text:
Immediate single implant restorations in mandibular molar extraction sockets: a controlled clinical trial.
ABSTRACT BACKGROUND: In the replacement of missing teeth, a paradigm shift is currently observed with immediate implant placement and/or restoration, particularly in the aesthetic zone. In molar sites, however, anatomical, occlusal and biomechanical considerations remain deterrent factors influencing the outcome of this treatment paradigm. The aim of this report was to evaluate immediate placement and immediate restoration of strongly tapered wide-diameter implant in fresh mandibular molar extraction sockets. METHODS: Twenty-four 8- or 9-mm diameter implants were placed in either a fresh molar extraction socket or a healed site. All the implants received provisional crowns within 48 h. The provisional crowns were replaced with full ceramic crowns after 8 weeks of implant placement. RESULTS: The overall implant success rate after 1 year of service for the 24 implants in two treatment groups was 75%. Success rates were 83.3% and 66.7% for the delayed and immediate placement groups respectively, with no significant difference observed between the two groups (P = 0.35). Implant stability measurements identified the immediately placed implants to be more stable immediately after surgery than delayed placed implants. In contrast, the delayed placed implants were more stable after 8 week healing time. CONCLUSIONS: The rehabilitation of single missing mandibular molars by immediately placed and restored wide-diameter implants was associated with a relatively high failure rate.
- Adi Sivan-Gildor, Eli E Machtei, Eran Gabay, Shai Frankenthal, Liran Levin, Marcelo Suzuki, Paulo G Coelho, Hadar Zigdon-Giladi[Show abstract] [Hide abstract]
ABSTRACT: Objectives: The primary aim was to evaluate clinical radiographic and histological parameters of novel implants with "three roots" design that were inserted into fresh multi-rooted extraction sockets. Secondary aim was to compare this new implant to standard root form dental implants. Methods: Immediate implantation of novel or standard design 6X6 mm implants was performed bilaterally into multi-rooted sockets in mini-pigs' mandible. Twelve weeks later, clinical, radiographic, stability (using an Ostell(®)), histomorphometric and micro-CT analysis were performed. Results: Survival rates were significantly higher in the test implants compared to control (92.8% vs. 33.3%, respectively p=0.0001). Sounding and radiographic bone loss were greater in the control compared to the test (sounding, mean: 3.42±0.68 mm vs. 1.96±0.34 mm; radiographic, mean: 3.35±0.62 mm vs. 2.27±0.33 mm, respectively). Histological and micro CT analyses demonstrated bone fill in the inner part of the test implants. Moreover, bone to implant contact (BIC) was higher in the test implants (55.50±3.68% vs. 42.47%±9.89%). Contrary to the clinical, radiographic and histomorphometric results, resonance frequency analysis (RFA) measurements were greater in the control group (77.74±3.21 ISQ) compared to the test (31.01±0.28 ISQ), p=0.0077. Conclusion: The novel design implants resulted in significantly greater survival rate in multi-rooted extraction sites. Further studies will be required to validate these findings.Journal of Periodontology 04/2014; · 2.57 Impact Factor - SourceAvailable from: Alan G.T. PayneMomen A Atieh, Nabeel H M Alsabeeha, Alan G T Payne, Rohana K de Silva, Donald S Schwass, Warwick J Duncan[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVES: It is of imperative clinical significance to define a safe threshold for planned immediate implant restoration. The aim of this report was to evaluate the prognostic accuracy of resonance frequency analysis (RFA) measurements recorded at two different times (implant placement and 8-week post-implant placement) and to determine the optimal threshold value for predicting failure risk of immediately restored/loaded implants. MATERIAL AND METHODS: Twenty-eight 8- or 9-mm-diameter implants were placed in either a fresh molar extraction socket or a healed site. An electronic RFA device was used to record the implant stability quotients (ISQs) at implant placement surgery, 8 weeks and 1 year. Receiver operating characteristic (ROC) analysis was used to identify the optimal cut-off level. Sensitivity and specificity were also determined at the selected cut-off value. RESULTS: The area under the ROC curve for RFA at 8 weeks was 0.93 with a significant P-value (P = 0.001). The optimum cut-off value for detecting implant stability was 60.5 ISQ measured at 8 weeks, with sensitivity and specificity of 95.2% and 71.4%, respectively. CONCLUSIONS: The implant stability measurements after 8 weeks showed a better accuracy in predicting implants that were at risk of failure than those taken at the time of implant placement.Clinical Oral Implants Research 10/2012; · 3.43 Impact Factor - [Show abstract] [Hide abstract]
ABSTRACT: The primary aim of this study was to compare the bone reaction around immediate-loaded non-splinted single implants vs. delayed loaded non-splinted single implants placed in healed ridges in the posterior mandible. Six adult Macaca Fascicularis monkeys were used in this study. The first and second premolars and the first molar were extracted in both sides of the mandible. After 3 months of healing, four implants (Replace Select Tapered; Nobel Biocare, Gothenburg, Sweden) with a moderately rough surface (TiUnite, Nobel Biocare) were placed in the edentulous areas of each monkey, two in each side. The implants had a length of 10 mm and a diameter of 3.5 mm. Four groups of varying time and occlusal loading aspects were created: (i) control group: implant placed non-loaded for 3 months; (ii) immediate loaded: implant placed and loaded immediately for 3 months; (iii) immediate loaded: implant placed and loaded immediately for 6 months; and (iv) delayed loaded: implant placed submerged for 3 months and then loaded for 3 months. At the loaded implants, after a second stage surgery, a composite crown was made directly on an abutment mounted on the implant reinsuring simultaneous occlusal contact on the implant crown and the neighboring teeth. After euthanization of the animals, histologic specimens were quantified in the light microscope. All implants were clinically, radiographically, and histologically osseointegrated at the time of euthanization and with only mild signs of inflammation in the peri-implant mucosa. The histologic marginal bone level was located on average 1.14-1.74 mm apical to the margin of the implants in the various groups. The average bone-to-implant contact (BIC) varied between 55% and 65% and the average bone density (i.e., the proportion of mineralized bone tissue from the implant surface and to a distance of 1 mm lateral to the implant) varied between 30.6% and 34.2%. No statistical significant differences between groups were observed in the above-stated histomorphometric parameters. Similar histologic and histomorphometric findings were observed in immediately and delayed loaded non-splinted implants placed in the posterior mandible of macaque monkeys.Clinical Oral Implants Research 10/2013; · 3.43 Impact Factor
Page 1
Momen A. Atieh
Nabeel H. M. Alsabeeha
Warwick J. Duncan
Rohana K. de Silva
Mary P. Cullinan
Donald Schwass
Alan G. T. Payne
Immediate single implant restorations
in mandibular molar extraction
sockets: a controlled clinical trial
Authors' affiliations:
Momen A. Atieh, Warwick J. Duncan, Rohana K.
de Silva, Mary P. Cullinan, Donald Schwass, Oral
Implantology Research Group, Sir John Walsh
Research Institute, School of Dentistry, University
of Otago, Dunedin, New Zealand
Nabeel H. M. Alsabeeha, Prosthetic Section, RAK
Dental Center, Ministry of Health, United Arab
Alan G. T. Payne, Private Practice, Whangarei,
New Zealand
Corresponding author:
Momen A. Atieh
Sir John Walsh Research Institute, School of
Dentistry, University of Otago, 310 Great King
Street, Dunedin 9016, New Zealand
Tel.:+64 479 7036
Fax:+64 479 0673
e-mail: firstname.lastname@example.com
Key words: bone level, immediate restoration, implant design, oral implant, platform
Background: In the replacement of missing teeth, a paradigm shift is currently observed with
immediate implant placement and/or restoration, particularly in the aesthetic zone. In molar sites,
however, anatomical, occlusal and biomechanical considerations remain deterrent factors
influencing the outcome of this treatment paradigm. The aim of this report was to evaluate
immediate placement and immediate restoration of strongly tapered wide-diameter implant in
fresh mandibular molar extraction sockets.
Methods: Twenty-four 8- or 9-mm diameter implants were placed in either a fresh molar
extraction socket or a healed site. All the implants received provisional crowns within 48 h. The
provisional crowns were replaced with full ceramic crowns after 8 weeks of implant placement.
Results: The overall implant success rate after 1 year of service for the 24 implants in two
treatment groups was 75%. Success rates were 83.3% and 66.7% for the delayed and immediate
placement groups respectively, with no significant difference observed between the two groups
(P = 0.35). Implant stability measurements identified the immediately placed implants to be more
stable immediately after surgery than delayed placed implants. In contrast, the delayed placed
implants were more stable after 8 week healing time.
Conclusions: The rehabilitation of single missing mandibular molars by immediately placed and
restored wide-diameter implants was associated with a relatively high failure rate.
The need for fewer surgical interventions and
shorter implant treatment times has led to
the development of revised placement and
loading protocols. Early attempts for immedi-
ate implant placement dates back more than
30 years(Schulteet al.
immediate/early placement protocols have
gained a growing interest and application to
become an acceptable treatment approach,
particularly in the aesthetic zone (Den Har-
tog et al. 2008). In addition to the consider-
able advantages that the immediate protocols
offer over the conventional ones, immediate
implant placement in fresh extraction sock-
ets may limit the extent of bone remodelling,
and avoids the need for augmentation proce-
dures (Evans & Chen 2008; Chen et al. 2009)
2 mm are usually filled during the osseous
healing (Paolantonio et al. 2001; Botticelli
et al. 2004). Several authors have shown that
success rates of implants immediately placed
in extraction sites are similar to those of
implants placed in healed extraction sites
(Polizzi et al. 2000; West & Oates 2007; Van
Kesteren et al. 2010). Similarly, the immedi-
ate restoration, with provisional crowns, of
implants that achieved primary stability,
resulted in comparable success rates to those
(Norton 2004; Lindeboom et al. 2006; Hall
et al. 2007), with the added advantage of bet-
ter soft tissue outcomes (Atieh et al. 2009b).
A number of systematic reviews, including a
Cochrane review have recently shown that
there is no significant difference between
immediate and conventional placement and/
or loading of implants in the anterior aes-
thetic zone using restorations with or with-
out occlusal contacts (Atieh et al. 2009a,b;
Accepted 18 December 2011
To cite this article:
Atieh MA, Alsabeeha NHM, Duncan WJ, de Silva RK,
Cullinan MP Schwass D, Payne AGT. Immediate single
implant restorations in mandibular molar extraction sockets:
a controlled clinical trial.
Clin. Oral Impl. Res. , 2012, 1–13
doi: 10.1111/j.1600-0501.2011.02415.x
© 2012 John Wiley & Sons A/S
Page 2
Esposito et al. 2009, 2010a). However, the
number of well-designed clinical trials com-
paring the different placement and loading
protocols in the posterior region is still lim-
ited so as to provide any conclusive evidence
(Atieh et al. 2010b).
While immediate implants in the anterior
zone serve the patients' aesthetic, mastica-
tory and phonetic needs, the immediate
replacement of molars offers the advantages
of maintaining a proper arch form and occlu-
sal scheme. However, it has been observed
that clinicians and researchers commonly
avoided implant placement in molar extra-
ction sockets or loading of implants immedi-
ately after placement in the posterior regions
of the jaw. This was due to a number of risk
factors that may jeopardize implant treat-
ment such as the difficulty in achieving
primary implant stability in fresh molar
extraction sockets even with the use of
tapered implant design. Additional risk fac-
tors include the higher occlusal forces, and
the limited bone quantity caused by the lin-
gual concavity and the presence of adjacent
vital structures such as the mandibular nerve
and maxillary sinus (Truhlar et al. 1997;
Muftu & Chapman 1998).
To overcome the limitations of reduced
bone height, enhance the bone-to-implant
contact (BIC) area, and to increase the surface
areafor osseointegration,
implants with reduced length were intro-
duced (Langer et al. 1993; Ivanoff et al. 1997,
1999; Eckert et al. 2001). A wide-diameter
implant has been defined as an implant
having a diameter ? 4.5 mm (Renouard &
Nisand 2006). Wide implants were originally
used as rescue implants to replace failed reg-
ular diameter implant (Langer et al. 1993).
The increased BIC is also thought to provide
the required primary stability (Misch 1999),
an essential prerequisite for immediate load-
ing (Ottoni et al. 2005). Considering that the
degree of loading is more significant than the
timing of loading (Szmukler-Moncler et al.
1998; Duyck et al. 2006), the wide-diameter
implants have significant advantage when
used in the molar regions, as they allow more
favourable distribution of occlusal forces, and
minimize the stresses around the crestal
bone, which may reduce potential marginal
bone loss (Siamos et al. 2002).
The aim of this prospective clinical trial
was to evaluate the hypothesis that there
would be no difference in the bone level
changes, implant stability
surgical and prosthodontic outcomes between
immediately restored/loaded wide-diameter
implants placed in mandibular molar extrac-
tion sockets, and those placed in healed sites.
Materials and methods
The study was conducted according to the
guidelines of the Helsinki Declaration of
1975 as revised in 2000. Ethical approval was
obtained from the Lower South Regional Eth-
ics Committee (LRS/08/08/034) and the Ngai
Tahu Research Consultation Committee in
New Zealand. The study was registered with
the Australian New Zealand Clinical Trial
Registry (ACTRN12608000569303).
Patient selection
recruited from a pool of patients seeking
extraction of a single molar in the mandible
or in need of prosthodontic treatment for a
School of Dentistry, University of Otago,
New Zealand. The patient recruitment pro-
cess included cost-effective methods that
were based on establishing a relationship
with other postgraduate students and with a
number of practices to ensure a well-func-
tioning referral system (Perri et al. 2006). All
the participants attended a prosthodontic
and surgical consultation and were invited
to participate in the study after meeting spe-
(Table 1). The participants were allocated
into two groups:
molar atthe
Control group: a single 8- or 9-mm wide-
Implants, Irene, South Africa) placed in a
healed mandibular molar site (at least
4 months post-extraction).
Test group: a single 8- or 9-mm wide-
Implants) placed immediately following
extraction of mandibular molar.
Thereafter, each implant was restored with
a platform switched abutment followed by
aprovisionalcrownwithin48 handa
Table 1. Details of inclusion/exclusion criteria
Inclusion criteria Exclusion criteria
Requires a single molar tooth extraction or had a missing single
molar tooth in the mandible
Aged 18 or over
ASA Class I or II
Controlled oral hygiene (full-mouth plaque and bleeding scores
?25% at baseline) (Cafiero et al. 2008; Buser et al., 2004)
Adequate bone quality (Type I–III) (Lekholm and Zarb, 1985)
Traumatic tooth extraction and/or ankylosed tooth
Acute localized infection (suppuration at the surgical field)
Aggressive periodontitis or untreated periodontal disease
Dehiscence in extraction socket wall greater than 4 mm
Medical risk patients (bone diseases, immune-compromised,
uncontrolled diabetes, coagulation disorders)
Severe limitation of mouth openingPresence of three to four remaining osseous walls (Cavicchia and
Bravi, 1999, Douglass and Merin, 2002).
Presence of ? 2 mm of keratinized tissue to allow soft tissue
manipulation (Cafiero et al. 2008)
Adequate sub-apical alveolar bone for immediate placement
(Schwartz-Arad and Chaushu, 1997, Douglass and Merin, 2002,
Cavicchia and Bravi, 1999)
Class I extraction socket (Juodzbalys et al., 2008)
Presence of adjacent teeth (Degidi et al. 2006; Levin et al. 2006;
Siciliano et al. 2009)
Implant insertion torque greater than 35 N cm (Hui et al., 2001,
Wohrle, 1998, Lorenzoni et al., 2003, Nikellis et al., 2004)
Good compliance and commitment to attend follow-up review
Willing to provide informed consent
History of heavy occlusion with parafunctional activity
Drug and/or alcoholic dependences
Past radiation to the head or neck
Pregnant or lactating females
Bisphosphonate therapy
ASA, American Society of Anaesthesiologists.
2 | Clin. Oral Impl. Res. 0, 2012 / 1–13
© 2012 John Wiley & Sons A/S
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 3
definitive crown 8 weeks later. The outline
of the clinical trial design is summarized in
Fig. 1.
Surgical protocol
On the day of implant surgery, antimicrobial
prophylaxis was obtained by giving each par-
ticipant a single oral dose of appropriate anti-
biotic(2 g Amoxicillin
Clindamycin if allergic to Penicillin) 1 h
prior to surgery (Binahmed et al. 2005; Espos-
ito et al. 2010b). Prior to the surgical proce-
dure, each participant was instructed to rinse
twice for 1 min each with 0.2% chlorhexi-
dine gluconate (Pineiro et al. 2010). Local
anaesthesia, mepivacaine hydrochloride 2%
with adrenaline 1 : 100,000 was administered
before the surgical procedure.
or 600 mg
Immediate implant placement group
The extractions were kept as minimally trau-
matizing as possible using fine luxators to
avoid damaging the buccal bony plate and the
surrounding bone margins of the alveolus.
Flap elevation was avoided, coronal portion
was cut off horizontally and then the roots
were sectioned to allow their elevation indi-
vidually with light twisting movements. All
visible soft tissue fragments were removed by
curette and the socket was meticulously
cleaned of any infected debris. The alveolar
socket was then irrigated with sterile saline
and its continuity was then evaluated with
periodontal probe (Williams markings, Hu-
Fried, Chicago, IL, USA). The implant surgery
drill sequence was not followed according to
the manufacturer's instructions due to the
presence of a large extraction socket. Instead,
the initial osteotomy was prepared with a
round bur under copious irrigation with sterile
saline to remove the inter-radicular bone and
provide a platform for implant bed prepara-
tion. The preparation of the osteotomy contin-
ued with the use of the implant tapered drills
(D-60TP and D-80TP MAX Southern implant
tapered drills, Irene, South Africa) in the cen-
tre of the socket and in relation to the desired
axis of the implant placement. A suitable
tapered osteotomy site was created to receive
the implant and the bone was pretapped to
avoid excessive friction during implant place-
ment. An 8- or 9-mm diameter implant was
then placed at a speed of 15–20 rpm and
using ? 45 N cm torque.
Delayed implant placement group
The surgical stent was used to guide the
2 9 25 mm pilot drill to mark the mucosa at
the planned implant position. A mid-crestal
incision with sulcular incisions at the adja-
cent teeth was performed. The osteotomy
site was prepared according to manufacturer's
instructions starting with a 2-mm twist drill
followed by the 3-mm drill. The implant
tapered drills (D-60TP and D-80TP MAX
Southern implant tapered drills, Irene, South
Africa) were then used to further widen the
osteotomy to the full depth. A bone tap was
used to define the thread configuration prior
to implant insertion at speed of 15–20 rpm
and using ?45 N cm torque.
For both groups, a pick-up impression cop-
ing was then placed to take an open tray
implant/bone level impression with a poly-
vinyl siloxane impression material (Exaim-
plant, GC, Tokyo, Japan). The impression
was disinfected by immersing it in a solution
of sodium dichloroisocyanurate for 5 min
(Coates 1988; Tebrock et al. 1989). The dis-
infectant solution was formed by using chlo-
Medical, Edenbridge, Kent, UK). The impres-
sion was then sent immediately to the labo-
ratory. The surgical procedure was completed
with the placement of a healing abutment
and suturing, if required, using polyglycolic,
polylactic acid polymer-derived sutures (3/0
or 4/0 Vicryl Rapide, Ethicon Inc., Somer-
ville, NJ, USA) to obtain primary soft tissue
closure (Invanoff & Widmark 2001).
(Haz-tabs, Guest
Prosthodontic protocol
Prior to surgery, an acrylic surgical stent
(Palavit G, Heraeus Kulzer GMBH, Wehr-
heim, Germany) and an open-type custom
tray (Ivoline, Ivoclar Vivadent AG, Liehten-
sein, Germany) were fabricated from the
diagnostic models. Following the implant
placement, the prosthodontic clinical proce-
dures were the same for both groups as all
implants receivedan
crown within 48 h and a definitive crown at
8 weeks of implant placement. The impres-
sion made at surgery was used to fabricate
the provisional crown using an acrylic den-
ture tooth, which was bonded to a silanated
(Rocatec Plus, 3M ESPE AG, Seefeld, Ger-
many) hexed titanium cylinder using light-
cured composite (Sinfony, 3M ESPE AG).
The provisional crown was delivered within
48 h of implant placement and tightened to
20 N cm. The occlusion was evaluated and
adjusted to avoid occlusal contact using
200 lm articulating
Germany). All provisional crowns had proxi-
paper(Bausch, Koln,
Implant surgery
provisional crown
Stability test
–8 weeks
0 weeks
52 weeks
surgical stent
–16 weeks
Definitive crowns
stability test
12 month
stability test
placement +
placement +
Definitive All-Ceramic
Definitive All-Ceramic
Fig. 1. Outline of clinical trial design.
© 2012 John Wiley & Sons A/S
3 | Clin. Oral Impl. Res. 0, 2012 / 1–13
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 4
mal contacts. Instructions on post-operative
care were repeated and participants were
advised to avoid chewing on the implant
crown and to adhere to a soft diet for
4–6 weeks.
At the 6-week post-operative visit, a subse-
quent implant/bone level impression using
vinyl polysiloxane(Exaimplant,
made for the fabrication of the definitive all-
ceramic crown. For both groups, the provi-
sional crown was replaced with a definitive
screw-retained zirconia-ceramic crown. Den-
sely sintered zirconia abutment made of HIP
yttrium-stabilized zirconium oxide (CER-ZR-
67, Southern Implants) was used. The abut-
ment was prepared for ceramic veneer accord-
ingto manufacturer's
abutment was then sintered with the veneer-
ing ceramic (Zirox, Wieland Dental & Tech-
nik GmbH, Pforzheim,
8 weeks of provisionalization, the zirconia-
ceramic crown was fitted to the implant in
occlusion.The prosthodontic
tightened to a torque of 20 N cm and then
covered with polytetrafluoroethylene tape.
The access cavity was restored with compos-
ite filling (Filtek Supreme XT, 3M ESPE,
Minnesota, USA). The 8- and 9-mm implants
had prosthodonticplatforms
7.5 mm respectively. Both implants were
restored with6-mm
using the platform switching concept, which
created an inward shift of 0.25 or 0.75 mm
depending on the implant's platform. The
surgical and prosthodontic protocols for both
the immediate and delayed placement groups
are summarized in Figs 2 and 3.
of 6.5 and
zirconia abutments
Data collection
Implant success outcome
The four-field table analysis, proposed by Al-
brektsson & Zarb (1993), was used to present
the 1-year implant outcome. The four-field
table model provided a simplified way of
assessing the final outcome of the clinical
study by squares for success, survival, drop-
outs and failures. Implants were classified as
successful after 1 year if they met the criteria
of success accepted by the European Federa-
tion of Periodontology (Albrektsson & Isidor
1994), which included absence of clinical
mobility, absence of pain, neuropathy, or peri-
implant radiolucency, and a maximal bone
loss of 1.5 mm during the first year of func-
tion and <0.2 mm annually thereafter. A sur-
vived implant was the one that remained
functional in the jaw, but failed to meet the
success criteria. An implant that was dropped
out of the study for any reason was considered
an "Unaccounted for" and a failed implant
was the one removed for any reason.
Marginal bone level
taken at the time of placing the definitive
crown and at 12 months to evaluate the bone
level changes. A paralleling technique was
applied with central rays of the beam on the
alveolar crest (Updegrave 1968). A holder
(Dentsply Rinn, Elgin, IL, USA) was used to
place the film away from the lingual concav-
ity and secure a parallel position to the long
axis of the implant to ensure standardization
of the thread geometry. The radiographs were
then digitally scanned and the images were
saved in a Tagged Image File Format (TIFF).
A computer software (ImageJ, National Insti-
tutes of Health, Bethesda, MD, USA) was
used to measure and calibrate each radio-
graphic image (Abramoff et al. 2004). The lin-
ear toolbar was used to measure the distance
between any two points on the image. To
provide accurate measurements, the known
distance between the threads was used for
calibrating the magnification error and calcu-
lating the precise pixel-to-millimetre ratio.
The implant shoulder/IAJ was considered
the reference line from which all measure-
ments were taken (Fig. 4). Three types of
(j) (k)
(f) (g)(h)
Fig. 2. Surgical and prosthodontic stages (immediate placement group). (a) Preoperative radiograph of failing tooth
36. (b) Atraumatic extraction of tooth 36. (c) Pilot drill. (d) 3 mm twist drill. (e) 6 mm drill. (f) Bone tap. (g) Place-
ment of implant. (h) Torque wrench to complete the final seating of the implant. (i) Measuring the primary implant
stability using resonance frequency analysis. (j) Pick-up impression coping placed. (k) Vinyl polysiloxane bone level
impression at surgery. (l) Placement of healing abutment. (m) Provisional screw-retained acrylic resin crown. (n) Pro-
visional crown placed within 48 h of implant placement.
4 | Clin. Oral Impl. Res. 0, 2012 / 1–13
© 2012 John Wiley & Sons A/S
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 5
measurements were recorded on the mesial
and distal surfaces of each implant:
1.The marginal bone (MB) level: the verti-
cal distance between the reference line
and the first BIC.
The bone crest (BC) level: the vertical
distance between the reference line and
the most coronal peak of the bone crest
between the implant and adjacent teeth.
The contact point (CP) - BC level: The
distance between the most coronal peak
of the bone crest and the CP between the
implant crown and adjacent teeth.
A plus value was used to suggest bone
gain, whereas a negative value indicated bone
loss after 12 months of function.
Implant stability
The electronic
Diagnostics AB, Go ¨teborg, Sweden), which is
often referred to as the third generation
(Sennerby & Meredith 2008), was used to
measure the implant stability at implant
RFA(Osstell, Integration
placement surgery, 8 weeks, and 1 year. The
device utilizes the RFA to measure the
implant stiffness (Meredith et al. 1996; Senn-
erby & Meredith 1998; Friberg et al. 1999),
and consists of a calibrated L-shaped trans-
ducer that is wired to resonance frequency
analyser. The transducer, which is connected
to the implant or abutment, produces a min-
ute lateral stress that increases in frequency
until the implant vibrates. The resonance fre-
quency in Hertz is then converted to implant
stability quotient (ISQ) unit by computer
software. The ISQ scale ranges from 0 to 100,
with a higher value indicating a more stable
implant. The machine is precalibrated by the
manufacturer and is only used for a limited
number of implant systems. However, RFA
has been suggested to be more accurate than
previous methods of implant stability assess-
ment (Zix et al. 2008).
Prosthodontic evaluation
All the prosthodontic maintenance events
were documented from baseline to the 1-
year follow up. The prosthodontic success
for the provisional crowns over 8 weeks
and definitive ceramic crowns over 1 year
was assessed based on established six-field
protocol (Walton 1998; Payne et al. 2001)
(Table 2).
Statistical analysis
A statistical software (SPSS 17.0, SPSS Inc.,
Chicago, IL, USA) was used to perform the
statistical analysis. The descriptive statistics
(means, ranges and SD) were reported for the
subjects' demographic details. The differences
between demographic variables were assessed
using Independent
tests. Normality of quantitative data was
assessed using histogram, stem and leaf plot,
boxplot, measures of skewness and kurtosis
as well as Shapiro-Wilk and Kolmogorov-
Smirnov tests. Independent samples t-tests
were used todetermine
between the two groups in marginal bone
level changes and implant stability. The
paired t-test was used for within-group com-
parison over time to compare the ISQ values
between the time of implant placement and
subsequent measurements. When the nor-
mality assumptions were not satisfied, the
equivalent non-parametric
and WilcoxonSigned
applied. The Chi-square was used to compare
the categorical variables, as in implant suc-
cess, among different groups. The signifi-
cance for statistical analysis was set at
and Chi-square
the difference
Ranktests were
(i) (j)(k)
(b)(c) (d)
Fig. 3. Surgical and prosthodontic stages (delayed placement group). (a) Preoperative image of missing tooth 47. (b)
Surgical stent guiding the pilot drill. (c) Mid-crestal incision with full mucoperiosteal flap reflection. (d) 3-mm twist
drill. (e) 6-mm drill. (f) placement of implant. (g) Torgue wrench to complete the final seating o the implant. (h)
Measuring the primary implant stability using resonance frequency analysis. (i) Vinyl polysilozane pick-up impres-
sion at surgery. (j) Placement of healing abutment. (k) Provisional screw-retained acrylic resin crown placed within
48 h of implant placement.
Fig. 4. Illustration of the landmarks used to describe
the linear measurements on radiographs in the vertical
plane: The marginal bone levels on the mesial (MBM)
and distal (MBD) sides of the implant, and the contact
points between the implant crown and the adjacent
teeth (CPMand CPD).
© 2012 John Wiley & Sons A/S
5 | Clin. Oral Impl. Res. 0, 2012 / 1–13
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 6
Demographic data
A total of 24 participants were recruited in
the main study according to the modified
inclusion and exclusion criteria, and follow-
ing the same surgical protocols. No statisti-
cally significant differences in participant
demographic characteristics were observed
between the two treatment groups (Tables 3
and 4).
Surgical outcomes
An overall failure rate of 25% was observed
at the end of 1 year of function, with a total
of four failed implants in the immediate
placement group and two failed implants in
the delayed placement group. All the failed
implants lost their osseointegration within
the first 3 months except for two, which
failed by the end of the 1-year follow-up per-
iod. One participant developed a rotational
mobility of the implant at 10 months follow-
ing the placement of the definitive prosthe-
sis. The implant was unloaded by removing
the permanent crown and a healing abutment
was placedto avoid
(Ivanoff et al. 1996). However, the implant
eventually failed within 2 months. The Chi-
square test did not show any significant
difference between the two groups (P = 0.35).
The four-field table analysis is summarized
in Table 5.
lossof integration
Bone level changes
The recorded MB, BC and CP-BC levels did
not show any statistically significant differ-
ence between the mesial and distal sites of
each implant. Therefore, the average of two
values was used as one bone measurement
per implant at one time point. The immedi-
ately placed implants showed a higher bone
gain of 0.41 ± 0.57 mm after the first year of
functional loading compared with only 0.04 ±
0.46 mm for the delayed placed implants.
Nevertheless, the difference was not statisti-
cally significant (P = 0.14).
A reduced BC level was demonstrated at
the immediately placed implants at the end
of the 1-year follow up (?0.17 ± 0.51 mm),
while the implants in the delayed placement
group showed a slight increase in BC level
(0.06 ± 0.48 mm). The bone gain was not
between the two treatment groups was not
statistically significant
groups showed a distance of ? 5 mm from
the BC to CP at baseline and during the first
(P = 0.34).Both
year of function. The mean increase in the
CP-BC distance at 1 year was 0.32 ± 0.56
mm for the immediately placed implants and
0.23 ± 0.68 mmfor
implants with no statistically significant dif-
ference between the two groups (P = 0.78)
(Table 6).
Implant stability
The immediately placed implants showed a
higher mean initial ISQ value than the
delayed placed implants (80.08 ± 5.07 vs.
78.83 ± 3.69 ISQ units) at surgery. In con-
trast, the mean implant stability value of
delayed placed implants (76.75 ± 10.24 ISQ
units) was higher than those placed in extrac-
tion sites (75.70 ± 10.52 ISQ units) at the
time of placing the permanent restoration
(8 weeks post-implant placement). Statisti-
cally, the difference between the two treat-
ment groups was not significant at implant
placement (P = 0.50) and 8 weeks (P = 0.82).
After 1 year, the implant stability measure-
ments of the remaining 18 implants were
recorded. A higher mean implant stability
value ofthedelayed
(83.90 ± 2.51 ISQ units) than the immedi-
atelyplaced implants
units) was demonstrated. The statistical dif-
ference between the two groups was only
placement protocol, host and implant vari-
ables, the differences in implant stability
measurements at different time points are
summarized in Table 7. No significant differ-
ences in the implant stability measurements
were observed for age, gender, bone quality,
implant length and placement protocol at dif-
placed implants
(P = 0.09). Forthe
Table 2. Six-field table analysis of prosthodontic outcome (Walton 1998; Payne et al. 2001)
Score Definitions
SuccessReview of documentation and patient examination reveal no evidence of
retreatment other than maintenance procedures
The patient cannot be examined directly, but the patient or another dentist
and examination of the patient's records confirm no retreatment other than
maintenance described in "success"
The patient could not be traced. This also includes a surviving prosthesis
removed to allow provision of a new prosthesis, e.g., implant supporting
a single crown is converted to support fixed partial denture following
further tooth loss
The patient dead, regardless of the condition of the prosthesis
Marginal integrity of the prosthesis and the associated original abutment or
replica abutment with the interface to the implant is maintained irrespective
of other modifications, including replacement of teeth or screw.
Part or all of the prosthesis has been lost, or the marginal integrity of the
original abutment or replica abutment with the face of the implant has been
lost. The prosthesis is in situ but implant required for support is identified as
failing to satisfy success criteria as described. An individual abutment screw
fractured more than twice in 5 years or a cemented prosthesis dislodges more
than once every year after the first year of loading.
(lost to follow up)
Retreatment (repair)
Retreatment (fail)
Table 3. Characteristics of the participants
Immediate placement
group (n = 12)
Delayed placement
group (n = 12)P-value
Gender (n)*
Age (years)
Mean (SD)*
Reasons for extraction (n)
Apical periodontitis
Implant location (n)†
Right first molar
Left first molar
Right second molar
Left second molar
Bone quality (n)†
Type II
Type III
Insertion torque (N cm) (n)†
*Independent t-test.
†Chi-square test.
51.5 (13.4)53.6 (12.3)0.69
6 | Clin. Oral Impl. Res. 0, 2012 / 1–13
© 2012 John Wiley & Sons A/S
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 7
ferent time points. The implant diameter,
however, had an influence on the ISQ values
recorded at the time of implant placement as
the 9-mm diameter implant resulted in a sig-
nificantly higher mean ISQ value than the 8-
mm diameter implant. With regard to the
ISQ values recorded at the time of placing
the permanent restoration (8 weeks) and after
1 year, the difference between the two diam-
eters was not statistically significant.
For the delayed placed implants, the ISQ
values increased during healing from a mean
of 78.83 ± 3.69 at time of implant placement
to a mean of 83.90 ± 2.51 ISQ units after
1 year. On the other hand, the initial ISQ
valuesfor immediately
decreased from a mean of 80.08 ± 5.07 to a
mean of 76.63 ± 10.65 ISQ units after 1 year.
The changes were gradual and did not reach
statistical significance. Nevertheless, when
the mean per cent changes over time were
calculated, the P-values showed a statisti-
cally significant mean per cent increase in
the recorded ISQ units after 1 year of loading
the delayed placed implants, while the per
cent changes in the immediate placement
group remained statistically
(Table 8).
placed implants
Prosthodontic outcomes
A total of seven prosthodontic maintenance
events were recorded. Of these, six were
related to veneer chipping and one event of
screw loosening. In the immediate place-
ment group,two chipped
reported within the first 3 months following
Another chipping event was observed at the
1-year recall. In the delayed group, the three
chipped crowns were recorded in the first
3 months. The chipping of the crowns was
limited to the disto-lingual cusps within the
ceramic veneer without extending to the
zirconia abutment. New impressions and
bite registration were taken. The chipped
crowns were all replaced with new semi-ana-
tomical crowns with narrower occlusal table
and minimal occlusal contacts in eccentric
movements. Similar
were usedin the
replaced crowns. The only event of screw
loosening was reported in one of the imme-
diately placed implants and a new gold
screw was used and tightened to 30 N cm
(Siamos et al. 2002). All the new implant
crowns survived the 12-month follow-up per-
iod without any further prosthodontic main-
tenance (Table 9).
permanent crowns.
The surgical outcomes
The reported success rates of the study were
considerably lower than those reported for
theanterior aesthetic
2009b). The early literature on oral implants
showed a higher failure rate for the conven-
tionally placed and loaded wide-diameter
implants compared with the standard size
implants (Ivanoff et al. 1999; Eckert et al.
zone(Atieh et al.
2001; Attard & Zarb 2003; Shin et al. 2004).
It is of interest to note that in previous stud-
ies, machined rather than roughened or sand-
blasted implant surfaces were used. Wide-
diameter implants with roughened surfaces
achieved high success rates under both con-
ventional (Gaucher et al. 2001; Testori et al.
2001) and immediate conditions (Gomez-
Roman et al. 2001; Botticelli et al. 2008;
Cafiero et al. 2008; Fugazzotto 2008; Penarro-
cha-Diago et al. 2008). This may suggest that
the implant design and surface may play an
important role in determining implant sur-
vival in the posterior mandible. Nonetheless,
the roughened-surfaced
implants were either immediately placed or
immediately loaded and none of the studies
reported on the survival rate when combining
the two protocols.
The implant tapering effect
Tapered implants were primarily designed for
immediate implantation in sites with poor
bone quality. O'Sullivan et al. (2004) showed
that the high degree of compression induced
by inserting the tapered implant can be bene-
ficial in enhancing primary implant stability
in Type IV bone. The authors suggested that
only a small degree of taper can improve pri-
mary implantstability
excessivestress at
Although an optimal implant taper angle for
implant placement in a molar extraction
socket has not been specified in literature,
the body of the implant used in this study
(MAX Southern Implants) is more tapered
diameter implants used for immediate place-
ment. The relatively large tapered angle of
the implant body (Atieh & Shahmiri 2011)
may have contributed to the significantly
higher risk of failure of those implants in
mandibular molar sites compared with other
wide-diameter implants
studies (Levin et al. 2006; Penarrocha-Diago
et al. 2008; Siciliano et al. 2009).
Excessive compressive pressure at crestal
bone level during implant insertion has been
proposed as one of the aetiologies for early
implant failure (Ueda et al. 1991; Oh et al.
2002). The coronal threads of the parallel
sidesof theimplant
Implants) often come into contact with the
cortical bone during insertion in the healed
favourable stress distribution around the cres-
tal bone than in extraction sockets, in which
a greater contact is observed bucco-lingually.
The mandibular molar extraction socket is
wider mesiodistally than bucco-lingually, and
bone. the
available wide-
used in previous
(MAX Southern
mayallow more
Table 4. Implant length and diameter distribu-
placement group
(n = 12)
Delayed placement
group (n = 12)
Implant diameter (mm)
Implant length (mm)
11 10
Table 5. Implant outcome: four-field implant analysis (Albrektsson & Zarb 1993)
Success number
number (%)
Unaccounted for
number (%)
Failure number
Immediate placement
Delayed placement
8 (66.7)004 (33.3)
10 (83.3)002 (16.7)
Table 6. Bone level changes after 1 year
IP group
mean (SD)
DP group
mean (SD)
Mean difference
and 95% CIP-value
MB level
BC level
CP-BC distance
0.41 (0.57)
?0.17 (0.51)
0.32 (0.56)
0.04 (0.46)
0.06 (0.48)
0.23 (0.68)
0.09 (?0.54, 0.72)
?0.23 (?0.73, 0.27)
0.38 (?0.13, 0.89)
IP, immediate placement; DP, delayed placement; MB, marginal bone; BC, bone crest; CP, contact
© 2012 John Wiley & Sons A/S
7 | Clin. Oral Impl. Res. 0, 2012 / 1–13
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 8
only minimal contacts are noted between the
implant and the mesial and distal walls of
the socket during insertion. Such an anatom-
ical discrepancy may not allow equal stress
distribution at the crestal level and may con-
tribute to the higher stress concentration in
the buccal cortical bone. The high compres-
sive stress at the dense marginal cortical
bone in the posterior mandible may result in
microcracks and bone resorption, which may
subsequently lead to early implant failure.
Radiographic bone level changes
The baseline for data collection in this study
was set at 8 weeks to exclude the bone
changes related to the osseous healing (Heitz-
Mayfield 2008; Lang & Berglundh 2011) and
to allow a meaningful comparison of radio-
graphic bone level changes between
immediate and delayed placement groups.
The overall MB changes after 1 year of func-
tion were more favourable than other studies
that assessed the radiographic bone changes
around immediately loaded or placed single
implants in the posterior mandible (Guncu
et al. 2008; Penarrocha-Diago et al. 2008;
Schincaglia et al. 2008; Vandeweghe et al.
2009; Prosper et al. 2010). All the remaining
implants in the present study were successful
according to the criteria of success accepted
by the European Federation of Periodontology
(Albrektsson & Isidor 1994), which were
based on the clinical experience of using
standard diameter implants and two-stage
conventional procedures. Nevertheless, the
same criteria were extensively used in the lit-
erature to evaluate the immediately placed
and loadedimplants
modalities and systems (Eghbali et al. 2010;
Van De Velde et al. 2010; Brown & Payne
2011). The favourable bone changes could be
attributed to the surface characteristics of the
of differentsurface
implants (Albrektsson & Wennerberg 2004;
Wennerberg & Albrektsson 2009; Svanborg
et al. 2010), the use of platform switched
abutments (Atiehet al.
reduction in the gap between the wide-diam-
eter implant surface and the bony socket
walls (Paolantonio et al. 2001). In a recent
systematic review (Atieh et al. 2009b), the
use of a combined approach (immediate
placement and immediate loading) resulted
in an advantageous bone gain in the aesthetic
2010a), andthe
Implant stability assessment
In the present study, the ISQ values mea-
sured at surgery, 8 weeks and after 1-year
observationwere higher
recorded for wide implants (Ostman et al.
2006; Schincaglia et al. 2007; Guncu et al.
2008; Becker et al. 2011). The most probable
explanation for this difference can be attrib-
uted to the implant diameter. Although the
diameter of implants did not seem to influ-
ence the ISQ values in previous studies (Bisc-
hof et al. 2004; Han et al. 2010), an 8- and
9-mm diameter implant is comparatively lar-
ger than the commercially available wide
implants and such width may have provided
more BIC area regardless of the placement
protocol. This was reflected in the high ISQ
values recorded for both groups in the present
study. In addition, the same 8-mm diameter
implants showed high ISQ values with no
significant changes over time, when used in
the midline of the mandible to support
mandibular singleimplant
(Alsabeeha et al. 2010a,b). This confirms the
than previously
Table 7. Mean implant stability quotient values and standard deviation (SD) for implants by placement protocol, host- and implant-related variables
At surgeryAt 8 weeks At 1 year
Mean (SD)
Mean difference and
value Mean (SD)
Mean difference
and 95% CI
value Mean (SD)
Mean difference and
Age (years)
Bone quality*
Type II
Type III
Implant length (mm)
Implant diameter (mm)
Placement protocol
80.33 (2.12)
78.93 (5.31)
1.40 (?2.47, 5.27) 0.38 72.75 (10.79)
78.29 (9.55)
?5.54 (?14.7, 3.71)0.23 82.75 (2.87)
80.07 (8.94)
2.68 (?7.12, 12.48)0.57
79.25 (6.41)
79.56 (3.20)
?0.313 (?4.34, 3.71)0.87 73.43 (11.39)
77.60 (9.62)
?4.17 (?13.98, 5.55) 0.3878.60 (11.61)
81.46 (6.57)
?2.86 (?17, 11.27) 0.63
81.86 (3.49)
78.47 (4.42)
3.39 (?0.51, 7.28)0.09 74 (13.12)
77.33 (8.75)
?3.33 (?13.13, 6.46) 0.49 75.40 (11.97)
82.69 (5.17)
?7.292 (5.54, 21.93) 0.25
79.90 (2.92)
79.14 (5.28)
0.76 (?3.08, 4.59)0.6975.70 (9.35)
76.75 (11.14)
?1.05 (?10.31, 8.21)0.82 81.22 (7.87)
80.11 (8.55)
1.11 (?7.10, 9.32) 0.78
77.87 (4.47)
82.11 (2.76)
?4.24 (?7.69, ?0.80)0.02†
76.21 (9.91)
76.38 (11.21)
?0.16 (?9.76, 9.44)0.9782.33 (5.12)
77.33 (11.81)
5 (?7.36, 17.36) 0.36
80.08 (5.07)
78.83 (3.69)
1.25 (?2.50, 5)0.50 75.70 (10.52)
76.75 (10.24)
?1.05 (?10.31, 8.21) 0.8276.63 (10.65)
83.90 (2.51)
?7.28 (?16.22, 1.68)0.10
*According to Lekholm and Zarb (1985).
†Statistically significant (P < 0.05).
Table 8. Mean implant stability quotient values and percent changes between baseline and 1 year
Baseline mean
One year mean
Per cent change and 95%
Delayed placement
80.08 (5.07)76.63 (10.65)
?3.99 (?15.51, 7.54) 0.44
78.83 (3.69)83.90 (2.51)7.19 (3.66, 10.71)0.001*
*Statistically significant (P < 0.05).
Table 9. Six-field table analysis of prosthodontic outcome (Payne et al. 2001; , Walton 1998)
Number (%)
Immediate placement group
Delayed placement group
4 (33.3)
7 (58.3)
4 (33.3)
3 (25)
4 (33.3)
2 (16.7)
8 | Clin. Oral Impl. Res. 0, 2012 / 1–13
© 2012 John Wiley & Sons A/S
Atieh et al?Immediately restored single implants in mandibular molar sites
Page 9
role of a large implant diameter in achieving
a relatively higher ISQ value than previously
The influence of different host site and
implant variables on the implant stability was
assessed at surgery, 8 weeks and 1-year recall
visit. The findings showed that age, gender,
bone quality, implant length and placement
protocol had no significant effect on the
implant stability. The factors influencing the
implant stability have been extensively evalu-
ated in literature. However, the results are
often contradictory.Ostman
showed that male participants had higher pri-
mary implant stability than females, while
Kessler-Liechti et al. (2008) showed no differ-
ence. Similarly, good correlation between the
bone quality and primary implant stability
was observed in several studies (Bischof et al.
2004;Ostman et al.
2009b), but not in others (Zix et al. 2005; De-
gidi et al. 2007; Huwiler et al. 2007). More-
over, implant length was shown to have a
positive impact on the implant stability as
longer implants provide more BIC (Sim &
Lang 2010), while other reports, including one
that used the same 8 mm implants, were not
able to find such a correlation (Bischof et al.
2004; Ostman et al. 2006; Fischer et al. 2009b;
Alsabeeha et al. 2010a).
et al.(2006)
2006; Fischeret al.
Prosthodontic maintenance
Two prosthodontic
reported in this study: the chipping of the
veneer material and the abutment screw loos-
ening. Zirconia implant abutments were used
for enhancing aesthetic and the health of
peri-implant soft tissues (Degidi et al. 2006).
However, a major drawback of zirconia-based
restorations is the chipping of the ceramic
veneer (Vult Von Steyern et al. 2005; Raig-
rodski et al. 2006; Sailer et al. 2007). Previous
research showed a variable chipping inci-
dence of ceramic veneers in implant-borne
zirconia restorations (Todescan et al. 2002;
Glauser et al. 2004; Zembic et al. 2009; Lars-
son et al. 2010; Nothdurft & Pospiech 2010).
Larsson et al. (2006, 2010) conducted two
studies on implant borne zirconia-based fixed
partial dentures in the posterior region. In
the first study (Larsson et al. 2006), a HIPed
zirconia was used and was associated with a
complications were
very high rate of chipping, 54%, during the
first year of function, while in the second
study (Larsson et al. 2010), a non-HIPed zir-
conia was used, but still a high chipping rate
of 34% was observed after a follow-up period
of 3 years. The frequency of veneer chipping
for tooth-borne zirconia-based restorations in
the posterior region varies between 0% (Mo-
lin & Karlsson 2008) and 15% (Sailer et al.
2007). It has been suggested that the absence
of periodontal receptors may cause an exces-
(Ha ¨mmerle et al. 1995) that could result in
higher rate of veneer chipping noted in the
implant-borne restorations.
In the present study, a high incidence of
veneer chipping of 25% was observed in the
main study, with a total of six events
reported during the first year of function. All
the chipping occurred in disto-lingual cusps
of first molars without exposing the underly-
ing zirconia abutment. This was in agree-
ment with previous studies that showed that
the chipping occurred in non-functioning
bearing areas (Raigrodski et al. 2006; Sailer
et al. 2007; Guess et al. 2009; Schmitter
et al. 2009). Several contributing factors have
been proposed to explain the chipping of the
ceramic veneer; the mismatch of the coeffi-
cient of thermal expansion between the
veneering ceramic and the zirconia core (Fi-
scher et al. 2009a), overload (Coelho et al.
2009), low fracture toughness of ceramic
(Beuer et al. 2009), porosities in the veneering
ceramic (Ohlmann et al. 2008), low thermal
conductivity of zirconia, which may contrib-
ute to the development of high tensile resid-
ual stresses in the veneering ceramic (Swain
2009), and the lack of adequate support by
the zirconia core and the uneven thickness of
the veneering ceramic (Marchack et al. 2008).
The second prosthodontic
was the screw loosening. Only one event of
screw loosening was reported with an inci-
dence rate of 4.2% after 1 year of function,
which was in agreement with previously
reported rates for wide-diameter implants
(Cho et al. 2004). Causes of screw loosening
included inadequate torque, implant site,
manufacturing defects and implant diameter
(Bakaeen et al. 2001; Conrad et al. 2008). Fur-
thermore, the external hex implant-abutment
connections have been classically blamed for
the high incidence of screw loosening (Jemt
& Pettersson1993;
Engquist et al. 1995; Henry et al. 1996).
However, a recent systematic review sug-
gested that the screw loosening is not influ-
enced by the geometry
abutment connection, but by providing the
appropriate torque and proper anti-rotational
features (Theoharidou et al. 2008). Therefore,
all the prosthodontic screws were tightened
to 30 N cm (Siamos et al. 2002) and all the
loose screws were replaced with new ones to
exclude any possibility of metal fatigue.
In general, the prosthodontic maintenance
of single implant crowns were frequently
reported in the literature with one of five sin-
gle tooth implants in need of prosthodontics
maintenance (Creugers et al. 2000). The most
frequent prosthodontic maintenance needed
in the present study were the chipping of the
veneering ceramicand
which were accordingly managed and all the
prostheses remained functional throughout
the observation period.
Ekfeldt et al.1994;
of theimplant-
The rehabilitation of single missing mandib-
ularmolars by immediately
restored wide-diameter implants was associ-
ated with a relatively high failure rate.
placed and
thank Mr Graham Blackbeard, Managing
Director of Southern Implants Ltd (Irene,
South Africa) for his technical guidance and
The authors
Conflict of interest and source of
The authors declare that they have no conflict
of interests in this study. The implant compo-
nents used in this study were funded by South-
ern Implants Ltd (Irene, South Africa).
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stability changes for immediately placed dental
implants. The International Journal of Oral &
Maxillofacial Implants 22: 623–630.
12 | Clin. Oral Impl. Res. 0, 2012 / 1–13
© 2012 John Wiley & Sons A/S
Atieh et al?Immediately restored single implants in mandibular molar sites
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aesthetic zone with immediate provisionaliza-
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Stern, R. (2008) Measurement of dental implant
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Atieh et al?Immediately restored single implants in mandibular molar sites


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Can retailers trace any tainted food product back in the supply chain to determine where and when its integrity was compromised? In these days of frequent product recalls, that has become an increasingly pertinent question. So SN asked the question in its latest industry survey on technology practices and priorities, conducted last fall. Less than half (46%) of survey respondents said their company had that traceback capability, while another 20% said this capability was under ...
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Posted: January 31, 2013
The Labor Department is releasing the latest unemployment figures. It's the first indication of job creation in 2013.
Please follow our community discussion rules when composing your comments.
Often important things happen below the radar of news organizations or you think a story in the news warrants more or different coverage. Help us tell the story you want to hear.


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Stories of family tragedies emerge from Boston marathon bombing
One of the most heartbreaking stories to emerge from Monday's terror attack at the Boston Marathon so far concerns the 8-year-old boy who died.
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Runners job along Peachtree Street as part of an organized moment of silence and memorial run to show solidarity with victims of the Boston Marathon bombing, Tuesday, April 16, 2013, in Atlanta. The explosions Monday afternoon killed at least three people and injured at least 100 others. (AP Photo/David Goldman)
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Photos from the 87th annual Academy Awards in Los Angeles, Feb. 22, 2015.


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Book your room at Three Cities Mandela Rhodes Place Hotel and Spa
4-star spa hotel in Cape Town (City Bowl) near Greenmarket Square
This spa hotel is located in Cape Town (City Bowl), close to AVA Gallery, Greenmarket Square, and South African National Gallery. Also nearby are Castle of Good Hope and Victoria and Alfred Waterfront.
Hotel Features
In addition to a restaurant, Three Cities Mandela Rhodes Place Hotel and Spa features an outdoor pool. Other amenities include a full-service spa and a coffee shop/café.
Room Amenities
Flat-screen televisions include satellite channels. Guestrooms also feature deep soaking bathtubs, kitchens, and complimentary wireless Internet access.
Information missing or incorrect? Tell us!Hotel Amenities
Hotel Amenities
In addition to a full-service spa, Three Cities Mandela Rhodes Place Hotel and Spa features an outdoor pool and a steam room. Dining options at the hotel include a restaurant, a coffee shop/café, and a snack bar/deli. Business-related amenities at this 4-star property consist of a business center and a meeting room.
A computer station is located on site and high-speed wireless Internet access is available for a surcharge. Event facilities measuring 1249 square feet (116 square meters) include conference space. This business-friendly hotel also offers a 24-hour fitness center, a rooftop terrace, and spa services. For a surcharge, the property provides an area shuttle within 0.1 km and a roundtrip airport shuttle (available 24 hours). Parking is available onsite for a surcharge.
Three Cities Mandela Rhodes Place Hotel and Spa is a smoke-free property.
- Coffee shop or café
- 24-hour front desk
- Babysitting or childcare (surcharge)
- Airport transportation (surcharge)
- Airport transportation - pickup (surcharge)
- Total number of rooms - 65
- ATM/banking
- Number of floors - 17
- Breakfast available (surcharge)
- Business center
- Free newspapers in lobby
- Conference space
- Elevator/lift
- 24-hour fitness facilities
- Full-service spa
- Free shopping center shuttle
- Tours/ticket assistance
- WiFi (surcharge)
- Beach/pool umbrellas
- Computer station
- Luggage storage
- Laundry facilities
- Concierge services
- Gift shops or newsstand
- Shopping on site
- Area shuttle (surcharge)
- Dry cleaning/laundry service
- Spa treatment room(s)
- One meeting room
- Multilingual staff
- Rooftop terrace
- Porter/bellhop
- Restaurant
- Self parking (surcharge)
- Pool sun loungers
- Conference space size (feet) - 1249
- Snack bar/deli
- Conference space size (meters) - 116
- Year Built 2007
- Smoke-free property
- Number of buildings/towers - 1
- Spa services on site
- Steam room
- Outdoor pool
Available in all rooms: Free WiFi
Available in some public areas: Wireless internet access ( 30.00 ZAR for multiple minutes )
Self parking (surcharge)
Room Amenities
- Room service (limited hours)
- Free WiFi
- DVD player
- Separate sitting area
- Climate control
- Air conditioning
- Coffee/tea maker
- Free bottled water
- Microwave
- Kitchen
- Daily housekeeping
- Private bathroom
- Designer toiletries
- Slippers
- Shower/tub combination
- Deep soaking bathtub
- Rainfall showerhead
- Free toiletries
- Hair dryer
- In-room childcare (surcharge)
- Desk
- Satellite TV service
- In-room safe
- Rollaway/extra beds available
- Blackout drapes/curtains
- Flat-panel TV
- Separate dining area
- Full-sized refrigerator/freezer
- Stovetop
- Washer/dryer
- Cookware, dishware, and utensils
- Separate living room
- In-room massage available
- Pillow menu
- Free cribs/infant beds
- Iron/ironing board (on request)
Where to Eat
Buffet breakfasts are available for a surcharge and are served each morning between 7 AM and 11 AM.
Doppio Zero - This restaurant specializes in international cuisine and serves breakfast, brunch, lunch, and dinner. Guests can enjoy drinks at the bar.
Room service (during limited hours) is available.
Nearby Things to Do
Recreational amenities at the hotel include an outdoor pool, a steam room, and a 24-hour fitness center.
The recreational activities listed below are available either on site or nearby; fees may apply.
- Golfing nearby
- Hiking/biking trails nearby
- Mountain biking nearby
- Skydiving nearby
- Bicycle rentals on site
- Boat tours nearby
Spa Services
The Wellness Club Spa has 4 treatment rooms including rooms for couples. Services include massages, facials, body wraps, and body scrubs. The spa is equipped with a sauna and a spa tub. A variety of treatment therapies are provided, including aromatherapy and hydrotherapy.
- Number of treatment rooms 4
- Couples treatment rooms
- Body wraps
- Body scrubs
- Aromatherapy treatments
- Hydrotherapy treatments
- Sauna in spa
- Spa tub in spa
- Massages
- Body treatments
- Facial treatments
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible bathroom
- In-room accessibility
- Accessible parking
Hotel Policies
Minimum check-in age is 18
Check-in time starts at 2 PM
Check-out time is 11 AM
Payment types
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
No pets or service animals allowed
Parking height restrictions apply
- 1 percent tourism fee will be charged
- Breakfast fee: ZAR 140 for adults and ZAR 75 for children (approximately)
- Fee for wireless Internet in public areas: ZAR 30.00 (for 59 minutes, rates may vary)
- Airport shuttle fee: ZAR 280 per vehicle (one way)
- Airport shuttle fee per child: ZAR 140.00 (one way), (from 1 to 12 years old)
- Self parking fee: ZAR 55 per day
- Late check-out fee: ZAR 950
- Rollaway bed fee: ZAR 250 per night
We should mention
This property offers transfers from the airport (surcharges may apply). Guests must contact the property with arrival details 72 hours prior to arrival, using the contact information on the booking confirmation. Reservations are required for massage services and spa treatments. Reservations can be made by contacting the hotel prior to arrival, using the contact information on the booking confirmation. Some facilities may have restricted access. Guests can contact the property for details using the contact information on the booking confirmation. No pets and no service animals are allowed at this property.
National Rating
Quality Graded by the Tourism Grading Council of South Africa (TGCSA) – South Africa's official quality assurance organization.


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Event: |
Swirl This beautiful portrait of rural life in Brazil fuses fiction and documentary as it centers on Batsu, an 81-year-old woman trying to start over after her husband's death. Swirl uses the lives of its nonprofessional cast and the histories of their village as starting points for an entrancing exploration of tradition and contemporary life, reality and dream, and life and death. (90 mins., 35mm) |
Date and time: | March 14, 2013 7:00 PM |
Location: | Wexner Center Film/Video Theater |
Contact: | Ticket office |
Phone Number: | 614-292-3535 |
Event category: | Wexner Center |
Event Type: | Film |