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Conventiona l care for pa-tients w ho suffer from part ial

edentulism includes fixed par-

tial dentures, resin-bonded

restorations and r emovable par-

tia l denturesor no treatm ent

a t a ll. Use of a more recently

developed trea tm ent, osseointe-

grated implant-supported pros-

theses, has increa sed based onthe successful outcomes of im-

plant restorations in partially

edentulous pa tients.1

The best t reat ment for a ny

patient varies with the patients

desires an d a bility t o afford

care, as w ell as t he dentist s

perception of th e reliabilit y of

any pa rt icular t reatm ent

modality. Avivi-Arber and Zarb2

ha ve stat ed tha t good evidence

regarding the relat ive efficacy,effectiveness, a nd longevity of

the tra dit ional t reatment op-

tions is largely a necdotal.

Thus, compar ing t ra ditiona l

treatments with implant t reat -

ment is extremely difficult.

There a re, however, d ocument -

ed reas ons to choose implan ts

over traditional treatments in

restoring par tia l edentulism.

These include problems with

tissue tolerance or comfort and

a ccepta nce of removable part ial

dentures, pat ients a nd dentists

relucta nce to sacrifice sound

tooth tissue to a ccommodat e

fixed partial dentures and the

unpredicta ble survival r a tes of

resin-bonded restora tions.2-5

The surviva l of impla nt

restorations in pa rtia lly edentu-

lous patients ha s been w ithin

ra nges simila r t o those for im-

plant surviva l in tota lly edentu-lous patients. In a follow-up

study of impla nt restora tions in

part ially edentulous pat ients in

wh ich some restora tions were

checked at one yea r a fter place-

ment a nd others checked at five

years, J emt and collea gues6 re-

ported overall fixture surviva l

rates of 94 percent in the maxil-

la a nd 99 percent in t he

mandible. A multicenter

prospective study by Higuchi,Folmer a nd Kultje7 demonstrat-

ed a cumulative success rate of

92.5 percent for the maxilla and

93.9 percent for t he ma ndible.

La ney a nd collea gues8 reported

a cumulative success ra te of

97.2 percent after three years in

maxillary or mandibular single-

tooth replacements.

Longer-term surviva l of im-

plants and their restorations

J ADA, Vol. 129, August 1998 1097

This article presents prospective

four-year prosthetic results of

the placement of 432 posterior

freestanding, conventionally ce-

mented prosthetic tooth im-

plants in posterior edentulous

spaces using the Bicon Dental

Implants system (Bicon Dental

Implants). Over four years, 0.74

percent of the abutments loos-

ened, 0.5 percent of the abut-

ments fractured, and 2.47 per-

cent of the crowns experienced

porcelain fracture, (all porcelain

fractures occurred at time of

placement). This low rate of

problems appears to make free-

standing single-tooth implant

restorations a reliable solution

to treating posterior edentulism.

A B S T R A C T

REPLACING POSTERIOR TEETH WITH FREESTANDING IMPLANTS:FOUR-YEAR PROSTHODONTIC RESULTS OF A PROSPECTIVE STUDYALI MUFTU, D.M.D., M.S.; ROBERT J. CHAPMAN, D.M.D.

JA D A

C

O

NT

INU

ING E DU

CAT

I

O

N

ARTICLE 1

Copyright 1998-2001 American Dental Association. All rights reserved.


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Mecha nical and potential

bacterial problems, even if they

do not result in bone loss

a round implant fixtures, can be

considered by both pa tient a nd

dentist a s fai lures, or a t least a sma jor complicat ions in the im-

plant reconstruction. P a tients

do not w ant implants , they

wa nt teeth. And problems such

a s broken or loosened screws, or

bad ta ste or odor from ba cteria

growing along abutment

threads, a re reminders tha t

they ha ve not teeth, but im-

plants .

Implant ma nufacturers have

attempted to overcome mechan-

ical problems by in corporat ing

a ntirota tional d esigns. These

include screw systems using ex-

terna l hexagons, interna l oc-

tagons, combination of screws

a nd frictional systems such as

Morse ta pers, conica l seal t a -

pers a nd a locking ta per sys-

tem. Among th ese, the lockingta per impla nt-a butment connec-

tion appea rs to have two main

a dva nta ges over existing screw

designs. These adva nta ges are

the a ntirota tion of the post in

the fixture a nd t he superior me-

chanical strength of the tita ni-

um a lloy over commercia lly

pure t i tanium.

This a rt icle presents pros-

thetic results from a continuing

have been of some concern.

There ha s been part icular con-

cern a bout t he use of implant s

in t he posterior region from mi-

crobial a nd mechanical a spects.

Studies have shown t hat therea re significa ntly higher num-

bers of periodonta l pat hogens in

th e peri-impla nt sulci of im-

plant restorations in partially

edentulous pa tients tha n in

those of implant restorations in

tota lly edentulous pat ients.9-11 I t

a lso ha s been hypothesized tha t

periodontal pockets a round na t-

ura l teeth can a ct as a r eservoir

for bacterial colonization

around t i tanium implant s .12Additiona lly, the screw thr eads

used to secure most a butments

to the implant fixture have been

shown both in vitro and in vivo

to harbor bacteria.13-15

Mecha nical concerns, on the

other ha nd, concentra te on un-

favora ble stress distribution

owing to ana tomica l reasons, in-

adequate number of implants,

excessive loa ds compa red w ith

a nterior regions tha t ma y com-promise osseoint egra tion.

Another common pr oblem a s-

socia ted w ith sin gle-tooth re-

placements a ppea rs t o be the

loosening of screws.15 Similar

problems a re experienced wit h

fixed par tia l dentures on im-

plant s. Interestingly, the per-

cent a ges of screw loosening a nd

need for retightening va ry

among reporting groups.2,16-22

P ossible reasons include a num-ber of varia bles such as t he

ma croscopic sha pe of screws,

the torque applied, ma terial

strength properties, fit of the

framework, occlusal contacts

a nd opera tor experience. One

study 22 noted th e frequency of

such complications in the par-

tially edentulous arch to be less

tha n in full-a rch implant pros-

theses.

prospective stud y on t he effec-

tiveness of the locking ta per in

posterior teeth replacements in

wh ich each implant is restored

as a freesta nding unit .

METHODS AND

MATERIALS

This st udy in cludes the pros-

thetic results of 168 patients

(84 men a nd 84 women) who

were trea ted between May 1992

and J uly 1996 at t he Implant

Dentistry Centre at the

Fa ulkner H ospital in B oston for

replacement of posterior t eeth.

All pat ients were examined

by a n oral surgeon a nd arestorative dentist . B efore

trea tment, t he clinicians re-

viewed ea ch patient s medical

and dental history in deta il .

P anoramic radiographs were

used for radiologic assessment.

The following inclusion criteria

were used for t he study:

dany posterior edentulous

space with sufficient bone qua li-

ty to allow for insertion of a t

least a 3.5 8-millimeter Biconimplant (Bicon Denta l

Implants);

dthe patient s relucta nce to

ha ve a removable pa rtia l den-

ture in d ista l extension cases;

dthe patient s relucta nce to

ha ve inta ct adjacent teeth pre-

pared for fixed partia l dentures;

dinsufficient periodonta l sup-

port on nat ura l abutm ents for a

conventiona l fixed pa rtia l den-

ture.Exclusion criteria for st udy

evalua tion were as follows:

da ny syst emic condition tha t

would pla ce the pat ient a t risk

during m inor ora l surgery pro-

cedures;

da current or past progra m of

radia t ion therapy in the head

and neck region;

ddrug a nd a lcohol a buse;

dpsychological problems;

1098 J ADA, Vol. 129, August 1998

RESEARCH

Mechanical and po -

tent ial bacter ial prob -

lems, even if they d o

not resul t in bone

loss around implant

f ix tures, can be co n-

s idered by bo th pa-

t ient and dent ist as

failures.



3/6

dpresence of complet e or re-

movable part ial dentures in the

opposing dentit ion.

The clinicians restored 98

ma xillas a nd 103 mandibles.

Forty-one ma xilla ry jaw s under-went sinus elevat ion surgery

a nd four ma ndibles underwent

ridge augmenta tion because

they did not ha ve an a dequate

qua nt ity of bone. The clinician s

placed 190 maxillary a nd 242

ma ndibular implant s. The same

experienced oral surgeon per-

formed a ll surgeries. Impla nt

site prepara tion wa s performed

according to the technique re-

quired for th e Bicon Denta lImplants system.23 Initia l pene-

tra t ion for the implant si te was

done under irriga tion using a

2.0-mm pilot d rill a t 1,100 rota -

tions per minute, or rpm, then

lat ch reamers of the a ppropri-

a te diameter at 50 rpm with out

irrigat ion. All implant s w ere ex-

posed after a healing period of

at least four months in the

ma ndible a nd six months in the

ma xilla. Specific healing t imefor a ny one of the implants w a s

determined by visual exa mina -

tion of the quantity of bone on

the 3.5-mm-diameter reamer.

The clinicia ns pla ced a nd ori-

ented the final cement-type

a butments a ccording to the

technique recommended by the

ma nufa cturer. All implant s

were restored by th ree sta ff

dentists a minimum of four to

six weeks after impla nt expo-sure surgery. In a reas w here es-

th etics were not a concern, a

knife-edge crown m a rgin a t the

sa me level a s or slightly superi-

or to the peri-impla nt mucosal

ma rgin wa s preferred. In es-

thet ically importa nt ar eas, a

1.0-mm bucca l sh oulder finish

line was prepa red below the

peri-implant mucosa l ma rgin.

Conventional prosthetic tech-

niques and materials were used

for impression procedures. E a ch

implant w a s restored using a

freesta nding cemented crown .

Occlusal tables of molar

restorations were narr owed in

most instances. All prosthetic

treatment wa s completed w ith-

in five clinical visit s.

P eriodic exam inat ions w ere

performed a t one week, sixmonths an d 12 months aft er the

final restorat ion placement a nd

every 12 months thereafter. At

these visits, the clinicians ob-

ta ined periapical and panoram -

ic radiographs a nd a ssessed soft

tissue. The clinicians reinforced

oral hygiene instructions a nd

removed plaque if necessary.

Removal of an implant w as

ba sed on presence of suppura -

tion, continuing pain, mobilityor progress ive bone loss. The

clinicians noted any problems

with the prosthetic abutments

a nd crown s and performed any

necessa ry corrections.

Statistical analysis. As th enum ber of prosthetic complica-

t ions wa s very small at the

four-yea r reporting period, we

did not use predictive sta tistics.

Inst ead, w e will use such pre-

dictive ana lyses at the six- a nd

eight-yea r reporting periods.

RESULTS

A tota l of 168 pa tient s received

432 posterior impla nt s to sup-

port 432 freestanding restora-

tions. Of t hese, 82 were single-

tooth replacements and 350

w ere mult iple-tooth r eplace-

ment s (Ta ble 1). S ingle-toothrepla cement w as defined as

placement of a single implant

between two na tura l teeth, or of

a single implant to restore a

distal extension edentulous

a rea . Multiple-tooth replace-

ment w a s defined a s restora tion

of more tha n one missing poste-

rior tooth in a qua drant in ei-

th er tooth -bounded or dist a l ex-

tension a reas, wit h each

implant supporting a singlecrown an d with no splinting.

Implant survival. The cu-mula tive success ra te for im-

plant survival a t t he end of four

years wa s 90.0 percent for the

ma xilla a nd 96.8 percent for t he

mandible. All implant lossesa

tota l of 28occurred w ith in one

year of loa ding, and t he ma jori-

ty of them (24) occurred w ith in

six months. After a ppropriat e

J ADA, Vol. 129, August 1998 1099

RESEARCH

TABLE 1

NUMBER OF

TEETH MISSINGIN A PATIENT

1

2

3

4

5

6

7

8

35

33

18

11

2

1

3

1

47

25

15

6

3

0

1

0

82

116

99

68

25

6

28

8

NUMBER OF MISSING TEETH PER JAW.TOTAL NUMBER OF PEO-

PLE MISSING THAT NUM-BER OF TEETH (BY JAW)

TOTAL NUMBER

OF MISSINGTEETH

Mandible Maxilla



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healing periods an d gra fting

procedures, each failure site

wa s reimplanted w henever t he

pat ient a greed (these sites werenot included in the prosthetic

analysis for the purposes of this

resear ch). The deta ils of im-

plant survival w ill be reported

in an other a rticle.

Dropouts. Two patients,each of whom ha d one ma ndibu-

lar single-tooth replacement,

died during t he course of the

study: one at the end of eight

months loa ding owing t o

aneurysm and t he other at theend of 13 month s loa ding owing

to lung cancer. In both of these

pat ients, the implant s were in

sta ble condition at t he last visit .

No other pa tients w ere lost to

follow-up. However, the interval

between annual appointments

var ied up to a month in some

cases.

Prosthetic complications.Two abutm ents fractured with -

in the first y ear of loa ding inteet h n os. 4 an d 30 (Ta ble 2).

The clinicia ns r etrieved th e

fractured posts by drilling out

the fra ctured portion with a

high-speed handpiece under co-

pious irriga tion using a no. 330

pea r-sha ped car bide bur, then a

no. 4 round ca rbide bur. The re-

ma ining part of the post w as

lifted from th e locking ta per re-

cepta cle in the implan t using a

sickle-sha ped scaler. After t his

procedure, t he clinicia ns placed

a butments of the sam e size as

used before, and they recement-ed the sa me crown s in place.

These pa tients did not ha ve fur-

ther problems with the new

abutments.

Three prosthetic abutments

became loosein t eeth nos. 2,

12 a nd 14over the period of

the study. After separa ting the

cemented crown from t he a but-

ment, t he clinicia ns r einserted

the same a butments and rece-

ment ed th e crow ns. The clini-cians observed no furt her loos-

ening of the abut ments or any

other prosth etic complica tions.

A total of 10 porcelain fail-

ures occurred. They all hap-

pened a t t he time of fina l ce-

mentation when porcelain

fra ctured or chipped on the

fa cial surfa ces of the crown s.

Therefore, the clinicians as-

sessed these problems a s iat ro-

genic and redid the restorations.Tw o pa tient s each lost one

crown that was temporarily ce-

mented. New restorations were

fabricat ed and delivered with

no furth er problems.

The ra te of abut ment compli-

cationsfra cture or loosening

for the four-year period was

1.24 percent, and the rate of

a butm ent-plus-prosthetic com-

plicationsporcelain fra cture

and crown fracture or loosen-

in gfor t he sam e period w as

3.71 percent .

DISCUSSION

Replacement of single or multi-

ple missing posterior teeth using

denta l implan t support ha s been

at tempted w ith va rying degrees

of success. Surgically, relatively

poor bone quantity an d qua lity

can be a problem, especia lly in

the m a xilla . Techniques t o save

bonesuch as immediat e im-

plant placement after extraction,

one-sta ge sur gical protocols,guided tissue regenera tion and

grafting techniqueshave been

developed to overcome such

problems.24-26 Prosthetically,

using screw-type a butment-im-

plant connection mecha nisms

ma ke mecha nical problems a

continuing challenge. E kfeldt,

Ca rlsson a nd B orjesson,5 in a

retr ospective stud y of single-

tooth replacement, reported the

ra te of screw retightening neces-sa ry over three years to be 43

percent a mong the restorat ions

studied. J emt a nd collea gues27

found t ha t loosening screws

were the ma in problem a mong

freesta nding fixed prostheses

during t he first y ear of service,

but th ey concluded tha t t hese

problems ca n be solved easily

with retightening and t orquing

of screw s.

1100 J ADA, Vol. 129, August 1998

RESEARCH

TABLE 2

RESTORATION

SITE BY JAW

170

234

404

2 (1.17)

1 (0.43)

3 (0.74)

2 (1.17)

0 (0)

2 (0.50)

6 (3.53)

6 (2.56)

12 (2.97)

160

227

387

Ma xilla

Mandible

Total

SUMMARY OF PROSTHETIC COMPLICATIONS.NUMBER OF

RESTORATIONSPLACED

AbutmentLoosening

AbutmentFracture

Porcelain orCrown Failure

TOTAL NUMBEROF INTACT

RESTORATIONS

NUMBER (CUMULATIVE FAILUREPERCENTAGE) OF COMPLICATIONS



5/6

Loosening of screws proba bly

can be overcome best by using

tw o implants t o replace a molar,

the t ype of tooth implant in

w hich th e tendency t o loosen is

great est . In a compara t ivestudy, B a lshi and collea gues28

showed that loosening of screws

could b e reduced t o 8 percent

from 33 percent using t his

method.

Another problem encoun-

tered with screws is odor a nd

bad ta ste around implants .

Although not universal, t his

problem d oes occur w ith some

frequency. Odor and bad taste

can be a ssocia ted with ba cteria lgrowth a long the internal im-

plantabutment screw inter-

face. In vivo and in vitro studies

ha ve shown t his a problem with

screw-reta ined sy stems.13-15

With t he impla nt system

used in this study , screws a re

not used to at t ach the a butment

to the implant fixture. Inst ead,

a locking ta per post is us ed. A

locking taper is defined as a

cylindrical post t ha t t a pers 1.5to 2.0 degrees and frictionally

locks int o a socket of a corre-

sponding degree of taper. Using

such an a butment connection

for freesta nding (unsplinted),

single-tooth-implant supported

crown s, we found th e abutm ent

loosening rate to be 0.74 per-

cent and a butment fracture rate

to be 0.5 percent. These values

a re considerably lower tha n

th ose for complicat ions reportedfor screw-retained implant

a butment connection mecha-

nisms.17,18,22 Our data also are in

genera l agreement with previ-

ously published ret rospective

dat a on this system,29 wh ich in-

dicat ed tha t a butment fracture

a nd loosening frequ encies over

four years were 0.05 percent and

1.7 percent, respectively.

The fracture data ar e traced

to the fracture of tw o a but-

ments, w hich most likely result-

ed from poor occlusion or mate-

rials failure. As th ese fra ctured

wit hin a sh ort t ime of their in-

sertion, fat igue-related failureis unlikely. The rea son for the

loss of the t empora rily cement-

ed crowns wa s also unknown . It

might have been related to poor

occlusion, cont a mina tion of the

abutments during cementation

or some other, but u ndeter-

mined, reason.

Loosening of the posts was

most likely a consequence of in-

adequate removal of blood from

th e inner sur fa ce of the lockingta per socket du ring second-

sta ge uncovering of the implan t.

As the same posts were rein-

serted w ith n o further complica -

tions, such conta mina tion of the

socket is t he most likely expla-

nat ion.

We strongly believe tha t t he

key to this low ra te of prosthetic

complications is the locking-

ta per impla nt a butment con-

nection m echa nism. C ombinedwith t he strength of the tita ni-

um-aluminum-vanadium alloy

of w hich the implan t is con-

structed, this mecha nism a p-

pear s to reduce abutm ent fra c-

tur e an d loosening considera bly.

P orcelain fra cture of a con-

ventional crown on placement

over a na tura l tooth is a lmost

alw ays caused by an undercut

in the t ooth prepa ra tion. As the

locking ta per a butments used

for tooth replacement in this

study were used for retention of

conventionally made cemented

crowns, they often were pre-

pared as a nat ural tooth w ouldbe. U ndercuts may ha ve oc-

curred during such prepara tion.

A minima l undercut on a na tu-

ra l tooth might be somewha t

forgiving, but the rigidity of a

meta l abut ment w ould likely re-

sult in flexure of the m etal sub-

structure, as w ell a s spalling or

chipping of th e porcelain on t he

crow n. These crowns w ere re-

ma de and were cemented wit h

no complica tions.Additionally, t here were no

report ed compla ints of odor or

bad t ast e from a round the im-

plant a rea. This ma y be relat ed

to a potential biological seal

tha t ca n be produced by t he ex-

ceptiona lly close fit of the abu t-

ment to the implant .15,28

CONCLUSIONS

At one time, implant trea tment

reports concentra ted a lmost en-tirely on surgical survival a nd

failure ra tes. Today, cost a na ly-

sis, prosthet ic complica tions

a nd, th erefore, obta ining in-

formed consent for prosthetic

a nd sur gical procedures a re be-

coming im port a nt issues. The

report ing of prosthetic compli-

cat ions, both retrospectively

and prospectively, is equally im-

porta nt a nd just as valid as the

report ing of implant successa nd fa ilure. Albrektsson an d

colleagues 30 have s ta ted tha t

clinical reports of oral implant

trea tment ca n provide highly

variable levels of information,

because the mode of collecting,

ana lyzing and present ing data

var ies considerably. However,

prosthetic reliability, document-

ed prospectively, must be cou-

pled with prospective implant

J ADA, Vol. 129, August 1998 1101

RESEARCH

The locking -taperimp lantabutment con-

nection mechanism

appears to reduc e

abutment fracture and

loosening consid-

erably.



6/6

relia bility wh en impla nt recon-

struction relia bility is dis-

cussed.

This prospective st udy indi-

cat es that the Bicon Denta l

Implant system s locking t a perabutment connection to the im-

plant for prosthetic reconstruc-

tion for single- or multiple-tooth

replacement is very successful

a nd provides reliable outcomes

in t he posterior regions. The

concept of using one impla nt

per missing t ooth a nd restoring

each implant as a freesta nding

unit resulted in predicted im-

plan t sur viva l of 90 percent suc-

cess in th e maxilla a nd 96.8percent success in the man-

dible . Equa lly a s importa nt is

our finding t ha t only 0.74 per-

cent of th e abut ment s loosened

a nd 0.5 percent of the a but-

ments fra ctured during the four

years. This yielded a n a butment

success rate of 98.76 percent.

Crown replacement owing to ce-

ment failure or porcelain fra c-

tur e wa s 3.71 percent. The im-

plantabutment prostheticsuccess rate for four years, ac-

count ing for a ll possible

prosthodontic complica tions,

w a s 95.05 percent.

At th e four-yea r r eport ing pe-

riod, the success of the locking

ta per a butment of the Bicon

Dental Implant and convention-

a lly ma de crowns pla ced on

such an a butment is very en-

couraging. The placement of ce-

mented restorat ions on screw-retained abutments, however,

might or might not ha ve the

sa me survival ra tes beca use of

th e potent ia l for screw loosen-

ing or breaka ge. Six- a nd eight-

year r eports a re pla nned.

Further dat a regarding pros-

thet ic and implant abutment

surviva l for single- or mult iple-

tooth restoration are needed for

all systems, so tha t pat ients

and dentists can a ssess the

most reliable treatm ents for

specific situa tions. s

Dr. Muftu is a clinical instructor, Hacett epe

University , F aculty of Dentistry , Ankara ,

Turkey.

Dr. Chapman is chairperson, Department of

Restorative Dentistry, Tufts UniversitySchool of Denta l Medicine, One Kneeland St .,

Boston, Mass. 02111. Address reprint re-

quests to Dr . Chapman.

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