseline and follow-up.
RESULTS
In total, 40 Ti-Zr narrow diameter implants
were evaluated. The results of this study are
reported in Table 1. All implants were in
place after at least 1 year of function; only
one implant demonstrated more than 1.5
mm marginal bone loss (without signs of
inammation), giving a 100% survival rate
and a 97.5% success rate according to the
oritoria publisnod by Busor ot al.
14
Marginal bone stability was excellent in
all groups (mean, 0.55 0.5 mm marginal
bone resorption), as were soft tissue
parameters, with only 3 of 40 implants
snowing BoP. Tno moan probing doptn
was 2.69 0.8 mm. The Plaque Index mea-
sured at the four sites on each implant
showed 70 sites showing 0 score (no
plaque), 64 showing score 1, and 14 and
12 sites showing scores of 2 and 3, respec-
tivoly. No statistioal oomparison botwoon
the different treatment modalities (no bone
grats, GBP, or bono blooks) was por-
formed because of the small size of the
subgroups, which did not allow for valid
statistical analysis.
Overdenture stability was considered at
the follow-up examination (May 2011) as
very stable in four cases, stable in four
cases, and unstable in two cases. In the
unstable cases, stability was improved (to
very stable) by changing the plastic inserts
40 VOLUME 44 NUMBEP 1 JANUAPY 2013
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Fig 2 Details of the GBR procedures. (a
and b) Fenestration around implant and
very thin buccal bone were evident in
both sides. (c and d) This situation was
addressed with GBR using a particulated
bone substitute and a collagen mem-
brane. Standard diameter implants
could not be placed without a block
graft. Thus, it can be safely afrmed that
3.3-mm Ti-Zr implants reduced the inva-
siveness of the procedure for this patient.
Fig 1 (a) Initial photograph of a patient
treated for maxillary edentulism. (b)
After the refection of a mucoperiosteal
fap, horizontal alveolar atrophy was evi-
dent. Four 3.3-mm Ti-Zr implants were
placed with the GBR procedure. (c and d)
The fnal photograph and the panoramic
radiographs showed good soft tissue
healing and proper implant placement.
of the locator attachments; these patients
did not show up at the 6-month control.
DISCUSSION
Limited data are available on the long-term
outcomes of reduced diameter implants in
dioront indioations. Narrow implants navo
been used for different indications, such as
limited tooth-to-tooth spacing,
15,16
partially
edentulous patients,
10,17
and edentulous
mandibles,
18
with acceptable survival rates
reported so far.
Previous studies also reported on nar-
row implants used to restore edentulous
maxillae. Veltri et al
19
documented 12 cases
in which narrow implants were used to sup-
port a xed rehabilitation. A mean of 6
implants per patient were inserted in narrow
ridges and followed for up to 1 year with a
100% survival rate.
19
Payne et al
20
used
a
a
c
c
b
b
d
d
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Fig 3 (a) Initial and (b) fnal clinical situa-
tions of a patient treated with two man-
dibular ramus grafts to correct a severe
horizontal alveolar atrophy to place 4 3.3-
mm Ti-Zr implants supporting an overden-
ture. (c and d) Panoramic radiographs
show the initial situation and the correct
implant placement.
three narrow implants to support maxillary
overdentures in a group of 39 patients with
81% success and 84.6% survival rate after
1 year. Hallman
21
published the results of a
case series in which edentulous and par-
tially edentulous maxillae were restored with
the aid of narrow nonsubmerged implants.
Fixed dental prostheses, overdentures, and
single crowns were delivered to the patients
and evaluated. A survival rate of 99.4% and
success rate of 94.6% was reported after at
least 1 year of function.
21
Although the
majority of the included patients were eden-
tulous, it is not possible to extrapolate the
data related to this subgroup of patients in
the Hallman study.
One of the potential drawbacks of the
reduced diameter titanium implants is their
lower mechanical strength, with the related
risk of fracture, especially at the implant-
abutment interface (where the presence of
the connecting screw reduces the width of
the residual metal implant structure).
8,9

Consoquontly, dioront titanium alloys navo
been used by some manufacturers to
increase the fatigue strength compared
with grade 4 commercially pure titanium.
Pooontly, a Ti-Zr alloy (13% to 17% zirooni-
um) with a superior resistance to fatigue
has been introduced and used to manufac-
ture implants with a diameter of 3.3 mm.
22,23

In a pilot study, Ti-Zr implants were
shown to be safe and effective in partially
edentulous patients when splinted to stan-
dard diameter implants.
10
In a randomized controlled trial, Ti-Zr
implants were compared with titanium
grade IV implants in a sample of patients
treated with mandibular overdentures
retained by two implants. One year after
loading, survival and success rates of
98.9% and 96.6%, respectively, were shown
by the test implants, with no statistical dif-
ference with the control group.
11
Patients included in our sample were
also treated with surgical approaches that
included staged mandibular block grafting
or simultanoous GBP proooduros. Tno
authors opinion is that the use of narrow
implants in these cases was instrumental in
making implant placement possible or sim-
pler in the given clinical situation, as evi-
donood by tno oasos snown. n GBP oasos,
simultaneous insertion and augmentation
could be performed without bone harvest-
ing (Figs 1 and 2). In block grafts cases, the
mandibular ramus could be used instead of
extraoral grafting, thus reducing morbidity
for the patient (Figs 3 and 4). It should be
noted that horizontal augmentation of
extremely narrow maxillary arches by
means of mandibular ramus block grafts
a
c
b
d
42 VOLUME 44 NUMBEP 1 JANUAPY 2013
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Fig 4 Photographs of the surgical phases. (a and b) The maxillary horizontal atrophy was severe, and (c and
d) two block grafts were harvested from the mandibular angles and secured to the alveolar process by means
of lag screws. (e and f) After 4 months of healing, the implants were placed. It is evident that 3.3-mm implants
could be placed. Standard diameter implants would have required additional grafting at the moment of
placement or extraoral block grafts during the frst surgical phase. Thus, it can be safely afrmed that 3.3-mm
Ti-Zr implants reduced the invasiveness of the procedure for this patient.
may still result in a 6-mm wide arch after
graft healing. In this condition, a narrow
diameter implant is needed.
The short-term follow-up observation
limits the results of this clinical observation.
However, it should be noted that the results
are worth reporting because of the consis-
tency of the prosthetic treatment objective
proposed and delivered to the patients with
the aid of narrow diameter implants.
It may be concluded that Ti-Zr implants
are a promising option for restoration of the
edentulous maxilla since they show excel-
lent survival and success rates and enable
less invasive surgery.
CONCLUSION
This case series, based on 10 patients,
showed promising results for the use of 4
unsplinted Ti-Zr implants to support maxil-
lary overdentures. Further studies are need-
ed to conrm the nding that 3.3-mm Ti-Zr
implants may reduce treatment complexity
and invasiveness.
REFERENCES
1. Gallucci GO, Morton D, Weber HP. Loading proto-
cols in edentulous patients. Int J Oral Maxillofac
Implants 2009;24:132146.
2. Weingart D, ten Bruggenkate CM. Treatment of
edentulous patients with ITI implants. Clin Oral
Implants Res 2000;11:6981.
3. Renouard F, Nisand D. Impact of implant length and
diameter on survival rates. Clin Oral Implants Res
2006:17;3551.
4. Dietrich U, Lippold R, Dirmeier T, Behneke N, Wagner
W. Statistische Ergebnisse zur Implantatprognose
am Beispiel von 2017 IMZ-Implantaten unter-
schiedlicher Indikation der letzten 13 Jahre.
ZZahnrztl Implantologie 1993;9:918.
5. Buser D, von Arx T, ten Bruggenkate C, Weingart D.
Basic surgical principles with ITI implants. Clin Oral
Implants Res 2000:11:5968.
a
d
b
e
c
f
VOLUME 44 NUMBEP 1 JANUAPY 2013 43
QUI NTESSENCE I NTERNATI ONAL
Cordaro at al
6. Cawood JI, Howell RA. A classifcation of the eden-
tulous jaws. Int J Oral Maxillofac Surg 1988;17:232
236.
7. Chiapasco M, Casentini P, Zaniboni M. Bone aug-
mentation procedures in implant dentistry. Int J
Oral Maxxillofac Implants 2009;24:237259.
8. Akca K, Cehreli MC, Iplikcjoglu H. Evaluation of the
mechanical characteristics of the implantabut-
ment complex of a reduced-diameter morse-taper
implant. A nonlinear fnite element stress analysis
Clin Oral Implants Res 2003;14:444454.
9. Allum SR, Tomlinson RA, Joshi R. The impact of
loads on standard diameter, small diameter, and
mini implants: A comparative laboratory study. Clin
Oral Implants Res 2008;19:553559.
10. Barter S, Stone P, Brgger U. A pilot study to
evaluate the success and survival rate of titanium-
zirconium implants in partially edentulous patients:
Results after 24 months of follow-up. Clin Oral
Implants Res 2012;23:873881.
11. Al-Nawas B, Brgger U, Meijer HJ, et al. A dou-
ble-blind randomized controlled trial (RCT) of
titanium-13 zirconium versus titanium grade
IV small-diameter bone level implants in eden-
tulous mandiblesResults from a 1-year obser-
vation period. Clin Implant Dent Relat Res 2011
Mar 17 [epub ahead of print]. doi:10.1111/j.1708-
8208.2010.00324.x.
12. Zitzmann NU, Marinello CP. Treatment plan for
restoring the edentulous maxilla with implant-
supported restorations: Removable overdenture
versus fxed partial denture design. J Prosthet Dent
1999;82:188196.
13. Atsumi M, Park SH, Wang HL. Methods used to
assess implant stability: Current status. Int J Oral
Maxillofac Implants 2007;22:743754.
14. Buser D, Mericske-Stern R, Bernard JP, et al. Long-
term evaluation of nonsubmerged ITI implants.
Part I: An 8-year life table analysis of a prospective
multicenter study with 2,359 implants. Clin Oral
Implants Res 1997;8:161172.
15. Reddy MS, ONeal SJ, Haigh S, Aponte-Wesson R,
Geurs NC Initial clinical efcacy of 3-mm implants
immediately placed into function in conditions
of limited spacing. Int J Oral Maxillofac Implants
2008;23:281288.
16. Cordaro L, Torsello F, Mirisola di Torresanto V,
Rossini C. Retrospective evaluation of mandibular
incisor replacement with narrow neck implants. Clin
Oral Implants Res 2006;17:730735.
17. Romeo E, Lops D, Amorfni L, Chiapasco M, Ghisolf
M, Vogel G. Clinical and radiographic evaluation of
small-diameter (3.3-mm) implants followed for 17
years: A longitudinal study. Clin Oral Implants Res
2006;17:139148.
18. Flanagan D. Avoiding osseous grafting in the atro-
phic posterior mandible for implant supported
fxed partial dentures: A report of two cases. J Oral
Implantol 2011;37:705711.
19. Veltri M, Ferrari M, Balleri P. One-year outcome of
narrow diameter blasted implants for rehabilitation
of maxillas with knife-edge resorption. Clin Oral
Implants Res 2008;19:10691073.
20. Payne AG, Tawse-Smith A, Thomson WM, Duncan
WD, Kumara R. One-stage surgery and early load-
ing of three implants for maxillary overdentures:
A 1-year report. Clin Implant Dent Relat Res
2004;6:6174.
21. Hallman M. A prospective study of treatment of
severely resorbed maxillae with narrow nonsub-
merged implants: Results after 1 year of loading. Int
J Oral Maxillofac Implants 2001;16:731736.
22. Thoma DS, Jones AA, Dard M, Grize L, Obrecht M,
Cochran DL. Tissue integration of a new titanium-
zirconium dental implant: A comparative histologic
and radiographic study in the canine. J Periodontol
2011;82:14531461.
23. Gottlow J, Dard M, Kjellson F, Obrecht M, Sennerby
L. Evaluation of a new titanium-zirconium dental
implant: A biomechanical and histological com-
parative study in the mini pig. Clin Implant Dent
Relat Res 2012;14:538545.