Influence of Surgical and Prosthetic Techniques on Marginal

Bone Loss around Titanium Implants. Part I: Immediate

Loading in Fresh Extraction Sockets
Antoine N. Berberi, BDS, MSc, PhD,1 Georges E. Tehini, DDS, MSc,2 Ziad F. Noujeim, DDS, CES,3
Alexandre A. Khairallah, BDS, DESS,4 Moustafa N. Abousehlib, DDS, MSc, PhD,5,6 &
Ziad A. Salameh, DDS, MSc, PhD3
1
Department of Oral and Maxillofacial Surgery, School of Dentistry, Lebanese University, Beirut, Lebanon
2
Department of Prosthodontics, School of Dentistry, Lebanese University, Beirut, Lebanon
3
Research Department, School of Dentistry, Lebanese University, Beirut, Lebanon
4
Department of Radiology, School of Dentistry, Lebanese University, Beirut, Lebanon
5
Department of Materials Science, ACTA, Amsterdam, The Netherlands
6
Faculty of Dentistry, Department of Materials Science, Alexandria University, Alexandria, Egypt

Keywords
Marginal bone loss; immediate loading;
radiological evaluation; titanium implant.
Correspondence
Moustafa N. Aboushelib, ACTA – Material
Science, Louwesweg 1 Amsterdam 1066 EA,
The Netherlands. E-mail: info@aboushelib.org,
bluemarline_1@yahoo.com
This work received support from a
reintegration grant (Grant number 489)
provided by the Science and Technology
Department Fund.
The authors deny any conflicts of interest.
Accepted October 22, 2013
doi: 10.1111/jopr.12153
Abstract
Purpose: Delayed placement of implant abutments has been associated with peri-
implant marginal bone loss; however, long-term results obtained by modifying surgical
and prosthetic techniques after implant placement are still lacking. This study aimed
to evaluate the marginal bone loss around titanium implants placed in fresh extraction
sockets using two loading protocols after a 5-year follow-up period.
Material and Methods: A total of 36 patients received 40 titanium implants (Astra
Tech) intended for single-tooth replacement. Implants were immediately placed into
fresh extraction sockets using either a one-stage (immediate loading by placing an in-
terim prosthesis into functional occlusion) or a two-stage prosthetic loading protocol
(insertion of abutments after 8 weeks of healing time). Marginal bone levels relative
to the implant reference point were evaluated at four time intervals using intraoral
radiographs: at time of implant placement, and 1, 3, and 5 years after implant place-
ment. Measurements were obtained from mesial and distal surfaces of each implant
(α = 0.05).
Results: One-stage immediate implant placement into fresh extraction sockets re-
sulted in a significant reduction in marginal bone loss (p < 0.002) compared to the
traditional two-stage technique. Whereas mesial surfaces remained stable for the 5-
year observation period, significant marginal bone loss was observed on distal surfaces
of implants after cementation of interim prostheses (p < 0.007) and after 12 months
(p < 0.034).
Conclusions: Within the limitations of this study, immediate loading of implants
placed into fresh extraction sockets reduced marginal bone loss and did not compro-
mise the success rate of the restorations.

Radiological assessment of bone quality and quantity around
dental implants is one of the most important evaluation cri-
teria in long-term follow-up studies; however, with regard to
marginal bone loss (MBL), most reports present only mean val-
ues, while frequency distributions of the data have rarely been
described. Only a few long-term studies have addressed this
issue from the patient level.1-9
Several criteria have been proposed for the evaluation of the
success of dental implants. A commonly used criterion was
suggested by Albrektsson et al10 and was further revised in
1993.11 According to the authors,12 a successful dental implant
should sustain less than 1.5 mm of bone loss during the first
year in function and less than 0.2 mm annually thereafter. In
1999, Wennström and Palmer13 suggested a modification of the
radiological criteria used to assess MBL. They suggested that
a maximum bone loss of 2 mm could be accepted over a 5-year
period after functional loading of the restoration.
The peri-implant tissue or biological width is composed of
connective tissue coated by layers of epithelial cells that at-
tach to the implant surface, forming the junctional epithelium.

Journal of Prosthodontics 23 (2014) 521–527 

C 2014 by the American College of Prosthodontists 521
Marginal Bone Loss around Implants
Biologic width should be physiologically and dimensionally
stable before and after loading.14,15 Dynamic changes can be
observed over time regarding the dimensions of gingival sulcus,
junctional epithelium, and connective tissue.16-20
Achieving optimal peri-implant mucosal dimension is a chal-
lenging procedure, and maintaining it over time can be an
equally demanding task.21,22 In fact, peri-implant mucosal ar-
chitecture implicates the position of the gingival zenith and
the interproximal tissue volume (papillae). It is also well ac-
cepted that peri-implant soft tissue preservation is related to
many anatomical and clinical parameters,23-27 and that follow-
ing implant, abutment, or crown placement, peri-implant soft
tissue changes may include papillary regrowth, among other
changes.15,19,20 Presence and maintenance of papillae is pri-
marily related to the bone level at the adjacent tooth,15,22,28 and
bone preservation is a key factor for the esthetic outcome.29,30
MBL can be influenced by several surgical and prosthetic
factors, such as immediate insertion of implants in fresh extrac-
tion sockets, the time of fixation of the implant superstructures,
and the time of functional loading.31-33 Previous studies9,34-38
have reported a possible association between increase in the
MBL and the removal of cover screws, placement of healing
abutments, and subsequent manipulations of the abutment. This
prosthetic handling is a potential compromising factor for the
stability of the subcrestal biological area. In 2006, Lazzara and
Porter39 reported that “the removal and reconnection of the
abutment created a soft tissue wound with subsequent bone re-
sorption due to the attempt made by the soft tissue to establish
a proper biologic dimension of the mucosal barrier attachment
to a stable implant surface.”38
Several studies have reported inconclusive evidence re-
garding the advantages or disadvantages of immediate versus
delayed implant placement.39,40 The correlation between the
timing of implant placement and tooth extraction has been
evaluated and has been reported not to be crucial for implant
survival or MBL.41,42 Some investigations43-45 have compared
bone level changes for immediately loaded versus convention-
ally loaded implants and have not reported any differences in
MBL levels. The results of recent studies have shown that in-
sertion of abutments at the time of implant placement resulted
in a significant reduction in MBL.38,43-47
Unfortunately, sound guidelines regarding the interaction of
these variables are not yet available in the dental literature, es-
pecially over long-term observation periods. The aim of this
retrospective study was to evaluate the influence of two pros-
thetic techniques on MBL around titanium implants placed into
maxillary fresh extraction sockets over a 5-year period. The null
hypothesis was that more MBL would not be observed around
immediately loaded implants compared to the delayed loading
technique.
Materials and methods
This study included 36 patients (21 men and 15 women, mean
age 31 years) who required single implant placement in ante-
rior maxillae. Ethics Committee approval (School of Dentistry,
Lebanese University, Beirut, Lebanon) was obtained for all pa-
tients.
522 Journal of Prosthodontics 23 (2014) 521–527 
Berberi et al
Patient selection criteria
Patients in need of bone grafts or bone regeneration, medically
compromised patients (corticosteroid therapy, uncontrolled di-
abetes, bisphosphonate therapy, immunocompromised cases),
smokers, and patients with periodontal disease were excluded
from the study. The selected cases included 20 central incisors,
13 lateral incisors, 1 canine, and 6 premolars; all were treated by
the same oral surgeon (n = 40). Study casts, diagnostic waxing,
and surgical guides were prepared for all patients. Provisional
crowns were prepared for implants when sufficient initial pri-
mary stability was observed (20 N/cm).48,49
Surgical phase
The diseased teeth were extracted, and full-thickness mucope-
riosteal flaps were raised for direct exposure of the surgical
fields. Titanium implants (Astra Tech Implant system; Dentsply
Implants, Mölndal, Sweden) were inserted into the prepared
sites using successive drill sizes and were countersunk to levels
approximately 2 mm apical to the cemento–enamel junctions
of the adjacent teeth. This process resulted in implant collars
1 mm below the crest of the ridge for greater primary stabil-
ity and optimal esthetics. Bone chips collected during drilling
were packed to fill the gaps between the defects and the inserted
implants. Implants with initial primary stability of 20 N/cm or
more were immediately restored; implants placed with less than
20 N/cm of insertion torque were restored with a delayed load-
ing protocol. Initial stability was evaluated during insertion of
the implants in the prepared sockets with a torque-controlled
low-speed handpiece. The torque (N/cm) values were visual-
ized on the surgical motor (Aseptico Inc., Woodinville, WA). A
manual torque control (Astra Tech Implant system) was used to
confirm initial stability by engaging it in the removal position;
force was stopped once the indicator passed the required level
(20 N/cm).
Immediate loading protocol (one stage)
Definitive abutments (Ti Design or Zir Design; Astra Tech Im-
plant system) were prepared outside the mouth for use intrao-
rally, and abutment screws were tightened with finger pres-
sure. No further preparation of the abutments was required.
Interim prostheses were fabricated and adjusted in the mouth
with demonstrable contact (holding shimstock) in the maxi-
mum intercuspal position. No eccentric contacts were permit-
ted. Temporary cement (Temp-Bond; Kerr USA, Romulus, MI)
was used to cement the acrylic resin interim prostheses (Pro-
Temp Garant III; 3M ESPE America, Norristown, PA). Excess
cement was removed, and the flaps were closed around the
cemented restorations by means of interrupted sutures (Vicryl
4–0; Johnson & Johnson Medical Ltd., Wokingham, UK).
Delayed loading protocol (two stages)
Implants that did not achieve 20 N/cm of insertion torque
were covered using flathead cover screws. After 8 weeks of
healing time, a tissue punch and small crestal incisions were
used to expose the cover screws, and the previously described
prosthetic protocol was applied. Abutment screws were tight-
ened with a torque controller, according to the manufacturer’s
C 2014 by the American College of Prosthodontists
Berberi et al Marginal Bone Loss around Implants

recommendations (20 N/cm for 3.5 and 4 S abutments; 25 N/cm

for ST abutments). Provisional crowns were prepared as for
the immediate loading group and cemented with occlusal con-
tacts until the delivery of the definitive restorations. Definitive
crowns (Empress 2; Ivoclar Vivadent, Schaan, Liechtenstein)
were cemented with glass ionomer cement (Ketac-Cem; 3M
ESPE America). Patients were instructed to rinse three times
daily (0.12% digluconate chlorhexidine, for 3 minutes after
each meal over a 2-week period) and to maintain proper oral
hygiene.

Radiological evaluation
Standardized periapical radiographs were obtained using a
long-cone paralleling technique, with the central beam per-
pendicular to the alveolar crest (XCP holder Rinn; Dentsply
International, York, PA). Each X-ray holder was individual-
ized with an occlusal record to standardize the procedure be-
tween visits for each patient. Radiographs were obtained at the
time of implant placement, after 8 weeks, then at 1, 3, and
5 years of function. All radiographs were processed accord-
ing to time/temperature guidelines (processing solutions were
maintained at 20°C and an immersion time of 4 minutes).
A digital camera (Kodak EOS camera equipped with 1:1 100
mm macro lens; Kodak, Rochester, NY) was used to convert the
images into digital formats (JPEG format). Measurements were
obtained with the aid of image-processing software (DBSWIN
5; DÜRR DENTAL AG, Bietigheim-Bissingen, Germany) and
were used to calculate the vertical distance between the bone
level and the implant shoulder (calibrated 10× magnifications).
Marginal bone level relative to the implant reference point (im-
plant shoulder) was measured on mesial and distal surfaces of
the implants (Fig 1). Two calibrated examiners performed all
measurements, which were recorded in millimeters. Figure 1 Measurement technique: (A) Mesial and distal marginal bone
loss (MBL) calculated as the vertical distance between the crestal bone
Statistical analysis level and the implant neck; (B) software calculation of the MBL.

Interexaminer correlation analysis was performed to calibrate

the accuracy of the measuring procedure. One- and two-way
ANOVA were performed to detect significant changes in the
marginal bone level at every time interval (α = 0.05). Measure-
ments were obtained on the mesial and distal surfaces of each
implant. Pairwise comparisons were performed using Bonfer-
roni’s post hoc test. Analyses were performed using computer
software (SPSS, version 18.0; SPSS Inc., Chicago, IL).
Results
Interexaminer correlation analysis revealed a nonsignificant er-
ror margin for all of the measurements obtained (p < 0.11).
Statistical analysis showed that immediate placement of in-
terim prostheses in occlusion as described resulted in a signifi-
cant reduction in MBL (F = 21.5, p < 0.002), compared to the
two-stage technique, where abutments were inserted 8 weeks
following implant placement. This finding was observed at all
time intervals (Figs 2 and 3). Significant MBL was observed
on the distal surfaces of the implants after cementation of pro-
visional crowns (F = 8, p < 0.007) and at 1 year (p < 0.034),
compared to the mesial surfaces, which remained stable over
the 5-year observation period (Table 1).
Discussion
All 40 implants were successfully integrated at the time of
definitive crown cementation. No failures were recorded over
the 5-year evaluation period. Complications included fracture
of three provisional crowns, two in the immediate group and
one on the delayed group, during the healing period. Minor
incisal porcelain chipping of four crowns occurred after 1 year,
and two crowns were replaced for esthetic reasons. The patients
reported no crown or abutment loosening.
Data analysis revealed that the majority of MBL was ob-
served during the second observation period, 8 weeks after
insertion of implants. Almost 85% of the total MBL observed
after 5 years occurred during the first 8-week period following
implant placement, after which the rate of bone loss remained
relatively constant (0.01 to 0.02 mm/year). This could be related
to the early loss of the bundle bone of the buccal aspect.26 After
the 8-week healing period, the formation of soft tissue attach-
ment, which protects peri-implant crestal bone from oral cav-
ity products, was observed. This tissue is important for initial
healing, osseointegration maintenance, and long-term implant
behavior.15,19-21

Journal of Prosthodontics 23 (2014) 521–527 

C 2014 by the American College of Prosthodontists 523
Marginal Bone Loss around Implants Berberi et al

Figure 2 Digital intraoral radiographs of implants placed into fresh extraction sockets with immediate loading (one-stage technique) at different
observation times. (A) Preoperative; (B) on the day of surgical placement of the implant; (C) placement of the abutment and provisional crown; (D) 8
weeks after definitive crown cementation; (E) after 1 year; (F) after 3 years; (G) after 5 years.

Significantly lower MBL associated with immediately
loaded implants inserted into fresh extraction sockets was ob-
served when compared to the delayed loading technique. Thus,
the suggested hypothesis that greater MBL would be observed
in immediately loaded implants was rejected.
During the one-stage surgery, the concept of immediate
placement of definitive abutments and insertion of immedi-
ate interim prostheses appeared to protect the blood clot and
to prevent interruption of the early mineralization of marginal
bone.31 This was in contrast with several studies that reported
no differences in MBL between immediate and delayed loading
of dental implants.33,41-45 This phenomenon was more obvious
in fresh extraction sockets, which demonstrated early MBL
during the first 8 weeks, after which a constant marginal bone
height was observed over 5 years.9,36,37
Evaluation of the MBL in extraction sites was also related
to discrepancies between the socket walls and the final drilling
dimensions. Filling the extraction sockets with bone chips re-
sulted in preservation of the marginal buccal wall during the
observation period of this study. The MBL values reported
in this study were lower compared to other studies with sim-
ilar observation periods.30,43-47 Another concern for the im-
mediate loading group was the predictability of peri-implant
mucosal healing, based on positive adaptation to the implant–
abutment complex. The rapid and reproducible reformation of
peri-implant mucosa within the gingival embrasures can be at-
tributed to minimal MBL, immediate delivery of the interim
prostheses, and absence of abutment manipulation during the
healing period.
Two-phase surgical procedures have been associated with
continuous MBL of between 0.01 and 0.02 mm/year, which
could be in part related to the additional surgical procedure.
During the removal of cover screws and tightening of implant
abutments, greater stress is delivered to the initially mineraliz-
ing marginal bone; this manipulation could interfere with the
healing process and thus result in increased MBL.19,34,35 More-
over, the amount of initial MBL during the first 8 weeks was
significantly greater (more than twofold), compared to imme-
diately loaded implants inserted into fresh extraction sockets.
Vascular ischemia associated with flap reflection for second-
stage surgery has been implicated as a potential source of
MBL.18 Significant changes did occur within the soft tissue
compartments, such that sulcus depth and connective tissue
contact dimensions decreased while the length of epithelium
barrier increased.24 The formation and maturation of the soft
tissue around implants in fresh extraction sockets were higher
than in healed sockets.19
Other reports have shown that simple procedures, such as
removing healing screws, are associated with an increase in
MBL.35,36 Thus, prevention of further disturbance of the im-
plant bone–soft tissue interface favored early placement of
definitive implant abutments.37 In some cases, if reflection of

524 Journal of Prosthodontics 23 (2014) 521–527 

C 2014 by the American College of Prosthodontists
Berberi et al Marginal Bone Loss around Implants

Figure 3 Digital intraoral radiographs of implants placed into fresh extraction sockets with delayed loading (two-stage technique): (A) preoperative;
(B) implant placement; (C) healing abutment placement; (D) 8 weeks after definitive crown cementation; (E) after 1 year; (F) after 3 years; (G) after 5
years.

Table 1 Marginal bone loss (mm) at different time intervals

Technique Observation interval Distal Mesial Average

One-stage 8 weeks 0.189 ± 0.270 0.039 ± 0.104 0.114 ± 0.135

1 year 0.261 ± 0.243 0.217 ± 0.233 0.239 ± 0.158
3 years 0.247 ± 0.270 0.220 ± 0.221 0.233 ± 0.182
5 years 0.200 ± 0.271 0.160 ± 0.241 0.180 ± 0.183
Two-stage 8 weeks 0.300 ± 0.283 0.160 ± 0.230 0.230 ± 0.244
1 year 0.400 ± 0.071 0.340 ± 0.241 0.370 ± 0.144
3 years 0.420 ± 0.084 0.300 ± 0.200 0.360 ± 0.089
5 years 0.450 ± 0.071 0.300 ± 0.141 0.375 ± 0.106

MBL was significantly greater for the two-stage technique at all time intervals (F = 14, p < 0.005). For every group, there was no significant difference in MBL
between the second and third observation periods or between the fourth and fifth observation periods.

a flap is required, greater bone loss is expected due to the in-
terruption of the blood supply reaching the bone crest. The
results of these studies warrant the immediate placement of im-
plant abutments when primary stability was achieved, to reduce
MBL.34-36,47
The difference in MBL values between mesial and distal
surfaces was observed statistically; however, this difference was
too small to have any clinical relevance (maximum difference
of 0.2 mm at all observation intervals). This difference could
be related to anatomical features, such as incisive fissures and
interdental septa, or due to the direction of stress around the
implant neck.23,32 Periodic follow-up radiographs are required
to detect the early stages of MBL and peri-implantitis.
An interesting observation was the remodeling of peri-
implant marginal bone around the implant collars, in association
with healthy gingival margins and sulcular depths. In an envi-
ronment with active biomechanical stimulation, several factors
should be considered to preserve marginal bone for adequate
protection and support of soft tissue, careful and regular oral
hygiene, and for proper placement of implant abutments.
Conclusions
Within the limitations of this study, less MBL was associated
with immediately loaded implants inserted into fresh extraction
sockets.
References
1. Lekholm U, Gunne J, Henry P, et al: Survival of the Brånemark
implant in partially edentulous jaws: a 10-year prospective
multicenter study. Int J Oral Maxillofac Implants
1999;14:639-645
2. Ekelund J-A, Lindquist LW, Carlsson GE, et al: Implant
treatment in the edentulous mandible: a prospective study on
Brånemark system implants over more than 20 years. Int J
Prosthodont 2003;16:602-608
3. Jemt T, Johansson J: Implant treatment in the edentulous
maxillae: a 15-year follow-up study on 76 consecutive patients
provided with fixed prostheses. Clin Implant Dent Relat Res
2006;8:61-69

Journal of Prosthodontics 23 (2014) 521–527 

C 2014 by the American College of Prosthodontists 525
Marginal Bone Loss around Implants
4. Roos-Jansåker A, Lindahl C, Renvert H, et al: Nine to
fourteen-year follow-up of implant treatment. Part II: presence of
peri-implant lesions. J Clin Periodontol 2006;33:290-295
5. Örtorp A, Jemt T: Clinical experiences with laser-welded
titanium frameworks supported by implants in the edentulous
mandible: a 10-year follow-up study. Clin Implant Dent Relat
Res 2006;8:198-209
6. Örtorp A, Jemt T: Laser-welded titanium frameworks supported
by implants in the partially edentulous mandible: a 10-year
comparative study. Clin Implant Dent Relat Res 2008;10:128-139
7. Wennström J, Ekestubbe A, Gröndahl K, et al: Oral rehabilitation
with implant-supported fixed partial dentures in
periodontitis-susceptible subjects: a 5-year prospective study. J
Clin Periodontol 2004;31:713-724
8. Fransson C, Lekholm U, Jemt T, et al: Prevalence of subjects
with progressive bone loss at implants. Clin Oral Implants Res
2005;16:440-446
9. Albrektsson T, Zarb GA, Worthington P, et al: The long-term
efficacy of currently used dental implants: a review and proposed
criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25
10. Albrektsson T, Zarb GA: Current interpretations of the
osseointegrated response: clinical significance. Int J Prosthodont
1993;6:95-105
11. Albrektsson T, Isidor F: Consensus report of session IV. In Lang
NP, Karring T (eds): Proceedings of the 1st European Workshop
on Periodontology. London, Quintessence, 1993, pp. 365-369
12. Wennström J, Palmer R: Consensus reports session 3: clinical
trials. In Lang NP, Karring T, Lindhe J (eds): Proceedings of the
3rd European Workshop on Periodontology. Implant Dentistry.
Berlin, Quintessence, 1999
13. Cochran DL, Hermann JS, Schenk RK, et al: Biologic width
around titanium implants. A histometric analysis of the
implanto-gingival junction around unloaded and loaded
nonsubmerged implants in the canine mandible. J Periodontol
1997;68:186-198
14. Henriksson K, Jemt T: Measurements of soft tissue volume in
association with single-implant restorations: a 1-year
comparative study after abutment connection surgery. Clin Impl
Dent Relat Res 2004;6:181-189
15. Abrahamsson I, Berglundh T, Lindhe J: The mucosal barrier
following abutment dis/reconnection. An experimental study in
dogs. J Clin Periodontol 1997;24:568-572
16. Hermann JS, Buser D, Schenk RK, et al: Biologic width around
titanium implants. A physiologically formed and stable
dimension over time. Clin Oral Impl Res 2000;11:1-11
17. Buser D, Martin W, Belser U: Surgical considerations with
regard to single-tooth replacements in the esthetic zone. In Buser
D, Belser U, Wismeijer D (eds): ITI Treatment Guide, Vol 1.
Implant Therapy in the Esthetic Zone: Single-Tooth
Replacements, Berlin, Quintessenz, 2007, pp. 26-37
18. Vignoletti F, de Sanctis M, Berglundh T, et al: Early healing of
implants placed into fresh extraction sockets: an experimental
study in the beagle dog. III: soft tissue findings. J Clin
Periodontol 2009;36:1059-1066
19. Blanco J, Carral C, Linares, A, et al: Soft tissue dimensions in
flapless immediate implants with and without immediate loading:
an experimental study in the beagle dog. Clin Oral Impl Res
2012;23:70-75
20. Phillips K, Kois JC: Aesthetic peri-implant site development.
The restorative connection. Dent Clin North Am 1988;42:57-70
21. Kan JY, Rungcharassaeng K, Umezu K, et al: Dimensions of
peri-implant mucosa: an evaluation of maxillary anterior single
implants in humans. J Periodontol 2003;74:557-562
22. Cardaropoli G, Lekholm U, Wennstrom JL: Tissue alterations at
implant-supported single-tooth replacements: a 1-year
prospective clinical study. Clin Oral Impl Res 2006;17:165-171
526 Journal of Prosthodontics 23 (2014) 521–527 
Berberi et al
23. Cooper LF, Ellner S, Moriarty J, et al: Three-year evaluation of
single-tooth implants restored 3 weeks after 1-stage surgery. Int J
Oral Maxillofac Implants 2007;22:791-800
24. Woelfel JB, Scheid RC: Dental Anatomy. Its Relevance to
Dentistry. Philadelphia, Lippincott, Williams and Wilkins, 2002,
100 p
25. Araujo MG, Sukekava F, Wennstrom JL, et al: Ridge alterations
following implant placement in fresh extraction sockets: an
experimental study in the dog. J Clin Periodontol
2005;32:645-652
26. Cooper LF: Objective criteria: guiding and evaluating dental
implant esthetics. J Esthet Restor Dent 2008;20:195-205
27. Choquet V, Hermans M, Adriaenssens P, et al: Clinical
and radiographic evaluation of the papilla level adjacent to
single-tooth dental implants. A retrospective study in
the maxillary anterior region. J Periodontol 2001;72:1364-
1371
28. Palmer RM, Farkondeh N, Palmer PJ, et al: Astra Tech single
tooth implants: an audit of patient satisfaction and soft tissue
form. J Clin Periodontol 2007;34:633-638
29. Degidi M, Piattelli A, Carinci F: Immediate loaded dental
implants: comparison between fixtures inserted in postextractive
and healed bone sites. J Craniofac Surg 2007;18:965-971
30. Crespi R, Capparè P, Gherlone E, et al: Immediate occlusal
loading of implants placed in fresh sockets after tooth extraction.
Int J Oral Maxillofac Implants 2007;22:955-962
31. Donati M, Botticelli D, La Scala V, et al: Effect of immediate
functional loading on osseointegration of implants used for
single tooth replacement. A human histological study. Clin Oral
Implants Res 2013;24:738-745
32. Abrahamsson I, Berglundh T, Sekino S, et al: Tissue reactions to
abutment shift: an experimental study in dogs. Clin Implant Dent
2003;2:82-90
33. Rodriguez X, Vela X, Mendez V, et al: The effect of abutment
dis/reconnections on peri-implant bone resorption: a radiologic
study of platform-switched and non-platform-switched implants
placed in animals. Clin Oral Impl Res 2013;24:305-311
34. Pikner SS, Gröndahl K, Jemt T, et al: Marginal bone loss at
implants: a retrospective, long-term follow-up of turned
Brånemark System implants. Clin Implant Dent Relat Res
2009;11:11-23
35. Pikner SS, Gröndahl K: Radiographic analyses of “advanced”
marginal bone loss around Brånemark dental implants. Clin
Implant Dent Relat Res 2009;11:120-133
36. Van Assche N, Collaert B, Coucke W, et al: Correlation between
early perforation of cover screws and marginal bone loss: a
retrospective study. J Clin Periodontol 2008;35:76-79
37. Degidi M, Nardi D, Piattelli A: One abutment at one time:
non-removal of an immediate abutment and its effect on bone
healing around subcrestal tapered implants. Clin Oral Implants
Res 2011;22:1303-1307
38. Lazzara RJ, Porter SS: Platform switching: a new concept in
implants dentistry for controlling postrestorative crestal bone
levels. Int J Periodontics Restorative Dent 2006;26:9-17
39. Esposito M, Grusovin MG, Polyzos IP, et al: Timing of implant
placement after tooth extraction: immediate, immediate-delayed
or delayed implants? A Cochrane systematic review. Eur J Oral
Implantol 2010;3:189-205
40. Sennerby L, Gottlow J: Clinical outcomes of immediate/early
loading of dental implants. A literature review of recent
controlled prospective clinical studies. Aust Dent J 2008;53
(Suppl 1):S82-S88
41. Ormianer Z, Piek D, Livne S, et al: Retrospective clinical
evaluation of tapered implants: 10-year follow-up of delayed and
immediate placement of maxillary implants. Implant Dent
2012;21:350-356
C 2014 by the American College of Prosthodontists
Berberi et al
42. Ostman PO, Hellman M, Albrektsson T, et al: Direct loading of
Nobel Direct and Nobel Perfect one-piece implants: a 1-year
prospective clinical and radiographic study. Clin Oral Implants
Res 2007;18:409-418
43. Testori T, Del Fabbro M, Capelli M, et al: Immediate occlusal
loading and tilted implants for the rehabilitation of the atrophic
edentulous maxilla: 1-year interim results of a multicenter
prospective study. Clin Oral Implants Res 2008;19:227-232
44. Collaert B, De Bruyn H: Immediate functional loading of
TiOblast dental implants in full-arch edentulous maxillae: a
3-year prospective study. Clin Oral Implants Res
2008;19:1254-1260
45. Boronat A, Peñarrocha M, Carrillo C, et al: Marginal bone loss in
dental implants subjected to early loading (6 to 8 weeks
postplacement) with a retrospective short-term follow-up. J Oral
Maxillofac Surg 2008;66:246-250
Journal of Prosthodontics 23 (2014) 521–527 
C 2014 by the American College of Prosthodontists
Marginal Bone Loss around Implants
46. De Bruyn H, Raes F, Cooper LF, et al: Three-years clinical
outcome of immediate provisionalization of single Osseospeed
implants in extraction sockets and healed ridges. Clin Oral
Implants Res 2012;24:217-223
47. Bergkvist G, Nilner K, Sahlholm S, et al: Immediate loading of
implants in the edentulous maxilla: use of an interim fixed
prosthesis followed by a permanent fixed prosthesis: a 32-month
prospective radiological and clinical study. Clin Implant Dent
Relat Res 2009;11:1-10
48. Norton M: A short-term clinical evaluation of immediately
restored maxillary Tioblast single-tooth implants. Int J Oral
Maxillofac Implants 2004;19:274-281
49. Donati M, La Scala V, Billi M, et al: Immediate functional
loading of implants in single tooth replacement: a prospective
clinical multicenter study. Clin Oral Impl Res 2008;19:
740-748
527