Immediate loading

IMMEDIATE LOADING
CONCEPT IN
IMPLANTOLOGY
Dr. Anuja Gunjal
MDS II
16/03/18
1

Content
 Introduction
 Rationale of immediate loading
 Factors decreasing risk of immediate loading
 Immediate loading procedure for completely edentulous patients
 Immediate loading of implants with overdenture prosthesis
 Immediate loading procedure for partially edentulous patients
2

 Single tooth non-functional immediate restoration procedures
 Risk of immediate occlusal loading
 Summary
 Review of literature
 References
3

Introduction
 treatment goal in implant dentistry - predictable formation of a direct
bone-implant interface
 reasons cited by Brånemark et al for the submerged, countersunk
surgical approach to implant placement were
 to reduce and minimize the risk of bacterial infection,
 to prevent apical migration of the oral epithelium along the body
of the implant,
 to reduce and minimize the risk of early implant loading during
bone remodeling.
4

 several authors have reported that root form implants may
osseointegrate, even though they reside above the bone and through
the soft tissue during early bone remodeling
 surgical approach has been called a one-stage or nonsubmerged
implant procedure and eliminates the second-stage implant
uncover surgery.
 Immediate loading of a dental implant not only includes a
nonsubmerged, one-stage surgery but also actually loads the
implant with a provisional restoration at the same appointment or
shortly thereafter
5

Terminology
 The immediate occlusal-loading protocol is an implant supported
temporary or definitive restoration in occlusal contact within 2 weeks
of the implant insertion.
 Early occlusal loading refers to an implant-supported restoration in
occlusion between 2 weeks and 3 months after implant placement.
 Delayed or staged occlusal loading refers to an implant prosthesis
with an occlusal load after more than 3 months after implant insertion.
6

 Nonfunctional immediate restoration describes an implant
prosthesis with no direct occlusal load within 2 weeks of implant
insertion and is primarily considered in partially edentulous patients.
 Nonfunctional early restoration describes a restoration in a
partially edentulous patient delivered between 2 weeks and 3
months after the implant insertion.
7

RATIONALE FOR IMMEDIATE LOADING
 The immediate load concept eliminates the second stage surgery and
thus the resultant discomfort and inconvenience of , and the time
required by the surgery and suture removal process
 In addition, splinted implants could decrease the risk of overload to
each implant because of greater surface area and improved
biomechanical distribution
8

 The patient does not need to wear a removable restoration during
initial bone healing which greatly increases comfort, function, speech
and stability and enhances certain psychological factors during
transitional period.
 Over the last few years several authors have reported on immediate
loading in completely edentulous patients, with 95-100% success rate

a) SURGICAL TRAUMA
 Surgical process of implant insertions causes regional accelerated
phenomenon of bone repair around the implant interface.
 As a consequence of surgical placement, lamellar bone in preparation
site becomes woven bone of repair next to the implants.

 Woven bone forms at a rate upto 60 MICRONS PER DAY as
compared to lamellar bone which forms at rate upto 10
MICRONS PER DAY.
 At 16 weeks ( 4 months) the surrounding bone is still only
70% mineralized and exhibits woven bone as a component.

 The immediate implant loading concept challenges the conventional
healing time of 3 to 6 months of no loading before the restoration of the
implant.
 Often the risks of this procedure are perceived to be during the first
week after the implant insertion surgery.
 In reality, the bone in the macroscopic thread design is stronger on the
day of the implant placement compared with the 3 months later, since
there is more mature lamellar bone in the threads in the implant

 Early cellular repair is triggered by the surgical trauma and begins to
form an increased vascularization and repair process to the injured
bone.
 Woven bone formation may start at 2nd week after implant placement.
And the bone implant interface is at highest risk of overload failure at
3-5 week after implant placement.

 Reduction of surgical trauma in an effective method to have more vital
bone at the implant- bone interface ( Roberts1984, found 1 mm wide
zone of devitalized bone at interface) which reduces the risk of
immediate occlusal overload .
The main causes of surgical trauma are THERMAL and
MECHANICAL TRAUMA.
 Temperature next drill --- 38’C to more than 41’C
37’C base line and required
34 to 58 seconds to return
to baseline

 Drills with internal cooled system drill at higher temperature than those
with external irrigation.
 Drill rpm of 2500 produce less heat than 2000 rpm, while 1250 rpm
produced created most heat.
 Factors related to heat production are-
- amount of bone prepared
- drill sharpness
- depth of osteotomy
- variation of cortical thickness
- temperature and solution chemistry of irrigatant.

 The implant bone interface will have a larger zone of repair when the
implant is significantly compressed against the bone. Eg a self tapping
implant may cause greater bone remodeling compared with a bone tap
and implant placement technique.
 The implant should not be mobile at placement but excessive stress
should be avoided. For immediate loading implant placement within the
bone is limited to 45-60 Ncm

 Reverse torque test of 20 Ncm is used to evaluate the quality of bone
and interface fixation ( Sullivan 1996, Palti 2002).
If implant does not unthread at 20Ncm the resistance indicates that the
bone is of sufficient density to consider immediate loading.

b) BONE LOADING TRAUMA
 Once the bone is loaded by an implant prosthesis, the interface begins to
remodel again but the trigger now is STRAIN TRANSFER CAUSED BY
OCCLUSAL FUNCTION, rather than the trauma of implant placement.
 The woven bone thus formed may be called REACTIVE WOVEN BONE
, and the remodeling is called BONE TURNOVER.
 INTERFACE REMODELING RATE is the period of time for the bone at
implant interface to be replaced with new bone

 When the surgical trauma is too great or the mechanical trauma
situation is too severe, fibrous tissue may form rather bone, resulting in
clinical mobility.

FACTORS WHICH REDUCE RISK IN IMMEDIATE LOADING
PROTOCOL
1. BONE MICROSTRAIN
2. INCREASED SURFACE AREA
a) implant no.
b) implant size
c) implant body design
d) implant surface condition

3. DECREASED FORCE CONDITION
a) patient conditions
b) occlusal load direction
c) implant position
4. MECHANICAL PROPERTIES OF THE BONE

1. BONE MICROSTRAIN
Microstrain levels 100 times less than ultimate strength of bone may trigger
a cellular response. The ideal microstrain for bone is called
PHYSIOLOGICAL / ADAPTED ZONE - 50 TO 1500 microstrain and is
IDEAL LOAD BEARING ZONE

 One goal for an immediate loaded implant/ prosthesis system is to
decrease the risk of occlusal overload and its resultant increase in the
remodeling rate of bone.
 Under these conditions the surgical regional acceleratory phenomenon
may replace the bone interface without the additional risk of
biomechanical overload.

 If occlusal overload is not managed it will result in 1500 – 3000
microstrains that is mild overload zone causing trauma from overload.
 And will hamper the bone remodeling from surgical trauma, leading to
bone being less mineralized, less organized, weaker, and lower mod. of
elasticity.

2. INCREASED IMPLANT SURFACE AREA
a) IMPLANT NUMBER
When immediate loading protocol is used increased no. of implants are of
special importance because-
- It increases the surface area
- Increases the success rate even if one or two implants fail.
- Increases the retention of prosthesis
- Reduces the no. of pontics

 Often more implants are used in maxilla ( 8-10) than mandible (5-9),
which compensates for less dense bone and increased directions of
force found in upper arch.

b) IMPLANT SIZE
 Implant height is not an effective method to decrease stress, as far as
non-immediate implant loading protocol is considered, because it
doesn't address the problem in functional surface area region of bone-
implant interface, which is better related to implant width and design
 However because the implant is loaded before the establishment of
histologic interface and implant height is important for initial stability of
implant , IMPLANT HEIGHT IS MORE RELEVANT FOR IMMEDIATE
IMPLANT LOADING applications, especially in softer bones.

c) IMPLANT BODY DESIGN
The implant design should be more specific for immediate loading
because the bone has not had time to grow into recess or undercuts ,
attach to surface conditions before application of occlusal load.

Threaded implants allow bone to be present in depth of threads from the
day of insertion as compared to press fit design.

Greater the no. of threads, greater the functional surface area at
the time of immediate load

Greater the thread depth greater the surface area for immediate
load applications

 Functional surface area of an implant may affect the remodeling
rate of the bone during loading.
 An implant with less surface area have more remodeling rate, and
higher the remodeling rate, weaker the bone interface.

Square threads show better resistance to torque than
V shaped or reverse buttress design.

TAPERED DESIGN PRESENTS DISADVANTAGES FOR
IMMEDIATE LOADING APPLICATIONS
- They do not engage the bone physically as nicely as parallel ,
reducing the initial fixation.
- Along with this they have lesser total surface area, lesser thread
depth and no.
- They engages lateral cortical plate to lesser extent at the apical
region, and any de-rotation may lead to lesser fixation.

d) IMPLANT SURFACE CONDITION
 Surface conditions the rate if the bone contact, lamellar bone
formation, and the % of bone contact.
 The surface condition that allows bone formation in greatest
percentage, higher bone implant contact % with higher mineralization
rate, and fastest lamellar bone formation would be of benefit to
immediate loading protocol.

 Hydroxypatite (HA) has been shown to have these properties
along with reduced rate of bone remodeling during occlusal
loading.
 Hence if bone is not of ideal density (D4) for immediate
loading HA may decrease risk of overload.

3. DECREASED FORCE CONDITION
The dentist should reduce the factors that magnify the noxious
effects of force factors in terms of magnitude, duration ,type and
direction
a) PATIENT FACTORS
Force factors increase the risk for immediate loading.
Parafunction such as bruxism and clenching not only leads to
increased force but also the duration , more horizontally directed
forces.

Parafunction also increases the risk of abutment screw loosening,
unretained restoration, and restoration fracture , jeopardizing the load
distribution on immediate loaded implants

b) OCCLUSAL LOAD DIRECTION
Axial load maintains the lamellar bone and has lower remodeling rate than
horizontally directed loads.
Therefore cantilevers in posterior regions should be avoided in immediate
loaded implant’s transitional restorations

C) IMPLANT POSITION
 Cross arch splinting is an effective design to reduce stress to entire
implant support system, especially in completely edentulous patients
rehabilitated with immediate loading.
 Mandible may be divided into three sections :
canine to canine area, and the bilateral posterior sections.

 In mandible cross splinting has been an issue of debate because of
flexion and torsion distal to mental foramen, but clinical reports
show that acrylic resin transitional prosthesis can solve this
problem.
 However final restoration must be made in three sections described.

 Maxilla require more implant support than mandible because or less
dense bone and direction of force outside of the arch in all eccentric
movements.
 Maxilla is divided in to 4 or 5 sections depending on force conditions
and arch shape.
 Minimum four sections are bilateral canine regions and bilateral
posterior regions.

 When force factors are high , the incisor region is included
along with the standard four sections.
 At least one implant should be inserted into each maxillary
section and splinted together during the immediate loading
applications.

Immediate loading procedure for completely
edentulous patients
 Two different approaches:-
 The first approach involves placing several more implants than the usual
treatment plan for a conventional healing period.
 Selected implants around the arch (three or more) then are loaded
immediately with a transitional prosthesis.
 Enough implants are left submerged for a regular healing period to allow
delivery of a fixed prosthesis, even if all immediately loaded implants fail.
45

 The other protocol for immediate occlusal loading of dental implants
initially loads all of the implants inserted.
 The implants are splinted together, which decreases the stresses
on all the developing interfaces and increases the stability,
retention, and strength of the transitional prosthesis during the initial
healing phase.
 Often additional implants also are used with this technique
compared with the traditional healing method
46

For fixed prostheses
 two different options are available for immediate occlusal loading for the
completely edentulous patient desiring a fixed prosthesis
 The first option loads the implants the same day as the surgery.
 The second option is to place the implants and make an impression at
surgery.
 Then at the suture removal appointment 7 to 12 days later, the dentist
delivers the transitional fixed prosthesis.
47

48
Option 1
A, A preoperative panoramic radiograph of eight failing mandibular
teeth. B, An intraoral view of the eight failing teeth in the mandible

49
C, The eight mandibular teeth are extracted. D, A rongeur is used after the
tissues are reflected to perform an osteoplasty to the anterior mandible

50
E. The reflected mandibular arch after osteoplasty. F, A surgical template
indexed to the upper teeth to evaluate the position of six guide pins in the initial
implant osteotomies.

51
G, BioHorizons Maestro implants (BioHorizons; Birmingham, Ala.), which are 15 mm long and
4 mm in diameter, are inserted between the foramens. Longer implants are used when
possible for immediate occlusal loading. H, An implant is positioned over each foramen to
increase the number of implants, increase the anterioposterior (A-P) distance, and decrease
the cantilever length of the final prosthesis.

52
I, The completed surgery demonstrates seven BioHorizons implants: five
between the mental foramens and two above the foramens. J, A torque wrench
is used to tighten the abutment screws to 30 N-cm to decrease abutment screw
loosening during the initial loading period.

53
K, A light-cured material (e.g., Triad, Dentsply) is used for the transitional restoration to eliminate
acrylic monomer contact on the bone and decrease restorative material shrinkage during setting.
L, An acellular dermal matrix (AlloDerm; LifeCell, Branchburg, N.J.) is used around the implants
to act as a barrier membrane for the extraction sites and to develop a zone of nonmobile tissue
around the implants.

54
M, A panoramic radiograph is obtained to evaluate implant position at the
conclusion of the surgery. N, After 4 months the immediate-loaded transitional
prosthesis is removed and the implants evaluated.

55
O, A full-arch fixed, porcelain-metal cemented prosthesis is delivered. P, A
maxillary complete denture opposes the mandibular fixed prosthesis.

Option 2
56
On day of surgery
Indirect two-piece
impression transfer
copings
Custom impression
tray

57
Impression of implant with
customized impression tray Addition silicone impression
Impression transfer engaged in
implant analog, reinserted into
impression

58
customized tray mounted to the
opposing arch
Master cast
Mounted cast with implant
analog and abutments

59
Transitional restoration
delivered at the suture
removal appointment
Within 2 weeks after surgeryTransitional restoration on
mounted cast

Diet
 diet of the patient should be limited to only soft foods during the
immediate-loading process
 Pasta and fish are acceptable, whereas hard crust of bread, meat, and
raw vegetables or fruits are contraindicated.
 the prosthesis and diet are similar to that for the first transitional
restoration delivered in a progressive bone-loading approach
60

Guidelines for Immediate Loading
 to reduce stress and reduce microstrain at the developing interface.
 Surface Area Factors:-
1. Implant number: Eight splinted implants or more -edentulous
maxillary arch and six splinted implants mandible more implants if
very soft bone (D4) is present or if force factors are greater or more for
the
2. Implant size: Larger-diameter implants are required in the posterior
regions of the mouth
61

3. Implant design
 High surface area implants
 Compressive versus shear loads
4. Implant surface condition:
 HA-coated implants in poor bone density types
 Rough versus smooth or machine surface condition implants in good
bone density situations
62

Force Factors
1. Patient conditions:
 Parafunction, crown height, and muscular dynamics require more
implant surface area.
 Severe parafunction may be a contraindication
2. Implant position:
 anterior implants should be at least in the bilateral canine position
and posterior implants in the first- to second-molar position for the
largest anteroposterior (A-P) dimension.
 When forces are greater, the dentist should insert an additional
implant between the canines.
63

 In the mandible the largest A-P dimension possible should be used.
 At least three implants, one in the anterior and one in each posterior
region, are necessary
3. Occlusal load direction: Narrow occlusal tables and no posterior offset
loads on the transitional prosthesis. Long-axis loads to the implant bodies
whenever possible. No posterior cantilevers should exist on transitional
64

Immediate loading of implants with
overdenture prosthesis
 The treatment plan for implant number and position for implant
overdentures that are completely implant supported should be similar to a
fixed restoration.
 The immediately loaded overdenture procedure is similar to the second
option with a fixed restoration.
65

 implant body impression at the initial surgery is made.
 The position of the denture and teeth and the contours of the
overdentures are important to know before fabrication of the bar and
attachments that will connect the implants
66

67
A, A panoramic radiograph of a failing mandibular implant overdenture. The
patient’s leftmost posterior implant has lost more than 50% of the surrounding
bone. The patient also desires more support and stability of the overdenture. B,
A press-form acrylic template is made over the patient’s existing denture. C,
The press-form acrylic template replicates the teeth and contours of the
restoration

68
D, The press form is positioned over the denture, and a bite registration
is made with the opposing arch at the ideal vertical occlusal dimension.
E, The maxillary denture, mandibular overdenture, and press-form
acrylic template are removed from the mouth.

69
F, The press-form template is now a customized impression tray that one may use
as a surgical guide for the implants and an impression tray for the overdenture
bar.
G, The tissue is reflected to allow evaluation of the implant on the far right.

70
H, The implant on the far right was removed, along with the fibrous tissue.
The remaining two implants are prepared for a cemented bar.
I, Three additional implants are positioned around the original two implants.
The abutments are prepared for a cemented bar.

71
J, The customized impression tray is positioned with the maxillary denture. The tray
is used as a surgical guide and an impression tray.
K, A final impression is made of the implant abutments at the approximate vertical
dimension of occlusion.

72
L, The customized impression tray records the implant positions relative to the
final contours of the overdenture prosthesis.
M, An acellular dermal graft is prepared with a tissue punch

73
N, The membrane is positioned over the implants and tacked into position.
O, The membrane is lifted over the failed implant site, and autologous bone is
positioned over the implant. The AlloDerm may be used as a barrier membrane for
bone regeneration.

Immediate loading procedure for
partially edentulous patients
 The immediate-load concept also may be used in the partially
edentulous patient, including single-tooth applications.
 Rather than immediate loading of the implant, most reports
suggest immediate restorations rather than full occlusal loading.
76

 Because the patient most often has enough remaining teeth in
contact to function, the transitional restoration is primarily for
esthetics, and the implant prosthesis is completely out of
occlusion.
 Therefore a nonfunctional immediate teeth (N-FIT) concept is
suggested
77

 The N-FIT concept presents a similar approach to the immediate-
loading technique for the completely edentulous patient, with two
major exceptions.
 Rather than submerge more than half the implants or place extra
implants in case of failure, most often the ideal number of implants is
positioned in the ideal locations for the final prosthesis.
 The second major difference is that the implant-supported transitional
prosthesis is placed out of all direct opposing occlusal contacts
during the bone-healing period
79

 Two clinical approaches to the N-FIT technique are similar to the fixed
prosthesis for the edentulous patient.
 The first option is to use a surgical-prosthetic protocol similar to
immediate loading with a diagnostic wax up to fabricate the
provisional restoration.
 Once the implants are inserted, the dentist recontour and relines the
acrylic provisional prosthesis to the abutments
 A second alternative is to make an implant body impression with
abutments or transfer copings that engage the antirotational
hexagon
80

 After the appropriate bone-remodeling period (3 to 8 months,
depending on the bone density), the dentist removes the first
transitional restoration, evaluates the implants, and inserts the
second transitional acrylic restoration in light occlusion with a
heavy bite force occlusal adjustment.
 This procedure allows progressive loading of the bone-implant
interface and increases the bone density next to the implant.
83

 tooth replacement soon after stage I surgery.
 No stage II surgery is necessary
 Implants - during initial healing for biomechanical
advantage.
 bite force is only during eating and is less than 30 psi. No
parafunctional forces from occlusion are possible.
84 Advantages of Nonfunctional Immediate Teeth

 Countersinking the implant below the crestal bone is eliminated,
which reduces early crestal bone loss.
 The soft tissue emergence may be developed with the
transitional prosthesis and the tissue allowed to mature during
the bone-healing process.
 The soft tissue hemidesmosome attachment on the implant body
below the microgap connection may heal with an improved
interface.
85

Disadvantages of Nonfunctional
Immediate Teeth
 Micromovement of implant that can cause crestal bone loss or
implant failure is greater than with two-stage approach.
 The dentist is less likely to reflect the tissue at stage II and can
evaluate implant crestal bone directly.
 Parafunction from tongue or foreign habits (pen biting) may cause
trauma and crestal bone loss or implant failure.
86

 Impression material or acrylic may become trapped under tissue or
between the implant and crestal bone.
 This problem is reduced greatly if the crest module of the implant is
larger in diameter than the implant body.
 Bone that is too soft, small implant diameters, or implant designs
with less surface area may cause too great crestal stress contours
and cause bone loss or implant failure.
87

RISKS OF IMMEDIATE OCCLUSAL LOADING
 In the immediate-loading technique for the completely edentulous
patient, more implants usually are inserted, which increases the fee
 As immediate loading of fixed prostheses is expensive, a failure may
increase a malpractice case against the dentist, especially because
the patient may need to wear a removable prosthesis and may be
subjected to several additional surgeries and appointments.
88

 Implant overload failure most often is associated with bone loss
around the implant.
 bone graft
 two or three appointments - diagnosis of the implant failure,
 two appointments - to remove the implant (one surgery and one
suture removal),
 two appointments are required for the bone graft
 When the additional appointments and procedures are added to the
implant failure, the doctor most often loses the profit
 future referral loss from the refering dentist
89

Summary
 A benefit/risk ratio should be assessed for each patient condition
to ascertain whether immediate occlusal loading is a worthwhile
alternative.
 The greater the benefit and/or the lower the risk, the more likely
that immediate loading is considered
90

Immediate functional loading of implants placed with
flapless surgery versus conventional implants in
partially edentulous patients: A 3-year randomized
controlled clinical trial
Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M.
Int J Oral Maxillofac Implants 2008;23:867-75.
92

Purpose :- To compare the efficacy of immediate functionally loaded
implants placed with a flapless procedure (test group) versus implants
placed after flap elevation and conventional load-free healing
(control group) in partially edentulous patients.
 total :- 40 patients
 20 to the flapless immediately loaded group and
 20 to the conventional group.
93

 Implants in the immediately loaded group were provided with full
acrylic resin temporary restorations the same day.
 Implants in the conventional group were submerged (anterior region)
or left unsubmerged (posterior region) and were left load-free for 3
months (mandibles) or 4 months (maxillae).
 definitive single metal-ceramic crowns 1 month post loading.
 Outcome measures were prosthesis and implant failures, biological
and prosthetic complications, postoperative edema, pain, and use of
analgesics.
94

 There was no statistically significant difference for complications;
however, patients in the conventional group had significantly more
postoperative edema and pain and consumed more analgesics
than those in the flapless group.
 Implants can be successfully placed flapless and loaded
immediately without compromising success rates; the procedure
decreases treatment time and patient discomfort.
95

Implant-retained mandibular overdentures with
immediate loading: a 3- to 8-year prospective
study on 328 implants.
Chiapasco M, Gatti C. Clin Implant Dent Relat Res.
2003;5(1):29-38.
96

 The purpose - to evaluate prospectively survival and success rates
of implants placed in the interforaminal area of edentulous
mandibles and immediately loaded with an implant-supported
overdenture.
 Eighty-two patients, 33 males and 49 females, aged between 42
and 87
 328 screw-type osseointegrated implants were placed in the
intraforaminal area of the mental symphysis (4 implants per patient).
97

 Immediately after implant placement, a U-shaped gold or titanium bar
was fabricated and implants were rigidly connected with the bar and
immediately loaded with an implant-retained overdenture.
Success rate by following parameters:
 (1) absence of clinical mobility 2) absence of peri implant
radiolucency (3) absence of pain and radiologic or clinical signs of
neural lesion,(4) peri implant bone resorption mesial and distal to
each implant less than 0.2 mm after the first year of prosthetic load
98

 Results of this study demonstrated that survival and success rates of
immediately loaded implants placed in the intraforaminal area of the
mandible and rigidly connected with a bar through an implant-
supported overdenture are consistent with those reported in the
literature as far as delayed loading is concerned after 3 years
of loading.
 After longer observation times - a moderate decrease in success
rates of implants was found.
99

Immediate Occlusal versus Non-
Occlusal Loading of Implants: A Randomized
Clinical Pilot Study.
Vogl S, Stopper M, Hof M, Wegscheider WA, Lorenzoni M
Clin Implant Dent Relat Res. 2015 Jun;17(3):589-97.
100

 Aim :- to compare clinical outcomes of immediate occlusal versus non-
occlusal loading of posterior implants.
 total 19 patients, nine patients with 21 implants were randomized to a
study group that received immediate restorations with occlusal loading,
whereas 10 patients with 31 implants were randomized to a control
group that received provisional restorations without occlusal loading.
101

 Occlusal loading was defined as full loading in maximum
intercuspation.
 Single-tooth or splinted multiunit restorations were incorporated by
screw retention or cementation. Marginal bone defects (MBD),
implant survival, and implant success were evaluated 12 months after
insertion.
RESULTS: Both groups revealed similar MBD levels consistent with
previous reports.
 No implants were lost.
 No significant intergroup differences were noted for any of the
evaluated parameters.
102

CONCLUSIONS: Immediate restorations in partially edentulous
mandibles demonstrated successful clinical and radiographic 12-
month results.
 Larger long-term prospective studies are needed to confirm the
final evidence and predictability of immediate functional loading
as a standard treatment concept for partially edentulous jaws.
103

References
 Misch C.E. Contemporary implant dentistry. Mosby Publishing Company.
 Babush C. Dental implants- Principles and Practice" W.B. Saunder's Company.
 Rationale for the application of immediate load in implant dentistry: part I. Misch
CE1, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KW. Implant Dent.
Implant Dent. 2004 Sep;13(3):207-17
 Rationale for the application of immediate load in implant dentistry: part II. Misch
CE1, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KW. Implant Dent. 2004
Dec;13(4):310-21
104

 Immediate functional loading of implants placed with flapless surgery versus
conventional implants in partially edentulous patients: A 3-year randomized
controlled clinical trial. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Int
J Oral Maxillofac Implants. 2008 Sep-Oct;23(5):867-75.
 Implant-retained mandibular overdentures with immediate loading: a 3- to 8-year
prospective study on 328 implants. Chiapasco M, Gatti C. Clin Implant Dent Relat
Res. 2003;5(1):29-38.
 Immediate Occlusal versus Non-Occlusal Loading of Implants: A Randomized
Clinical Pilot Study. Vogl S, Stopper M, Hof M, Wegscheider WA, Lorenzoni M Clin
Implant Dent Relat Res. 2015 Jun;17(3):589-97.
105

Immediate loading

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