Annals of Anatomy 199 (2015) 85–91

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Annals of Anatomy
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Research article

Immediately loaded mini dental implants as overdenture retainers:

1-Year cohort study of implant stability and peri-implant marginal
bone level
Miodrag Šćepanović a,∗ , Aleksandar Todorović a , Aleksa Marković b , Vesna Patrnogić a ,
Biljana Miličić c , Adel M. Moufti d , Tijana Mišić b
a
Department of Prosthodontics, Faculty of Dental Medicine, University of Belgrade, Rankeova 4, Belgrade 11000, Serbia
b
Department of Oral Surgery, Faculty of Dental Medicine, University of Belgrade, Dr Subotića 4, Belgrade 11000, Serbia
c
Department of Medical Statistics and Informatics, University of Belgrade, Dr Subotića 1, Belgrade 11000, Serbia
d
Department of Restorative Dentistry, University of Manchester, Higher Cambridge Street, Manchester M156FH, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Aim: This 1-year cohort study investigated stability and peri-implant marginal bone level of immediately
Received 8 September 2013 loaded mini dental implants used to retain overdentures.
Received in revised form Materials and methods: Each of 30 edentulous patients received 4 mini dental implants (1.8 mm × 13 mm)
10 December 2013
in the interforaminal mandibular region. The implants were immediately loaded with pre-made overden-
Accepted 20 December 2013
tures. Outcome measures included implant stability and bone resorption. Implant stability was measured
using the Periotest Classic® device immediately after placement and on the 3rd and 6th weeks and the
Keywords:
4th, 6th and 12th months postoperatively. The peri-implant marginal bone level (PIBL) was evaluated at
Mini dental implants
Immediate loading
the implant’s mesial and distal sides from the polished platform to the marginal crest. Radiographs were
Implant stability taken using a tailored film holder to reproducibly position the X-ray tube at the 6th week, 4th and 12th
Periotest® months postoperatively.
Peri-implant marginal bone level Results: The primary stability (Periotest value, PTV) measured −0.27 ± 3.41 on a scale of −8 to + 50
(lower PTV reflects higher stability). The secondary stability decreased significantly until week 6 (mean
PTV = 7.61 ± 7.05) then increased significantly reaching (PTV = 6.17 ± 6.15) at 12 months. The mean PIBL
measured −0.40 mm after 1 year of functional loading, with no statistically significant differences at the
various follow-ups (p = 0.218).
Conclusions: Mini dental implants placed into the interforaminal region could achieve a favorable pri-
mary stability for immediate loading. The follow-up Periotest values fluctuated, apparently reflecting
the dynamics of bone remodeling, with the implants remaining clinically stable (98.3%) after 1 year of
function. The 1-year bone resorption around immediately loaded MDIs is within the clinically acceptable
range for standard implants.
© 2014 Elsevier GmbH. All rights reserved.

1. Introduction additional surgical procedures such as bone augmentation (Griffitts

Implant-retained dentures have become a successful, increas-
ingly popular treatment option to enhance the stability and
retention of complete dentures over resorbed ridges (Das et al.,
2012). However, this option is challenged by a number of factors
including bone volume and available finances. Mini dental implants
are considered to be a good alternative to standard dental implants
due to their small diameter, low primary costs, and avoidance of
∗ Corresponding author. Tel.: +381 637700797.
E-mail addresses: midents@yahoo.com (M. Šćepanović), maleksa64@mail.com
(A. Marković), biljana.milicic@stomf.bg.ac.rs (B. Miličić), adelmoufti@yahoo.co.uk
(A.M. Moufti), tijana.misic@gmail.com (T. Mišić).
et al., 2005; Preoteasa et al., 2010).
In a recent systematic review, the calculated mean of one-
year survival rate for mini dental implants used for definitive
prosthodontic treatment in the mandible was 94.7% (Bidra and
Almas, 2013). Middle-term survival rates for mini dental implants
used for immediate stabilization of mandibular prostheses ranged
between 91% and 97% (Bidra and Almas, 2013; Bulard and Vance,
2005; Elsyad et al., 2011; Mundt et al., 2013; Shatkin et al., 2007),
whereas sound long term data are not available.
The clinical outcomes of immediately loaded mini dental
implants used as retainers for mandibular overdenture were
recently investigated (Scepanovic et al., 2012). The authors
reported a 98.3% implant success rate at the 1-year follow-up and
a 1-year overdenture success rate of 100%. Patients reported a

0940-9602/$ – see front matter © 2014 Elsevier GmbH. All rights reserved.
http://dx.doi.org/10.1016/j.aanat.2013.12.005
86 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91

significant improvement in quality of life, overdenture stability,

comfort, speaking and chewing ability following implant rehabili-
tation. Apart from the dentures retention and patients’ satisfaction,
little is known regarding the effects of immediate loading of mini
dental implants on implant stability or the ability of peri-implant
bone to withstand this load (Elsyad et al., 2011; Jofre et al., 2010;
Jofré et al., 2010). The present study reports data on these clinical
measures from the same cohort (Scepanovic et al., 2012).
Different methods are available to measure implant stability.
The Periotest value of an oral implant is an objective and easily
applied measure of stability that may assist the clinician in decid-
ing whether to extend the healing period before loading fixtures
(Olive and Aparicio, 1990). PTV’s range on a scale of −8 to +50,
with the negative range presenting better stability. Researchers
reported different ranges of PTVs for successfully osseointegrated
standard-diameter implants (−9 to +9; −5 to +5; −7 to 0; −4 to −2;
−4 to +2) (Aparicio, 1997; Eitner et al., 2008; Morris et al., 2003; Fig. 1. Measurement of implant stability. The rod of the Periotest Classic® device
Olive and Aparicio, 1990; Teerlinck et al., 1991). Data regarding approaching the square point at the collar part of the implant used as a reference
these PTV values for mini dental implants are scarce. In a 3-year point.
prospective study on mini dental implants supporting a mandibular
overdenture, PTV from −3.7 ± 1.1 to −4.2 ± 1.2 were recorded for
history, whereas 10 had hypertension, 2 had asthma, 2 had con-
successfully osseointegrated implants (Elsyad et al., 2011). Experi-
trolled diabetes mellitus type 2, and 3 had thyroid dysfunction. Each
mental data from nonviable bovine femoral bone, have shown that
patient received 4 mini dental implants (MDI; 3M ESPE, St. Paul,
mini dental implants, designed for immediate loading, can only be
MN, USA) in the interforamine region, which were immediately
loaded immediately if their Periotest values are measured to be
loaded with overdentures. A flap surgical approach was required
between the range of −8 to +9 (Dilek et al., 2008). Further clin-
in 7 patients due to narrow alveolar ridge in order to prevent acci-
ical research is needed to be performed in order to draw more
dental perforation of the lingual cortical plate and subsequent risk
definite conclusions about immediate loading of the mini dental
of sublingual hematoma. All patients were treated by the same oral
implants (Dilek et al., 2008). There is no defined PTV that would
surgeon, prosthodontist and dental technician in order to provide
allow immediate loading of standard-diameter implants, but an
uniform conditions.
insertion torque of at least 32 Ncm is mandatory (Ottoni et al., 2005;
Outcome measurements in this study were primary and sec-
Payer et al., 2010).
ondary implant stability as well as peri-implant bone loss.
Bone resorption around the implant naturally occurs as part of
the bone tissue maturation and reaction to loading forces. Studies
have suggested criteria for the expected “physiologic” resorp- 2.1. Implant stability measurements
tion of crestal bone around dental implants (Buser et al., 1997).
On the other hand, pathologic peri-implant crestal bone loss can Primary implant stability was measured immediately after
compromise implant treatment (Hermann et al., 2001). There- implant placement using the Periotest Classic® device (Medi-
fore, measuring PIBR is one of the important outcome measures in zintechnik Gulden, SiemensAG, Germany). In order to achieve
implantology, and an indication of success of the implant (Hermann reproducible measurement of implant stability, the square point
et al., 2001). at the collar part of the implant was chosen as a reference (Fig. 1).
The aim of this 1-year cohort study was to investigate primary The Periotest rod was positioned perpendicularly to the implant
and secondary implant stability as well as changes in peri-implant axis and alveolar ridge. The device produces 16 hits in 4 s. Contact
marginal bone level of immediately loaded mini dental implants time of the rod and implant surface is measured in milliseconds.
used to retain mandibular overdentures. Our first hypothesis was, The test values are measured on a numeric scale from −8 to +50,
that, despite their narrow diameter, mini dental implants could where negative values present better implant stability.
achieve primary stability within the accepted range for immedi- After measuring primary stability, the metal housings were
ately loaded standard diameter implants. The second hypothesis incorporated into the dentures. The recently made dentures were
was that secondary stability and peri-implant bone resorption of drilled on the inner surface in order to make a proper space for the
mini dental implants immediately loaded by mandibular overden- metal housing. When passive fit was achieved, cold curing acrylic
ture are not different from standard diameter implant’s accepted was used to underline and retain the metal housings into the den-
values. ture. To avoid the acrylic penetration into the undercut spaces of
the implant, block-out shims were placed.
Secondary implant stability was measured postoperatively on
2. Materials and methods the 3rd and 6th weeks and on the 4th, 6th and 12th months in the
same way used to measure primary stability.
After obtaining the Ethics Committee’s approval (no. 36/5), this
cohort study was conducted at the Clinic of Prosthodontics and 2.2. Peri-implant marginal bone level assessment
Clinic of Oral Surgery, School of Dentistry, University of Belgrade
from January 2010 to June 2011. Patient selection as well as surgi- Peri-implant marginal bone level was evaluated by means of
cal and prosthetic protocols have been previously reported in detail a special film holder that was made from a commercial X-ray
(Scepanovic et al., 2012). A total of 120 mini dental implants (MDI; film holder (Dentsply® film holder) using a silicone key (Zeta plus
3M ESPE, St. Paul, MN, USA) with a length of 13 mm, diameter of Zhermack® ) to reproducibly position the X-rays tube in the dif-
1.8 mm and with polished collar were used for the rehabilitation ferent follow-up points (Fig. 2). The film holder was retained in
of mandibular edentulism of 30 patients (16 female and 14 male) place using a snap connection to the implant-retained denture. All
aged from 45 to 63. Twelve patients presented with sound medical radiographs were taken by the long cone technique. A plastic ring,
 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91
Fig. 2. Obtaining radiographs using long cone technique. A plastic ring, connected
to the film holder provided control of tube orientation.
connected to the film holder provided control of the tube direction.
Exposition parameters were 65–90 kV, 7.5–10 mA and 0.22–0.25 s.
The obtained radiographs were oriented and marked with the
number of participant and follow-up points before they were
scanned and digitized using Canoscans® (Radiograph Scanner,
Japan). These were then imported in the software Ray Mage® (Cefla
Group, Italy). All digitized radiographs were of 512 × 512 pixels.
Uniform planes were defined as starting point for further measur-
ing. The radiographs were calibrated. As a baseline, we used the
already measured and known distance between the implant apex
and polished collar, which was 15.5 mm (Fig. 3a).
The level of peri-implant marginal bone level changes was mea-
sured on the mesial and distal sides of the implant from the polished
platform level to the marginal crestal level (Fig. 3b). The measure-
ment was performed by the same person, independently of the
research team. The radiographs were coded (no information on the
Fig. 3. Peri-implant marginal bone level assessment. (a) Calibration for baseline measurement with already measured and known distance between the implant apex and
polished collar (15.5 mm). (b) Measurement of peri-implant marginal bone level on the mesial and distal sides of the implant from the polished platform to the marginal
crestal level.
87
the observation time or of the patient’s identity) during the bone
level assessment.
The peri-implant marginal bone level was measured at the time
of implant loading (baseline) as well as on the 6th week, as well
as the 4th and 12th months postoperatively. The crestal bone level
at the implant loading stage was used as a baseline and reference
for postoperative measurments. Changes in the bone levels at each
observation time point were calculated by subtracting correspond-
ing bone levels recorded at a particular time from the baseline bone
levels.
2.3. Statistical analysis
Statistical analysis was performed using the software package
SPSS 18.0 for Windows (SPSS, Chicago, IL, USA). Measures of central
tendency (mean) and of dispersion (minimum, maximum, standard
deviation) were used for the description of both observed vari-
ables Periotest values (PTV) and Peri-implant bone level (PIBL). We
examined the dynamic changes in PTV and PIBL during follow-
up points. Data were first tested for normal distribution using
the Koglomorov–Smirnov test. As PTV values were not normally
distributed, non-parametric Wilcoxon Signed Rank test was used
for their analysis. PIBL data were normally distributed; hence the
“repeated measures of analysis of variance (RM-ANOVA)” test was
used for analysis including variable time as within-subject factor.
All reported p-values were two sided. Differences were considered
significant when p-value was <0.05.
3. Results
Out of 60 patients who were examined for eligibility, 30 were
included in the study (25 did not meet inclusion criteria due to
severe bone resorption or chronic condition; 4 were not able to
attend check-ups; 1 had unrealistic expectations from the treat-
ment). The 30 recruited patients, aged from 45 to 63, 16 female
88 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91

Fig. 4. Frequency distribution of baseline Periotest values (PTV).

and 14 male were monitored for 1 year and no dropout occurred.
Their data were used for statistical analyses.
The recruitment and implant placement were undertaken
between January and June 2010. A total of 120 mini dental implants
achieved an insertion torque of at least 35 Ncm and were imme-
diately loaded. Patients were monitored during the first year of
immediate implant loading with the last 1-year check-up per-
formed in June 2011, resulting in a total follow-up time of 18
months. Two implants were excluded from the analysis due to lack
of osseointegration in 2 patients in the second and sixth weeks
postoperatively.
3.1. Implant stability
4. Discussion
The negative Periotest values recorded at baseline indicate pri-
mary stability of mini dental implants (MDIs) that is in the accepted
range for immediately loaded standard-diameter implants used
to retain mandibular overdentures. This result supports the first
hypothesis. The second hypothesis must partly be rejected. The
Periotest values of the MDIs were higher than those of standard
implants reported in the literature; however, the changes in the
marginal bone level of MDIs corresponded to those of standard
diameter implants.
Although the general limitation of our study is the short obser-
vation period, further considerable changes in Periotest values

The primary stability ranged from −6 to 16 (expressed in PTV)

with a mean value of −0.27 ± 3.41. Seventy out of 120 implants
(58.33 %) achieved primary stability lower than +1 PTV; 49 implants
(40.83 %) had PTV between +1 and +9; while only 1 implant
exceeded +9 PTV (Fig. 4).
As shown in Fig. 5, there was a trend to increase in PTV (reduc-
tion in stability) towards the 6th week post-op, which was followed
by a small but statistically significant decrease in PTV until the 6th
month post-op, at which point PTV remained the same until the 1
year follow-up.
The maximum individual PTV value was 30 and recorded in the
6th week post-op in one implant, which failed in that week. This
implant had shown a continuous and significant increase in the PTV
from baseline (+6) through the 3rd week post-op (+12) up to the
critical 6th week post-op (+30). The other implant that failed in the
2nd week post-op had achieved a primary stability of −3 PTV.

3.2. Peri-implant marginal bone level

The differences between PIBLs across time points were not sta-
tistically significant (p = 0.218) (Fig. 6). After one year of loading,
only 8 out of 120 implants (6.67%) had bone loss greater than
1.5 mm.
Fig. 5. The dynamic changes in PTV of immediately loaded mini dental implants
over 1-year. Asterisks indicate statistically significant difference from baseline:
*,**,***,****,*****
p ≤ 0.0005. Crosses indicate statistically significant difference between
two consecutive time points: + p ≤ 0.0005; ++ p ≤ 0.0005; +++ p = 0.008.
 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91
Fig. 6. The dynamic changes in peri-implant bone level (PIBL) of immediately loaded
mini dental implants over 1-year.
and in bone levels are not expected because the osseointegration
of implants (including bone remodelling) is accomplished mainly
after one year. Another limitation could be that the sensitivity
of Periotest measurements may be low, however, MDIs as one
piece implants restricted the measurement method (Aparicio et al.,
2006).
Our study has several strengths. First, all implants used in this
study were of same diameter and length, providing better sample
homogeneity and reliability of the results. Additionally, in order to
establish a standardized baseline and measurement conditions, a
new set of dentures were made prior to implant placement. Fur-
thermore, a tailored radiograph holder was designed to ensure
standardized radiographic assessment.
Since this clinical trial is based on the use of single piece mini
dental implants we used the Periotest® to measure primary and
secondary implant stability. It is a non-invasive and reliable instru-
ment for objective measurement of implant mobility and clinical
assessment of osseointegration (Drago, 2000). To monitor stabil-
ity over a long period of time, the measurement method must
be standardized. Ichikawa et al. (1994) found that a change in
the Periotest® rod direction can vary the measurements up to ±5
units. Measurement of stability in this clinical study was performed
in a uniform and standardized way, always on the same part of
the implant, by the same examiner and with the same Periotest®
instrument.
In the present study, PTVs were lowest after implant placement,
indicating high primary stability, a crucial matter for the immedi-
ate loading of MDI (Javed and Romanos, 2010). Baseline PTVs were
close to zero or in the negative range. This can be explained by the
self-tapping design of MDI, which offers maximum primary stabil-
ity (principle of osseo-compression) (Markovic et al., 2013). The
following period showed a significant reduction in implant sta-
bility up to the 6th week post-op, which was then followed by a
significant increase in the stability from 4th to 6th months post-op.
This improvement in MDI’s stability corresponds to the histological
finding of mature, remodeled bone interfacing immediately loaded
MDI, 4 and 5 months postoperatively that was reported by Balkin
et al. (2001). The mean PTV measured during the entire observation
period did not exceed +9. According to Eitner et al. (2008) values
like these can be considered as sign of implant osseointegration.
Elsyad et al. (2011) used Periotest® to record the stability of
112 MDIs with diameters of 1.8 mm and lengths of 12–18 mm
placed into mandible in the canine and first premolar region and
89
immediately loaded to retain mandibular overdentures. The
obtained values of primary stability were in the negative range,
which is in accordance with our results. However, the results
obtained in the follow-ups (secondary stability) were in the neg-
ative range, and do not agree with ours. The reason can be the
fact that, in Elsyad’s research, longer implants were used, pro-
viding more surface area and consequentially improvement of
implant stability. In our clinical trial same diameter and length
implants (1.8 mm and 13 mm) were used in order to provide valid
and comparable results. Also, the differences in PTV could arise
from different implant designs (with and without collars) used
in the studies. Elsyad et al. (2011) recorded statistically insignif-
icant changes in PTVs over 3-year follow-up, which is in contrast to
our results. This discrepancy in dynamics of PTVs changes remains
unclear.
Primary stability of mini implants is an essential factor in making
decisions about immediate loading with a complete denture (Javed
and Romanos, 2010). In the literature, there is no strict baseline
PTV that could be considered a reliable threshold/requirement for
immediate loading of MDIs. It is difficult to define this PTV threshold
due to the wide variability of implant length and diameter, abut-
ment length, and anatomic location (Drago, 2000). Experimental
data, from nonviable bovine femoral bone, have suggested that mini
dental implants can only be loaded immediately if their Periotest
values are measured to be between the range of −8 to +9 (Dilek
et al., 2008). In our clinical study, immediately loaded MDIs with
mean primary stability of −0.27 ± 3.41 PTV achieved a 1-year suc-
cess rate of 98.3%. However, surprisingly, one of our implants, with
a primary stability of (PTV = −3) failed. The possible reason might
be a jeopardized regeneration capacity of peri-implant bone due to
friction that generated excessive heat during implant placement,
while, at the same time providing sufficient mechanical (primary)
implant stability (Eriksson and Albrektsson, 1983). Another MDI
with a baseline PTV of 6 failed in the 6th week when a PTV of 30
was recorded. A continuous and rapid increase in PTV should be
considered an early sign of failure.
The secondary stability of implants supporting mandibular
overdentures in edentulous patients was examined previously.
Payne et al. (2002) evaluated early loaded unsplinted standard-
diameter implants of different lengths. During the first year of
observation, they found no statistically significant changes in the
stability measurements which were in the negative range. Similar
results were found in a 2-year prospective study of standard-
diameter implants in the intraforaminal area of the mandible
immediately loaded to retain overdentures (Romeo et al., 2002). In
contrast to these 2 studies, the mini implants in the present study
exhibited statistically significant change in the Periotest® values
(PTV) from the primary stability measurement (negative range or
close to zero just after implant placement) to in the positive range
during the subsequent observations. This can be explained by the
difference in length and diameter, which according to Drago (2000)
can affect PTV, whereby the longer and wider implants are, the
better results (Drago, 2000).
This leads to another important issue regarding the interpreta-
tion of Periotest values. The recommended PT values for successful
treatment are mainly derived from studies on standard-diameter
implants, and one should ask whether these still hold up when we
discuss MDIs; i.e. when we consider implants of different length
and diameter to the standard-implants. Chai et al. (1993) set PTV of
−7 to 0 as a criterion for successful osseointegration of standard-
diameter implants in bone type 1–3. According to this criterion,
the MDIs in our study would be considered non-osseointegrated
from the 3rd observation week. However, they remained clini-
cally stable and with no sign of peri-implantitis or excessive bone
loss by the end of the 1-year observation period. This suggests the
need for a new scale of Periotest values that takes into account the
90 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91
diameter and length of the implant. This would be of tremendous
help for the clinicians to estimate proper time for loading and judge
the treatment outcomes for the selected implant’s diameter and
length.
The peri-implant marginal bone level (PIBL) is an essential treat-
ment outcome measure (Albrektsson et al., 1986; Albrektsson and
Zarb, 1993; Roos et al., 1997; Zarb and Albrektsson, 1998). This mea-
sure is generally accepted as a reliable indicator of bone response
to the surgical procedure and subsequent occlusal loading (Ma
et al., 2010). We noticed insignificant changes in PIBL over time
with value of −0.40 ± 1.24 mm after 1 year of functional loading
of non-splinted, single-piece MDIs with ball abutments. This suc-
cess can be partially attributed to the flapless surgical approach
that preserves most of the periosteal and endosteal blood vessels
and to the O-ring that acts as a shock absorber reducing the loads
on the implants (Jayaraman et al., 2012; Jeong et al., 2007; Kim
et al., 2009). The greatest amount of peri-implant bone loss was
noticed between the point of implantation and week 6. This can be
related to bone remodeling which starts immediately after implan-
tation and represents the phase of active bone change. Our results
meet the criteria for successful standard implants set by Buser et al.
(1997), Albrektsson et al. (1986), and Smith and Zarb (1989).
Jofre et al. (2010) researched peri-implant bone loss around the
MDIs of the same diameter, but different length to the implants
used in our study. They found significant peri-implant bone loss of
0.60 mm after 5 months, 0.79 mm after 10 months, 1.04 after 15
months and 1.13 after 2 years of loading. A greater peri-implant
bone loss was recorded in their study compared with ours, which
could be explained by the lower number (only two) of MDIs used as
overdenture retainers in that study, potentially increasing the load
on the MDIs.
Our PIBL results also appeared to be better than those recorded
in another study on MDIs used to support mandibular overdentures
(Elsyad et al., 2011). After one year of functional loading, the authors
found PIBL of −1.2 mm in comparison to −0.40 mm in our research.
5. Conclusion
The results of this study suggest that MDIs placed into the inter-
foraminal region could achieve primary stability that is favorable
for immediate loading. The Periotest values became relatively high
after immediate loading, but followed the dynamics of bone remod-
eling. Nonetheless, the MDIs remain clinically stable (98.3%) after
1 year of function. The 1-year bone resorption around immedi-
ately loaded MDIs is found within the clinically acceptable range for
standard implants. The present study has also identified the need
for further research to establish a new scale of Periotest values that
takes into consideration implant diameter and length.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.aanat.
2013.12.005.
References
Albrektsson, T., Zarb, G., Worthington, P., Eriksson, A.R., 1986. The long-term efficacy
of currently used dental implants: a review and proposed criteria of success. Int.
J. Oral Maxillofac. Implants 1, 11–25.
Albrektsson, T., Zarb, G.A., 1993. Current interpretations of the osseointegrated
response: clinical significance. Int. J. Prosthodont. 6, 95–105.
Aparicio, C., 1997. The use of the perio test value as the initial success criteria of an
implant: 8-year report. Int. J. Periodont. Rest. Dent. 17, 151–161.
Aparicio, C., Lang, N.P., Rangert, B., 2006. Validity and clinical significance of biome-
chanical testing of implant/bone interface. Clin. Oral Implants Res. 17 (Suppl. 2),
2–7.
Balkin, B.E., Steflik, D.E., Naval, F., 2001. Mini-dental implant insertion with the auto-
advance technique for ongoing applications. J. Oral Implantol. 27, 32–37.
Bidra, A.S., Almas, K., 2013. Mini implants for definitive prosthodontic treatment: a
systematic review. J. Prosthet. Dent. 109, 156–164.
Bulard, R.A., Vance, J.B., 2005. Multi-clinic evaluation using mini-dental implants for
long-term denture stabilization: a preliminary biometric evaluation. Compend.
Contin. Educ. Dent. 26, 892–897.
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. Clin. Oral Implants Res. 8, 161–172.
Chai, J.Y., Yamada, J., Pang, I.C., 1993. In vitro consistency of the Periotest instrument.
J. Prosthodont. 2, 9–12.
Das, K.P., Jahangiri, L., Katz, R.V., 2012. The first-choice standard of care for an eden-
tulous mandible: a Delphi method survey of academic prosthodontists in the
United States. J. Am. Dent. Assoc. 143, 881–889.
Dilek, O., Tezulas, E., Dincel, M., 2008. Required minimum primary stability and
torque values for immediate loading of mini dental implants: an experimental
study in nonviable bovine femoral bone. Oral Surg. Oral Med. Oral Pathol. Oral
Radiol. Endodontol. 105, e20–e27.
Drago, C.J., 2000. A prospective study to assess osseointegration of dental endosseous
implants with the Periotest instrument. Int. J. Oral Maxillofac. Implants 15,
389–395.
Eitner, S., Schlegel, A., Emeka, N., Holst, S., Will, J., Hamel, J., 2008. Comparing bar
and double-crown attachments in implant-retained prosthetic reconstruction:
a follow-up investigation. Clin. Oral Implants Res. 19, 530–537.
Elsyad, M.A., Gebreel, A.A., Fouad, M.M., Elshoukouki, A.H., 2011. The clinical
and radiographic outcome of immediately loaded mini implants supporting
a mandibular overdenture. A 3-year prospective study. J. Oral Rehabil. 38,
827–834.
Eriksson, R.A., Albrektsson, T., 1983. Temperature threshold levels for heat induced
bone tissue injury. A vital microscopic study in rabbit. J. Prosthet. Dent. 50,
101–107.
Griffitts, T.M., Collins, C.P., Collins, P.C., 2005. Mini dental implants: an adjunct for
retention, stability, and comfort for the edentulous patient. Oral Surg. Oral Med.
Oral Pathol. Oral Radiol. Endod. 100, e81–e84.
Hermann, J.S., Schoolfield, J.D., Nummikoski, P.V., Buser, D., Schenk, R.K., Cochran,
D.L., 2001. Crestal bone changes around titanium implants: a methodologic
study comparing linear radiographic with histometric measurements. Int. J. Oral
Maxillofac. Implants 16, 475–485.
Ichikawa, T., Miyamoto, M., Horisaka, Y.N., M, 1994. Clinical evaluation of Periotest
for two-piece apatite implants. Int. J. Oral Maxillofac. Implants 9, 461–467.
Javed, F., Romanos, G.E., 2010. The role of primary stability for successful immediate
loading of dental implants. A literature review. J. Dent. 38, 612–620.
Jayaraman, S., Mallan, S., Rajan, B.M.P., A, 2012. Three-dimensional finite element
analysis of immediate loading mini over denture implants with and without
acrylonitrile O-ring. Indian J. Dent. Res. 23, 840–841.
Jeong, S.M., Choi, B.H., Li, J., Kim, H.S., Ko, C.Y., Jung, J.H., Lee, H.J., Lee, S.H., Engelke,
W., 2007. Flapless implant surgery: an experimental study. Oral Surg. Oral Med.
Oral Pathol. Oral Radiol. Endod. 104, 24–28.
Jofre, J., Cendoya, P., Munoz, P., 2010. Effect of splinting mini-implants on marginal
bone loss: a biomechanical model and clinical randomized study with mandibu-
lar overdentures. Int. J. Oral Maxillofac. Implants 25, 1137–1144.
Jofré, J., Hamada, T., Nishimura, M., Klattenhoff, C., 2010. The effect of maximum
bite force on marginal bone loss of mini-implants supporting a mandibular
overdenture: A randomized controlled trial. Clin. Oral Implants Res. 21, 243–249.
Kim, J.I., Choi, B.H., Li, J., Xuan, F., Jeong, S.M., 2009. Blood vessels of the peri-implant
mucosa: a comparison between flap and flapless procedures. Oral Surg. Oral
Med. Oral Pathol. Oral Radiol. Endod. 107, 508–512.
Ma, S., Tawse-Smith, A., Thomson, W.M., Payne, A.G., 2010. Marginal bone loss with
mandibular two-implant overdentures using different loading protocols and
attachment systems: 10-year outcomes. Int. J. Prosthodont. 23, 321–332.
Markovic, A., Calvo-Guirado, J.L., Lazic, Z., Gomez-Moreno, G., Calasan, D., Guardia,
J., Colic, S., Aguilar-Salvatierra, A., Gacic, B., Delgado-Ruiz, R., Janjic, B., Misic, T.,
2013. Evaluation of primary stability of self-tapping and non-self-tapping dental
implants. A 12-week clinical study. Clin. Implant Dent. Relat. Res. 15, 341–349.
Morris, H.E., Ochi, S., Crum, P., Orenstein, I., Plezia, R., 2003. Bone density: its influ-
ence on implant stability after uncovering. J. Oral Implantol. 29, 263–269.
Mundt, T., Schwahn, C., Stark, T., Biffar, R., 2013. 2013. Clinical response of edentulous
people treated with mini dental implants in nine dental practices. Gerodontol-
ogy..
Olive, J., Aparicio, C., 1990. Periotest method as a measure of osseointegrated oral
implant stability. Int. J. Oral Maxillofac. Implants 5, 390–400.
Ottoni, J.M., Oliveira, Z.F., Mansini, R., Cabral, A.M., 2005. Correlation between
placement torque and survival of single-tooth implants. Int. J. Oral Maxillofac.
Implants 20, 769–776.
Payer, M., Heschl, A., Wimmer, G., Wegscheider, W., Kirmeier, R., Lorenzoni, M.,
2010. Immediate provisional restoration of screw-type implants in the posterior
mandible: results after 5 years of clinical function. Clin. Oral Implants Res. 21,
815–821.
Payne, A.G., Tawse-Smith, A., Duncan, W.D., Kumara, R., 2002. Conventional and
early loading of unsplinted ITI implants supporting mandibular overdentures.
Clin. Oral Implants Res. 13, 603–609.
Preoteasa, E., Melescanu-Imre, M., Preoteasa, C.T., Marin, M., Lerner, H., 2010. Aspects
of oral morphology as decision factors in mini-implant supported overdenture.
Rom. J. Morphol. Embryol. 51, 309–314.
 M. Šćepanović et al. / Annals of Anatomy 199 (2015) 85–91
Romeo, E., Chiapasco, M., Lazza, A., Casentini, P., Ghisolfi, M., Iorio, M., Vogel, G.,
2002. Implant-retained mandibular overdentures with ITI implants. Clin. Oral
Implants Res. 13, 495–501.
Roos, J., Sennerby, L., Lekholm, U., Jemt, T., Grondahl, K., Albrektsson, T., 1997. A
qualitative and quantitative method for evaluating implant success: a 5-year
retrospective analysis of the Branemark implant. Int. J. Oral Maxillofac. Implants
12, 504–514.
Scepanovic, M., Calvo-Guirado, J.L., Markovic, A., Delgardo-Ruiz, R., Todorovic,
A., Milicic, B.T., M, 2012. A 1-year prospective cohort study on mandibu-
lar overdentures retained by mini dental implants. Eur. J. Oral Implantol. 5,
367–379.
91
Shatkin, T.E., Shatkin, S., Oppenheimer, B.D., Oppenheimer, A.J., 2007. Mini dental
implants for long-term fixed and removable prosthetics: a retrospective analysis
of 2514 implants placed over a five-year period. Compend. Contin. Educ. Dent.
28, 92–99, quiz 100–101.
Smith, D.E., Zarb, G.A., 1989. Criteria for success of osseointegrated endosseous
implants. J. Prosthet. Dent. 62, 567–572.
Teerlinck, J., Quirynen, M., Darius, P., van Steenberghe, D., 1991. Periotest: an objec-
tive clinical diagnosis of bone apposition toward implants. Int. J. Oral Maxillofac.
Implants 6, 55–61.
Zarb, G.A., Albrektsson, T., 1998. Consensus report: towards optimized treatment
outcomes for dental implants. J. Prosthet. Dent. 80, 641.