The completely edentulous maxilla remains a challenge in implant dentistry. Conventional two-stage surgical techniques require two independent invasive surgeries separated by a 5-6-month healing period. In addition, an increased risk of trauma to the implant-bone interface may be caused by a removable transitional complete denture during the interim submerged period, which can compromise implant success or increase crestal bone loss around the implants during initial bone healing. The purpose of this clinical trial was to evaluate the safety and efficacy of immediately loading a fixed implant-supported prosthesis without bone augmentation in moderately to severely resorbed, completely edentulous maxillae. Over a 41-month period, 783 titanium implants (627 laterally inserted disk implants, with or without 156 axially inserted Structure implants) were placed in 72 consecutive patients with completely edentulous maxillae using an immediate loading protocol. After 6 months of function, the fixed restorations were removed and each implant status was verified using radiographs, Periotest evaluations, clinical osseointegration criteria, and torque testing at 20 N-cm. Six months postoperatively, 98% of the implants were radiologically and clinically osseointegrated. Fifty-six gold screws (7%) required retightening after 10 months, but no screw fractures occurred during this study period. The postrestorative follow-up of these patients ranged from 6 to 48 months. As of this report, all of the fixed prostheses remain functional, and no additional implants have been lost. This clinical trial demonstrates that immediate loading of nonsubmerged, laterally inserted disk-design implants may provide adequate primary anchorage and longterm osseointegration in completely edentulous maxillae. The initial multicortical anchorage afforded by the disk-design implant in this study, coupled with biomechanical splinting of the disks (sometimes with more traditional root-form design implants) using a rigid prosthesis, permits a one-stage predictable implant procedure offering rapid restoration of patients to masticatory function.

Fragments of cancellous and cortical bone from human maxilla and mandible were cultured by the explant technique. Cells isolated by trypsinization of primary cultures were characterized as osteoblasts on the basis of intracellular alkaline phosphatase activity, the constituents of the extracellular matrix, and response to human parathormone (PTH). In culture, the osteoblasts often gave rise to superposed clumps of large cells whose cytoplasm contained endoplasmic reticulum, numerous mitochondria, vacuoles, and a dense network of intermediate filaments, often at the level of the plasma membrane. In the presence of vitamin C and 1,25-dihydroxyvitamin D3, the osteoblasts produced an extracellular matrix composed of collagen type I and various non-collagenous proteins, including osteocalcin. Biochemical test results were comparable to those reported for osteoblasts of other origins (rat calvaria, human iliac crest), and namely elevated intracellular alkaline phosphatase activity and cAMP accumulation in response to stimulation by human PTH (1-34). Osteoblasts isolated in this manner were cultured in the presence of pure titanium disks to determine the effects of exposure to this metal. Electron microscopy revealed few significant differences in cell growth and specific enzyme activity compared to control osteoblasts grown on plastic dishes, reflecting the excellent biologic and biochemical relationship between the osteoblasts and pure titanium. This experimental system thus appears suitable for biocompatibility studies, and in particular, evaluation of dental implants.

Rehabilitation of severely atrophic jaws is facilitated when basal disk implants are used after activation of the future bony implant bed with a purpose-designed instrument (Osteotensor) 45 to 90 days before implant surgery. Fabrication of a highly rigid, screw-secured fixed prosthesis that acts as an external orthopedic fixator permits immediate functional loading. This protocol also represents a second chance for patients who have experienced complete implant loss and/or bone graft failure.

The authors describe a case of squamous cell carcinoma of the oral cavity managed by ablative surgery, mandibular reconstruction with a fibula free flap, and implant placement during the same session. Immediate functional implant loading, respecting the principles of basal implantology, was performed 48 hours later using a highly rigid, screw-secured fixed prosthesis that served as an external fixator for the implants and grafted bone. Implant loading before external beam radiotherapy improves flap stability, bone consolidation, and quality of life. Functional and esthetic outcomes were evaluated 2 years after radiotherapy was completed.

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