10.59987/ads/2013.3-4.263-268


Aim. A partial edentulous area was restored with a tooth to implant fixed partial denture and a rigid connection between the two elements. Maintenance recalls were performed over a 19-year period of observation on a yearly basis. 

Methods. The following parameters were collected during each examination over the entire period of observation: PD around the implant and natural tooth abutment, gingival index, modified gingival index, plaque index, modified plaque index, occlusal assessment, marginal bone loss. Radiographic assessment of peri-implant bone remodeling was performed in a retrospective way. The following reference points were assessed on each image: fixture-abutment junction, threads, first contact of the crestal bone with the implant on both mesial and distal side. This made possible, with the known values for implant diameter and length, to make linear measurements of remaining peri-implant bone measured from the mesial and distal marginal bone levels and the fixtureabutment junction. The amount of bone change over the baseline to a 19 years follow-up observation time was calculated for both the implant and the natural tooth. Results. Clinical parameters showed healthy values over the entire period of observation with slight isolated positive bleeding on probing. Bone remodeling values were constant over the entire period with slight higher values around the tooth. Peri-apical radiographs did not show any intrusion of the tooth. Conclusions. The present case report showed the complete functionality and stability of a tooth to implant rigidly connected FPD over a period of 19 years




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A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up
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                                                                                                                          Case report



                  A case report of a TPS dental implant rigidly
                  connected to a natural tooth: 19-year follow-up




                                                                                                                                       li
                                                                                   na
                  Alessandro Quaranta, DDS, PhD1                              Conclusions. The present case report showed the
                  Ottavia Poli, MD, DDS2                                      complete functionality and stability of a tooth to im-




                                                                                 io
                  Iole Vozza, DDS, PhD2                                       plant rigidly connected FPD over a period of 19
                                                                              years.

                  1 School of Dentistry, “Politecnica delle Marche” Univer-   Key words: dental implants, natural tooth, rigid




                                                                              az
                    sity, Ancona, Italy                                       connection, follow-up.
                  2 Department of Oral and Maxillo-facial Sciences,

                    “Sapienza” University of Rome, Italy
                                                                              Introduction




                                                                           rn
                  Corresponding Author:                                       The incorporation of natural teeth as abutments in im-
                  Alessandro Quaranta                                         plant-supported restorations is sometimes necessary to
                  School of Dentistry                                         reach chewing comfort. However, the survival rates of




                                                                        te
                  Politecnica delle Marche University                         both implants and reconstructions in combined tooth-
                  Via Tronto 10,                                              implant supported fixed partial dentures (FPDs) are
                  60020 Ancona, Italy                                         lower than those reported for solely implant supported
                  E-mail: alessandro.quaranta@univpm.it
                                                                     In       FPDs (1). In addition, the convenience of connecting
                                                                              tooth to implant is a very discussed issue since an im-
                                                                              plant does not feature the same anatomical and physio-
                  Summary                                                     logical aspects of a tooth. In fact, while the tooth is pro-
                                                                              vided with periodontal ligament that functions as an hy-
                                                            ni
                  Aim. A partial edentulous area was restored with a          draulic system, a dental implant does not feature any
                  tooth to implant fixed partial denture and a rigid          periodontal ligament and is directly connected with the
                  connection between the two elements. Maintenance            surrounding bone. Teeth with healthy periodontal liga-
                  recalls were performed over a 19-year period of ob-         ment show mobility of 50-200 μm upon displacement of
                                             o

                  servation on a yearly basis.                                the crown with a force of 01. N (2, 3) while dental im-
                  Methods. The following parameters were collect-             plants demonstrate values less than 10 μm (4). More-
                                         izi


                  ed during each examination over the entire period           over, tactile perception of natural tooth abutments was
                  of observation: PD around the implant and natural           shown to be significantly higher than that demonstrated
                  tooth abutment, gingival index, modified gingival           for implant abutments. Sensory feedback due to peri-
                  index, plaque index, modified plaque index, oc-             odontal mechanoreceptors located in the periodontal
                          Ed




                  clusal assessment, marginal bone loss. Radi-                ligament are extremely sensitive to external stimuli.
                  ographic assessment of peri-implant bone remod-             These receptors have thresholds of about 20 μm of
                  eling was performed in a retrospective way. The             thickness in between antagonistic teeth and 1-2 g upon
                  following reference points were assessed on each            tooth loading. After extraction of teeth the periodontal
                  image: fixture-abutment junction, threads, first            ligament and its receptors disappear.
                  contact of the crestal bone with the implant on             Following the placement of dental implants detection
               C




                  both mesial and distal side. This made possible,            thresholds are increased to at least 50-100 μm of
                  with the known values for implant diameter and              thickness and 50-100 g upon tooth loading. The un-
    CI




                  length, to make linear measurements of remain-              derlying mechanism of the so-called ‘bone-percep-
                  ing peri-implant bone measured from the mesial              tion’ phenomenon remains a matter of debate, but it
                  and distal marginal bone levels and the fixture-            is assumed that mechanoreceptors in the 4 peri-im-
                  abutment junction. The amount of bone change                plant bone and neighbouring periosteum may be acti-
                  over the baseline to a 19 years follow-up observa-          vated by implant loading (5). In order to compensate
                  tion time was calculated for both the implant and           the different intrusion behaviours of teeth and im-
©




                  the natural tooth.                                          plants in a tooth to implant FPD, a stress disposer
                  Results. Clinical parameters showed healthy values          has been suggested (6). In this experimental study it
                  over the entire period of observation with slight iso-      was noted that the value of resorption around the im-
                  lated positive bleeding on probing. Bone remodel-           plant rigidly attached with the natural tooth did not
                  ing values were constant over the entire period with        jeopardize implant integration. Additionally it was ob-
                  slight higher values around the tooth. Peri-apical ra-      served that the rigid connection is more favourable
                  diographs did not show any intrusion of the tooth.          than the connection with disposer because it is able

                  Annali di Stomatologia 2013; IV (3-4): 263-268                                                                      263
7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 264




                  A. Quaranta et al.


                  to attenuate the intrusion of natural tooth. Finally, in
                  this study it was recommended to design pontic as
                  short as possible to prevent the phenomenon of intru-
                  sion and more straight as possible to prevent lateral
                  displacement of the natural abutment. Other re-




                                                                                                                                          li
                  searchers have evaluated the biomechanical stress
                  of perimplant bone in tooth to implant FPDs (7). Spe-




                                                                                   na
                  cific factors that positively reduced the stress were
                  the rigid connection, the number of splinted teeth and
                  the direction of the prosthetic loading. This in vitro re-
                  search was performed using 3-D finite element analy-




                                                                                 io
                  sis. The three variables were compared to the value
                  of the stress on the bone and mobility of teeth in-
                  volved. The results showed that load direction and
                  tooth mobility were the main elements affecting stress




                                                                              az
                                                                               Figure 1. Baseline X-ray showing the absence of 2.8, 2.9
                  value on bone tissue. The occlusal stress as cause of        natural teeth.
                  teeth lateral movement in FPDs has been investigat-
                  ed in another study (8). This experiment was carried
                  out with the non-linear finite element analysis and          thetic elements. A gold ceramic crown was also




                                                                           rn
                  computed tomography. One-piece and two-piece im-             planned on tooth # 30. The patient adopted an antimi-
                  plants splinted to natural teeth were used and the           crobial prophylaxis with a mouthwash of 0.12% chlorex-
                  quality of periodontal support was varied. The analyti-      idine (Dentosan 0.12%, Pfiezer, New Brunswick, NJ,




                                                                        te
                  cal results showed as oblique load caused greater            USA) rinsing for 1 minute prior to surgery and three
                  stress on the bone tissue than axial stresses. One-          times a day for the following 10 days. Systemic antibi-
                  piece implant absorbed occlusal forces better than           otics were prescribed (Zimox ® 1gr, Pfiezer, New
                  two-piece one while the degree of periodontal support        Brunswick, NJ, USA; 3 gr for day; amoxicillin for 6 days
                  and the number of splinted teeth according to these
                                                                     In
                  authors slightly affected the transmission of stress on
                                                                               starting 1 hour before surgery). Local anesthesia was
                                                                               induced by infiltration with articaine/epinephrine (Eco-
                  the bone around FPDs (9). The purpose of the pre-            cain® 20 mg/ml, Molteni Dental, Italy). A full thickness,
                  sent study was to evaluate on a long follow-up time          crestal incision was made and the bone site exposed.
                  (19 years) the peri-implant bone remodeling, the peri-       The implant placement was performed following the in-
                                                        ni
                  odontal and peri-implant health and the success rate         structions of the implant manufacturer under abundant
                  of a combined tooth to implant FPD supported by a            saline solution irrigation. A TPS cylindrical hollow-bas-
                  plasma sprayed (TPS) implant rigidly splinted to a           ket design implant was inserted (ITI Bonefit®, Strau-
                  natural tooth abutment.                                      mann, Switzerland) (4.1 mm diameter x 12 mm length)
                                           o

                                                                               (Fig. 2). The patient was instructed to maintain a liquid
                                                                               or semiliquid diet for the first three days and then grad-
                                       izi


                  Materials and methods                                        ually return to a normal diet. Painkiller medications
                                                                               (Aulin®, nimesulide 100 mg, Roche, Italy) were pre-
                  Treatment plan, implant surgery                              scribed and adopted by patient when needed. A two-
                  and prosthetic restoration                                   stages surgery was adopted and the implant healed
                         Ed




                                                                               completely covered and uneventfully. The surgical un-
                  On January 1994 a 53 years old, healthy patient              covering of the implant was performed 4 months later
                  (G.L.R.), was visited in the Unit of Prosthodontics and      and an healing abutment was connected to the implant.
                  Implant Dentistry, School of Dentistry, “Sapienza” Uni-      Fifteen days after the suture removal an impression
                  versity of Rome. The patient reported as his chief com-      was taken and a temporary methacrylate resin FPD
                  plaint the need to restore a distal edentulous area in       connecting the implant and the tooth # 29 was deliv-
               C




                  the left lower jaw. The patient also reported severe hy-     ered. Five months following the implant placement a
                  persensitivity on tooth # 28. The clinical assessment        pick-up impression with polivinylsiloxane material (Op-
    CI




                  confirmed that teeth # 30 and 31 were missing and a          tosil ® and Xantopren ® , Bayer, Germany) was per-
                  deep gingival recession was observed on the buccal           formed. A single casting with a proper design to
                  aspect of tooth # 2.89 (A.D.A. Classification). No addi-     achieve a reduced occlusal surface and avoid exces-
                  tional dental treatments were required. Peri-apical radi-    sive deflecting stress was made. In order to prevent
                  ographs and clinical examination revealed optimal peri-      premature contacts on the implant occlusal surface and
                  odontal status on teeth # 28 and 29 and sufficient bone      consequent excessive stress to the abutment natural
©




                  to place standard dental implants in the area of teeth #     tooth a “group” occlusal model was made. In this type
                  30 and 31 (Fig. 1) Several treatment modalities were         of occlusal model, the residual teeth had the first oc-
                  proposed to the patient and because of financial rea-        clusal contact. A gold-ceramic FPD was finally deliv-
                  sons he opted for a tooth to implant FPD with the            ered and cemented. Although the patient was thor-
                  placement of a dental implant in position 31 while in-       oughly informed about the need of a strict periodontal
                  volving tooth 29 as mesial abutment. The FPD was             and implant maintenance therapy, he did not show up
                  planned with a rigid connection between the two pros-        at the first control visit that was planned 6 months after

                  264                                                                          Annali di Stomatologia 2013; IV (3-4): 263-268
7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 265




                  A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up




                                                                                                                                            li
                                                                                    na
                                                                                  io
                                                                               az
                  Figure 2. Periapical X-ray performed following implant
                  placement.                                                      Figure 3. The fixed partial is rigidly connected between the
                                                                                  natural tooth and the dental implant.

                  the prosthetic loading. The first supportive visit was car-




                                                                            rn
                  ried out after one year; when the temporary crown on
                  tooth # 28 was removed and a definitive gold alloy and
                  ceramic crown was fixed (Figs. 3, 4). After wards, a




                                                                         te
                  supportive therapy program was performed on a regu-
                  lar basis (every 4 to 6 months). The final clinical and ra-
                  diographic assessment was made on March 2012.       In
                  Clinical evaluation

                  Over the entire period of observation, the following pa-
                  rameters were collected during each examination:
                                                            ni
                  a. PD around the implant and natural tooth abutment;
                  b. gingival index (GI) and modified gingival index (mGI)        Figure 4. Periapical X-ray performed after fixed partial den-
                  (10, 11);                                                       ture and single crown delivery.
                  c. plaque index (PI) and modified plaque index (mPI)
                                             o

                  (12, 13);
                  d. occlusal assessment;                                         veloper under standardized conditions. The radi-
                                         izi


                  e. marginal bone loss.                                          ographs, set on a cephalometric unit in a dark room,
                  Probing depth was recorded at four aspects for both             were acquired and converted in digital images with a
                  the implant and the natural tooth (mesio and disto buc-         camera, and saved into a computer memory in TIFF
                  cal, buccal, lingual). Plaque and gingival indices for the      format. Later each image was processed with specific
                          Ed




                  natural tooth and modified plaque index (mPI) and gin-          software (Scion Image Beta 4.03 for Windows XP,
                  gival index (mGI) for the implant respectively were             Scion LTD USA) and displayed on a high resolution
                  used. The patient was instructed about proper daily oral        monitor. A computer assisted calibration was made on
                  hygiene procedures to perform 3 times a day through             mesial and distal side of each implant measuring the
                  the use of medium hardness dental brush, interdental            known distance between 2 threads. This calibration al-
                  brushes, and mouth washes.                                      lowed a correct measurement even if there was a
               C




                                                                                  slight deviation of the central beam and a consequent
                                                                                  magnification of the image. The following reference
    CI




                  Radiographic assessment                                         points were assessed on each image: fixture-abut-
                                                                                  ment junction, threads, first contact of the crestal bone
                  Radiographic assessment of peri-implant bone remod-             with the implant on both mesial and distal side. This
                  eling was performed in a retrospective way according            made possible, with the known values for implant di-
                  to two previously published papers (14, 15). Briefly,           ameter and length, to make linear measurements of
                  standardized peri-apical radiographs were taken using           remaining peri-implant bone measured from the
©




                  a Rinn XCP Ring positioner (Dentsply, Constanz, Ger-            mesial and distal marginal bone levels and the fixture-
                  many) and a beam guiding rod to allow parallelization           abutment junction. The linear measurements were
                  between the x-ray tube and the film and standardize             made by a trackball driven cursor on a 10 times mag-
                  all the radiographs. The radiographs were performed             nified digitized image of the implant on the monitor.
                  with a dental x-ray machine (Dentsply, Constanz, Ger-           The amount of bone change over the baseline to a 19
                  many) equipped with a long tube that operated at                years follow-up observation time was calculated for
                  70Kw/7.5mA and were developed in an automatic de-               both the implant and the natural tooth.

                  Annali di Stomatologia 2013; IV (3-4): 263-268                                                                           265
7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 266




                  A. Quaranta et al.


                  Results                                                         of the bridge. This may subject the entire framework
                                                                                  to flexion and significantly dislocate the tooth in the
                  All the clinical and radiographic parameters collected          apical direction. It is important to emphasize that, al-
                  over the entire period of follow-up are reported in             though in a different way, dental implants allow mod-
                  Table 1. The values of GI and PI for natural tooth and          ulation of functional occlusal loads similarly to teeth.




                                                                                                                                                  li
                  mGI and mPI for the implant showed a minimal in-                To better understand the behavior of perimplant
                  crease over time with a slight increase around the              bone, which is able of activating a continuous dynam-




                                                                                     na
                  natural tooth during the seventeenth year when the              ic remodeling in order to adapt to the variations of oc-
                  presence of bleeding on probing and calculus was                clusal loads, it has been introduced the concept of
                  observed. No peri-implant and periodontal pockets               "bone-perception" (17). Some researchers published
                  were observed during all the follow-up period. No               recommendations that should be considered during




                                                                                   io
                  prosthetic complications as discementation, abutment            the treatment planning of a tooth to implant rehabilita-
                  loosening, ceramic or metallic fracture were ob-                tion. Firstly, it is essential to assess the morphology
                  served. Peri-apical radiographs did not show any in-            of the natural abutment roots and it is better to use
                                                                                  curved or oval-section roots. Secondly, the connec-




                                                                                az
                  trusion, even minimal, of the tooth abutment (Fig. 5).
                  Bone remodeling around the two abutments is                     tion between anterior teeth and implants should be
                  showed in Table 2. Constant values over the time                avoided because anterior teeth have a greater hori-
                  with slight higher values around the tooth were ob-             zontal clinical mobility (90-108 μm) compared to im-
                                                                                  plants (18). From the clinical point of view, in order to




                                                                             rn
                  served.
                                                                                  ensure predictability of the tooth and implant support-
                                                                                  ed restoration, it is appropriate not to splint periodon-
                  Discussion and conclusion                                       tally compromised dental elements with high mobility




                                                                          te
                                                                                  since this causes a cantilever with excessive stress
                  Tooth to implant FPDs are characterized by the pres-            on implants with massive loss of peri-implant bone
                  ence of supporting elements (teeth and implants) that           tissue as final result. Some Authors suggested the
                  feature a different viscoelastic deformation. This may          use of rigid connection to avoid the intrusion of teeth
                                                                       In
                  determine tooth intrusion and the possibility of lateral        in tooth to implant FPDS (19). Other Authors re-
                                                                                  viewed the incidence of intrusion in tooth-implant
                  movement followed by a fast viscoelastic return. Im-
                  plants have very reduced movements compared to                  connection and concluded that rigid connections
                  natural teeth. For these reasons, tooth to implant              seem to produce the greatest stress on the natural
                  FPDs should be planned and made after a very care-              tooth, periodontal ligament and perimplant bone tis-
                                                          ni
                  ful evaluation. In order to correctly select the natural        sue while the non-rigid connections reduce stress on
                  abutment the following parameters should be consid-             the bone while increasing it on the prosthetic restora-
                  ered: periodontal status and bone support around the            tion. These Authors observed that FPDs with rigid
                  natural tooth. Teeth with clinical mobility should not          connection had an higher success rate than non-rigid
                                           o


                  be used as prosthetic abutments (16). The tooth to              one (20). Another study carried out on 876 implants
                  implant distance is another key factor. An increased            in 244 partially edentulous patients rehabilitated with
                                       izi


                  tooth to implant distance may increase shock and                fixed prostheses anchored on implants rigidly con-
                  cause peri-implant bone remodeling (17). Moreover,              nected to the natural elements showed as after 15
                  the presence of a long intermediate pontic between              years of functioning just one single implant failed
                  the implant and the tooth and any axial force applied           while all the remaining implants did not show any
                         Ed




                  to the restoration may determine a bending moment               functional or stability loss (21). Similar results were


                  Table I. Clinical parameters during 19-years follow-up.

                  Follow-up   IPD      IPD       IPD       IPD       mPI    mGI     TPD       TPD         TPD         TPD          PI       GI
               C




                  period      mesio    facial    disto     lingual                  mesio     facial      disto       lingual
                              facial             facial                             facial                facial
    CI




                  Baseline    NA       NA        NA        NA        NA     NA      NA        NA          NA          NA           NA       NA
                  1 year      2.5      2.0       2.5       2.5       0      0       2.0       1.5         2.0         2.0          0        0
                  3 years     2.5      2.0       2.0       2.5       0      0       2.0       1.5         2.0         2.0          0        0
                  5 years     3.0      2.0       2.5       3.0       0      0       2.0       2.0         2.5         2.0          0        0
                  7 years     3.0      2.0       2.5       3.0       1      0       2.0       2.0         2.5         2.0          0        0
                  9 years     3.5      3.0       3.0       3.0       1      1       2.5       2.0         2.5         2.5          1        1
©




                  11 years    3.5      3.0       3.0       3.0       1      1       2.5       2.0         3.0         2.5          1        1
                  13 years    3.5      3.0       3.5       3.0       1      1       2.5       2.5         3.0         3.0          1        1
                  15 years    3.5      3.0       3.5       3.5       1      1       2.5       2.5         3.0         3.0          1        2
                  17 years    4        3.0       4.0       3.5       2      1       3.0       2.5         3.0         3.0          2        2
                  19 years    4        3.0       4.0       4.0       2      2       3.0       2.5         3.5         4.0          2        2
                  Mean        3.3      2.6       3.05      3.01      0.9    0.7     2.4       2.1         2.7         2.6          0.8      0.9

                  NA: Not Assessed

                  266                                                                               Annali di Stomatologia 2013; IV (3-4): 263-268
7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 267




                  A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up


                                                                                                       Figure 5. Periapical X-rays made dur-
                                                                                                       ing the maintenance therapy per-
                                                                                                       formed on a two year basis.




                                                                                                                                          li
                                                                                    na
                                                                                  io
                                                                               az
                                                                            rn
                                                                         te
                                                                      In
                                             o                 ni
                                         izi
                          Ed




                  published in a review in which a total of 25 papers             limits of the present case-report and we do think that
                  were included. The Authors concluded that the use of            longitudinal studies about the success and survival
                  rigid connectors produce clinical results more favor-           rates of tooth to implant restorations are urgently
                  able compared to interlock or to heat sinks of the oc-          needed. However, in the present case report it was
                  clusal load with evident predictability in the long term        possible to observe the complete functionality and
               C




                  and reducing severe biological and prosthetic compli-           stability of a tooth to implant rigidly connected FPD
                  cations as intrusion of natural tooth abutment (22).            over a period of 19 years. This paper described the
                  The TPS screw is a commercially pure titanium im-               case of a fixed tooth to implant partial denture that
    CI




                  plant with a plasma-sprayed surface that was origi-             has been observed for 19 years. Although a case re-
                  nally described by Ledermann (23). In recent years              port manuscript does not feature the highest level of
                  most of dental implant manufacturers do not produce             scientific evidence, the present paper describes the
                  TPS implants anymore. As a matter of fact, these sur-           successful restoration of an edentulous area with a
                  faces were replaced by sandblasted and etched ones              fixed tooth to implant rehabilitation. The long term
©




                  (SLA) because it has been shown that medium rough               success of this case was possible because a very
                  surfaces may increase the bone-implant contact                  careful treatment planning has been developed. In
                  (BIC) in both the early (3 months from healing) and             fact, evaluation of the root morphology of the natural
                  late (12 months) stages of osseointegration process             tooth abutment, the adoption of a rigid connection
                  (24). However, different studies did not register any           and the design of the pontic are the main key factors
                  differences in bone covering between the TPS and                for the long term successful restoration of this type of
                  SLA surfaces (25). We are, of course, aware of the              implant prosthetic rehabilitation.


                  Annali di stomatologia 2013; IV (3-4): 0-0                                                                            267
7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 268




                  A. Quaranta et al.


                  Table II. Peri-implant bone remodeling during 19-years follow-up.

                  Follow-up                                                           BIO-OS- TPS IMPLANT                             NATURAL TOOTH
                  Baseline                                                            0                                               0
                  1st Year following Prosthetic Loading                               0.29                                            0.40




                                                                                                                                                              li
                  3rd Year following Prosthetic Loading                               0.31                                            0.41




                                                                                             na
                  5th Year following Prosthetic Loading                               0.21                                            0.45
                  7th Year following Prosthetic Loading                               0.18                                            0.47
                  9th Year following Prosthetic Loading                               0.29                                            0.48
                  11th Year following Prosthetic Loading                              0.31                                            0.46




                                                                                           io
                  13th Year following Prosthetic Loading                              0.30                                            0.49
                  15th Year following Prosthetic Loading                              0.21                                            0.47




                                                                                        az
                  17th Year following Prosthetic Loading                              0.30                                            0.48
                  19th Year following Prosthetic Loading                              0.20                                            0.45
                  Total mm                                                            2.6                                             3.10




                                                                                     rn
                  References                                                                 13. Danza M, Tortora P, Quaranta A, et al. Randomised study
                                                                                                 for the 1-year crestal bone maintenance around modified di-




                                                                                  te
                   1. Lang NP, Pjetursson BE, Tan K, Brägger U, Egger M, Zwahlen                 ameter implants with different loading protocols: a radiographic
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                      FPDs. Clin Oral Implants Res 2004; 15:643-53.
                   2. Muhleman HR. Die physiologische und pathologische Zahn-
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                                                                                             15. Lulic M, Brägger U, Lang NP, et al. Ante's (1926) law revisit-
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                                                                                                 ed: a systematic review on survival rates and complications of
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                      tooth mobility. Oral Surgery 1951; 4:1220-1223.
                                                               ni
                                                                                             16. Baron M, Haas R, Baron W, et al. Peri-implant bone loss as
                   4. Cohen SR, Orenstein JH. The use of attachments in com-
                                                                                                 a function of tooth-implant distance. Int J Prosthodont
                      bination implant and natural tooth ﬁxed partial dentures: a tech-
                                                                                                 2005; 18:427-33.
                      nical report. Int J Oral Maxillofac Implants 1994; 9:230-234.
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