Graftless Full-Arch Implant Rehabilitation with Interantral

Implants and Immediate or Delayed LoadingPart II:

Transition from the Failing Maxillary Dentition
Dieter Busenlechner, DDS, PhD1/Georg Mailath-Pokorny, DDS, MD, PhD1/
Robert Haas, DDS, MD, PhD1/Rudolf Furhauser, DMD, MD1/Carina Eder, DMD1/
Bernhard Pommer, DDS, PhD1/Georg Watzek, DDS, MD, PhD1

Purpose: To compare long-term survival and marginal bone loss of immediate interantral implants in the
nonaugmented maxilla subjected to immediate vs delayed loading. Materials and Methods: Graftless
maxillary cross-arch rehabilitation was performed in a total of 362 patients in the years 2004 to 2013 (1,797
implants). Of the 240 patients with immediate implants replacing their failing maxillary dentition, 81% were
subjected to immediate loading and 19% to delayed loading of their 4 to 6 interantral implants (980 and
235 implants, respectively). Kaplan-Meier survival estimates were computed and marginal bone loss was
evaluated in a stratified random sample of 20 patients per group. Results: Thirty-one of 1,215 implants failed
within the mean observation period of 3.9 years, and no difference in 8-year survival estimates could be
seen between immediate (97.6% [95% CI: 96.7 to 98.6]) and delayed (96.6% [95% CI: 94.3 to 98.9]) loading
protocols (P = .359). Mean marginal bone resorption following implant insertion did not differ significantly
between the groups (1.5 1.7 mm vs 0.7 1.1 mm, P = .379); however, it was significantly associated with
a reduced number of implants (P = .017) and patient history of periodontal disease (P < .001). Conclusion:
Immediate loading of interantral implants yields satisfactory results in the transition of patients from a failing
maxillary dentition to full-arch implant rehabilitation and thus may be favored over delayed loading concepts.
Int J Oral Maxillofac Implants 2016;31:11501155. doi: 10.11607/jomi.4326

Keywords: complete denture, dental implants, edentulous arch, immediate dental implant loading, implant-
supported dental prosthesis, maxilla

P atients with hopeless residual dentition frequently

present with difficulties and concerns regarding the
management of the provisional phase until their defini-
tive prosthetic restoration.1 Full-arch oral rehabilitation
is thus associated with significant treatment planning2
and the attempt to minimize surgical invasion,3 treat-
ment duration,4 and the inherent need for provisional
dentures.5,6 The combination of immediate implant
placement (at the time of tooth extraction) and imme-
diate provisional restoration (equivalent to immediate
functional loading in full-arch therapy) represents the
most progressive therapeutic concept that has been
propagated in recent years.79 This treatment ap-
proach is of particular relevance in the maxilla due to
esthetic demands and limited bone volume between
1Professor, Academy for Oral Implantology, Vienna, Austria.
Correspondence to: Dr Georg Watzek, Akademie fur orale
Implantologie, Lazarettgasse 19/DG, A-1090 Vienna, Austria.
Fax: +43 1 402 8668 10. Email: watzek@implantatakademie.at
2016 by Quintessence Publishing Co Inc.
the maxillary sinus for the placement of interantral im-
plants without bone augmentation procedures.
Avoidance of removable prostheses is rated as a
high priority by dental implant patients, and fixed
dentures are furthermore believed to be of higher
longevity.10 Immediate provisional loading of full-
arch fixed partial dentures on immediate implants is
thus a patient-friendly approach that is considered to
completely avoid periods of removable provisionals
in cases of failing maxillary dentition.11 The combina-
tion of simultaneous tooth extraction at the time of
implant placement and immediate prosthetic reha-
bilitation may, however, carry an increased risk of os-
seointegration failure12particularly in cases of low
initial stabilitydue to decreased resistance against
implant micromotions during the healing phase.13
The major patient-related determinant for impaired
primary implant stability is low bone density,14 awk-
wardly reduced in the atrophic maxilla in the ma-
jority of cases along with bone quantity.15 Further
factors influencing initial stability required for im-
mediate loading protocols are the presence of bony

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 Busenlechner et al

a b

c d
Fig 1 Representative example of rehabilitation of a patient with failing dentition in the maxilla with interantral implants and imme-
diate loading. (a) Initial situation. (b) Panoramic radiograph immediately after tooth removal and implant insertion with impression
posts on implants for manufacture of a provisional, implant-mounted suprastructure, which is inserted on the same day. (c) Pan-
oramic radiograph after definitive prosthetic treatment 4 months later. (d) Radiographs 4 years later.

periodontal pockets16 as well as advanced periapical
pathology.17,18
Transition from a failing dentition to fixed implant-
supported full-arch restoration has been investigated
using a staged approach19 (ie, conventional loading
after a healing period of 3 to 6 months); however, it
has rarely been evaluated in the long term after ap-
plication of immediate loading of postextraction im-
plants.20 Influencing variables related to patients (age,
sex, smoking habits, history of periodontal disease)
and implant sites (implant length, implant diameter,
number of implants per patient, local bone quality)
have rarely been studied in a large patient sample.
The aim of the present retrospective study thus was to
compare implant survival and peri-implant marginal
bone resorption following the transition from a failing
maxillary dentition to full-arch fixed partial dentures
on four to six interantral implants subjected to either
immediate or delayed loading (Fig 1).
MATERIALS AND METHODS
Patient Selection
Graftless maxillary cross-arch rehabilitation was per-
formed in a total of 362 patients in the years 2004 to
2013 (1,797 implants). Retrospective evaluation of
implant survival was performed in collaboration with
the referring dentists, and the study protocol was ap-
proved by the Ethics Committee of Vienna (EK 13-145-
VK). Inclusion criteria involved (1) patients referred to
the Academy for Oral Implantology (Vienna, Austria)
for transition from their failing maxillary dentition to
full-arch implant rehabilitation, (2) by means of den-
tal implants inserted at the time of tooth extraction,
(3) without prior or simultaneous application of bone
augmentation procedures, (4) subjected to either im-
mediate loading of their provisional full-arch (glass
fibre reinforced) acrylic fixed partial dentures at the
day of implant placement or else to conventional
delayed loading after a healing period of at least 3
months wearing removable complete dentures. For
the evaluation of peri-implant marginal bone resorp-
tion, a random sample of 20 patients per group was
drawn and measurements were taken using Sidexis XG
radiographic software (Version 2.3, Sirona Dental Sys-
tems). The baseline for bone resorption measurements
was the day of implant insertion (rather than the time-
point of prosthetic rehabilitation).
Surgical and Prosthodontic Procedures
Surgery was performed with local anesthesia (Ultra-
cain dental forte), and one-shot antibiosis was ad-
ministered at the day of implant placement (2 1 g
Augmentin or 3 300 mg Dalacin C). Of the four to
six implants placed in each patient via a flapless proce-
dure, the most distal ones were tilted up to 30 degrees
to guarantee a favorable biomechanical situation
and short distal cantilevers. Placement of more than
four implants was considered in cases of high patient
age21,22 (to account for compromised osseous healing
capacity) and application of short implant lengths23
(to account for reduced total bone-to-implant con-
tact area). The implant lengths ranged between 8 to
16 mm, and diameters of 3.5 to 6 mm were used. Pre-
operative cone beam computed tomographic scans
were acquired using a Classic i-CAT (Imaging Sciences
International, 0.25 voxel mode, high resolution). Trans-
fer copings and prefabricated equilibrated trays were
used for impressions. The immediate loading group re-
ceived straight or angulated abutments and provision-
al acrylic fixed partial dentures avoiding long distal
cantilevers at the day of implant placement. Implants
in the delayed loading group were subjected to trans-
mucosal healing after wound closure and adaptation
of complete dentures. Definitive prosthetic restoration

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Busenlechner et al

Table 1 Comparison of Patient and Implant Characteristics Between the Immediate Loading and
Delayed Loading Groups
Immediate loading Delayed loading P
No. of implants 980 235
No. of women 111 27 .112
No. of men 84 18
Mean age at implant placement (y) 61.0 11.1 61.6 10.1 .698
Mean length of follow-up (y) 3.2 1.9 4.1 2.3 .018*
Percentage of smokers (%) 31.1 30.4 1.000
History of periodontal disease (%) 56.4 69.2 .155
Mean no. of implants per patient 4.9 0.8 5.1 0.8 .265
Mean implant length (mm) 13.2 1.4 12.7 1.4 .212
Mean implant diameter (mm) 4.3 0.3 4.1 0.4 .433
Mean implant insertion torque (Ncm) 40.5 15.2 39.0 13.9 .600
*Indicates statistical significance.

Table 2 Comparison of Survival Rate, Failures, and Marginal Bone Resorption Between the
Immediate Loading and Delayed Loading Groups
Immediate loading Delayed loading P
8-year implant survival rate 97.6% 96.6% .359
(Kaplan-Meier) [95% CI: 96.7%98.6%] [95% CI: 94.3%98.9%]
Early failures 1.6% 2.6% .358
Late failures 0.7% 0.9%
Marginal bone resorption 1.5 1.7 mm 0.7 1.1 mm .379
No significant differences between immediate and delayed loading of four to six immediate interantral implants in the nonaugmented edentulous
maxilla could be observed with regard to implant survival and marginal bone resorption.

using screw-retained full-arch implant fixed partial RESULTS

dentures (NobelProcera Implant Bridges, Nobel Bio-
care) was performed after 4 months in both groups.
Statistical Analysis
Baseline characteristics were compared between the
two study groups as well as between total collectives
and random samples using the Fisher exact and Wil-
coxon rank sum tests. Estimates of 8-year implant sur-
vival including 95% confidence intervals (95% CI) were
computed using the Kaplan-Meier method and com-
pared using Mantel-Cox log-rank tests. Influence of
variables (patient age and sex, smoking habits, history
of periodontal disease, implant length and diameter,
number of implants per patient, and bone quality) was
evaluated in a Cox proportional hazards model. Predic-
tors of peri-implant marginal bone loss were investi-
gated by multiple linear regression. All analyses were
performed at a significance level of .05 using R-project
statistical software version 3.1.0 (R Foundation for Sta-
tistical Computing).
A total of 240 patients (138 women, 102 men; mean
age, 61.1 10.9 years) received 4 to 6 interantral
implants at the time of extraction of their residual
maxillary dentition, of which 81.2% were subjected
to immediate prosthetic loading (195 patients, 980
implants) and 18.8% to delayed loading (45 patients,
235 implants). Patient and implant characteristics did
not differ significantly between the groups (Table 1)
apart from shorter length of follow-up in the imme-
diate loading group (difference of 0.9 years, on aver-
age, supposedly related to later implementation of the
treatment concept). A total of 31 implants failed within
the observation period of 3.9 2.1 years: in the im-
mediate loading group, 16 implant failures occurred
within the first year after implant placement (1.6%)
and 7 implants failed after the first year (0.7%), while 6
early failures (2.6%) and 2 late failures (0.9%) occurred
in the delayed loading group. No difference regarding
implant survival rates (97.7% vs 96.6%, P = .358) could
be observed (Table 2).
Kaplan-Meier estimates of 8-year implant survival
were 97.6% [95% CI: 96.7% to 98.6%] in the immediate

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loading group compared with 96.6% [95% CI: 94.3% to
98.9%] in the delayed loading group (Fig 2) without sig-
nificant differences (P = .359). Survival rates were not
associated with patient age (P = .587) and sex (wom-
en: 98.1%, men: 96.6%; P = .110), smoking habits (pos-
itive: 98.5%, negative: 97.1%; P = .184), or history of
periodontal disease (positive: 97.8%, negative: 97.0%;
P = .325). Implant survival did not differ between im-
plant lengths (8 mm: 100%, 10 mm: 95.5%, 11.5 mm:
95.0%, 13 mm: 97.4%, 16 mm: 99.4%; P = .779), diam-
eters (3.5 mm: 97.7%, 4.3 mm: 97.6%, 5.0 mm: 91.4%,
6.0 mm: 100%, P = .850), and number per patient (4
implants: 96.2%, 5 implants 98.5%, 6 implants: 97.1%;
P = .112). Implants placed in bone qualities I, II, III, and
IV showed similar survival rates of 95.3%, 97.9%, 97.6%,
and 97.3%, respectively (P = .482).
In the immediate loading group, the random sam-
ple comprised 8 women and 12 men who did not differ
significantly regarding mean age (55.9 9.5 years; P =
.713), sex distribution (P = .163), percentage of smok-
ers (20.0%; P = .557), history of periodontal disease
(68.4%; P = .342), mean implant length (13.3 1.5
mm; P = .710), mean implant diameter (4.2 0.3 mm;
P = .247), mean number of implants per patient (4.8
0.8; P = .149), mean implant insertion torque (42.1
13.3 Ncm, P = .558), and bone quality (P = .381) com-
pared with the total collective. In the delayed loading
group, the random sample comprised 15 women and
5 men who also did not differ significantly regarding
mean age (65.1 8.7 years; P = .371), sex distribution
(P = .276), percentage of smokers (27.3%; P = 1.000),
history of periodontal disease (78.9%; P = .541), mean
implant length (12.4 1.2 mm; P = .099), mean im-
plant diameter (4.1 0.4 mm; P = .178), mean num-
ber of implants per patient (5.2 0.7; P = .919), mean
implant insertion torque (36.8 13.1 Ncm; P = .083),
and bone quality (P = .720) compared with the total
collective.
Marginal bone loss was 1.5 1.7 mm around im-
mediate loaded implants (mean observation period:
3.8 2.3 years) and 0.7 1.1 mm around delayed
loaded implants (mean observation period: 2.7 2.6
years) without significant differences between the
random samples (P = .379). Bone resorption did not
differ between tilted and axially placed implants (P
= .156). No differences regarding relevant confound-
ing variablespatient age (P = .330), sex (P = .450),
smoking (P = .474), implant length (P = .305), implant
diameter (P = .548), insertion torque (P = .191), and
bone quality (P = .201)could be observed. Marginal
bone resorption, however, was significantly higher in
patients with 4 vs 5 to 6 implants (1.6 1.7 mm vs 0.8
1.3 mm; P = .017) as well as with vs without a history
of periodontal disease (1.9 1.5 mm vs 0.8 1.3 mm;
P < .001).
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Busenlechner et al
1.0
0.8
Implant survival
0.6
0.4
0.2
0.0
0 2 4 6 8
a Years
1.0
0.8
Implant survival
0.6
0.4
0.2
0.0
0 2 4 6 8
b Years
Fig 2 Kaplan-Meier curves of implant survival rates following
(a) immediate loading and (b) delayed loading did not reveal sig-
nificant differences after a follow-up period of 8 years.
DISCUSSION
Comparing the results of part I24 and part II of the pres-
ent long-term follow-up of full-arch implant rehabilita-
tions in the maxilla, the following conclusions may be
drawn: estimated 8-year implant survival rates were
98.3% with immediate loading following late implant
placement, 96.7% with delayed loading following late
implant placement, 97.6% with immediate loading
following immediate implant placement, and 96.6%
with delayed loading following immediate implant
placement. No significant differences could be ob-
served between the four groups (P = .666), either be-
tween immediate vs late implant placement (P = .978)
or between immediate vs delayed loading protocols
(P = .283); however, implant survival with immediate
loading protocols was slightly higher overall (97.7% vs
96.6%). Marginal bone resorption was 1.1, 1.4, 1.5, and
0.7 mm, respectively, and did not differ significantly
between treatment regimes (P = .075), either between
timing of implant placement (immediate: 1.1 1.5 mm,
late: 1.2 1.4 mm; P = .122) or between loading proto-
cols (immediate: 1.3 1.6 mm, delayed: 1.0 1.3 mm;
P = .371).
A significant impact of (1) the number of implants
per patient as well as (2) the history of periodontal dis-
ease on marginal bone resorption could be observed
The International Journal of Oral & Maxillofacial Implants 1153
Busenlechner et al
in patients with a failing maxillary dentition; howev-
er, both factors did not affect implant survival rates.
Placing five or six implants resulted in a mean bone
resorption of 0.8 mm (compared with 1.6 mm with
four implants) corresponding to a significant mean
reduction of 0.8 mm (odds ratio: 2.0; P = .017). A re-
cent systematic review concluded that four implants
can suffice to support cross-arch prostheses if im-
plants are 10 mm long; however, long-term results
and randomized controlled trials (RCTs) comparing
different numbers of implants and designs for fixed
prostheses in edentulous arches are not available.25
A biomechanical analysis published in the same F.O.R.
consensus report26 concluded that compressive axial
loads are virtually the samebased on a Skalak-type
model27in configurations with four or six implants,
as long as the four implants span the same arc as the
six implants. In the first part dealing with completely
edentulous patients,24 contrary to the second part,
no differences could be substantiated between four
and five to six implants. In line with recent systematic
reviews,28,29 tilted implants were not associated with
increased bone resorption in both parts of the present
investigation (P = .624 and P = .156, respectively).
The same is true for patients with a history of peri-
odontitis: while no difference was found in edentulism,
mean bone resorption was 1.9 mm in periodontitis pa-
tients with a failing maxillary dentition (compared with
0.8 mm in patients without periodontitis) correspond-
ing to a significant mean reduction of 1.1 mm (odds
ratio: 2.4; P < .001). Again, implant survival rates were
not affected. It might be argued that bacteria related
to periodontitis and peri-implantitis can survive easily
when implants are placed at the time of tooth extrac-
tion, and one should refrain from immediate implant
insertion in cases of severe periodontal disease. A re-
cent microbial investigation, however, discovered that
complete edentulation and two-stage implant place-
ment after 6 months does lead to a significant reduc-
tion of bacteria, but also that key pathogens such as
Prevotella intermedia and Aggregatibacter actinomy-
cetemcomitans can survive without pockets.30 If peri-
odontopathogens do not disappear even 6 months
after full-mouth tooth extraction31ie, no eradication
can be achieved by elimination of subgingival niches
it remains doubtful if a pause between tooth extraction
and implant placement provides any benefit. By con-
trast, comparing immediate vs delayed implants in pa-
tients suffering from periodontitis yielded comparable
marginal bone loss (1.9 1.5 mm vs 1.3 1.3 mm;
P = .161) and even higher survival rates in periodontitis
patients with a failing dentition (97.8%) compared with
edentulous periodontitis patients (92.8%; P = .260).
Immediate implant placement at the time of tooth
extraction has been associated with a higher risk of
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implant failure and complications than delayed im-
plants.32 The present results, however, yielded no dif-
ference in failure rates between immediate (2.5%) and
delayed24 (2.6%) implants (P = .978). One possible ex-
planation might be that more than four implants are
often placed to replace a failing maxillary dentition,
while in the atrophic maxilla, the reduced bone volume
suffices for four implants only; however, mean numbers
of implants per patient were similar in both groups (4.9
and 4.7 implants, respectively). With immediate im-
plants, 71% of all failures occurred prior to definitive
prosthetic rehabilitation, while the percentage was
somewhat lower with delayed implants (53%). This may
as well serve as an argument for immediate loading, as
early implant failures do not necessitate refabrication
of the definitive prosthesis. The definitive implant fixed
partial denture may still be used after late failure of one
or even two implants, however, only if the most distal
ones are not affected or no more than four implants
were inserted in the first place. Neither implant survival
nor marginal bone levels were associated with implant
insertion torque; however, bridge insertion torque val-
ues23 were greater than 35 Ncm in all patient cases.
The present results compare favorably with the
scarce data in scientific literature33 reporting on Ka-
plan-Meier implant survival estimates of 94.9% [95%
CI: 92.7% to 97.1%] following immediate loading
(compared with 97.6% [95% CI: 96.7% to 98.6%] in the
present study) and 97.9% [95% CI: 95.5% to 100%] fol-
lowing conventional delayed loading (compared with
96.6% [95% CI: 94.3% to 98.9%] in the present study).
While in line with the established belief that immediate
loading does not deteriorate the outcome of full-arch
rehabilitation in the edentulous maxilla,34 the present
study results conquer the view that the combination of
immediate loading and immediate implant placement
in patients with a failing maxillary dentition may repre-
sent a risk factor for biologic complications.20 Further
research is indicated to investigate potential differenc-
es between staged and immediate approaches to the
transition from a failing maxillary dentition to full-arch
implant rehabilitation.
CONCLUSIONS
Summing up the results of part I24 and part II of the
present long-term follow-up of full-arch implant treat-
ment with 4 to 6 implants in the maxilla (1,797 implants
in 362 patients), it can be concluded that no differenc-
es regarding implant survival and marginal bone loss
were found between immediate loading (97.7%, 1.3
mm) and delayed loading (96.6%, 1.0 mm) protocols.
Similar rates of early (1.7%) and late (0.9%) implant fail-
ures were observed. In the edentulous arch, however,

53% of failures occurred prior to definitive prosthetic
restoration, compared with 71% after transition from a
failing dentition. In cases of immediate implant place-
ment at the day of tooth extraction (part II), marginal
bone resorption was significantly higher in patients
with 4 vs 5 to 6 implants (1.6 vs 0.8 mm) as well as with
vs without a history of periodontal disease (1.9 vs 0.8
mm). When choosing between loading paradigms for
fixed maxillary implant rehabilitation, immediate res-
toration may thus be favored to shorten periods of re-
movable provisionals.
ACKNOWLEDGMENTS
The authors would like to acknowledge the statistical support
by Magistra Petra Pokorny. The authors reported no conflicts of
interest related to this study.
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