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Immediate provisionalization

Immediate provisionalization






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    Immediate provisionalization Immediate provisionalization Document Transcript

    • 29Immediate Provisionalization of DentalImplants Placed in Fresh ExtractionSockets Using a Flapless TechniqueRoberto Crespi, MD, MS*/Paolo Capparè, MD* Tooth extraction induces boneEnrico Gherlone, MD, DDS, PhD* crest resorption of approximatelyGeorge Romanos, DDS, Dr Med Dent, PhD** 23% after a 6-month period, with an additional loss of 11% or moreThe aim of this clinical study was to evaluate the 24-month clinical outcomes of after 2 years.1–3 The alveolar boneimmediate provisionalization of dental implants placed in fresh extraction sockets collapse after tooth extraction mayusing a flapless technique. Fifteen patients were included under strict inclusion severely modify the architecture ofand exclusion criteria. All patients required one or two teeth to be extracted for the hard and soft tissues, and dur-lesions with a hopeless prognosis in the maxillary monoradicular or first premolar ing implant surgery, flap reflection4region. Twenty implants were placed immediately after tooth extraction, andimmediate provisionalization was performed. Sixteen implants had a diameter induces tissue loss, compromisingof 5 mm, and four implants had a diameter of 3.80 mm, all with a 13-mm length. the final prosthetic rehabilitation.After 24 months of follow-up, a cumulative survival rate of 100% was reported for To preserve the alveolar boneall implants. Modified Bleeding Index (mBI), modified Plaque Index (mPI), probing level from collapsing during heal-depth (PD), marginal gingiva level (MGL), and keratinized mucosa (KM) remained ing procedures, different authors5–8stable for up to 24 months. Mean MGL at 24 months was 0.22 ± 0.15 mm; placed dental implants into freshno significant changes occurred in MGL between baseline and 24 months. extraction sockets, obtaining highMean KM remained stable from baseline to 24 months. At 24 months, a mean success rates. Covani et al9 ana-bone loss of 0.83 ± 0.52 mm was measured. The results of this study indicate lyzed bone remodeling around 15that flapless surgery for immediately provisionalized implants placed in fresh implants placed immediately afterextraction sockets provides soft tissue and marginal bone maintenance for up to tooth removal and observed a heal-24 months of follow-up. (Int J Periodontics Restorative Dent 2012;32:29–37.) ing pattern of coronal bone around immediate implants, with new bone    * linical Professor, Vita Salute University, Milano, Italy. C apposition around the neck of the   ** linician, Department of Dentistry, San Raffaele Scientific Institute, Milan, Italy. C implants, and, at the same time,  *** ull Professor and Chair, Department of Dentistry, San Raffaele Scientific Institute, F bone resorption with horizontal Milan, Italy.**** rofessor of Clinical Dentistry, Eastman Institute for Oral Health, Division of Periodon- P width reduction of the bone ridge. tology, University of Rochester, Rochester, New York, USA; Formerly, Department of Further bone assessment and Periodontology and Implant Dentistry, College of Dentistry, New York University, New soft tissue management around York, New York, USA. implants represents an esthet- Correspondence to: Dr Roberto Crespi, Department of Dentistry, Vita Salute University, ic concern for patients. Several San Raffaele Hospital, Via Olgettina N.48, 20123 Milano, Italy; email: robcresp@libero.it. authors9–12 carried out immediate Volume 32, Number 1, 2012 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 30Fig 1    Preoperative clinical view. Fig 2    Crowns were removed, and it was noted that the incisors needed to be removed because of their elevated mobility.loading (occlusal load applied to were to evaluate the 24-month clini- The following inclusion crite-provisional crowns positioned im- cal outcomes and soft tissue profile ria were adopted for each patient:mediately to implants) of implants changes of immediately provisional- good health, no chronic systemicplaced in fresh extraction sockets in ized dental implants placed in fresh disease, presence of four bony wallsthe anterior (premolar to premolar) extraction sockets using a flapless of the alveolus, presence of at leastregion to maintain an excellent soft technique, as well as marginal bone 4 mm of bone beyond the roottissue esthetic profile around the changes around implants. apex, and informed consent for im-implant-prosthetic restoration with a mediate implant loading obtained.survival rate of 100%. However, con- Exclusion criteria were as follows:tradictory results were reported by Method and materials presence of dehiscence or fenes-Chaushu et al.13 In that clinical study, tration of the residual bony walls,17 implants with machined surfaces Fifteen patients (10 women, 5 men; coagulation disorder, signs of acutewere placed in immediate extrac- age range, 24 to 68 years) were in- infection around the alveolar bonetion sockets, and 9 were placed in cluded in this study. All patients re- at the surgical site, heavy smokerhealed alveolar ridges. The authors quired extraction of one or two teeth (more than 10 cigarettes per day),found a cumulative survival rate of for root fractures, caries, endodontic alcohol or drug abuse, and bruxism.82.4% for implants placed in fresh lesions, or periodontal disease (Figs The local ethical committee ap-extraction sockets and 100% for im- 1 to 3). Implants were placed im- proved this study, and all patientsplants placed in healed ridges. mediately after tooth extraction and signed an informed consent form. Since few studies14–16 have fo- were loaded immediately. Patientscused on immediate loading of included in this clinical study wereimplants placed in fresh extraction treated by one oral surgeon andsockets, with limited data for soft tis- one prosthetic specialist in the De-sue measurements around implants, partment of Dentistry, San Raffaelethe aims of the present clinical study Hospital, Milan, Italy.The International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 31 Table 1 Implant positions and dimensions Implant size (mm) Implant position 5.0 × 13 3.80 × 13 Total Maxillary incisor 9 2 11 Maxillary canine 5 0 5 Maxillary premolar 2 2 4 Total 16 4 20 Fig 3 (left)    Periapical radiograph before tooth extraction.Surgical protocol Implant sites were prepared with standard handpieces follow-Patients received 1 g amoxicillin ing the palatal bony walls as guides,1 hour prior to surgery and twice and the apical portion of the implanta day for 1 week after the surgical was always placed at least 4 mm be-procedure. Surgery was performed yond the root apex; no countersink-under local anesthesia (opto- ing was used. The coronal margin ofcaine 20 mg/mL with adrenaline the implant was located at the buc-1:80,000). cal level of the bone crest. The al- Twenty maxillary teeth in the in- veolar bone quality was determinedcisor, canine, and premolar regions during surgery for each site and waswere extracted while maintain- predominantly classified as type 2ing the integrity of the socket and and 3, according to the Lekholmavoiding buccal and palatal flaps; and Zarb classification.17a periodontal probe was used to Twenty titanium implants (Sev-verify the integrity of the four walls en, Sweden & Martina) were placedof the extraction sockets (Fig 4). All immediately after extraction (Tableexperimental sites showed the ab- 1). Implants had a machined necksence of fenestration or dehiscence of 0.8 mm and a roughened-surfaceof the bone walls and a residual (titanium plasma spray) body with agap between the implant surface progressive thread design. Sixteenand adjacent bone ≤ 2 mm. No implants had a diameter of 5 mm,regenerative procedures were per- and four implants had a diameter offormed in any sites. 3.80 mm, all with a 13-mm length, and were loaded immediately. Volume 32, Number 1, 2012 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 32Fig 4    Sockets immediately after extraction of the incisors. Fig 5    Provisional abutments positioned on the implants.Fig 6    Provisional crowns placed immediately after implant insertion. Fig 7    Definitive restoration 6 months after implant placement. Immediately after the surgical Restorative protocol instrument and secured with abut-procedure, an oval cross-sectional ment screws. Impressions wereacetalic resin provisional abutment Prefabricated provisional acrylic taken with a silicon material us-(Seven) was placed, and the junc- resin crowns were adapted us- ing individual impression trays.tional point with the implant was ing acrylic resin along the margins Prepared definitive metal abut-located at the level of the buccal of the provisional abutment and ments were placed on the im-bone margin (Fig 5). Immediate fit with cement (Fig 6). All provi- plants, and provisional crowns wereloading of the implants was per- sional crowns were in full contact repositioned.formed with an implant insertion in centric occlusion, making the Six months later, definitive metal-torque ≥ 30 Ncm, and resonance occlusal surfaces flat and avoiding ceramic restorations were cementedfrequency analysis demonstrated horizontal relations. All patients on the abutments (Fig 7).an implant stability quotient > 60, followed a soft diet for 2 months.confirmed by an Osstell device (In- Three months after implant place-tegration Diagnostic). No flap was ment, the provisional restorationsraised in any site. Chlorhexidine were removed, and transfer cop-mouthwash was prescribed twice ings were inserted into the internaldaily for the next 15 days. hex of the implants with a seatingThe International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 33 Fig 8 (left)    Definitive restoration at the 24-month follow-up. Fig 9 (right)    Periapical radiograph at the 24-month follow-up.Follow-up Hu-Friedy). The distance between the implant with the long-cone par- the platform of the implant and the allel technique using an occlusalPain, occlusion, and prosthesis mo- marginal gingiva level (MGL) was template to measure the marginalbility were checked. Success criteria measured at the same four sites bone level. A blinded radiologistfor implant survival were accepted per implant as that for mPI. Width measured the changes in marginalas presence of implant stability and of the keratinized mucosa (KM) was bone height over time. The dis-absence of radiolucency around recorded at the midbuccal aspect. tance between the platform of theimplants, mucosal suppuration, implant and the most coronal pointand pain. Follow-up examinations of contact between the bone andwere performed at baseline and Radiographic assessments the mesial and distal aspects was12 and 24 months (Fig 8). Probing considered. The difference in bonedepth (PD), modified Plaque Index Intraoral digital radiographic ex- level was measured using software(mPI), and modified Bleeding Index aminations were conducted at (Schick CDR, Schick Technologies).(mBI) values were determined on baseline and 12 and 24 months Marginal bone loss was evaluatedthe mesial, distal, buccal, and pala- after implant placement (Fig 9). at 12 and 24 months of healing.tal surfaces of the implants18 using Periapical radiographs were taken Mesial, distal, and mean bone lossa periodontal probe (PGF-GFS, perpendicular to the long axis of were calculated in the maxilla. Volume 32, Number 1, 2012 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 34 Table 2 Clinical parameters throughout follow-up (mean ± standard deviation) Baseline 12 mo 24 momPI 0.51 ± 0.18 0.68 ± 0.25 0.72 ± 0.27mBI 0.47 ± 0.27 0.66 ± 0.32 0.75 ± 0.35MGL (mm) 0.16 ± 0.09 0.18 ± 0.11 0.22 ± 0.15KM (mm) 3.81 ± 0.79 3.66 ± 0.70 3.64 ± 0.62PD (mm) 1.44 ± 0.43 1.82 ± 0.66 2.01 ± 0.61Results Clinical parameters Radiographic evaluationSurgical and prosthetic Plaque accumulation (mPI) was Radiographic results were reportedprocedures 0.51 ± 0.18 at baseline and at 24 months from implant place- 0.72 ± 0.27 after 24 months. mBI at ment (Table 3). At 12 months ofAfter 24 months of follow-up, a sur- baseline was 0.47 ± 0.27, and later follow-up, a mean mesial bone lossvival rate of 100% was reported for registered a value of 0.75 ± 0.35 of 0.79 ± 0.42 mm and a mean dis-all implants. No pain or prosthesis at 24 months. The soft tissue pro- tal bone loss of 0.83 ± 0.56 mmmobility was registered. There was file (MGL and KM) remained stable were reported (mean bone loss,suitable wound healing around pro- for up to 24 months. The mean 0.81 ± 0.49 mm). At 24 monthsvisional abutments, with acceptable value for MGL at 24 months was of follow-up, a mean mesial boneadaptation to the provisional crown. 0.22 ± 0.15 mm; no significant loss of 0.80 ± 0.49 mm and a meanMinor swelling of the gingival muco- changes occurred in MGL from distal bone loss of 0.87 ± 0.55 mmsa was present in the first days after baseline to 24 months. Mean KM were measured (mean bone loss,the surgical procedures; no muco- remained stable from baseline to 0.83 ± 0.52 mm).sitis or flap dehiscences with sup- 24 months as well. Mean PD waspuration were found. Four occlusal obtained from PD measurementsscrews unscrewed in provisional on the mesial, distal, buccal, andplastic abutments. The definitive palatal surfaces of the implants; theceramic-fused-to-metal restorations mean values were 1.44 ± 0.43 mmwere cemented 6 months after im- and 2.01 ± 0.61 mm at baseline andplant placement. 24 months, respectively (Table 2).The International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 35 Table 3 Radiographic results from implant placement (mean ± standard deviation) Mean mesial Mean distal Mean bone Survival bone loss (mm) bone loss (mm) loss (mm) rateBaseline 0.98 ± 0.27 1.04 ± 0.31 1.01 ± 0.29 100%12 mo 0.79 ± 0.42 0.83 ± 0.56 0.81 ± 0.49 100%24 mo 0.80 ± 0.49 0.87 ± 0.55 0.83 ± 0.52 100%Discussion moved. After 12 months, all im- plants remained osseointegrated,The present study, reporting a sur- although marginal bone and gin-vival rate of 100% after 24 months giva level changes were statisticallyof follow-up, showed that immedi- significant from pretreatment to 12ate restoration of implants placed in months of follow-up.fresh extraction sockets may prove In a similar study, Cornelini eta successful treatment procedure. al10 reported no implant failuresAlveolar bone volume preserva- at 12 months. Radiographic ex-tion following placement of dental amination revealed a mean boneimplants in fresh extraction sockets resorption of 0.5 mm after 1 year,improves esthetic and functional and mean variation in gingiva level,prosthetic procedures.19 The results compared with neighboring teeth,of this study are in accordance with was –0.75 mm. Barone et al11 in-survival rates reported in studies on serted single implants in fresh ex-immediate loading in immediate traction sockets and immediatelypostextraction implants.10–12 restored them with provisional Kan et al12 prospectively evalu- abutments and crowns and report-ated 35 threaded, hydroxyapa- ed a complete, successful healingtite-coated implants placed and process at the 12-month follow-up.provisionalized immediately after Successful immediate loadingeach failing tooth had been re- implant treatment was documented Volume 32, Number 1, 2012 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 36by Romanos and Johansson,20 who moderate recession of the gingival bone maintenance. The patientpresented histologic data from re- margin (0.22 ± 0.15 mm) observed population was limited because oftrieved biopsies of an edentulous in this study after 24 months may the strict inclusion and exclusionfemale (heavy smoker under che- be a result of the flapless implant criteria. However, this approach hasmotherapy) who received implant- surgery, since flap reflection induc- been used by the authors for moresupported complete restoration es tissue loss and negatively influ- than 60% of maxillary implants theyin the maxilla and mandible using ences implant esthetic outcomes.9 have placed.the immediate loading procedure. Oh et al24 placed endosseous im- Since few studies are availableAll implants were osseointegrated plants via flapless surgery and im- and differing results are reportedand surrounded by dense lamellar mediate loading. The soft tissue regarding the survival of postextrac-bone. However, around the upper profile remained stable for up to 6 tion immediately placed and provi-portions of the implants, much of months without significant modifi- sionalized implants, many clinicalthe bone had been resorbed. The cations, showing that creeping at- and histologic studies are necessaryhistomorphometric evaluation of tachment (ie, soft tissue recovery) to achieve further knowledge onbone-to-implant contact revealed might occur 2 months after imme- this implant therapy protocol.a mean available surface of ap- diate loading.proximately 51% and a mean bone Since flapless implant place-volume of approximately 52%. The ment is generally a “blind” surgi- Referencesinitial stability of implants is one cal technique, care must be taken  1. Carlsson GE, Persson G. Morphologicof the main requirements for im- during positioning of the implants. changes of the mandible after extrac-mediate loading, while good bone Angulation of the implants affected tion and wearing of dentures. A longi- tudinal, clinical, and x-ray cephalometricquality and quantity are important by drilling is critical to avoid perfo- study covering 5 years. Odontol Revyfor resonance frequency analysis ration of the cortical plates, both 1967;18:27–54.values above implant stability quo- palatal and buccal, especially in   2. Atwood D. Postextraction changes in the adult mandible as illustrated by micro-tients of 60, which are necessary for the anterior maxilla. There should radiographs of midsagittal section anda successful healing process21 since be no problem if the patient has serial cephalometric roentogenograms. J Prosthet Dent 1963;13:810–816.the amount of micromotion over been selected appropriately and  3. Ulm C, Solar P, Blahout R, Matejka M,threshold values could stimulate the appropriate bone width is avail- Gruber H. Reduction of the compact andconnective tissue formation at the able for implant placement. There cancellous bone substances of the eden- tulous mandible caused by resorption.bone-implant interface.22 is a learning curve for every surgical Oral Surg Oral Med Oral Pathol 1992; Another condition for high procedure, after which it becomes 74:131–136.  4. Van der Zee E, Oosterveld P, Van Waassuccess rates may be the use of routine. There are many advan- MA. Effects of GBR and fixture installa-acrylic resin provisional abutments tages to the current procedure for tion on gingiva and bone levels at adja-because of the shock-absorbing the patient as well as the surgeon, cent teeth. Clin Oral Implants Res 2004; 15:62–65.capacity of acrylic resins. The use since the procedure is less time-  5. Becker W, Becker BE, Handelsman M,of an acrylic resin provisional abut- consuming, bleeding is minimal, Ochsenbein C, Albrektsson T. Guided tissue regeneration for implants placedment immediately after implant implant placement is expedited, into extraction sockets: A study in dogs.placement limits the functional oc- and there is no need to place and J Periodontol 1991;62:703–709.clusal forces directed toward the remove sutures.25  6. Tolman DE, Keller EE. Endosseous im- plant placement immediately followingbone, and this effect appears to be The results of this study indi- dental extraction and alveoloplasty: Pre-a major advantage in preventing cate that flapless surgery in im- liminary report with 6-year follow-up. Int J Oral Maxillofac Implants 1991;6:24–28.destabilization of the implants.23 mediately provisionalized implants The minimal change in margin- placed in fresh extraction socketsal bone level (0.83 ± 0.52 mm) and provides soft tissue and marginalThe International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 37 7. Becker W, Dahlin C, Becker BE, et al. 17. Lekholm U, Zarb GA. Patient selection The use of e-PTFE barrier membranes and preparation. In: Brånemark P-I, Zarb for bone promotion around titanium im- GA, Albrektsson T (eds). Tissue-Integrat- plants placed into extraction sockets: A ed Prostheses: Osseointegration in Clini- prospective multicenter study. Int J Oral cal Dentistry. Chicago: Quintessence, Maxillofac Implants 1994;9:31–40. 1985:201–209.  8. Wilson TG Jr, Schenk R, Buser D, Cochran 18. Mombelli A, Lang NP. Clinical parame- D. Implants placed in immediate extrac- ters for the evaluation of dental implants. tion sites: A report of histologic and his- Periodontol 2000 1994;4:81–86. tometric analyses of human biopsies. 19. Prosper L, Gherlone E, Redaelli S, Int J Oral Maxillofac Implants 1998;13: Quaranta M. Four-year follow-up of 333–341. larger-diameter implants placed in fresh  9. Covani U, Cornelini R, Barone A. Bucco- extraction sockets using a resorbable lingual bone remodeling around implants membrane or a resorbable alloplastic ma- placed into immediate extraction sock- terial. Int J Oral Maxillofac Implants 2003; ets: A case series. J Periodontol 2003;74: 18:856–8564. 268–273. 20. Romanos GE, Johansson CB. Immediate10. Cornelini R, Cangini F, Covani U, Wilson loading with complete implant-support- TG Jr. Immediate restoration of implants ed restorations in an edentulous heavy placed into fresh extraction sockets for smoker: Histologic and histomorpho- single-tooth replacement: A prospective metric analyses. Int J Oral Maxillofac Im- clinical study. Int J Periodontics Restor- plants 2005;20:282–290. ative Dent 2005;25:439–447. 21. Degidi M, Piattelli A, Gehrke P, Carinci11. Barone A, Rispoli L, Vozza I, Quaranta F. Clinical outcome of 802 immediately A, Covani U. Immediate restoration of loaded 2-stage submerged implants single implants placed immediately af- with a new grit-blasted and acid-etched ter tooth extraction. J Periodontol 2006; surface:12-month follow-up. Int J Oral 77:1914–1920. Maxillofac implants 2006;21:763–768.12. Kan JYK, Rungcharassaeng K, Lozada J. 22. Szmukler-Moncler S, Piattelli A, Favero Immediate placement and provisionaliza- GA, Dubruille JH. Considerations pre- tion of maxillary anterior single implants: liminary to the application of early and 1-year prospective study. Int J Oral Max- immediate loading protocols in dental im- illofac Implants 2003;18:31–39. plantology. Clin Oral Implants Res 2000;13. Chaushu G, Chaushu S, Tzohar A, Dayan 11:12–25. D. Immediate loading of single-tooth im- 23. Tepret F, Sertgöz, Basa S. Immediately plants: Immediate versus non-immediate loaded anterior single-tooth implants: implantation. A clinical report. Int J Oral Two cases. Implant Dent 2005;14: Maxillofac Implants 2001;16:267–272. 242–247.14. Anderson E, Haanaes HR, Knutsen BM. 24. TJ, Shotwell JL, Billy EJ, Wang HL. Oh Immediate loading of single-tooth ITI im- Effect of flapless implant surgery on soft plants in the anterior maxilla: A prospec- tissue profile: A randomized controlled tive 5-year pilot study. Clin Oral Implants clinical trial. J Periodontol 2006;77: Res 2002;13:281–287. 874–882.15. Campelo LD, Camara JRD. Flapless im- 25. Campelo LD, Camara JRD. Flapless im- plant surgery: A 10-year clinical retro- plant surgery: A 10-year clinical retro- spective analysis. Int J Oral Maxillofac spective analysis. Int J Oral Maxillofac Implants 2002;17:271–276. Implants 2002;17:271–276.16. Rocci A, Martignoni M, Gottlow J. Im- mediate loading in the maxilla using flapless surgery, implants placed in pre- determined positions, and prefabricated provisional restorations: A retrospective 3-years clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):29–36. Volume 32, Number 1, 2012 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.