R e p l a c e m e n t of maxillary and mandibular molars with single

e n d o s s e o u s implant restorations: A r e t r o s p e c t i v e study

W i l l i a m B e c k e r , D D S , M S D , a a n d B u r t o n E. B e c k e r , D D S b
University of Southern California, Los Angeles, Calif., and University of Texas, Houston, Tex.

This r e t r o s p e c t i v e report p r e s e n t s findings on 22 patients w i t h 24 implants

replacing single m o l a r s w i t h i m p l a n t - s u p p o r t e d restorations. P a t i e n t s w i t h k n o w n
b r u x i s m habits w e r e not considered for s i n g l e - m o l a r implant replacement. The
p a t i e n t s u n d e r w e n t f o l l o w - u p for an a v e r a g e of 24 months. The c u m u l a t i v e s u c c e s s
rate was 95%, w h i c h reflects the loss of one 5 • 6 mm wide implant. Eleven
i m p l a n t s w e r e placed in edentulous ridges, and 13 were placed in extraction
sockets. Most of the i m p l a n t s w e r e placed in type B and C bone quantity and type 2
and 3 bone quality. All i m p l a n t s w e r e restored on a b u t m e n t s w i t h nonrotating gold
cylinders. The occlusion for all restorations w a s d e v e l o p e d to m i n i m i z e centric
contacts and lateral interferences. The f r e q u e n c y of gold r e t a i n i n g - s c r e w l o o s e n i n g
w a s o b t a i n e d for 21 patients. The gold retaining s c r e w s l o o s e n e d in eight i m p l a n t s
b e t w e e n one and three t i m e s (38%). No incidence of c r o w n or i m p l a n t fracture
occurred. Within the limits of this study, r e p l a c e m e n t of single-tooth molars by
i m p l a n t - s u p p o r t e d restorations w a s predictable; h o w e v e r , a high incidence of gold
s c r e w l o o s e n i n g w a s seen. (J PROSTHET DENT 1995;74:51-5.)

T h e long-term data relating to commercially pure

titanium endosseous implants have revolutionized modern
dentistry. Implant-supported restorations for fully and
partially edentulous patients have exceedingly good long-
term success rates. 13 Jemt et al. 4 reported on osseointe-
grated implants that were restored in mainly bicuspid and
anterior teeth positions. Five implants were placed into
molar positions. One hundred six implants were placed,
and of these, three implants (2.8 % ) were lost. Although the
cited studies provided longitudinal evidence of implant
survival for fully edentulous, partially edentulous, and
single-tooth anterior replacements, no data relating to re-
placement of molars exist. Rangert and Sullivan 5 recently
suggested that molars replaced by one implant may frac-
ture as a result of bending moments. They suggested that
wide implants or multiple implants may withstand the oc- Fig. 1. Periapical radiograph of lower left second molar.
clusal forces on molars better than a single standard 3.75 There is advanced furcation invasion.
mm implant.
This article presents the retrospective findings of 24
consecutively placed mandibular and maxillary molar sin- MATERIAL AND METHODS
gle-tooth implants. The patients were evaluated for bone Twenty-two patients, 16 women and six men, whose ages
quality and quantity, implant survival, and length of time ranged from 48 to 73 years (average 58.6 years) participated
of loading. Complications related to screw loosening and in this study. The patients were referred for periodontal
fracture were also recorded. therapy and implant placement for single maxillary or
mandibular molars and were considered to be in good gen-
aPrivate Practice, Tucson, Ariz.; and Assistant Professor, Depart- eral health. At the initial examination a periodontal eval-
ment of Periodontology, University of Southern California, Los uation was made, and radiographs were taken (Fig. 1).
Angeles, Calif. These were supplemented by a panoramic radiograph. Di-
bprivate Practice, Tucson, Ariz.; and Associate Professor, Depart- agnostic casts and clinical photographs were made. Con-
ment of Periodontology, University of Texas, Houston, Tex.
sultations were made with the referring doctor, the patient,
Copyright | 1995 by The Editorial Council of THE JOURNALOF
PROSTHETICDENTISTRY. and on occasion, the laboratory technician. Patients with
0022-3918/95/$3.00 + 0. 10/1/63630 known bruxism or clenching habits were not considered for

JULY 1995 THE JOURNAL OF PROSTHETICDENTISTRY 51

THE JOURNAL OF PROSTHETIC DENTISTRY BECKER AND BECKER

Fig. 2. A. Molar has been removed, socket debrided, and distal socket prepared to receive
13 mm implant. B, Implant installed slightly below crest is entirely within distal extrac-
tion socket.

Fig. 3. Five months after implant placement, implant has been exposed with bone sur-
rounding implant.

single-tooth molar implant placement. Alternative treat-
ment plans were discussed with the patients. Once the de-
cision was made to place and implant, surgical guides were
fabricated.
The patients underwent premedication with either pen-
icillin or erythromycin (2 gm to be taken 2 hours before
surgery and 1 gm p/day for 7 days). The patients underwent
premedication with light intravenous conscious sedation,
and local anesthesia was administered. Incisions for eden-
tulous sites were begun within the sulcus of the adjacent
posterior tooth and were extended across the palatal or
lingual aspect of the edentulous ridge, terminating one
tooth anteriorly. Vertical buccal releasing incisions were
made for access, and full-thickness mucoperiosteal flaps
were reflected. In the mandible the mental foramen was
always identified to prevent injury to the nerve.
If the tooth was presented and was to be replaced by an
immediate implant, mesial-distal luxation was carefully
applied. Once the tooth was loosened, i t was gently re-
moved with forceps. The sockets were debrided with
curettes and files. When the tooth was missing, incisions
were made lingual or palatal to the crest, and the tissues
were reflected to the buccal surface. The implant sites were
prepared according to the methods described by Adell and
Lekholm. 6 The bone quality and quantity were determined
from the preoperative radiographs and were registered in
the patient's chart. 7
For extraction sockets the implants were either placed
into .the interradicular bone (Fig. 2) or within one of the
engaging socket's bony walls in an attempt to engage part
of the interradicular bone. Most implants were placed
without tapping. Twenty-one standard implants 3.75 mm
wide, one implant 4 mm wide, and two implants 5 mm in
diameter were placed. In instances where the bone quality
was of low density and complete tapping could have over-
prepared the surgical sites, only the coronal half of the

52 V O L U M E 74 NUMBER 1
BECKER AND BECKER THE J O U R N A L OF PROSTHETIC DENTISTRY

F i g . 4. A, I m p l a n t restored on nonrotating a b u t m e n t gold cylinder and in occlusion. B,

Radiograph taken at 2-year evaluation. Bone level is at second thread.

T a b l e I. I m p l a n t success T a b l e II. M e t h o d of placement

Success Standard
rate implant Immediate implant
No. No. within Cumulative Location placement placement
Time of Implants of group success
period Patients followed Failures (%) r a t e (%) Maxilla 4* 3
Mandible 7 10
Implant 22 24 0 100 100
insertion- *One implant was lost and replaced.
0 (yrs)
0-1 yrs 21" 23 1 95.7 95.7
1-2 yrs 20 ^ 22 0t 100.0 95.7
ment screw was loose, a radiograph was taken to evaluate
*One p a t i e n t moved a n d was lost to follow-up.
t O n e p a t i e n t died.
the complete seating of the a b u t m e n t and crown (Fig. 4, B).
If nonworking contacts were noted, they where reduced by
occlusal adjustment. Patients were given oral hygiene and
socket was tapped. The implants were then placed, cover appointments for 6 months, and they also underwent an-
screws were inserted, and the flaps were closed. The sutures nual examinations. The number of implants placed be-
were removed in 7 days. tween two adjacent teeth and the number of implants ter-
Second-stage surgery was performed 4 to 5 months after minally placed in the arch were tabulated.
healing occurred in the mandible and 6 months after it oc- As part of the s t u d y the participating restorative dentists
curred in the maxilla. A periapical radiograph of the were surveyed to determine whether crowns had fractured
implant site was taken before second-stage surgery was or loosened. The frequency of screw loosening was also re-
done. The surgical site was anesthetized and flaps were re- corded.
flected, exposing the implant head and surrounding bone
RESULTS
(Fig, 3). T h e cover screws were removed, and either heal-
ing a b u t m e n t s or nonrotating a b u t m e n t cylinders were The results are based on placement of 24 implants in 22
placed onto the implant. The gingival tissues were apically patients. Two patients received two implants each. One
positioned and sutured with interrupted sutures. Periapi- patient lost a 5 x 6 m m implant after 6 months of function.
cal radiographs were taken to confirm the complete seating This implant was replaced with another 5 mm wide implant
of the a b u t m e n t on the implant. and has been functioning for 4 months. One patient died
Six to 8 weeks after the second-stage surgery was done, and one patient moved out of the city. The average time of
the restorative dentists made impressions and began fab- implant function was 24 months. T h e cumulative success
rication of the single-tooth implant crowns. All 24 implants rate after 1 year of function was 95.7 % (Table I).
were restored by seven dentists trained in restoring the Table II describes the number of implants placed in
implant system (Nobelpharma, Chicago, Ill.). The precise healed edentulous ridges or into extraction sockets. The
restorations were retained with screws, and the occlusal implant size and arch location are listed in Table III. Eigh-
relationships were developed to eliminate lateral and bal- teen implants were placed in the mandible, and six were
ancing interferences and to ensure only light contacts in placed in the maxilla. Table IV delineates the bone quality
centric occlusion (Fig. 4, A). Two weeks after crown inser- and quantity. Eleven implants were placed in alveolar
tion, the gold screws were retightened and the occlusion ridges with minimal bone resorption (type B). Nine im-
was reevaluated by the dentists. If the gold screw or abut- plants were placed in type 3 bone and indicated the pres-

J U L Y 1995 53
THE JOURNAL OF PROSTHETIC DENTISTRY BECKER AND BECKER

T a b l e III. Size and location of implants in millimeters

Position 10 x 3 . 7 5 m m * 13 • 3.75 m m 15 • 3 . 7 5 m m 10 • 4 m m 6 x 5 mm 8 • 5 mm Total

Maxilla 2 2 0 0 It 1 6
Mandible 3 11 3 1 0 0 18
Total 5 13 3 1 1 1 24
*Standard implant diameter is 3.75 m m wide.
t o n e 6 m m long x 5 m m wide implant was lost and replaced.

T a b l e IV. I m p l a n t placement according to bone quality T a b l e V. N u m b e r and frequency of screw loosening for
and q u a n t i t y as determined from preoperative 21 implants
radiographs
Loosened Loosened Loosened
Stable once twice three times
Quantity

Quality A B C D E Total Maxillary 4 1 0 1

1 2 1 0 0 0
2 0 3 3 0 0
3 2 5 2* 0 0
4 1 2 3 0 0
Total 5 11 8 0 0 24
*One implant was lost and replaced.
ence of a thin cortical plate with a compact trabecular pat-
tern.
All implants were restored on single-tooth nonrotating
a b u t m e n t s with gold cylinders. The number of implants
and frequency of loosening of the gold screws are listed in
Table V. Table V is based on information for 22 implants.
The gold screws in 13 implants (61.9 %) remained tight-
ened, and three gold screws (14.3%) became loose three
times. The a b u t m e n t screw fractured in one p a t i e n t and
was retrieved and then replaced. No implant fractures oc-
curred. Twenty implants were placed between two adjacent
teeth, and six implants were in terminal positions.
DISCUSSION
The results of this retrospective analysis represent the
first report of replacement of single molars with implant-
supported prostheses. The results indicate t h a t maxillary
and m a n d i b u l a r molars can be successfully (95.7%) re-
placed by single, threaded, endosseous implants. Laney et
al. s reported the results of t r e a t m e n t for single-tooth
replacements for bicuspids and anterior teeth. Ninety-five
patients were treated and followed-up, and at 3 years a
97.2% success rate was reported.
Parel* has cautioned against the use of one implant to
replace single molars. Replacement of a molar with a sin-
gle implant may present problems of force distribution and
stress. Rangert and Sullivan 5 suggest the use of 4 m m wide
implants with CeraOne a b u t m e n t s (Nobelpharma, Goth-
*Parel S. Personal communication, Nobelpharma Team Day.
Sidney, Australia, 1993.
Mandible 9 2 2 2
3 Total (%) 13 (61.9) 3 (14.2) 2 (9.5) 3 (14.3)
6
9
6
enburg, Sweden) ~for single-tooth implants. This implant is
reported to be 30% stronger t h a n the standard 3.75 m m
implant and m a y be more resistant to bending forces. 9
With one implant, there is a discrepancy between the
implant length and width and the size of the restored
crown. P l a c e m e n t of a crown t h a t extends beyond the long
axis of the implant could generate cantilevering forces on
the crown and implant. These forces could contribute to
screw loosening and eventual i m p l a n t fatigue. Ideally, two
implants should be used to replace a single molar; however,
a molar edentulous space is often bound by natural teeth,
which results in insufficient mesial-distal bone width for
placement of more than one implant. According to Wheel-
er 1~ the average mesial-distal width of a maxillary first
molar is 7.5 mm, whereas the average width of a mandib-
ular first molar is 8.5 mm. These dimensions provide
insufficient space for placement of more than one 3.75 m m
wide implant.
Several factors may account for the high success rate re-
ported in this study, namely bone quality, bone quantity
length of implants placed, and exclusion of patients with
bruxism habits. Twelve of the implants were placed at the
time of tooth extraction, thereby having the advantage of
a large q u a n t i t y of bone volume. Sixteen implants were ei-
ther 13 m m or 15 m m in length, and 16 implants were
placed in either type A or B bone quantity. Laney et al. s
placed 65 of the 95 implants in t y p e 2 or type 3 quality bone.
Most of the implants (78) in the Laney study were placed
in the maxillary arch and ranged from 13 to 18 m m in
length.
Patients with known bruxism or clenching habits were
not considered for single-tooth i m p l a n t replacement in this
group of patients. Parafunctional habits may be a risk fac-
tor related to implant fracture and screw loosening and
may create uncontrolled and excessive occlusal loading
forces.

54 VOLUME 74 NUMBER 1
BECKER AND BECKER
T h e r e s t o r a t i v e dentists were r e q u e s t e d to m i n i m i z e oc-
clusal contacts in centric occlusion. Occlusal tables were
narrow to reduce t h e c a n t i l e v e r effect of wide buccolingual
restorations.* Occlusal c o n t a c t for p a t i e n t s w i t h 5 • 6 m m
i m p l a n t s were m i n i m i z e d . T h e occlusion was e v a l u a t e d by
t h e restorative d e n t i s t 2 weeks after crown p l a c e m e n t and
at 6 m o n t h s and 1 year. M o s t of t h e i m p l a n t s were placed
b e t w e e n a d j a c e n t teeth. T h i s r e l a t i o n s h i p m a y be related
to t h e high success rate. T h e a d j a c e n t t e e t h m a y h a v e con-
t r i b u t e d to m i n i m i z a t i o n of excessive loading on t h e
i m p l a n t s and m a y have " p r o t e c t e d " t h e i m p l a n t s during
function:
J e m t et al.5 r e p o r t e d t h a t 26 % of gold retaining screws
b e c a m e loose d u r i n g the first year. L a n e y et al. 8 p r e s e n t e d
t h e 3-year follow-up results f r o m t h e s a m e study. A b u t -
m e n t screw loosening occurred in 10 (10.8 % ) of 92 p a t i e n t s
who received e i t h e r single-tooth i m p l a n t - s u p p o r t e d resto-
rations for bicuspids or incisors. T h e incidence of screw
loosening in this r e p o r t is greater t h a n t h a t in the previous
studies (38%). In this study, if gold screws b e c a m e loose
m o r e t h a n twice, t h e y were r e p l a c e d and the occlusion of
t h e r e s t o r a t i o n was readjusted. N o reports of crown frac-
t u r e s were made.
P l a c e m e n t of C e r a O n e restorations ( N o b e l p h a r m a ) m a y
h a v e r e d u c e d t h e incidence of screw loosening. T h e o r e t i -
cally, t h e C e r a O n e a b u t m e n t has a high p r e t e n s i o n abut-
m e n t screw that, w h e n p r o p e r l y t o r q u e d , will resist
unscrewing. S t u d i e s t h a t v a l i d a t e and d o c u m e n t t h e com-
plications with this type of r e s t o r a t i o n need to be per-
formed. Carlson and Carlsson 11 r e p o r t e d complications
f r o m 600 i m p l a n t - s u p p o r t e d prostheses (2709 implants)
p l a c e d b e t w e e n 1972 and 1991. C o m p l i c a t i o n s o c c u r r e d
least often in single-tooth r e p l a c e m e n t s .
CONCLUSION
W i t h i n t h e limits of this r e t r o s p e c t i v e study, replace-
m e n t of molars w i t h single i m p l a n t - s u p p o r t e d crowns were
successful. One i m p l a n t was lost (5 • 6 m m ) , and a 95.7%
*Lewis S. Personal communication. Gainesville, Florida, 1993.
JULY 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
survival rate resulted. Factors such as b o n e quality, quan-
tity, l e n g t h of i m p l a n t s , and m i n i m i z e d occlusal contacts
m a y have c o n t r i b u t e d to t h e favorable success rate. Pa-
t i e n t s with known p a r a f u n c t i o n a l h a b i t s were n o t included
in t h i s population. T h e m a i n c o m p l i c a t i o n was loosening of
gold retaining screws, which occurred in eight (38 % ) of the
21 i m p l a n t s and in s o m e cases m o r e t h a n once (Table V).
We thank Dr. Bo Rangert for his technical assistance in writing
this article.
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WILLIAMBECKER,DDS, MSD
801 N. WILMOT;B-2
TUCSON,AZ 85711
55