title: Minimally invasive treatment of the atrophic posterior maxilla: a proof-of-concept prospective study with a follow-up of between 36 and 54 months.
abstract: BACKGROUND
  In the posterior maxilla, tooth loss is usually associated with alveolar bone resorption and sinus pneumatization, limiting the placement of implants without grafting procedures.
  
  
  OBJECTIVE
  The purpose of this study was to evaluate a minimally invasive treatment of the atrophic posterior maxilla, with axial and tilted implants and immediate loading. The research hypothesis was that the combination of a guided, minimally invasive approach and the biomimetic features of computer-aided design and computer-aided manufacturing (CAD/CAM) abutments would be an effective alternative to maxillary sinus floor augmentation procedures with reduced bone resorption around implants.
  
  
  METHODS
  Twenty-seven consecutive participants (female=12, male=15) (mean age 54.18 years) with severe atrophy of the posterior maxilla were treated by using guided surgery with immediately loaded axial (39) and tilted (42) implants supporting CAD/CAM zirconia (39) and titanium (42) abutments (81 total) and partial fixed prostheses. Each participant underwent a computed tomography scan, after which 2 or 3 implants were positioned with a flapless or miniflap approach. The drilling protocol was adapted to the bone density of each implant site to obtain an insertion torque ranging between 40 and 50 Ncm. CAD/CAM customized abutments composed of zirconia or titanium were fixed to the implants with prosthetic screws tightened with a torque of 35 Ncm. An acrylic resin interim restoration reinforced with metal was placed immediately. Five to 6 months after initial loading, a zirconia framework was manufactured, and a definitive prosthesis was placed. Clinical and radiological controls were performed at baseline and after 1 and 3 years to assess implant and prosthesis survival and success rate and compare marginal bone remodeling of axial and tilted implants. Inferential statistics for radiological data were acquired by using the Mann-Whitney U-test. All statistical comparisons were conducted at the .05 significance level.
  
  
  RESULTS
  The mean follow-up period was 43.3 months (ranging from 36 months to 54 months). The cumulative implant survival rate was 96.3% at 3 years. All prosthetic restorations were stable and in good function, resulting in a cumulative prosthetic survival rate of 100%. Three restorations had chipping of the veneer material; thereafter, the cumulative prosthetic success rate was 91.9%.
  
  
  CONCLUSIONS
  Treatment of the posterior partially edentulous atrophic maxilla with guided surgery and immediate loading of tilted and straight implants supporting short-span partial fixed dental prostheses is effective.
authors.affiliation: Department of Oral Rehabilitation, University of Rome Tor Vergata, School of Dentistry, Rome, Italy. tudiopozzi@me.com
authors.forename: Alessandro
authors.initials: A
authors.lastname: Pozzi
authors.forename: Gianpaolo
authors.initials: G
authors.lastname: Sannino
authors.forename: Alberto
authors.initials: A
authors.lastname: Barlattani
mesh_terms: D000328:Adult; D000368:Aged; D016301:Alveolar Bone Loss / Q000601:surgery*; D017076:Computer-Aided Design; D000044:Dental Abutments; D003758:Dental Implantation, Endosseous / Q000379:methods*; D017267:Dental Prosthesis Design; D019094:Dental Prosthesis, Implant-Supported; D005260:Female; D006801:Humans; D057893:Immediate Dental Implant Loading; D008297:Male; D008439:Maxillary Diseases / Q000601:surgery; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D025321:Surgery, Computer-Assisted