Clin Oral Impl Res 2000: 11 (Suppl.

): 5968 Printed in Denmark All rights reserved

Copyright C Munksgaard 2000

ISSN 0905-7161

Chapter 3

Basic surgical principles with ITI implants

Buser D, von Arx T, ten Bruggenkate C, Weingart D. Basic surgical principles with ITI implants. Clin Oral Impl Res 2000: 11 (Suppl.): 5968. C Munksgaard 2000. Daniel Buser1, Thomas von Arx1, Christiaan ten Bruggenkate2, Dieter Weingart3
1

Dept. of Oral Surgery, University of Bern, Bern, Switzerland; 2Dept. of Oral and Maxillofacial Surgery, St. Elisabeth Hospital, Leiderdorp, The Netherlands; 3 Dept. of Maxillofacial Surgery, Katharinenhospital, Stuttgart, Germany

The basic surgical principles governing the placement of ITI implants are based on research-oriented developments in harmony with evidencebased and outcome-oriented clinical procedures. In the past 15 years, the range of implant indications has been signicantly widened, and partially edentulous patients clearly represent the majority of patients seeking treatment with dental implants today. An important aspect of the successful rehabilitation of patients with ITI implants is the careful selection of implant candidates with respect to systemic and local risk factors. These factors are presented based on current knowledge. Today, solid-screw implants in various screw dimensions and neck congurations comprise the ITI Dental Implant System. These different implant types are necessary to handle the full range of implant indications, in particular in partially edentulous patients. The main clinical factors are presented for the selection of the appropriate implant type, length and diameter. These implants are utilized both in a non-submerged and in a submerged approach. The main goal of surgical therapy is low trauma and the least demanding surgical procedure for patient and clinician to optimize the cost-effectiveness of implant therapy. Hence, a non-submerged approach is preferred in all sites without esthetic priority, such as in fully edentulous patients or in posterior sites of partially edentulous patients. These indications clearly represent the majority of implant patients. In esthetic sites, a submerged approach is utilized to satisfy the specic esthetic demands. The possibility to successfully utilize short implants (6 and 8 mm) and a reduced healing period of 3 months are further advantages of ITI implants due to favorable properties of the rough TPS surface. With the introduction of the microrough SLA surface, a reduction of the healing period to 6 weeks facilitates further progress towards simplication of implant therapy. In summary, the ITI Dental Implant System represents a scientically well-documented, complete implant system for the treatment of fully and partially edentulous patients, offering straightforward surgical concepts based on predictable treatment outcome and excellent cost-effectiveness.

Key words: cost-effectiveness ITI implants non-submerged approach risk factors short implants SLA surface submerged approach surgical procedures TPS surface Committee Members: Leon A. Assael, USA, Jay Beagle, USA, Alexandra Behneke, Germany, JeanPierre Bernard, Switzerland, Daniel Buser, Switzerland, Karl Dula, Switzerland, Christian Foitzik, Germany, Michael Gahlert, Germany, So lve Hellem, Sweden, Hans Peter Hirt, Switzerland, Hideaki Katsuyama, Japan, Barbara Lehmann, Switzerland, Herbert Niederdellmann, Germany, Stephen Rimer, USA, Marcel Scacchi, Switzerland, Wilfried Schilli, Germany, Christiaan ten Bruggenkate, The Netherlands, A.V. van Gool, The Netherlands, Thomas von Arx, Switzerland, Gerhard Wahl, Germany, Dieter Weingart, Germany Prof. Dr. Daniel Buser, Department of Oral Surgery, School of Dental Medicine, University of Berne, Freiburgstrasse 7, CH-3010 Berne, Switzerland Tel.: 41 31 632 25 55 Fax: 41 31 632 98 84 e-mail: daniel.buser/zmk.unibe.ch

Many factors play an integral and important role in the successful rehabilitation of fully and partially edentulous patients with osseointegrated ITI implants. These include careful selection of appropriate patients with respect to systemic and local

risk factors, the selection of appropriate implant shape, diameter and length, and proper surgical procedure with regard to implant placement, wound closure techniques and the healing period required in different clinical situations. This chap59

Buser et al. ter deals with the general surgical aspects of implant therapy. Step-by-step surgical procedures to be used in fully and partially edentulous patients will be presented in chapters 4 and 5. High risk factors O Serious systemic diseases like rheumatoid arthritis or osseous disorders like osteomalacia or osteogenesis imperfecta are considered high risk factors. However, osteoporosis does not contraindicate the use of dental implants (Baxter & Fattore 1993; Dao et al. 1993). O Patients who are immunocompromised due to viral infection (HIV) or medication (corticosteroids, oncologic chemotherapy or other immunosuppressives) have a clearly reduced wound healing capacity and an inappropriately responding immune system. O Alcohol and drug abusers as well as patients with psychological or mental disorders are not reliable with regard to compliance, home care and follow-up appointments (uncooperative patient) (Hogenius et al. 1992). Risk factors O Radiotherapy may induce vascular brosis and thrombosis, with subsequent tissue breakdown and development of chronic nonhealing wounds (Epstein et al. 1997; Wong et al. 1997). Therefore, irradiated bone should be viewed as a risk factor for implant insertion, and an adequate waiting period after radiotherapy is recommended (Esser & Wagner 1997; Jisander et al. 1997; Granstro m & Tjellstro m 1997). O Severe diabetes, especially juvenile diabetes (type 1), is considered a risk factor, whereas patients with well-controlled type 2 diabetes do not need to be excluded from implant therapy (Shernoff et al. 1994; Oikarinen et al. 1995). O Bleeding disorders such as hemorrhagic diathesis or drug-induced anticoagulation should be considered as risk factors for implant therapy. O Heavy smoking has been shown to adversely affect the long-term prognosis of dental implants (Bain & Moy 1993; Gorman et al. 1994; Bain 1996; Haas et al. 1996; Lindquist et al. 1996). Local aspects (Table 3.2) General local prerequisites for implant placement are a stomatognathic system without infectious diseases and apparently healthy bone at the recipient site. Local contraindications include temporary contraindications and local risk factors. Temporary contraindications O Insufcient bone volume at the future implant site is nowadays considered only a temporary contraindication because a number of different bone reconstructive techniques have been developed for ridge augmentation prior to or simultaneous with implant placement (Buser et al.

Indications and contraindications for implant placement Treatment planning is essential for the long-term success of oral rehabilitation using dental implants. From the very beginning, indications and contraindications must be carefully balanced for each patient who is eligible for implant therapy. Indeed, proper patient selection is one of the most difcult steps in treatment planning (Blanchaert 1998). Therefore, the implant surgeon must have a sound knowledge of the indications and contraindications for implant placement. General and medical aspects (Table 3.1) Prior to any dental or surgical procedure, a medical history must be obtained from the patient. The knowledge of former and current diseases, surgeries, and medications helps to identify patients who are at risk. When there are doubts, the physician or medical specialist treating the patient must be consulted for further clarication. A general prerequisite for implant placement is that the patient must have an undisturbed wound healing capacity. In addition, implants should not be inserted before jaw growth is complete (Cronin et al. 1994; Thilander et al. 1994). However, implants might be installed before end of growth in special indications, i.e. for orthodontic reasons or in posterior areas (Bergendal et al. 1996; Wehrbein et al. 1996). In the following, general medical contraindications have been arranged in two groups: risk factors and high risk factors.

Table 3.1. General and medical aspects Prerequisites for implant placement Undisturbed wound healing capacity Jaw growth completed (in standard situations) Prior to completed jaw growth (only in special indications, i.e. posterior areas, orthodontic cases) Irradiated bone Severe diabetes Bleeding disorders Heavy smoking Serious systemic diseases Immunocompromised patients Drug abuse Uncooperative patients

Risk factors

High risk factors

60

Basic surgical principles with ITI implants

Table 3.2. Local aspects Prerequisites for implant placement Relative/temporary contraindications Stomatognathic system without infectious diseases Apparently healthy bone at recipient site Insufcient bone volume at recipient site Untreated periodontitis Residual root in recipient site Local infection in recipient site Erosive/bullous diseases of the mucosa Xerostomia Bruxism

plant fractures or loss of osseointegration (Perel 1994; Rangert et al. 1995). Informed consent (Table 3.3) The patient can only consent to the proposed implant treatment if the following issues have been discussed in detail (Worthington 1995): O Treatment alternatives: A number of different therapeutic approaches might exist to solve the dental problem in question. The decision to use dental implants for oral rehabilitation must be based on careful evaluation of all possible treatment alternatives. O Risk of implant surgery: Any surgical procedure implies certain risks pertaining to local complications or adverse systemic effects. Local complications include damage of adjacent anatomical structures (nerves, vessels, teeth, sinuses). The possibility of immediate or late postoperative complications (soft tissue dehiscence or hyperplasia; peri-implantitis; fracture of implant, suprastructure or a part thereof) should also be mentioned to the patient (Ellies 1992; Weyant 1994; Mordenfeld et al. 1997). O Long-term prognosis: Long-term clinical studies enable the implant surgeon to assess the long-term prognosis of a specic implant system and to disclose this information to the patient (Buser et al. 1997; Fritz 1997). O Cost: The patient should be informed about the approximate cost of the proposed implant therapy. Selection of the appropriate implant type (Table 3.4) The various implant types comprising the ITIA Dental Implant System were developed and rst clinically tested in 1986, in particular for the treatment of partially edentulous patients with implantsupported single crowns or xed partial dentures. The system initially included three implant types with standard diameters, namely the hollow-cylinder (HC), the hollow-screw (HS), and the standard solid-screw implant (S 4.1). In more than 14 years of clinical experience and clinical observation, prospective clinical studies have been conducted at various centers to evaluate the survival and success rates up to 10 years of follow-up (Buser et al. 1990; Buser et al. 1991a; Behneke et al. 1992; Buser et al. 1992; MericskeStern et al. 1994; Buser et al. 1997; Behneke et al. 1997; Buser et al. 1999a). The multicenter study by Buser et al. (1997) provided a life table analysis with the 8-year cumulative survival and success rates of more than 2,300 implants, and an actual 61

Local risk factors

Table 3.3. Informed consent Treatment alternatives Risks of implant surgery Long-term prognosis of implants Cost

1994; Buser et al. 1996; von Arx et al. 1998; von Arx & Kurt 1998). O Untreated periodontitis must be adequately addressed prior to initiation of implant therapy. Possible cross-infections from periodontally diseased teeth to implants should be prevented by periodontal therapy and a proper maintenance protocol (Mombelli & Lang 1992; Meffert 1993; Mombelli 1993; Cune & de Putter 1996; Gouvoussis et al. 1997). O A residual root also poses a temporary contraindication and should be removed prior to implant placement. In special cases, the root can be immediately replaced by a dental implant. O Any local infection or pathologic condition of the bone and the covering soft tissues must be adequately treated well before implant placement. Local risk factors O Erosive or bullous diseases of the oral mucosa such as cicatrical pemphigoid are local contraindications for implant placement due to their autoimmune background. They usually require a topical or systemic immunosuppressive treatment (Weinberg et al. 1997). O Xerostomia (dry mouth) may be associated with long-term drug therapy or autoimmune diseases and is frequently encountered in elderly patients (Wu & Ship 1993; Navazesh et al. 1996). Saliva contains antimicrobial agents and exerts a cleansing effect. Therefore, a reduced saliva ow rate is considered to be a local risk factor. O Bruxism has been shown to be correlated with an increased risk for implant failure, such as im-

Buser et al.
Table 3.4. Overview of the various implant types comprising the ITI Dental Implant System specic indications and clinical recommendations Implant type S 4.1 Minimal crest width 5.5 mm Indications and remarks Most frequently used ITI implant Short implants (6 and 8 mm) should be splinted to other implants, whenever possible 6 mm implants should not be used for single-tooth replacement in molar sites For posterior sites with limited bone height For immediate implant placement in extraction sites of appropriate bone volume As emergency implants, when S 4.1 implants do not achieve primary stability For molar-sized units in molar sites with adequate bone width For recipient sites with limited bone width Splinting of implants is recommended, whenever possible Not suitable for any application risking excessive bending moments (such as single-tooth replacements in canine and molar sites) For sites with reduced mesio-distal width For single-tooth replacement of lateral incisors in the maxilla For single-tooth replacement of incisors in the anterior mandible For sites with axis problems (such as single-tooth replacement in the anterior maxilla)

S 4.8

6.2 mm

WN 4.8 S 3.3

6.2 mm 4.8 mm

NN 3.3

4.8 mm

angled HC

5.5 mm

5-year analysis of more than 500 implants. This study demonstrated excellent long-term stability for all tested implant types. The best cumulative success rates were seen for solid-screw implants (96.7% at 7 years of prospective follow-up), closely followed by hollow-screw implants (95.8%), whereas non-threaded, press-t hollow-cylinder implants were slightly less favorable with 91.6%. As a result, the solid-screw implant has become the main implant type of the ITI system since the mid 1990s. This concentration on the solid-screw implant allowed the manufacturer to design additional screw-type implants with various dimensions and diameters to satisfy the growing demand by clinicians for the rehabilitation of all possible indications in partially edentulous patients, such as single-tooth gaps in the anterior mandible or in molar sites. Hence, the diameter-reduced screw implant (S 3.3), the wide-body screw implant (S 4.8) and the narrow-neck implant (NN 3.3) were developed, each for specic clinical situations. Most recently, an additional wide-neck implant (WN 4.8) was designed for tooth replacement in molar sites. Thus the updated ITIA Dental Implant System, based on the solid-screw implant with three different screw diameters (3.3 mm, 4.1 mm, and 4.8 mm) and three different congurations in the shoulder area (Fig. 3.1), represents a complete system to treat both fully and partially edentulous patients with all possible indications for implant therapy. The system of various screwtype implants is supplemented with the angled HC implant, which is still used by some clinicians primarily in esthetic sites in the anterior maxilla to correct axis problems. More technical details 62

about the development and the evolution of the ITIA Dental Implant System are described in chapter 1. The selection of the appropriate implant type with regard to implant diameter and length clearly depends on clinical parameters such as the crest width and the bone height at the recipient site, and the planned prosthetic reconstruction. The width of the alveolar crest at the recipient site is important for the selection of the appropriate implant diameter. It has been demonstrated in retrospective studies that a missing buccal bone wall has a negative impact on the long-term prognosis of titanium implants (Dietrich et al. 1993). Hence, no compromise should be made in that respect, and a bone wall of at least 1 mm thickness should be present orally and buccally when an implant is inserted.

Fig. 3.1. The family of ITI screw implants with various congurations, from left to right: NN 3.3, S 3.3, S 4.1, S 4.8, and WN 4.8.

Basic surgical principles with ITI implants

Fig. 3.4. Another typical indication for the standard screw implant (S 4.1): utilization of two implants to support a bar-type overdenture in the mandible.

Fig. 3.2. Utilization of a standard screw implant (S 4.1) for a single-tooth replacement in the anterior maxilla.

Fig. 3.5. Combination of a standard (S 4.1) and a wide-body implant (S 4.8) to support a 4-unit bridge in the posterior mandible.

Fig. 3.3. A standard screw implant (S 4.1) is also used in premolar sites to support single crowns.

Consequently, a crest width of at least 5.5 mm is needed for the placement of a standard screw implant, since the core diameter of this implant measures 3.5 mm. Diameter-reduced and wide-body implants need a different minimal crest width according to the implant diameter in the crestal area (core diameter 2 mm). Details of the recommendations of the ITI Consensus Conference concerning selection of an appropriate implant type are listed in Table 3.4., and documented with a series of case reports (Figs. 3.2 through 3.7). Selection of implant length The selection of the appropriate implant length depends on the vertical bone height at the recipient

Fig. 3.6. Utilization of a wide-neck implant (WN 4.8) as anchorage of a single crown in a rst molar site.

site. These implants are available in various lengths between 6 and 14 mm. Based on the implant design and the favorable properties of the TPS and SLA surfaces, ITI implants do not require bicortical 63

Buser et al.

Fig. 3.9. In this patient, two 6 mm implants (one standard, one wide-body) are combined with a standard screw to support a 3-unit restoration.

Fig. 3.7. Typical indication for a narrow-neck implant (NN 3.3) to replace a missing lateral incisor in the maxilla.

short 6 and 8 mm implants, they should preferably be connected to longer implants. Whenever possible, wide-body implants (S 4.8) with an increased implant surface due to the larger diameter are utilized in these sites to compensate for the short implant length (Figs 3.8 & 3.9). Moreover, particularly in distal extension situations an additional implant is inserted to improve the anchoring base for implant-supported prostheses. Longer implants (14 mm) may be indicated in special circumstances, such as in conjunction with the simultaneous application of autogenous bone grafts for vertical ridge augmentation in the extremely atrophied mandible, or in immediate extraction sites to improve implant stability in the bone structure beyond the apex of the removed tooth. Surgical infrastructure and premedication The ultimate goal of surgical implant therapy is a low-trauma surgical procedure during implant placement. This includes the avoidance of unnecessary tissue damage during surgery as well as the avoidance of unnecessary contamination of implant sites with intra- and extraoral bacteria. A low-trauma surgical procedure requires an implant surgeon with appropriate surgical experience. In addition, a room suitable for surgical procedures under hygienic conditions is mandatory. It is recommended that the patient be covered with sterile drapes, and that the surgeon and assistants wear acceptable attire. As demonstrated by a clinical study, an aseptic operatory is not necessary for successful implant integration (Scharf & Tarnow 1993). A competent sterile assistant and a second nonsterile assistant are very useful during surgery. It is clear that all surgical instruments need to be sterilized properly, and a special drilling unit with

Fig. 3.8. In this case with a reduced bone height, an additional 8 mm wide-body implant has been inserted and then splinted to a standard 10 mm screw. Please note the security distance of 2 mm to the mandibular canal.

stabilization. This is a distinct difference from titanium screw-type implants with a machined surface (Brnemark et al. 1985; Ivanoff et al. 1996). The TPS and SLA surfaces offer several advantages, such as the utilization of shorter implants in fully and partially edentulous patients, hence clearly increasing the number of potential implant candidates. In addition, there is no need to come close to vital structures such as the mandibular canal, with its neurovascular bundle, thereby clearly reducing the risk for postsurgical nerve irritations (Bernard et al. 1995a). In standard sites, the longest possible implant up to 12 mm is selected. If a reduced bone height demands the insertion of 64

Basic surgical principles with ITI implants sterile irrigation is highly recommended. In addition, a sufcient stock of implants and implant components allows the clinician to handle unexpected situations during surgery. Premedication includes a rinse of the oral cavity with chlorhexidine-digluconate (0.12% or 0.2%) for 1 minute and the disinfection of the perioral skin prior to the surgery. When indicated, the utilization of a sedative medication is recommended. Antibiotic prophylaxis is not indicated in healthy patients if an uncomplicated surgical procedure is expected. When an extensive or complex surgery is anticipated, prophylaxis with 2 Mio. Penicillin V in one dose per os (one hour prior to surgery) is recommended in healthy patients (for patients with an allergy to penicillin: 600 mg Clindamycin per os). In high-risk patients, antibiotic prophylaxis is indicated based on recommendations of national medical societies. Basic surgical technique with ITI implants As outlined above, a low-trauma surgical procedure is the ultimate goal during preparation of the implant bed in the alveolar process. Thus, the following recommendations should be respected for the placement of ITI implants: a reduced drilling speed (800 rpm), copious cooling with chilled sterile saline, the use of sharp drills, a light hand pressure during drilling, and an intermittent drilling technique. For solid-screw implants (S 3.3, NN 3.3, S 4.1, S 4.8, WN 4.8), the bone excavation is done stepwise with spiral drills of increasing diameter (2.2 mm, 2.8 mm, 3.5 mm, and 4.2 mm). This facilitates a low-trauma preparation of the bone at the recipient site. It also allows minor corrections of the implant position and its axis during this procedure. These drills have been modied a few years ago to reduce overdrilling to 0.4 mm. This reduction was important in particular for implant sites above the mandibular canal. Based on personal preference, tapping and implant insertion can either be done with a hand ratchet or with a surgical adapter attached to a special contra-angle handpiece with 15 rpm. Concerning the healing modality, numerous experimental and clinical studies have clearly demonstrated that both the non-submerged and the submerged approach offer predictable tissue integration of endosseous implants (Gotfredsen et al. 1991; Ericsson et al. 1994; Bernard et al. 1995b; Weber et al. 1996; Ericsson et al. 1996). Today, ITI implants are utilized with both modalities depending on the clinical situation. The non-submerged approach is generally preferred, in particular in all standard sites without esthetic priority. This includes implant therapy in fully edentulous patients and all implants being inserted in posterior areas in partially edentulous patients. Consequently, a precise adaptation of the wound margins to the implant post or the healing cap is necessary, allowing for a primary wound closure with tension-free, interrupted sutures. In contrast, the submerged approach is utilized for all implants being inserted in esthetic sites or in combination with bone graft procedures. Healing periods of ITI implants The healing period of an ITI implant depends primarily on the bone density at the recipient site as perceived at the time of implant placement and on the achieved implant stability. Clinical experience has proven that loading of ITI implants with a TPS surface can be initiated after 3 months in all sites with adequate bone density (class IIII according to the classication of Lekholm & Zarb 1985), irrespective of whether the implant is inserted in the maxilla or in the mandible. This is a distinct difference from titanium implants with a machined surface. These implants require 6 months of healing when inserted in the maxilla, prior to the second-stage surgery to uncover the implant, and an additional healing period of 46 weeks is necessary to achieve proper soft tissue healing following second-stage surgery. In sites with less bone density (class IV), the initiation of functional loading of ITI implants needs to be delayed, and a healing period of at least 4 months is recommended. Immediate implant loading is possible in the edentulous mandible and maxilla when at least four ITI implants are post-surgically splinted with a bar or a xed cross-arch bridge (Ledermann 1979; Babbush et al. 1986; Salama et al. 1995; Jafn et al. 2000). The clinical experience of more than 20 years has proven the validity of this surgical protocol for bar-type overdentures supported by four ITI implants (Ledermann 1996). A general reduction of the healing period is possible with the new SLA (Sandblasted with Large grit and Acid-etched) titanium surface introduced with the ITIA Dental Implant System in 1998. In more than 10 years of experimental research, numerous in vivo studies have demonstrated the superiority of this non-coated and microrough SLA surface when compared with the TPS surface, in particular during the initial healing period (Wilke et al. 1990; Buser et al. 1991b; Wong et al. 1995; Cochran et al. 1998; Buser et al. 1998; Buser et al. 1999b). An ongoing multicenter study is testing this new implant surface for a healing period of 6 weeks in fully and partially edentulous patients in standard sites with sufcient bone vol65

Buser et al. ume and normal bone density (class IIII). The preliminary results are promising with success rates exceeding 98% at the completion of the healing period, and will be published in the near future (Cochran et al. 2001).
regeneration in implant dentistry, 1st edition. Chicago: Quintessence. Buser, D., Dula, K., Hirt, H.P. & Schenk, R.K. (1996) Lateral ridge augmentation using autografts and barrier membranes: a clinical study with 40 partially edentulous patients. Journal of Oral and Maxillofacial Surgery 54: 420432. Buser, D., Mericske-Stern, R., Bernard, J.P., Behneke, A., Behneke, N., Hirt, H.P., Belser, U.C. & Lang, N.P. (1997) Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clinical Oral Implants Research 8: 161172. Buser, D., Nydegger, T., Hirt, H.P., Cochran, D.L. & Nolte, L.P. (1998) Removal torque values of titanium implants in the maxilla of miniature pigs. A direct comparison of sandblasted and acid-etched with machined and acid-etched screw implants. International Journal of Oral and Maxillofacial Implants 13: 611619. Buser, D., Mericske-Stern, R., Dula, K. & Lang, N.P. (1999a) Clinical experience with one-stage, non-submerged titanium dental implants. Advances of Dental Research 13: 153. Buser, D., Nydegger, T., Oxland, T., Cochran, D.L., Schenk, R.K., Hirt, H.P., Sne tivy, D. & Nolte, L.P. (1999b) The interface shear strength of titanium implants with a sandblasted and acid-etched surface. A biomechanical study in the maxilla of miniature pigs. Journal of Biomedical Materials Research 45: 7583. Cochran, D.L., Schenk, R.K., Lussi, A., Higginbottom, F.L. & Buser, D. (1998) Bone response to unloaded and loaded titanium implants with a sandblasted and acid-etched surface. A histometric study in the canine mandible. Journal of Biomedical Materials Research 40: 111. Cochran, D.L., Buser, D., ten Bruggenkate, C.M., Weingart, D., Taylor, T.M., Bernard, J.P., Peters, F. & Simpson, J.P. (2001) The use of shortened healing times on ITI implants with a sandblasted and acid-etched (SLA) surface. Early results from clinical trials on ITI SLA implants. Clinical Oral Implants Research (Submitted). Cronin, R.J., Oesterle, L.J. & Ranly, D.M. (1994) Mandibular implants and the growing patient. International Journal of Oral and Maxillofacial Implants 9: 5562. Cune, M.S. & de Putter, C. (1996) A single dimension statistical evaluation of predictors in implant-overdenture treatment. Journal of Clinical Periodontology 23: 425431. Dao, T.T., Anderson, J.D. & Zarb, G.A. (1993) Is osteoporosis a risk factor for osseointegration of dental implants? International Journal of Oral and Maxillofacial Implants 8: 137 144. Dietrich, U., Lippold, R., Dirmeier, T., Behneke, N. & Wagner, W. (1993) Statistische Ergebnisse zur Implantatprognose am Beispiel von 2017 IMZ-Implantaten unterschiedlicher Indikation der letzten 13 Jahre. Zeitschrift fu r Zahna rztliche Implantologie 9: 918. Ellies, L.G. (1992) Altered sensation following mandibular implant surgery: a retrospective study. Journal of Prosthetic Dentistry 68: 664671. Epstein, J., van der Meij, E., McKenzie, M., Wong, F., Lepawsky, M. & Stevenson-Moore, P. (1997) Postradiation osteonecrosis of the mandible. A long-term follow-up study. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 83: 657662. Ericsson, I., Randow, K., Glantz, P.O., Lindhe, J. & Nilner, K. (1994) Clinical and radiographical features of submerged and nonsubmerged titanium implants. Clinical Oral Implants Research 5: 185189. Ericsson, I., Nilner, K., Klinge, B. & Glantz, P.O. (1996) Radiographical and histological characteristics of submerged and nonsubmerged titanium implants. An experimental study in the labrador dog. Clinical Oral Implants Research 7: 2026.

References
Babbush, C.A., Kent, J.N. & Misiek, D.L. (1986) Titanium plasma-sprayed (TPS) screw implants for the reconstruction of the edentulous mandible. Journal of Oral and Maxillofacial Surgery 44: 274282. Bain, C.A. (1996) Smoking and implant failure: benets of a smoking cessation protocol. International Journal of Oral and Maxillofacial Implants 11: 756759. Bain, C.A. & Moy, P. (1993) The association between the failure of dental implants and cigarette smoking. International Journal of Oral and Maxillofacial Implants 8: 609615. Baxter, J.C. & Fattore, L. (1993) Osteoporosis and osseointegration of implants. Journal of Prosthodontics 2: 120125. Behneke, A., Behneke, N. & Wagner, W. (1992) Klinische Ergebnisse mit transgingival inserierten enossalen Implantaten (Bonet-System). Zeitschrift Zahna rztliche Implantologie 8: 97102. Behneke, A., Behneke, N., dHoedt, B. & Wagner, W. (1997) Hard and soft tissue reactions to ITI screw implants: 3-year longitudinal results of a prospective study. International Journal of Oral and Maxillofacial Implants 12: 749756. Bergendal, B., Bergendal, T., Hallonsten, A.L., Koch, G., Kurol, J. & Kvint, S. (1996) A multidisciplinary approach to oral rehabilitation with osseointegrated implants in children and adolescents with multiple aplasia. European Journal of Orthodontics 18: 119129. Bernard, J.P., Belser, U.C., Szmukler, S., Martinet, J.P., Attieh, re ` t de lutilisation dimplants A. & Saad, P.J. (1995a) Inte rieurs: re sultats ITI de faible longueur dans les secteurs poste tude clinique de 3 ans. Medicine buccale Chirurgie dune e buccale 1: 1118. Bernard, J.P., Belser, U.C., Martinet, J.P. & Borgis, S.A. (1995b) Osseointegration of Brnemark xtures using a single-step operating system. A preliminary prospective one-year study in the edentulous mandible. Clinical Oral Implants Research 6: 122129. Blanchaert, R.H. (1998) Implants in the medically challenged patient. Dental Clinics of North America 42: 3545. Brnemark, P.I., Zarb, G.A. & Albrektsson, T., eds. (1985) Tissue integrated prostheses. Osseointegration in clinical dentistry. Chicago: Quintessence Publishing Co. Buser, D., Weber, H.P. & Lang, N.P. (1990) Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clinical Oral Implants Research 1: 3340. Buser, D., Weber, H.P., Bra gger, U. & Balsiger, C. (1991a) Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study with hollow-cylinder and hollowscrew implants. International Journal of Oral and Maxillofacial Implants 6: 405412. Buser, D., Schenk, R.K., Steinemann, S., Fiorellini, J.P., Fox, C.H. & Stich, H. (1991b) Inuence of surface characteristics on bone integration of titanium implants: a histomorphometric study in miniature pigs. Journal of Biomedical Materials Research 25: 889902. Buser, D., Sutter, F., Weber, H.P., Belser, U. & Schroeder, A. (1992) The ITI Dental Implant System. Basics, clinical indications and procedures, Results. Clarks Clinical Dentistry, Vol. 1, pp. 123. Buser, D., Dahlin, C. & Schenk, R., eds. (1994) Guided bone

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Basic surgical principles with ITI implants

Esser, E. & Wagner, W. (1997) Dental implants following radical oral cancer surgery and adjuvant radiotherapy. International Journal of Oral and Maxillofacial Implants 12: 552 557. Fritz, M.E. (1997) Overview of clinical trials on endosseous implants. Annals of Periodontology 2: 270283. Gorman, L.M., Lambert, P.M., Morris, H.F., Ochi, S. & Winkler, S. (1994) The effect of smoking on implant survival at second-stage surgery. Implant Dentistry 3: 165168. Gotfredsen, K., Rostrup, E., Hjrting-Hansen, E., Stoltze, K. & Butz-Jrgensen, E. (1991) Histological and histomorphometrical evaluation of tissue reactions adjacent to endosteal implants in monkeys. Clinical Oral Implants Research 2: 3037. Gouvoussis, J., Sindhusake, D. & Yeung, S. (1997) Cross-infection from periodontitis sites to failing implant sites in the same mouth. International Journal of Oral and Maxillofacial Implants 12: 666673. Granstro m, G. & Tjellstro m, A. (1997) Effects of irradiation on osseointegration before and after implant placement: a report of three cases. International Journal of Oral and Maxillofacial Implants 12: 547551. Haas, R., Haimbock, W., Mailath, G. & Watzek, G. (1996) The relationship of smoking on peri-implant tissue: a retrospective study. Journal of Prosthetic Dentistry 76: 592596. Hogenius, S., Berggren, U., Blomberg, S., Jemt, T. & Ohman, S.C. (1992) Demographical, odontological, and psychological variables in individuals referred for osseointegrated dental implants. Community Dentistry and Oral Epidemiology 20: 224228. Ivanoff, C.J., Sennerby, L. & Lekholm, U. (1996) Inuence of mono- and bicortical anchorage on the integration of titanium implants. A study in the rabbit tibia. International Journal of Oral and Maxillofacial Surgery 25: 229235. Jafn, R.A., Kumar, A. & Berman, C.L. (2000) Immediate loading of implants in partially and fully edentulous jaws: A series of 27 case reports. Journal of Periodontology 75: 833838. Jisander, S., Grenthe, B. & Alberius, P. (1997) Dental implant survival in the irradiated jaw: a preliminary report. International Journal of Oral and Maxillofacial Implants 12: 643 648. Ledermann, P.D. (1979) Stegprothetische Versorgung des zahnlosen Unterkiefers mit Hilfe von plasmabeschichteten Titanschraubenimplantaten. Deutsche Zahna rztliche Zeitschrift 34: 907911. ber 20ja Ledermann, P.D. (1996) U hrige Erfahrung mit der sofortigen funktionellen Belastung von Implantatstegen in der regio interforaminalis. Zeitschrift fu r Zahna rztliche Implantologie 12: 123136. Lekholm, U. & Zarb, G.A. (1985) Patient selection and preparation. In: Brnemark, P.I., Zarb, G.A. & Albrektsson, T., eds. Tissue integrated prostheses. Osseointegration in clinical dentistry. Chicago: Quintessence Publishing Co. Lindquist, L.W., Carlsson, G.E. & Jemt, T. (1996) A prospective 15-year follow-up study of mandibular xed prostheses supported by osseointegrated implants. Clinical results and marginal bone loss. Clinical Oral Implants Research 7: 329 336. Meffert, R.M. (1993) Periodontitis and periimplantitis: one and the same? Practical Periodontics and Aesthetic Dentistry 5: 7982. Mericske-Stern, R., Steinlin Schaffner, T., Marti, P. & Geering, A.H. (1994) Peri-implant mucosal aspects of ITI implants supporting overdentures. A ve-year longitudinal study. Clinical Oral Implants Research 5: 918. Mombelli, A. (1993) Microbiology of the dental implant. Advances of Dental Research 7: 202206. Mombelli, A. & Lang, N.P. (1992) Antimicrobial treatment of peri-implant infections. Clinical Oral Implants Research 3: 162168. Mordenfeld, A., Andersson, L. & Bergstro m, B. (1997) Hemorrhage in the oor of the mouth during implant placement in the edentulous mandible: a case report. International Journal of Oral and Maxillofacial Implants 12: 558561. Navazesh, M., Brightman, V.J. & Pogoda, J.M. (1996) Relationship of medical status, medications, and salivary ow rates in adults of different ages. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 81: 172176. Oikarinen, K., Raustia, A.M. & Hartikainen, M. (1995) General and local contraindications for endosseal implantsan epidemiological panoramic radiograph study in 65-year-old subjects. Community Dentistry and Oral Epidemiology 23: 114118. Perel, M.L. (1994) Parafunctional habits, nightguards, and root form implants. Implant Dentistry 3: 261263. Rangert, B., Krogh, P.H., Langer, B. & van Roekel, N. (1995). Bending overload and implant fracture: a retrospective clinical analysis. International Journal of Oral and Maxillofacial Implants 10: 326334. Salama, H., Rose, L.F., Salama, M. & Betts, N.J. (1995) Immediate loading of bilaterally splinted titanium root-form implants in xed prosthodonticsa technique reexamined: two case reports. International Journal of Periodontics and Restorative Dentistry 15: 344361. Scharf, D.R.. & Tarnow, DP. (1993) Success rates of osseointegration for implants placed under sterile versus clean conditions. Journal of Periodontology 64: 954956. Shernoff, A.F., Colwell, J.A. & Bingham, S.F. (1994) Implants for type II diabetic patients: interim report. Implant Dentistry 3: 183185. Thilander, B., Odman, J., Grondahl, K. & Friberg, B. (1994) Osseointegrated implants in adolescents. An alternative in replacing missing teeth? European Journal of Orthodontics 16: 8495. von Arx, T. & Kurt, B. (1998) Implant placement and simultaneous peri-implant bone grafting using a micro titanium mesh for graft stabilization. International Journal of Periodontics and Restorative Dentistry 18: 117127. von Arx, T., Wallkamm, B. & Hardt, N. (1998) Localized ridge augmentation using a micro titanium mesh: a report on 27 implants followed from 1 to 3 years after functional loading. Clinical Oral Implants Research 9: 123130. Weber, H.P., Buser, D., Donath, K., Fiorellini, J.P., Doppolapudi, V., Paquette, D.W. & Williams, R.C. (1996) Comparison of healed tissues adjacent to submerged and non-submerged unloaded titanium dental implants. A histometric study in beagle dogs. Clinical Oral Implants Research 7: 1119. Wehrbein, H., Merz, B.R., Diedrich, P. & Glatzmaier, J. (1996) The use of palatal implants for orthodontic anchorage. Design and clinical application of the orthosystem. Clinical Oral Implants Research 7: 410416. Weinberg, M.A., Insler, M.S. & Campen, R.B. (1997) Mucocutaneous features of autoimmune blistering diseases. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 84: 517534. Weyant, R.J. (1994) Characteristics associated with the loss and peri-implant tissue health of endosseous dental implants. International Journal of Oral and Maxillofacial Implants 9: 95102. Wilke, H.J., Claes, L. & Steinemann, S. (1990) The inuence of various titanium surfaces on the interface shear strength between implants and bone. In: Heimke G, Solte sz U & Lee AJC, eds. Advances in Biomaterials, Vol. 9, Clinical implant materials, pp. 309314. Amsterdam: Elsevier Science Publishers BV. Wong, M., Eulenberger, J., Schenk, R.K. & Hunziker, E. (1995) Effect of surface topography on the osseointegration of im-

67

Buser et al.
plant materials in trabecular bone. Journal of Biomedical Materials Research 29: 15671575. Wong, J.K., Wood, R.E. & McLean, M. (1997) Conservative management of osteoradionecrosis. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 84: 1621. Worthington, P. (1995) Medicolegal aspects of oral implant surgery. Australian Prosthodontic Journal 9 (Suppl): 1317. Wu, A.J. & Ship, J.A. (1993) A characterization of major salivary gland ow rates in the presence of medications and systemic diseases. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 76: 301306.

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