Christian Mertens

Helmut G. Steveling

Authors affiliations:
Christian Mertens, Helmut G. Steveling, Department
of Oral and Maxillofacial Surgery, University of
Heidelberg, Heidelberg, Germany

Implant-supported fixed prostheses in

the edentulous maxilla: 8-year
prospective results

Key words: dental implants, edentulous maxilla, fixed prostheses, long-term follow-up, implant

survival, marginal bone loss

Abstract

Corresponding author:
Dr Christian Mertens
Department of Oral and Maxillofacial Surgery
University of Heidelberg
Im Neuenheimer Feld 400
69120 Heidelberg
Germany
Tel.: 49 6221 56 39705
Fax: 49 6221 56 4222
e-mail: christian.mertens@med.uni-heidelberg.de

Objective: The purpose of this prospective study was to evaluate the long-term survival and success
rates of implants and screw-retained, full-arch prostheses placed in edentulous maxillae over 8 years of
function.
Materials and methods: A total of 106 Astra Tech implants were placed in the maxillae of 17
edentulous patients in a one-stage surgical approach. After a healing period of 6 months, the patients
received fixed screw-retained bridges. Follow-up visits, including clinical and radiographic
examinations, were performed after 6 months and at yearly intervals. Implant survival, implant
success, and marginal bone-level changes were defined as the primary outcome variables. The
secondary aims were to report periodontal pathogens at 5 years follow-up and patients satisfaction
at the 8-year follow-up.
Results: The overall observation time was 8 years. One patient died during the study and one implant
failed during the healing period, yielding an 8-year cumulative implant survival rate of 99%. The
prosthetic survival rate was 100%. The mean crestal bone loss amounted to 0.3  0.72 mm. Patients
subjective evaluations demonstrated an overall high level of satisfaction. In all cases, except for one,
microbiologic probing of the peri-implant sulcus after 5 years showed no higher incidence of
periodontal pathogens.
Conclusions: Screw-retained, full-arch restorations on six implants in an edentulous maxilla are a
predictable and highly successful treatment concept as observed throughout this study with an
observation period of 8 years of function, in particular with respect to low crestal bone loss and high
patient satisfaction.

Introduction and objective

Date:
Accepted 21 June 2010
To cite this article:
Mertens C, Steveling HG. Implant-supported fixed
prostheses in the edentulous maxilla: 8-year prospective
results.
Clin. Oral Impl. Res. 22, 2011; 464472.
doi: 10.1111/j.1600-0501.2010.02028.x

464

A lower density frequently characterizes maxillary bone, as opposed to mandibular bone. The
anatomic and morphologic structure of the maxilla and the reduced bone volume caused by a
high degree of alveolar ridge resorption are considered to be critical to the success of dental
implants. The literature shows that maxillary
implants are generally less successful than those
in the mandible (Esposito et al. 1998). Implantretained maxillary overdentures seem to be affected most frequently, and they show higher
failure rates, as well as greater marginal bone
loss, compared with mandibular implants. In a 3year follow-up report by Hutton et al. (1995), the
implant failure rate in cases of mandibular implant-supported overdentures was 3.3%, whereas
it was 27.6% for maxillary overdentures.
Schwartz-Arad et al. (2005) reported a 10-year
implant survival rate for removable maxillary

implants of 83.5%, while the success rate was

only 41.9% when using the Albrektsson et al.
(1986) success criteria.
On the contrary, fixed prostheses in the maxilla
are more successful than removable dentures. Prospective long-term studies present implant survival
rates ranging from 95.5% to 97.9% when evaluating fixed full-arch bridges in the maxilla.(Bergkvist
et al. 2004; Rasmusson et al. 2005; Fischer et al.
2008). Gallucci et al. (2009) have concluded that
fixed-implant prostheses in the edentulous maxilla
are a scientifically validated treatment option.
Offsetting their high survival rates, phonetic problems have been reported frequently for implantsupported maxillary fixed bridges, resulting in low
patient satisfaction (Lundqvist et al. 1992a, 1992b;
Heydecke et al. 2004). The gap between mucosa
and fixed prostheses is thought to be a major cause
of speech difficulties (Lundqvist et al. 1992a).
Minimizing this gap, however, leads to impairment of hygienic procedures.

c 2010 John Wiley & Sons A/S

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

The aim of this study was to investigate

whether appropriately designed, screw-retained,
full-arch prostheses retained by six to eight implants are a feasible treatment option for the
edentulous maxilla.
To ensure complete assessment of this prosthetic design, not only implant and prosthetic
survival but additional parameters were also
evaluated during the observation period. The
primary objectives were implant survival as
well as marginal bone-level changes and implant
success, according to the Albrektsson success
criteria. The secondary outcome objectives were
patient satisfaction for assessment of all functional aspects, such as phonetics. Plaque accumulation and soft tissue reactions were measured
at every follow-up to evaluate the clinical parameters and the success of patients hygienic
procedures, because fixed restorations may be
difficult to clean. Additionally, microbiologic
probing of the peri-implant sulcus was performed
to determine a possible higher incidence of periodontal pathogens and whether any specific microbiota composition could be identified. All
technical complications were recorded as well.
Patients included in this prospective clinical
trial were followed up over a period of 8 years,
and data were statistically evaluated because
long-term observations in prospective studies
can help validate the predictability of this treatment modality.

Material and methods

Patient selection

The study protocol was approved by the ethics

committee for clinical studies of the Medical
Faculty, University of Heidelberg.
To be included in the study, patients had to
meet the following criteria: 1875 years of age,
edentulous maxilla, and sufficient bone to support implants at least 9 mm in length. The
exclusion criteria were as follows: (1) need for
bone augmentation, (2) simultaneous tooth extraction and implant placement, (3) Class 4 bone
quality according to the Lekholm & Zarb classification (1985; assessed by the surgeon during
fixture installation), (4) any systemic disease or
condition that could compromise postoperative
healing or osseointegration, and (5) taking systemic corticosteroids or any other medication
that could compromise postoperative healing or
osseointegration. Smokers, bruxers, and patients
with poor oral hygiene were not excluded from
this study.
Each patient was thoroughly informed about
the study, and each signed an informed consent
form before entering the study. All patients were
treated between January and October 1999 in the

c 2010 John Wiley & Sons A/S

Department of Oral and Maxillofacial Surgery of

the Heidelberg University by the same experienced clinician.
Surgical procedure

After clinical and radiographical examination

(including intraoral and panoramic radiography)
and verification that the patient fulfilled the
inclusion criteria and that none of the exclusion
criteria applied, he or she was scheduled for
implant surgery. All patients had been edentulous in the maxilla for 6 months or longer. No
simultaneous tooth extractions were performed
during implant surgery.
All patients received prophylactic antibiotics
1 h before surgery, which was performed under
local anaesthesia. After crestal incision and elevation of a full-thickness muco-periosteal flap, six to
eight implants were placed using a standardized
surgical procedure. The number and location of
implants depended on the anatomic and morphologic conditions of the bone. Implants were evenly
distributed in the anterior and posterior segments
of the edentulous maxilla, depending on the size,
curvature, and shape of the ridge. No surgical
templates were used. Inclination of the implants
was adapted to the opposing dentition. The quantity and quality of the alveolar bone were assessed
during surgery according to the index described by
Lekholm and Zarb (1985). Insertion depth of the
implant was determined by the surrounding bone
to ensure that the implant neck and the alveolar
ridge were at the same level.
The implants (TiOblastt, Astra Tech AB,
Molndal, Sweden) were moderately rough titanium, screw shaped, and parallel walled. The
fixtures had a coronal portion equipped with
minute threads (MicroThreadt, Astra Tech
AB). Only implants of 3.5 and 4 mm diameter
and having a length of 915 mm were used,
depending on the bone dimensions. The implants
were placed using a one-stage surgical procedure.
After connection of healing abutments (Healing
Abutment Zebrat, Astra Tech AB), the flap was
closed and sutured. No postoperative antibiotics
were prescribed. The sutures were removed 7
days after the operation. Throughout this period,
mouth rinsing with chlorhexidine was prescribed. Patients were not allowed to use their
existing complete upper denture until suture
removal. At that time, any pressure from the
denture base on the healing abutments was
relieved, and a resilient relining material was
applied to the base.

were removed and replaced by permanent, onepiece titanium abutments (Uni-Abutmentt, Astra Tech AB), which were connected using an
insertion torque of 20 Newton-centimetres
(N cm), according to the manufacturers guidelines. Abutment height was selected clinically,
taking into account the mucosal thickness and
interocclusal space. After abutment connection,
impressions were taken using an individual open
tray, screw-retained transfer copings, and a polys
ether impression material (Impregum , 3M
ESPE, Seefeld, Germany). Subsequently, a
screw-retained registration of jaw relations in
centric occlusion was taken. Fitting of the complete functional wax-up with assessment of occlusion, phonetics, and aesthetic parameters and
fitting of the cast framework were performed
during the next appointment. The framework
needed to fit passively without tension. Cantilevers were not to exceed 10 mm distal to the
position of the most distal implant. As occlusal
concepts, either a bilateral balanced occlusion or
canine guidance was applied, depending on the
opposing dentures. Finally, the permanent, onepiece, fixed reconstruction was manufactured.
To allow for optimal oral hygiene, the relationship between the gingival mucosa and the base of
the bridge was evaluated. To avoid mucosal
irritations by impaired cleaning, the base of the
full-arch restoration was provided with a convex,
bridge-like design, slightly contacting the oral
mucosa. Concavities of the base should be completely avoided (Figs 13). Additionally, the acrylic base had to be free from porosities and show
well-polished surfaces. After the denture was
screwed onto the abutments, the openings of

Prosthetic procedure
Prosthetic rehabilitation began after a healing
period of 6 months. The healing abutments

Fig. 1 and 2. To avoid mucosal irritations by impaired

cleaning, the acrylic base should have a convex surface
design.

465 |

Clin. Oral Impl. Res. 22, 2011 / 464472

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

Fig. 3. Bridge-like design with slight contact to the oral

mucosa, permitting the use of interdental brushes and
flossing techniques.

Fig. 4. Clinical situation after 60 months of function.

Screw-retained prostheses were removed for the first time
for microbiologic probing of the periimplant sulcus. Only
minimum mucosal irritations are visible.

the screw holes were sealed with composite.

Hygiene instructions, including the use of interdental brushes and floss, were given to all
patients.

Both bleeding and plaque accumulation were

obtained on the buccal, lingual, mesial, and distal
surfaces and were calculated per implant as one
unit. The bridges were not routinely removed at
the follow-ups. Only the 60-month follow-up
included completely unscrewing the denture to
test the implants for mobility (Fig. 4). A nonmobile implant had to resist torquing of the
abutment to 20 N cm. Any implant mobility or
painful response was defined as implant failure.
Additionally, microbiologic probing of the peris
implant sulcus was performed (ParoCheck I Kit,
Lambda GmbH, Freistadt, Austria). Pooled subgingival plaque samples were collected from all
implants of each individual patient. To avoid
contamination, samples were not taken before
supragingival plaque removal and isolation of the
area with cotton rolls. Around each abutment,
samples were obtained using two sterile paper
points, which were inserted into the sulcus until
resistance was met and left there for 15 s. All tips
used for one patient were transferred into a single
transport container.
The purpose of this test was to investigate
the composition of the microbiota of the periimplant sulcus in edentulous patients wearing
fixed restorations for many years. Because fixed
restorations are often suspected of having excessive plaque accumulation owing to impaired
cleaning, the goal was to determine whether
there was a higher incidence of periodontal pathogens and whether any specific pattern could be
identified.

Follow-up protocol

After delivery of the bridge, follow-up visits were

scheduled after 6 months, 12 months, and at
yearly intervals thereafter.
During the follow-ups, the following clinical
parameters were evaluated in accordance with
Mombelli et al. (1987):
Assessment of plaque accumulation Modified Plaque Index:
Score 0: no detection of plaque;
Score 1: plaque recognized only by running a
probe across a smooth marginal surface of the
implant;
Score 2: plaque can be seen at a glance;
Score 3: abundance of soft matter.
Assessment of bleeding Modified Bleeding
Index:
Score 0: no bleeding when the periodontal
probe is passed along the gingival margin
adjacent to the implant;
Score 1: isolated bleeding spots visible;
Score 2: blood forms a confluent red line on
the margin;
Score 3: heavy or profuse bleeding.

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Clin. Oral Impl. Res. 22, 2011 / 464472

Radiographic examination

In addition to clinical assessments, radiographic

examinations were performed after implant surgery, at prosthetic loading (radiographic baseline),
and at follow-up visits, which began 6 months
after prosthetic loading and then at yearly intervals. The distance between the implant shoulder
and the first visible boneimplant contact was
measured (in mm) at the mesial and distal aspect
of each implant using periapical radiographs taken using the long-cone technique. (Arvidson
et al. 1998; De Bruyn et al. 2008). To correct
dimensional distortion, the apparent dimension
of each implant was measured on the radiograph
and compared with the actual implant size. To
ensure reproducibility between examinations,
radiographs were taken with the parallel technique using film holders. Care was exercised to
ensure that threads on both the mesial and distal
sides of the implants were clearly imaged (Bergkvist et al. 2004; Fischer et al. 2008). All radiographs were analysed by the same examiner, who
had not previously been actively involved in this
study. For evaluations and measurements, the Xrays were digitalized and analysed using the

computer program Friacom Dental Office Version 2.5 (Friadent, Mannheim, Germany).
Statistical method

Data were evaluated using SPSS (SPSS Inc.,

Chigaco, IL, USA) and SAS Software (SAS, Heidelberg, Germany). Statistical tests were applied
for descriptive and explorative reasons. The
MannWhitney test was used to compare the
variables between the groups (Lehmann 1998).
Associations between two variables were established based on Spearmans rank-correlation coefficient (Lehmann 1998). A P value of  0.05 was
considered to indicate an exploratory significant
difference. Arithmetic mean and standard error
were given for descriptive purposes.
Technical complications

Any problems with respect to implants, abutments, prostheses, or treatment as such were
recorded as complications. Survival was defined
as implants or prostheses not requiring replacement and still in function after 8 years. The
Albrektsson (1986) criteria were applied to determine implant success.
Prostheses presenting complications, such as
fractures of metal frameworks or smaller repairs,
such as repair of acrylic parts, were considered
survivors but not successful.
Patients satisfaction

At the 8-year-follow-up, patients were asked to

fill in questionnaires related to satisfaction and
the psychological effects concerning their implant-supported bridges. Evaluation of function,
involving both chewing and phonetics, aesthetics, and overall satisfaction were recorded.
Response alternatives for patients were as follows: 1 very satisfied, 2 satisfied, 3 neutral,
4 dissatisfied, and 5 very dissatisfied. In addition, patients were asked whether they would
have chosen the same treatment again, knowing
what this particular treatment consisted of.

Results
Patients

A total of 106 Astra Tech dental implants were

placed in the edentulous maxillae of 17 patients
(12 female, 5 male). On the day of surgery,
patients ages ranged from 41 to 69 years, with
a mean of 55.6  7.3 years.
Eight patients were smokers (47%), four were
previous smokers (23.5%), and five were nonsmokers (29.4%).
All patients had an opposing denture in the
mandible at the time of implant surgery to ensure
stable occlusion. Three patients had natural
teeth, nine had removable partial prostheses,

c 2010 John Wiley & Sons A/S

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

two had fixed partial prostheses, and one patient

had an implant-supported denture. Only two
patients had a complete denture.

each subsequent year of function. Using these

radiographic criteria on our patients, crestal bone
loss after 8 years of function should not exceed
2.4 mm in total. Throughout this study, only
four individual implants failed to meet these
criteria. Additionally, all implants were tested
individually for mobility and were found to be
clinically stable, no peri-implant radiolucency
was identified around any of the implants, and
no signs or symptoms of pain were reported.
Thus, the overall success rate according to Albrektsson et al. (1986) was 96% after 8 years.

Implants

In aggregate, 99 implants could be evaluated and

assessed throughout an observation period of 8
years (mean observation period, 8.34  0.53
years). Originally, 106 implants had been placed
in 17 patients eligible for clinical evaluation.
During the first year after installation, one patient died from cancer (six implants) and one
patient lost one implant during the healing period, which was not replaced. No further implant
losses occurred during the course of the study.
Patients received six to eight implants at surgery.
In most patients (n 15), six implants were
placed to retain the fixed full-arch bridge
(88.2%). The 8-year cumulative implant survival
rate was 99%. When applying the Albrektsson
implant success criteria, an implant is defined as
being successful if the marginal bone loss is
1 mm or less within the first year after insertion
of the prosthesis and not greater than 0.2 mm in

Clinical examination

According to Mombellis plaque index, 92% of

the implants had a satisfactory oral hygiene
status (grades 0 and 1; Table 1) at the 8-year
follow-up. Bleeding on probing was also evaluated, showing an incidence of bleeding in the
peri-implant mucosa of around 45% of the implants. A high tendency towards bleeding was
found in only one implant site.

Microbiologic probing of the periimplant sulcus showed normal flora in all cases, except for
two, after 60 months of function (Table 2).

Radiographic examination

Radiographic examination of the remaining 99

implants after 8 years of loading revealed a mean
marginal bone resorption of 0.3  0.72 mm
(minimum: 0 mm, maximum: 4.48 mm). Mesially, a bone loss of 0.28  0.87 mm was recorded; the distal value was 0.33  0.68 mm.
Altogether, 62 implants (63% of all examined
implants) remained without any evidence of
crestal bone-level changes or angular defects at
the proximal sites. An additional 24 implants
(87% of all implants) showed a marginal bone
loss of less than 0.5 mm. Fig. 5 summarizes the
results of the radiographic assessment. Only four
implants (4%) showed a bone loss greater than
2.4 mm. All four of these implants showed four
mesial measurements worse than 2.4 mm, but

Marginal bone loss [mm]

100%

Table 1. Scores of the clinical examination after 8

years

mean: 0.3 mm
SD: 0.72 mm
min: 0 mm
median: 0 mm
max: 4.48 mm
sample size: 99

80%

Periimplant parameters 8 years

Score
Score
Score
Score

0
1
2
3

MPI

MBI Mobility

49
42
6
2

54
38
6
1

60%

99
0
0
0

40%
20%
0%

Score range 03 in accordance with Mombelli et al.

(1987).
MPI, Modified Plaque Index; MBI, Modified Bleeding
Index.

0
n=62

<0.5
n=24

0.5
n=5

1
n=1

1.5
n=3

2
n=0

>2
n=4

Fig. 5. Frequency distribution including descriptive statistics of marginal bone loss after 8 years in function.

Table 2. Results of microbiologic probing per patient analyzed after 60 months of function
Results of microbiologic probing

Actinobacillus actinomycetemcomitans
Actinomyces viscosus
Tannerella forsythensis
Campylobacter rectus
Treponema denticola
Eikenella corrodens
Prevotella intermedia
Peptostreptococcus micros
Porphyromonas gingivalis
Fusobacterium nucleatum
Actinomyces odontolyticus
Campylobacter concisus
Campylobacter gracilis
Capnocytophaga gingivalis
Prevotella nigrescens
Eubacterium nodatum
Streptococcus constellatus
Streptococcus gordonii
Streptococcus mitis
Veillonella parvula

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11

12

13

14

15

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c 2010 John Wiley & Sons A/S

467 |

Clin. Oral Impl. Res. 22, 2011 / 464472

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

only three of these (3%) also had distal bone loss

measurements above 2.4 mm.
The analysis of marginal bone-level changes in
relation to implant length and diameter indicates
that shorter implants (9 and 11 mm) showed no
greater bone resorption than longer implants (13
and 15 mm). The Spearman rank correlation
coefficient showed an association between implant length and bone loss (r 0.22, P 0.03),
with higher losses with increasing implant length
(Fig. 7).
Large-diameter implants showed somewhat
less bone loss than small-diameter implants,
but without statistical significance (P 0.146).
Implants with a 3.5 mm diameter showed a
marginal bone loss of 0.33 mm; implants of
4 mm diameter showed a marginal bone loss of
0.2 mm (Fig. 6).
The mean marginal bone loss around implants
related to smoking is presented in Table 3; no
exploratory differences were found between smokers and nonsmokers.

ing the same fixed bridges. The most common

complications observed were related to the resin
part of the prostheses, that is, chipping of acrylic
teeth (three patients), ageing of the acrylic base,
or discolorations at the contact area between the
teeth and the acrylic base (six patients). All of
these complications were reparable without having to replace the prosthesis or entailing high
costs, as compared with ceramic works. No
complications were recorded concerning fractures
of the metal frameworks or loosening or fracture
of abutments or abutment screws. During the
observation period, loss of the composite seals
over screw holes was recorded as well. The
prosthetic success rate was 82.4%.

Patients satisfaction

The results of the 8-year evaluation of function,

aesthetics, speaking, and overall patient satisfaction ranged from high to very high (Table 4). After
8 years, all patients declared that they would
choose the same treatment concept again.

Technical complications

The survival rate of the suprastructure was

100%. After 8 years, all patients were still wear-

marginal bone loss [mm]

3.5
3
2.5

Spearman's rank
correlation of implant
length and marginal
bone loss: r = 0.15
(p=0.146)

2
1.5
1
0.5
0

3.5
4
implant diameter [mm]
Fig. 6. Marginal bone loss in relation to implant diameter.

Discussion
Because of anatomical structure and specific bone
quality, implant treatment of the completely
edentulous maxilla is often associated with
higher implant failure rates and higher marginal
bone loss as compared with mandibular implants.
In this study, patients received fixed, screwretained, full-arch bridges with distal cantilevers
on six to eight implants, and they were examined
annually over a period of 8 years. A high homogeneity of the data was achieved by treating all
patients for the same indication. The prospective
study design, combined with the fact that almost
all patients were available for the complete observation period, is another strength of this study.
Additionally, not only implant survival but also
marginal bone loss, clinical parameters, microbiologic probing, and patient satisfaction were
observed and assessed.

marginal bone loss [mm]

5
Spearman's rank
correlation of implant
length and marginal bone
loss: r = 0.22 (p=0.030)

4
3
2
1
0
9

11
13
implant length [mm]

Fig. 7. Marginal bone loss in relation to implant length.

468 |

Clin. Oral Impl. Res. 22, 2011 / 464472

15

With respect to implant survival, the results of

this study are comparable with the outcome of
similar studies analysing patients with fixed,
screw-retained implant dentures in the edentulous maxilla ranging from 95.5% to 97.9% (Ferrigno et al. 2002; Bergkvist et al. 2004;
Rasmusson et al. 2005; Fischer et al. 2008).
Further, literature search reveals that the survival rates of implants with rough surfaces are
significantly higher than those of machined implants. Moreover, the survival rates of machined
implants were found to decrease continuously
over the years, whereas the rates for roughsurface implants remained stable for up to
10 years of follow-up (Lambert et al. 2009).
Lambert concludes that a rough surface on dental
implants is important for stable, long-term results of fixed-implant rehabilitation of the edentulous maxilla.
The aspect of marginal bone stability is also
positively influenced by rough surface implants
as compared with machined implants (Weber
et al. 2000; Watzak et al. 2006), consequently
leading to an increase in the overall implant
success (Van de Velde et al. 2007; De Bruyn
et al. 2008). Le Guehennec et al. (2007) concluded in a review on surface roughness that by
means of increased surface roughness not only
osseointegration can be enhanced, but also the
prevention of bone resorption.
Measurement of marginal bone-level loss over
time is a valuable indicator in evaluating the
clinical performance of implants, because the
gradual loss of marginal bone eventually leads
to implant failure. By measuring each implant
mesially and distally, very accurate objective
results can be obtained. All implants in the
present study were evaluated radiographically
on a regular basis. Initial intraoral radiographs
were taken after implant placement, followed by
radiographs taken 6 months later at the time
of prosthetic loading. After a further 6-month
period, the first radiographic follow-up was
obtained, followed by annual radiographic controls. The accuracy of marginal bone-level measurements is influenced by the precision of both
the radiographic technique and the measurement
technique. To ensure reproducibility between
examinations, radiographs were taken using the
parallel technique, using commercially available
film holders. Care was exercised to ensure that
threads on mesial distal sides of the implants
were clearly imaged (Bergkvist et al. 2004, 2009;
Fischer et al. 2008). To correct dimensional
distortion, the apparent dimension of each implant was measured on the radiograph and compared with the actual implant size. Radiographs
were not standardized using individually fabricated film holders for each implant at that
time, although the standardization of radiographs

c 2010 John Wiley & Sons A/S

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

Table 3. Marginal bone loss around implants related to smoking

Mean bone loss (mm)

Marginal bone loss (mesial) (mm)
Marginal bone loss (distal) (mm)

Exposure of implants
to smoking

Mean

SE

Minimum

Median

Maximum

Sample size

P-value

0.15
0.51
0.08
0.54
0.21
0.48

0.04
0.16
0.03
0.20
0.06
0.13

0
0
0
0
0
0

0
0
0
0
0
0

1.62
4.48
1.46
5.76
2.63
3.21

57
42
57
42
57
42

0.07

Table 4. Scores of the item denture satisfaction questionnaire 8 years after treatment
Satisfaction

8 years

Patients (N)

Function (eating)

Speaking

Appearance

Satisfaction

Score
Score
Score
Score
Score

14
2
0
0
0

13
3
0
0
0

12
4
0
0
0

13
3
0
0
0

1
2
3
4
5

Scale range 15: 1 very satisfied, 2 satisfied, 3 neutral, 4 dissatisfied, 5 very dissatisfied.

would have further increased the comparability

and accuracy of the data. The measurement
technique used in this study, however, is identical to that used in most investigations analyzing
marginal bone levels in the edentulous maxilla
(Bergkvist et al. 2004; De Bruyn et al. 2008;
Fischer et al. 2008).
With respect to marginal bone stability around
the implants (mean marginal bone loss: only
0.3 mm after 8 years), the treatment outcome
can be rated as high. Our results in terms of
maintained marginal bone corroborate the longterm results of other authors using the same
implant system although for different indications (Rasmusson et al. 2005; Gotfredsen 2009;
Vroom et al. 2009).
From a statistical point of view, implant data
have to be considered as dependent data observations when assessing marginal bone-level
changes related to individual implants retaining
a full-arch restoration. Chuang et al. (2001)
statistically validated three different models for
estimating implant survival. The models they
used for studying a total of 660 patients were
based on (1) a random selection of one implant
per patient only; (2) the inclusion of all implants,
assuming independence among all implants of
the same subject; and (3) the inclusion of all
implants, assuming dependence among all implants of the same subject. They were not able to
demonstrate significant differences and concluded that both the survival point estimates as
well as the standard-error estimates varied very
little among the three models. Considering the
number of patients in this study, the independence model was selected as appropriate to analyse the data available on implant level.
The analysis of marginal bone-level data with
respect to implant length in this study demon
c 2010 John Wiley & Sons A/S

strated that shorter implants involve no higher

bone loss than longer implants.
These findings are supported by the recent
literature on short implants. While studies using
short machined implants document far lower
survival rates than longer implants (Winkler
et al. 2000; Herrmann et al. 2005), studies with
rough surface implants reported that implant
length did not influence the survival rates (Buser
et al. 1997; Testori et al. 2001; Feldman et al.
2004). Implant surface topography seems to be
one of the main factors influencing implant
survival. An unfavourable implant-to-crown ratio was believed to cause overloading. The increased bone stress leads to atrophy and higher
marginal bone loss (Rangert et al. 1997). A
systematic review by Blanes (2009), however,
demonstrated that implant-to-crown ratios do
not influence marginal bone loss. One article
showed even less marginal bone loss with higher
crown-to-implant ratios (Blanes et al. 2007).
Marginal bone loss was further assessed using
the Albrektsson success criteria (Albrektsson
et al. 1986). With an implant survival of 99%
and a respective implant success of 96% after 8
years, the difference between implant survival
and success was only minor. Albrektsson et al.
(1981) had already described the following factors
as preconditions for successful osseointegration:
implant material, implant design, surface quality,
status of the bone, surgical technique, and implant loading conditions.
The exceptional use of native bone in this
study could have also contributed to the high
success rates, because patients requiring augmentation procedures were excluded. Lambert et al.
(2009) showed that the survival rates of machined implants were significantly higher when
placed in native bone compared with implants in

0.12
0.26

augmented bone. However, this study also found

that the survival rates for rough-surface implants
were the same whether placed in native or
regenerated bone. Survival of machined implants
placed in augmented maxillary bone, in contrast,
decreased significantly over the years.
Concerning the number of implants necessary
to retain a fixed, full-arch restoration in the
edentulous maxilla, this study shows that the
use of six implants seems to be sufficient for
providing long-term stability, because all, except
for two, patients received six implants. Other
studies report that for fixed maxillary reconstructions, eight implants distributed strategically are
necessary for long-term success (Lambert et al.
2009). However, our 8-year data demonstrate
that six implants seem to be able to provide
long-term, stable reconstruction. Even with other
loading modalities, such as early or immediate
loading, the survival rates of rough-surfaced implants are comparable to conventional loading
protocols. Fischer et al. (2008) showed that there
were no significant differences between early and
delayed loading in the edentulous maxilla using
five or six implants for implant-supported, fixed
prostheses. Bergkvist et al. (2009) reported similar survival rates, comparing conventionally
loaded and immediately loaded implants. All
fixed, screw-retained reconstructions were retained by six implants.
The use of fixed implant rehabilitations of the
edentulous maxilla also seems to improve implant survival and reduce marginal bone loss in
contrast to removable solutions (Hutton et al.
1995; Schwartz-Arad et al. 2005). Comparison
of various fixed prosthetic concepts such as eight
strategically distributed implants with retaining
segmented rehabilitations, that is, four threeunit fixed bridges (Gallucci et al. 2004, 2005)
with one-piece, full-arch reconstructions
yielded no statistical differences (Lambert et al.
2009).
The advantages of screw-retained, full-arch
prostheses are besides high hard- and soft-tissue
stability the capability to compensate for complications such as divergent implant axes, long
teeth, wide interdental spaces, missing congruence of implant location, and tooth position, as
well as compensating for sagittal miscorrelations
between jaws. Such adverse morphological

469 |

Clin. Oral Impl. Res. 22, 2011 / 464472

Mertens & Steveling  Implant-supported fixed prostheses in the edentulous maxilla

effects cannot be eliminated simply by the use of

normal fixed dentures. Phonetic problems, long
teeth, wide interdental spaces, and other aesthetic problems can be better compensated for
by using an acrylic base. Patients with small
vertical dimensions combined with a high
lip line, however, are not eligible for this prosthetic design, because the transition zone
between the alveolar ridge and the acrylic base
would be exposed, leading to compromised
aesthetics.
Phonetic problems are often implicated when
using fixed prostheses (Jemt 1991; Lundqvist
et al. 1992a, 1992b; Jemt 1994). Besides the
accessibility for hygienic purposes, the design of
the denture base should preclude any interference
with speech. A highly cleansable prosthetic design in the maxilla might lead to the entry of air
and saliva through open spaces, impairing phonetics. Therefore, the base should have a convex,
bridge-like design, slightly contacting the mucosa to admit floss and interdental brushes.
Concavities of the base must be avoided to
prevent mucosal irritations from impaired cleaning. Because of our specific design, this complication was successfully avoided in the present
study, because none of the patients reported any
phonetic problems.
The fact that this design did not impede the
patients hygienic procedures was particularly
underlined when the dentures were removed for
the first time after 5 years of function. Only
minor mucosal irritations could be documented,
and microbiologic probing of the peri-implant
sulcus showed normal flora in all cases, except
for two. These two patients, however, did not
show any clinical signs of inflammation. Our
data are in accordance with the finding that
Actinobacillus actinomycetemcomitans and
Porphyromonas gingivalis are rarely detected in
completely edentulous patients with osseointegrated implants (Mombelli & Mericske-Stern
1990; Mombelli et al. 1995; Danser et al. 1997;
Quirynen et al. 2002). In contrast, the 10-year
findings of a recent investigation (Quirynen et al.
2005) demonstrated that the periodontal pathogens A. actinomycetemcomitans and P. gingivalis, which were thought to be eliminated with the

extraction of all natural teeth (Danser et al. 1994,

1997), existed in significant numbers in edentulous patients with implants. The authors posit
that initially pristine peri-implant pockets might
slowly become infected by periopathogens in a
manner similar to natural teeth.
Concerning the prosthetic outcome, only
minor complications were recorded, leading to a
prosthetic success rate of 82.4%. These were
always associated with resin-related complications (i.e., chipping of acrylic teeth, discolorations of the acrylic base). All these complications
were easily repairable, without entailing high
costs. These findings are in accordance with
several other studies (Johansson and Palmqvist
1990; Carlson et al. 1994; Jemt 1994). Torbjorner
and Fransson (2004) reported that tooth fractures
are usually caused by fatigue because of mechanical factors such as the magnitude and frequency
of occlusal loads, direction of forces, and the
dimension and shape of the restorative material.
They concluded that, with proper occlusal design,
the nonaxial forces can be markedly reduced.
Edentulous patients who lack periodontal receptor information show an impaired fine motor
control of the mandible (Trulson 2006). This
might lead to uncontrollable, high bite forces,
especially in a jaw without periodontal receptors,
thus explaining fractures of the resin. These
findings corroborate our study results, wherein
all patients had an opposing denture at the time of
implant surgery. Further, the two patients who
had a complete denture in the mandible received
implant-supported prostheses at a later stage
during the observation period. Additionally, implant distribution seems to influence the prosthetic survival rate. When implants were placed
only in the anterior region, the prosthodontic
survival rate was significantly lower than those
having an anteroposterior distribution (Lambert
et al. 2009).
In addition to clinical and radiographic evaluation, patient satisfaction was documented by
means of a standardized evaluation form. All
patients showed high to very high satisfaction
rates and declared that they would choose the
same treatment concept again. The literature
provides no long-term follow-up studies on pa-

Acknowledgements: This study was

supported by Astra Tech AB, Molndal, Sweden.
The authors declare that they have no conflicts
of interest in this study.

Bergkvist, G., Nilner, K., Sahlholm, S., Karlsson, U. &

Lindh, C. (2009) Immediate loading of implants in
the edentulous maxilla: use of an interim fixed prosthesis followed by a permanent fixed prosthesis: A 32month prospective radiological and clinical study.
Clinical Implant Dentistry & Related Research 11:
110.
Bergkvist, G., Sahlholm, S., Nilner, K. & Lindh, C.
(2004) Implant-supported fixed prostheses in the
edentulous maxilla. A 2-year clinical and radiological

follow-up of treatment with non-submerged ITI

implants. Clinical Oral Implants Research 15: 351
359.
Blanes, RJ. (2009) To what extent does the crown
implant ratio affect survival and complications of
implant-supported reconstructions? A systematic review. Clinical Oral Implants Research 20 (Suppl. 4):
6772.
Blanes, R.J., Bernard, J.P., Blanes, Z.M. & Belser, U.C.
(2007) A 10-year prospective study of ITI dental

tient satisfaction with fixed, full-arch prostheses

in an edentulous maxilla. In contrast, similar
studies of edentulous mandibular reconstructions
have been published (Quirynen et al. 2005).
According to Feine and Lund (2006), 89% of
the variation in general satisfaction can be explained by comfort, chewing ability, speech,
aesthetics, and denture stability. Comparisons
between maxillary and mandibular prostheses
demonstrate that aesthetics and speech are
more important in the maxilla than in the mandible. However, eating comfort remains the main
factor; it is as important in the maxilla as it is in
the mandible (De Bruyn et al. 1997; Dierens
et al. 2009).

Conclusions
Our prospective study evaluated the long-term
survival and success rates of implants and screwretained full-arch prostheses placed in completely
edentulous maxillae. The defined primary outcome variables implant survival, implant success, and marginal bone-level changes as well as
secondary aims such as incidence of periodontal
pathogens and the overall patients satisfaction
ensured a complete assessment of this treatment
modality. Implant survival was high, marginal
bone was well maintained, and microbiologic
probing of the periimplant sulcus showed no
higher incidence of periodontal pathogens, and
no specific composition of microbiota could be
identified.
The results of this study indicate that screwretained, full-arch restorations on six microthreaded implants in an edentulous maxilla are
a predictable and highly successful treatment
concept for restoration, in particular with respect
to low crestal bone loss, high patients satisfaction, and normal microflora, as observed
throughout an observation period of 8 years of
function.

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