IMPLANT

SINGLE CROWNS
RESD 854

Charles J. Goodacre, DDS, MSD

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

Osseointegrated implants have been successfully used to replace single teeth, both
anteriorly and posteriorly (figure 1A, 1B, 1C, 1D, 2A, 2B, 3A, 3B, 4A, 4B, 4C, 4D, 5A,
5B, 5C, 5D, 6A, 6B, 7A, 7B). While implant single crowns have been used for shorter
time periods than other types of implant prostheses, considerable information has
emerged regarding their design, clinical procedures, and success/failure/complications1-37.
A list of the complications identified in clinical studies of implant single crowns is
presented in table 1.

SUCCESS, FAILURE, COMPLICATIONS

Implant Loss
Between 1991 and 2001, 27 clinical studies10-36 reported data regarding the number of
implants placed and lost over a specified time. In the combined data from all the studies,
1870 implants were placed and they were observed for times between 1 and 10 years. A
total of 51 implants were lost for a mean loss of 3%. This failure rate, shared with
implants that support mandibular fixed complete dentures, is the lowest failure rate
encountered in implant prosthodontics. Three studies24,34,36 provided data that permitted
a comparison of maxillary and mandibular implant loss.

Six studies10,15,17,18,24,36 provided data regarding the time (preprosthetic or postposthetic)

when the implants were lost. Forty-seven percent of the implants were lost
preprosthetically and 53% postprosthetically.

Other Complications
Other implant single crown complications identified in the studies included prosthesis
screw loosening (26%)20,29; abutment screw loosening with early screw designs reported
from 1991-1996 (25%)10,13,15,16,18,19,21; fistulas at implant-abutment level
(8%)10,13,15,17,18,22;abutment screw loosening with newer screw designs reported from
1998-2000 (7%)25,26,30-33; esthetic problems (7%)10,15,19,25,30,37; implant dehiscence before
stage two (4%)10,17,22,23; neurosensory disturbance after surgery (4%)10,22; and abutment
screw fracture (2%)22,30.

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These incidences are specific to implant single crowns and therefore they differ from the
data presented in the implant complications portion of this CD (which was calculated by
combining the data from all types of prostheses).

DESIGN PRINCIPLES

Rangert, Jemt and Jörneus1 (reference 1) evaluated the forces and moments that occur on
Brånemark implants. They proposed some general design guidelines for implants that
included recommendations regarding how far the crown can extend lateral to the implant
without creating a potential overload situation (the dimensions of the occlusal table
compared to the implant diameter). In another article2, information regarding bending
overload and implant fracture is presented (reference 2). Rangert et al3 also identified
risk factors that increase the load applied to implants and several of these factors can be
related to implant single crowns (reference 3).

Anterior Biomechanics
Given the previously cited guidelines of Rangert et al1, it appears reasonable to conclude
that anterior implant single crowns can extend laterally beyond the implant a distance that
is about 2 times the diameter of the implant (the maximum horizontal cantilever). As an
example, if an anterior crown is being placed on a 4 millimeter diameter implant, the
crown can safely extend mesial, distal, facial, or lingual to the implant a distance of 8
millimeters (2 times the implant diameter) before a biomechanical overload is developed.

There are no anterior teeth where the mesiodistal or faciolingual dimensions would create
an adverse lever arm since no anterior tooth even approaches such a mediodistal (figure
8, 9) or faciolingual dimension. However, in an incisocervical dimension, biomechanical
overload of an anterior crown is more likely to occur since the distance from the top of
the implant to the location of occlusal contact can be substantial especially when the
implant is placed deep below the soft tissue for esthetic reasons (figure 10A, 10B).

When there is the potential for implant overload due to the presence of risk factors,
alterations in the incisal guidance and implant angulation in the bone may be helpful in
decreasing the potential for overload4 (reference 4).

Posterior Biomechanics
In applying the previous recommendations about forces and moments1 to posterior single
crowns being placed on implants, it appears the crown should not extend lateral to the
implant more than one implant diameter. For a 4 millimeter diameter implant, the
maximum lateral cantilever is 4 millimeters. Therefore, the crown can only extend
mesially, distally, facially or lingually a distance of 4 millimeters beyond the implant
(figure 11A, 11B).

This relationship limits the total mesiodistal or faciolingual dimension of the crown to 12
millimeters. The dimensions of a typical premolar do not exceed these guidelines nor do
average sized molars. However, there can be a potential biomechanical overload with

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molars due to the presence of heavy occlusal forces (figure 12A) or larger than normal
mesiodistal/faciolingual dimensions.

Figure 13 has been adapted from a figure in reference 2 and documents the relative
number of fractures that occurred with implants located in first molar sites. Should a
single molar implant be placed so it is not centered under the crown, biomechanical
overload is much more likely to occur (figure 14A, 14B, 14C, 14D, 15A, 15B). The
possibility of an overload also increases as the distance from the occlusal surface to the
implant increases (figure 16A, 16B).

Methods of compensating for potential overload of 4 millimeter diameter molar implants

include narrowing the occlusal table or the use of 2 implants to support one molar crown
(figure 17A, 17B, 17C, 17D, 18A, 18B, 19A, 19B). A common method of compensating
for potential overload is to use a wider diameter implant (5 or 6 millimeters) (figure 7A,
7B, 12A, 12B, 12C).

A clinical report5 has been published regarding the use of wide diameter implants and
double implants. The report indicates good success is possible but the authors emphasize
the importance of proper surgical execution (Bahat, 1996).

A study6 of 47 patients compared the use of one implant with the use of 2 implants to
replace a single molar. Of 72 implants placed, one was lost. There was much greater
screw loosening (48%) in the one implant group compared with the two implant group
(8%), demonstrating a biomechanical advantage of using 2 implants to replace one molar
(Balshi, 1996).

Implant Location/Alignment
The location of the implant in the bone is an important aspect of biomechanical success
and crown esthetics with using implant single crowns.

The implant should be centered mesiodistally in the edentulous space for esthetic and
biomechanical reasons (figure 1A, 1D, 4B, 4D, 20A, 20B). This position equalizes the
lever arm developed by the mesial and distal portions of the crown which project laterally
to the implant. When the implant is displaced to the mesial or distal of center and
occlusal forces are applied, there is greater leverage exerted on the implant and other
components than if the implant were centered (figure 21A, 21B).

Centering the implant mesiodistally also facilitates the development of normal emergence
profile and permits better morphologic replication of the contralateral tooth (figure 22A,
22B).

When locating the implant in bone, care must be exercised to avoid approximating
adjacent teeth which can lead to the need for endodontic treatment, damage to the roots,
and/or loss of the implant (figure 23A, 23B).

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The faciolingual positioning of the implant is also important to biomechanical success.
Centering an implant beneath a posterior crown helps reduce the potential for
biomechanical overload, a factor particularly important for molars or premolars when
heavy occlusal forces are present.

In esthetically critical locations, a position slightly to the facial is preferred when existing
bone dimensions permit (figure 1A, 24). Centering the implant faciolingually may
produce a crown with deficient cervical contour (figure 6A) or a crown where porcelain
must overlap the facial soft tissue to create the desired cervical crown morphology
(figure 25A, 25B, 22B, 26A, 26B). The overlapping makes oral hygiene more difficult
and could present an esthetic liability should the soft tissue position recede apically.

When the implant is placed lingual to the faciolingual center of the adjacent teeth, there
will either be a substantial amount of the crown overlapping (figure 27A, 27B, 27C)
facial soft tissue (like occurs with certain fixed partial denture pontics) or the crown will
assume a form with significant cervical deficiencies (figure 28A, 28B). Placing an
implant too far facially creates substantial esthetic challenges that often cannot be
overcome (figure 29A, 29B). It is possible that an implant could be so malaligned that it
would have to be removed, bone fill allowed to occur, and another implant subsequently
placed in a more favorable position.

Aligning the implant so it will be perpendicular to the occlusal surface decreases the
leverage that will be applied to the various metal components (figure 30A, 30B).

The incisocervical/occlusocervical location of the implant is largely determined by the

location of existing bone (figure 1C, 4B, 10B, 16B) and the esthetic need to transition
from a smaller diameter round form to a larger diameter form with a different geometric
perimeter. Typically, implants have been placed apical to the cementoenamel junction of
adjacent teeth to permit the required changes in morphology to occur somewhat gradually
(figure 31). One textbook7 recommended that implants located in the esthetic zone be
placed 4 millimeters or more apical to the cementoenamel junctions of adjacent teeth
(Parel, 1989).

Soft Tissue/Interdental Papilla Form

Achieving ideal soft tissue form and interdental papilla height can be a challenge when
placing implants into highly visible edentulous areas (figure 1D, 2B, 3B, 4D, 5C, 5D).

Interdental dark spaces may be present (figure 2B, 32A, 32B, 32C, 32D), the marginal
tissue may be thicker than the gingival margin present around adjacent teeth (figure 32B,
33A, 33B, 33C, 33D), the apical location of the soft tissue margin may not be at the same
height as adjacent or contralateral natural teeth (figure 3B, 22B), interdental papillae may
not possess the most desirable form or height (figure 1D, 2B, 3B, 32B, 32C, 32D, 33C,
33D), or recession of the soft tissue may lead to crown length variations and/or exposed
metal (figure 34A, 34B).

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Some of these deficits may not be noticeable to patients whereas others can produce
substantial esthetic challenges. Fortunately, if bone is present at the proper height
interproximally, the soft tissue can fill in small spaces over time (figure 4C, 4D).

One study8 of 21 patients compared the use of a conventional surgical flap that included
the interdental papilla with a design that did not sever the 2 interdental papillae when a
single implant had been placed. The modified flap design preserved at least 1 millimeter
of both papillae (adjacent to the natural teeth). A reduction in the crestal bone loss was
noted which presumably would enhance the esthetic result achieved (Gomez-Roman,
2001).

Gingival recession has been measured in a 1-year prospective study9. The authors
indicate about 1 millimeter of recession can generally be expected following abutment
connection surgery. Eighty percent of the buccal sites exhibited recession. Since most of
the recession occurred within the first 3 months, the authors proposed waiting 3 months
after abutment connection surgery before making the definitive impression (Small, 2000).

The longer the area has been edentulous, the more likely there will be a soft tissue
discrepancy due to bone resorption and concomitant changes in the soft tissue contour.
When there will be a substantial esthetic deficiency as noted clinically or from a
diagnostic wax pattern formed on a cast, bone and/or soft tissue grafting may be
necessary (figure 35A, 35B, 35C). However, some esthetic deficiencies are not totally
correctable through grafting procedures and therefore it is generally felt that emphasis
should be placed on retaining soft tissue form rather than restoring lost tissue. Methods
of retaining soft tissue form and location include immediate implant placement and
immediate placement of a provisional restoration when these procedures are indicated.

SYNOPSIS OF DESIGN GUIDELINES

• Center the implant mesiodistally in the edentulous space.

• If possible, position the implant faciolingually so a normal emergence profile can be
developed and the crown does not have to overlap the peri-implant mucosa on the
facial surface to develop proper cervical contour.
• If facial overlapping of the soft tissue will be necessary, consider some type of bone
augmentation procedure so the implant can be placed in a more facial location.
• Place the implant as perpendicular to the occlusal surface as possible.
• With posterior implant single crowns, avoid extending the occlusal surface lateral to
the implant by a distance greater than the diameter of the implant.
• Use wider diameter implants when access, bone dimensions, and esthetics permit.
• Maintain light centric occlusal contact (shim stock just slides through) between the
implant single crown and the opposing tooth during normal tapping occlusal contact.
• When the patient fully engages their musculature, the shim stock should only then be
grasped by the crown with the same intensity as opposing natural teeth.
• Avoid eccentric occlusal contact on the implant single crown or develop group
function if contact cannot be avoided.

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• The presence of bruxism increases the magnitude of the force applied and its
frequency. Avoid using short implants and have the patient wear an occlusal device
(night guard).

CLINICAL PROCEDURES

Examination/Diagnosis and Treatment Planning

A clinical examination, medical and dental history, periapical and bitewing radiographs,
and diagnostic casts are required to plan treatment. There should be an evaluation of
systemic factors that can compromise implant success. The clinical examination and
radiographs should be used to evaluate bone health and quality,
incisocervical/occlusocervical bone dimensions, the distance between adjacent roots,
presence of any caries, the pulpal and periodontal health of adjacent teeth, and the
quality/integrity of existing restorations in adjacent teeth. Any diseases in teeth
approximating the edentulous area should be treated. Untreated diseases can cause
implant loss.

When examining patients who have single missing teeth and could potentially benefit
from implant supported/retained single crowns, it is important to determine if the
morphologic form of a crown would be esthetically appropriate when developed on the
existing edentulous ridge with the implant contained in available bone (figure 36A, 36B,
36C, 36D). This decision requires that a diagnostic pattern of the crown be developed.
Any esthetic deficiencies in crown dimensions or cervical contour due to bone resorption
of the alveolar ridge will be identified by this diagnostic procedure.

Radiographic Template
Through either bone sounding or a linear tomogram, it is possible to determine available
bone dimensions in the alveolar ridge. By using a radiographic template in conjunction
with a linear tomogram (figure 37A, 37B, 37C, 37D), the diagnostic form/location of the
crown can be related to available bone to determine if an implant can be positioned
within available bone and lead to the development of a crown with appropriate form and
dimensions. This data coupled with the clinical examination, diagnostic casts, and
diagnostic pattern of the most desirable crown form will identify patients where bone
augmentation will be necessary to achieve the best possible esthetic result and allow the
patient to make decisions regarding their treatment.

Ridge Augmentation
When ridge augmentation is needed, the ideal ridge form can be developed in wax on the
diagnostic cast while simultaneously adapting a denture tooth to the wax ridge. This
process is continued until the desired crown form is established (figure 38A). A
provisional removable partial denture can then be fabricated over the form of the ideal
ridge that was developed in wax.

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The provisional prosthesis serves to validate the desired esthetic crown form (figure 38B,
38C) and also can be used as a template during the ridge augmentation procedure. The
flap is reflected (figure 38D), bone graft material packed against the ridge (figure 38E),
the provisional prosthesis placed into the mouth for the purpose of evaluating whether the
ridge has been sufficiently enhanced in size (figure 38F), and then a barrier membrane
placed over the graft material (figure 38G).

The flap is then closed and sutured (figure 38H). After healing, an assessment can be
made as to whether the desired ridge form has been achieved. A less than optimal
incisocervical result can be seen in figures 38I, 38J, 38K, 38L, and 38M.

A better result can be observed in figures 35A, 35B, 35C, 39A, 39B, 39C, 39D, 39E.

Surgical Template/Implant and Abutment Placement/Provisional Crown

Based on a pattern of the most desirable crown form and location, a surgical template is
fabricated to guide implant placement (figure 40A, 40B, 40C, 40D). The implant is
placed and the soft tissue sutured. After the appropriate healing time, the implant is
uncovered and either a healing abutment or a definitive abutment placed.

In esthetic zones, placement of a definitive abutment and provisional crown allows the
soft tissue form to be developed around the contours of the provisional crown which can
be more natural in shape than healing abutment contours (figure 41A, 41B, 41C, 41D,
41E, 41F, 41G, 42A, 42B, 42C).

Impression/Cast/Crown Fabrication
When a definitive prefabricated abutment (supplied by a manufacturer) has been placed,
an abutment level impression is made using an impression coping (figure 43A, 43B,
43C, 43D, 43E, 43F). An abutment analog is positioned into the impression coping and
a cast poured (figures44A, 44B).

More commonly, an implant level impression is made using an impression coping that
attaches to the implant (figure 45A). There are two types of impression copings: tapered
(allows the impression to be removed from the mouth while the impression coping
remains attached to the implant); and geometrically shaped copings that possess
undercuts (the impression cannot be removed from the mouth until the coping is
unscrewed from the implant).

Tapered impression copings are used when the long axis of the implant (and therefore the
long axis of the coping) is sufficiently parallel to the natural teeth that the impression can
be removed from the mouth after the impression material polymerizes (Video A). This
type of impression has been termed a closed-tray impression because a conventional
impression tray can be used (the impression tray does not have to have a hole in its
surface to provide access to the impression coping after the impression material
polymerizes).

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When the long axis of the implant is different from the remaining teeth, impression
material locks around a tapered impression coping (due to its angulation being different
from the teeth) and prevents removal of the polymerized impression from the patient's
mouth. Under these circumstances, a geometrically shaped coping is used (Video B).
The geometric form (that possesses undercuts) allows the coping to be grasped by the
impression material and it is therefore retained in the impression material. A screw (in
the form of a metal rod) is used to attach this form of coping to the implant. The metal
rod (screw) is long enough to pass through the impression tray. The screw can then be
loosened after the impression material polymerizes, allowing the impression to be
removed while the coping is retained within the impression material. This type of
impression has been termed an open-tray impression because the impression tray must
contain a hole through which the screw can project, thereby permitting the screw to be
loosened after the impression material hardens.

An implant analog (machined replica of the implant) is attached to the coping and a cast
poured (figure 45B). The resulting cast can then be used to determine the most
appropriate size and type of prefabricated abutment to used (figure 46A, 46B, 46C, 46D,
46E, 47A, 47B, 47C, 47D, 47E, 47F) or a custom abutment can be fabricated (figure
48A, 48B).

It is also possible to place a prefabricated abutment, prepare the metal in the same manner
that a tooth would be prepared (figure 49A), place gingival retraction cord, make a
conventional impression (figure 49B) that records the abutment finish line and shape of
the prepared abutment, and then pour a die and cast (figure 49C).

The definitive crown is fabricated on the working cast in a manner that it can be
cemented over the abutment (figure 50A, 50B, 50C) or be retained by a screw (figure
51A, 51B, 51C, 51D).

TABLE

Table 1
Implant Single Crown Complications

# Studies Total # Patients or

Providing Data
Prosthesis screw loosening
Abutment screw loosening (1991-1996)
Fistula at implant-abutment level
Abutment screw loosening (1998-2000)
Esthetic problems
Implant dehiscence before stage two
Neurosensory disturbance (after surgery)
Implant loss
Abutment screw fractures
Components Affected (%)
2 27 of 105 screws (26)
7 151 of 613 screws (25)
6 38 of 451 implants (8)
6 42 of 623 screws (7)
6 34 of 483 crowns (7)
4 11 of 270 implants (4)
2 5 of 141 patients (4)
27 51 of 1870 implants (3)
2 4 of 165 screws (2)

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REFERENCES

1. Rangert B, Jemt T, Jörneus L. Forces and moments on Brånemark implants. Int J

Oral Maxillofac Implants 1989;4:241-247.

Based on theoretical considerations and clinical experience with Brånemark implants,

this article presented quidelines for controlling the forces applied to implants. They
recommended that the restoration not extend lateral to the implant more than
approximately one implant diameter in the molar region and no more than two implant
diameters in the incisor region. They indicated greater extensions may be acceptable if
more than one implant is being subjected to the bending moment, such as with an implant
fixed partial denture or an implant fixed complete denture.

2. Rangert B, Krogh PHJ, Langer B, Van Roekel, N. Bending overload and implant
fracture: A retrospective clinical analysis. Int J Oral Maxillofac Implants
1995;10:326-334.

Probable causes of 39 implant fractures were discussed as they related to 39 patients that
had been treated by 3 of the authors. Eighteen implants fractured while supporting a
posterior fixed partial denture, 9 while supporting a single crown, 7 while connected to a
natural tooth, 4 while supporting a maxillary fixed complete denture, and 1 while
supporting an overdenture.

All 9 fractures of implants supporting single crowns occurred in the mandibular molar
area (8 first molars and 1 second molar). Several factors were discussed that place
adverse loads on implants and they included the following:
a. excessive height of the occlusal surface above the implant;
b. deviation of the long axis of the implant from a perpendicular relationship to
the occlusal plane;
c. substantial differences between the dimension of the occlusal surface and the
diameter of the implant; and
d. bruxism or heavy occlusal forces.

3. Rangert BR, Sullivan RM, Jemt TM. Load factor control for implants in the posterior
partially edentulous segment. Int J Oral Maxillofac Implants 1997;12:360-370.

This article identified risk factors that increase the load applied to implants. Several of
the factors can be related to implant single crowns: extension of the occluding surfaces
lateral to the implant (creating leverage); increasing the distance from the occlusal
contact to the implant; use of one implant to support a multi-rooted tooth; and bruxism or
the presence of heavy occlusal forces as evidenced by wear/tooth structure fractures.

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When a molar is replaced by using a single implant, the authors emphasize the
importance of controlling the occlusion so it is not in heavy centric occlusal contact.
They suggest light centric occlusal contact.

4. Katona TR, Goodacre CJ, Brown DT, Robert WE. Force-moment systems on single
maxillary anterior implants: effects of incisal guidance, fixture orientation, and loss
of bone support.

An engineering model was developed that compared the effects of incisal guidance
steepness, implant angulation in the bone, and the level of bone support on the moment
developed on the implant. Reducing the steepness of the incisal guidance reduced the
moment and labial component of force. Implants that can be placed more vertically in
the bone because of existing maxillary bone morphology will have reduced moments
placed on the implant. Changes in the bone height (either due to bone loss or from more
apical placement of the implant) increased the moment. Five millimeters of change in the
bone height doubled the moment.

REFERENCE LIST

1. Rangert B, Jemt T, Jörneus L. Forces and moments on Brånemark implants. Int J

Oral Maxillofac Implants 1989;4:241-247.
2. Rangert B, Krogh PHJ, Langer B, Van Roekel N. Bending overload and implant
fracture: a retrospective clinical analysis. Int J Oral Maxillofac Implants
1995;10:326-334.
3. Rangert B, Sullivan RM, Jemt TM. Load factor control for implants in the posterior
partially edentulous segment. Int J Oral Maxillofac Implants 1997;12:360-370.
4. Katona TR, Goodacre CJ, Brown DT, Roberts WE. Force-moment systems on single
maxillary anterior implants: effects of incisal guidance, fixture orientation, and loss
of bone support. Int J Oral Maxillofac Implants 1993;8:512-522.
5. Bahat O, Handelsman M. Use of wide implants and double implants in the posterior
jaw: a clinical report. Int J Oral Maxillofac Implants 1996;11:379-386.
6. Balshi TJ, Hernandez RE, Pryszlak MC, Rangert B. A comparative study of one
implant versus two replacing a single molar. Int J Oral Maxillofac Implants
1996;11:372-378.
7. Parel SM, Sullivan DY. Esthetics and Osseointegration, Dallas, Osseointegration
Seminars Incorporated, 1989, pp19-23.
8. Gomez-Roman G. Influence of flap design on peri-implant interproximal crestal
bone loss around single-tooth implants. Int J Oral Maxillofac Implants 2001;16:61-
67.
9. Small PN, Tarnow DP. Gingival recession around implants: a 1-year longitudinal
prospective study. Int J Oral Maxillofac Implants 2000;15:527-532.
10. Jemt T, Laney WR, Harris D, Henry PJ, Krogh PH Jr, Polizzi G, et al.
Osseointegrated implants for single tooth replacement: a 1-year report from a
multicenter prospective study. Int J Oral Maxillofac Implants 1991;6:29-36.

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11. Babbush CA, Shimura M. Five-year statistical and clinical observations with the
IMZ two-stage osteointegrated implant system. Int J Oral Maxillofac Implants
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12. Fugazzotto PA, Gulbransen JH, Wheeler SL, Lindsay IA. The use of IMZ
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19. Haas R, Mensdorff-Pouilly N, Mailath G, Watzek G. Brånemark single tooth
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20. Becker W, Becker BE. Replacement of maxillary and mandibular molars with single
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21. Henry PJ, Laney WR, Jemt T, Harris D, Krogh PHJ, Polizzi G, Zarb GA, Herrmann I.
Osseointegrated implants for single-tooth replacement: a prospective 5-year
multicenter study. Int J Oral Maxillofac Implants 1996;11:450-455.
22. Avivi-Arber L, Zarb GA. Clinical effectiveness of implant-supported single tooth
replacement: the Toronto study. Int J Oral Maxillofac Implants 1996;11:311-321.
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Astra Tech dental implants: a 2-year report. Int J Prosthodont 1997;10:318-324.
24. Kemppainen P, Eskola S, Ylipaavalniemi P. A comparative prospective clinical
study of two single-tooth implants: a preliminary report of 102 implants. J Prosthet
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25. Andersson B, Ödman P, Lindvall A-M, Brånemark P-I. Cemented single crowns on
osseointegrated implants after 5 years: results from a prospective study on CeraOne.
Int J Prosthodont 1998;11:212-218.
26. Scheller H, Urgell P, Kultje C, Klineberg I, Goldberg PV, Stevenson-Moore P,
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