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P h y s i o l o g i c a l b o n e r e m o d e l i n g o n O s s t e m i m p l a n t s Table 1 Type Subtype Implant protocol and location Conventional preparation Adapted preparation technique Narrow preparation Halfway preparation Osteotome technique Healed site Freehand, maxilla required immediate loading, post-extractive implants, poor bone quality Guided surgery, maxilla, immediate loading Maxilla, needed to perform bone spreading Table 1 Drilling protocols. remnant was immediately removed using an air–water syringe with the patient’s mouth closed. After 5 min of setting, the patient was clinically and radiographically inspected. Other- wise, CAD/CAM screw-retained restorations were delivered at implant or abutment level. The final abutments and screw-retained frameworks were screwed on at the torque setting recom- mended by the manufacturer. The patients that received cemented resto- rations were inspected again after three to five days. All of the patients were then enrolled in a standard implant recall program. Oral hygiene maintenance was checked and radiographs were taken early after final prosthesis delivery. Occlu- sion was checked at every appointment. An expla natory case is illustrated in Figures 1 to 10. O u t c o m e s Primary outcome measures were the success rates of the implants and prostheses, evaluated by an independent assessor. An implant was con- sidered a failure if it presented any mobility, as- sessed by tapping or rocking the implant head with the metallic handles of two instruments, progressive MBL or infection, and any mechanical complications rendering the implant unusable, although still mechanically stable in the bone. A prosthesis was considered a failure if it needed to be replaced with another prosthesis. Secondary outcomes were as follows: – Complications: Any biological (pain, swelling, suppuration, etc.) and/or mechanical (screw loosening, fracture of the framework and/or the veneering material, etc.) complications were evaluated and treated by the same surgeon. – Marginal bone levels: The levels were assessed using intraoral digital periapical radiographs (Digora Optime, SOREDEX, Tuusula, Finland; photostimulable phosphor imaging plate, size 2, pixel size of 30 μm, resolution of 17 lp/mm) at the subsequent follow-ups: implant place- ment (baseline), second-stage surgery, defin- itive crown delivery and one year after loading. Intraoral radiographs were taken with the paralleling technique by means of a periapical radiograph with a commercially available film holder (Rinn XCP, Dentsply Rinn, Elgin, Ill., U.S.). The radiographs were accepted or rejec- ted for evaluation based on the clarity of the implant threads. All readable radiographs were uploaded to an image analysis software package (DfW 2.8, SOREDEX) that was cali- brated using the known length or diameter of the dental implants and displayed on a 24 in. LCD screen (iMac, Apple, Calif., U.S.) and eval- uated under standardized conditions (ISO 12646:2004). The marginal bone levels were determined from linear measurements per- formed by an independent calibrated exam iner on each periapical radiograph, from the mesial and distal margin of the implant neck to the most coronal point where the bone appeared to be in contact with the implant. – Insertion torque. This was recorded at implant placement by the same surgeon (MT) using the iChiropro surgical unit (Bien-Air, Bienne, Switzerland). – Implant stability quotient (ISQ): The measure- ments were performed at implant placement and at the six-month follow-up by the surgeon (MT) using resonance frequency analysis (Osstell Mentor device, Osstell, Gothenburg, Sweden). – Residual alveolar bone quality: This was assessed during surgery by the same surgeon (MT) and classified according to the Lekholm and Zarb classification. Journal of Oral Science & Rehabilitation Volume 3 | Issue 1/2017 71