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Immediate loading- Kelly

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Kelly Norton

The document discusses immediate loading of dental implants. It begins with introducing immediate loading and defining related terms like immediate restoration, non-functional early restoration, and early occlusal loading. It then covers indications and contraindications for immediate loading, as well as advantages and disadvantages. The rationale for immediate loading is discussed, focusing on reducing surgical trauma and promoting bone remodeling. Factors that can decrease risks of immediate loading like implant number, size, design, and surface area are also outlined.

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Immediate loading Presented by: DR. KELLY NORTON 01-05-2018 170
CONTENTS: • Introduction • Definition • Indications and contra-indications • Advantages and disadvantages • Rationale for immediate loading • Diagnosis and treatment planning • Completely edentulous patients • Immediate loading with overdentures • Partially edentulous patients. • Single implant studies • Risk of Immediate loading protocols • Cross-References • Conclusion • References and Cross-References 01-05-2018 270
INTRODUCTION • The introduction of osseointegrated implants in dentistry symbolizes a turning point in clinical dental practice. • Immediate loading (IL) of dental implants has recently gained popularity due to several factors including reduction in treatment time and trauma as well as aesthetic and psychological benefits to the patient. 01-05-2018 370
• The two-stage surgical protocol established by Brånemark et al. to accomplish osseointegration consisted of the following guidelines:  Countersinking the implant below the crestal bone.  Obtaining and maintaining a soft tissue cover over the implants for 3-6 months.  Maintaining a non-loaded environment for 3-6 months. 01-05-2018 470
• The primary reasons cited for this submerged, countersunk surgical approach to implant placement were:  To minimize or reduce the risk of bacterial infection  To prevent apical migration of oral epithelium along the body of the implant  To reduce & minimize the risk of early implant loading during bone remodeling. * Following this procedure, a second stage surgery is necessary to uncover these implants and place a prosthetic abutment. 01-05-2018 570
• One stage or non-submerged approach has advocated that, implants osseointegrate , even when they reside above the bone & soft tissue during early healing and has the following advantages: 1. Eliminates second stage surgery. 2. Tissue discomfort and healing associated with 2nd stage surgery are eliminated. 3. Surgical time for suture removal and uncovering are avoided. 4. Soft tissue is already mature before the fabrication of the final prosthesis. Immediate loading of a dental implant not only includes a non-submerged one stage surgery, but also actually loads the implant with a provisional restoration at the same appointment.01-05-2018 670
DEFINITION Immediate Restoration or /Occlusal Loading (IOL)— • immediate occlusal-loading protocol is an implant supported temporary or definitive restoration in occlusal contact within 2 weeks of the implant insertion. 01-05-2018 770 Contemporary implant dentistry Carl E. Misch 3rd Edition
Non functional early restoration: • A restoration in a partially edentulous patient delivered between 2 weeks and 3 months after the implant insertion. 01-05-2018 870 Contemporary implant dentistry Carl E. Misch 3rd Edition Non functional immediate restoration: • An implant prosthesis with no direct occlusal load within 2 weeks of implant insertion and is primarily considered in partially edentulous patients.
Early occlusal Loading: • An implant-supported restoration in occlusion between 2 weeks and 3 months after implant placement and may use the time period in parentheses (i.e., early [5-week] occlusal loading). Delayed loading/ staged occlusal loading: • An implant prosthesis with an occlusal load after more than 3 months after implant insertion. 01-05-2018 970 Contemporary implant dentistry Carl E. Misch 3rd Edition
TIMING OF IMPLANT PLACEMENT 19 10Chen S, Buser D. Implants in post-extraction sites: A literature update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide.Vol 3: Implants in extraction sockets. Berlin: Quintessence, 2008.
19 11 http://glidewelldental.com/education/inclusive-dental-implant-magazine/volume-2-issue-2/the-immediate-loading-of-dental-implants/
INDICATIONS • Adequate bone quality (Types I, II, or III) • Sufficient bone height ( i.e. approximately 12mm ) for a minimum length of 10 mm implant • Sufficient bone width ( i.e. approximately 6 mm) • Ability to achieve an adequate antero- posterior spread between the implants. • A poor AP spread decreases the mechanical advantage gained by splinting and the ability to cantilever the restoration 01-05-2018 1270
CONTRAINDICATIONS 1. Poor systemic health 2. Severe parafunctional habits 3. Bone of poor quality 4. Bone height less than 12 mm 5. Bone width less than 6 mm 6. Inability to achieve an adequate AP spread 01-05-2018 1370
ADVANTAGES AND DISADVANTAGES OF IMMEDIATE OCCLUSAL LOADING Advantages: 1. Eliminates the need for and maintenance of a removable provisional prosthesis 2. Provides emotional benefit for a patient scheduled to be rendered edentulous 3. Improves bone healing 4. Facilitates soft tissue shaping 5. Eliminates premature implant exposure often associated with wearing of a removable denture during healing period. 01-05-2018 1470
DISADVANTAGES: • Micro-movement of implant that can cause crestal bone loss or implant failure is greater than two stage procedure. • Direct visual evaluation of crestal bone during 2nd stage surgery is lost. • Parafunction from tongue or foreign bodies( Pen biting) may cause trauma and crestal bone loss. • Too soft bone, small implant diameters or implant designs with less surface area, may cause too great crestal stress contours and cause bone loss or implant failure. • If immediate loading leads to failure of the implants, there may be adjuvant bone loss, which may require additional bone grafting procedures. 01-05-2018 1570
01-05-2018 70 16 RATIONALE FOR IMMEDIATE LOADING
(A)SURGICAL TRAUMA: • Bone interface is stronger on the day of implant placement compared with the time three months later. • The surgical process of implant osteotomy preparation and implant insertion, causes a regional acceleratory phenomenon of bone repair around the implant interface. • The implant bone interface is the weakest & most at risk of overload at 3 to 6 weeks, due to bone remodeling at the interface. • Causes such as thermal injury & microfracture of bone, can lead to osteonecrosis and fibrous encapsulation of the implant. • Heat generated may depend on the amount of bone prepared, drill design and sharpness, depth of osteotomy, irrigation and rpm of the drill. 01-05-2018 1770
(B) BONE LOADING TRAUMA • The woven bone of surgical trauma has been called repair bone • The woven bone formed from a mechanical or loading response may be called reactive woven bone • Remodeling from mechanical strain or bone turnover, permits the repair of the bone after trauma or allows the bone to respond to It’s local mechanical environment. • Lamellar bone is organized, highly mineralized, is the strongest bone type, has the highest modulus of elasticity -> Load Bearing Bone. • Woven bone in comparison is unorganized, less mineralized, weaker, more flexible, though it forms at a faster rate than lamellar bone. • The rationale for immediate loading hence, is not only to minimize woven bone formation or fibrous tissue formation, but also to promote lamellar bone maturation to sustain occlusal load. 01-05-2018 1870
HISTOLOGIC EVALUATION 01-05-2018 1970 Histological studies by Randow et al. have suggested that immediate loading may enhance bone remodeling and further enhance bone density. Short term study results show that immediately loading of the implant does not necessarily place the interface at the risk of fibrous tissue formation. Long term study results showed that immediately loaded implants exhibited twice the BIC compared to unloaded implants.
IMMEDIATE OCCLUSAL LOADING FACTORS THAT DECREASE RISKS (A) Bone Microstrain : • Goal for an immediately loaded implant/ prosthesis system is to decrease the risk of occlusal overload & resultant increase in remodeling rate of the bone. • One method to decrease microstrain & remodeling rate in bone is to provide conditions that increase functional area to the implant bone interface. • The area of load may be increased by :  Implant number  Implant size  Implant design  Implant body surface conditions 01-05-2018 2070
1. IMPLANT NUMBER: • The functional surface area for an occlusal load at an implant interface can be increased by increasing the number of implants. • The decrease in the number of pontics may also decrease the risk of fracture of transitional prosthesis, which could have again be a source of overload to remaining implants. • maxilla : 8 - 12 implants • mandible 5-9 implants are recommended. • Increased number of implants may be used, in case of reduced bone density in either arches. 01-05-2018 2170
2. IMPLANT SIZE: • Implant length is a more relevant factor in case of immediate loading, especially in case of softer bone. • For every 3mm increase in implant, the overall surface area will increase by 20%. • The additional implant length may also permit the implant to engage the opposing cortical plate (bi-cortical stabilization), which further increases implant initial stability. • Width is more important for the crestal bone where the occlusal stress are greatest. • Major increase in tooth size occurs in the molar region where the surface area is double than the rest of the dentition. Therefore implant diameter is increased in the molar region. • If increasing width is not possible, then bone grafting or additional implants may be considered for replacing teeth. 01-05-2018 2270
Do Longer Implants Improve Clinical Outcome In Immediate Loading? • It is generally believed that longer implants (length >13 mm) have higher success rates than standard implants (length = 13mm) • A total of 244 standard and 536 long implants were inserted and immediately loaded. The mean follow-up was 3 years. • Only 4 of 780 implants (99.5%) were lost, and these 4 were all 13 mm long. • Only 4 of the 244 13-mm-long implants were lost (98%), but this was statistically different from the survival rate of longer implants. • Poor quality bone was related to increased marginal bone loss and thus a worse outcome in both groups. • IL standard length implants have a high survival rate, but it is statistically worse than that of IL longer implants. Standard or longer implants are reliable devices for insertion in poor quality bone, although slightly higher bone resorption is to be expected. 01-05-2018 2370 M. Degidi & A. Piattelli International Journal Of Oral And Maxillofacial Surgery 2014
3. IMPLANT BODY DESIGN: • Threaded implants are preferred in comparison to press fit implants. • The increase in the number and depth of threads, corresponds to the increase in the functional surface area of the implants, hence corresponds to better load distribution, which is critical in the success of immediate loading of implants. • The thread depth of the implant body is related to the initial functional surface area for immediate load. • Implant design affects functional surface area more than implant size – Square thread design are better than v shaped thread design. • Parallel walled threaded are better for immediate loading than tapered threaded.01-05-2018 2470
IMPLANT SURFACE CONDITIONS • Implant surface conditions affect the rate of bone contact , lamellar bone formation and percentage of bone contact which are beneficial in immediate loading. • HA coatings decrease the remodeling rate , therefore beneficial in D4 bone and may decrease the risk in case of immediate loading. • Calcium phosphate coated and titanium plasma sprayed also have been found to increase BIC. • Coating or surface condition is most beneficial during initial healing and early loading conditions. 01-05-2018 70 25
 The greater the occlusal force applied to the prosthesis , the greater the stress at the implant bone interface and the greater the strain to the bone.  Patients with parafunctional habits present with increased duration and magnitude of force along with a more horizontal direction of force on the implant with a greater shear component.  Parafunctional loads increase the risk of abutment screw loosening, un-retained prosthesis or fracture of the transitional prosthesis used for immediate loading.  One should have narrow occlusal tables and eliminate posterior cantilevers for immediately loaded implants.  Axial load to the implant bodies are preferred whenever possible. 01-05-2018 2670 PATIENT FACTORS
IMPLANT POSITIONS • Splinted arch position concept is advantageous in immediate loading as it is effective in reducing stresses to the entire implant support system. • In the completely edentulous maxilla: • Anterior implants - bilateral canine position and • Posterior implants -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. • In the mandible: • At least three implants, one in the anterior and one in each posterior region, are necessary. 01-05-2018 70 27
01-05-2018 2870 • The modulus of elasticity of bone is related to the bone quality. The less dense the bone, the lower the modulus. • The strength of the bone is also directly related to the density of the bone. • The amount of bone–implant contact is also decreased for less dense bone. • Cortical bone is more likely to remain lamellar in structure during the immediate loading process, compared with trabecular bone. • More implants, larger implants (length and width), greater surface area, implant designs, implant positions with greater A-P dimensions, and reduced cantilevers should all be considered in lower density bone types. MECHANICAL PROPERTIES OF BONE
DIAGNOSIS AND TREATMENT PLANNING • Reason for extraction of tooth. • General systemic and oral health status • Amount of available bone , bone shape, quality, width and height • Sufficient distance from maxillary sinus floor, inferior alveolar canal 01-05-2018 29 A minimum of 4-5mm of bone width at the alveolar crest and 10mm length above inferior alveolar canal 70
TOOTH EXTRACTION AND IMPLANT PLACEMENT PROCEDURES • Teeth to be removed and implants placed immediately after extraction can be assessed using either an open flap surgery or a minimally invasive surgical technique. • Avoid damaging the buccal plate during extraction. • Surgical guides should be used for precise osteotomy site preparation. • In anterior region, the implants must correspond to the incisal edges of the adjacent teeth or be slightly palatal to this landmark. • Implant should be placed at least 3mm apical to the imaginary line joining the cementoenamel junction of adjacent teeth- Good emergence profile 01-05-2018 3070
IMMEDIATE LOADING PROTOCOLS  Patients should be healthy or a controlled systemic condition  Cigarette smoking to be avoided  Avoiding /reducing bone tapping of the osteotomy site or tapping osteotomies sites in dense bone only.  Engaging both cortices where available to provide bicortical stabilization  Performing under preparation of the osteotomy site using narrower twist drills  Using wider implant when primary stability was not obtained with the initial implant.  Avoid placing immediate loading in areas of active infection. 01-05-2018 3170
PRIMARY STABILITY • Primary stability is one of the most critical factors and must be obtained at the time of the implant’s insertion, before any load is applied. 01-05-2018 3270
PERIOTEST • An electronic device, the Periotest (Siemens AG, Bensheim,Germany), • able to measure the damping characteristics of the periodontium in a very reproducible way, • permit the objective discrimination between an implant that has a close bone apposition and one that is fibrously encapsulated. • of values ranging from -8 to -50 01-05-2018 70 33
Resonance frequency analysis • Developed by Meredith and colleagues, provides a clinical, noninvasive, and nondestructive method to assess the implant stability and osseointegration • Resonance Frequency Analysis (RFA) is the measurement of the frequency with which a device vibrates. • A Smart Peg sensor is mounted on top of the implant and the sensor is then brought to vibration by gently moving it with magnetic pulses. The sensor will vibrate for a short while and then stop. • If the implant stability (stiffness of the bone-implant interface) increases, the vibration frequency of the sensor will increase. 24 34 RESONANCE FREQUENCY ANALYSIS (RFA)
The role of primary stability for successful immediate loading of dental implants. A literature review. Journal of dentistry. • Objectives: To assess the role of primary stability for successful immediate loading (IL) of dental implants. • Original articles studying the role of primary stability for successful immediate loading of dental implants were included. • Results: • There is a significant biological response by the hard and soft tissues to IL of dental implants. • Within the limitations of the present literature review, it is evident that the core issue to observe during IL is the establishment of a good implant primary stability. • There is sufficient evidence to suggest that the degree of achieved primary stability during IL protocols is dependent on several factors including bone density and quality, implant shape, design and surface characteristics and surgical technique. 01-05-2018 70 35 Javed F, Romanos GE. The role of primary stability for successful immediate loading of dental implants. A literature review. Journal of dentistry. 2010 Aug 1;38(8):612-20.
COMPLETELY EDENTULOUS PATIENTS • Option 1: Loading the implants the same day as the surgery. 01-05-2018 70 36
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01-05-2018 70 39 De Bruyn H, Raes S, Östman PO, Cosyn J. Immediate loading in partially and completely edentulous jaws: a review of the literature with clinical guidelines. Periodontology 2000. 2014 Oct 1;66(1):153-87.
Option 2 : Split the surgical appointment from the prosthesis delivery appointment • Place the implants and make an impression at surgery. • In addition, the dentist records a vertical occlusal dimension and centric bite registration. • The bite registration may be made with the shell of the transitional restoration on the abutment or with a baseplate and wax rim (made before surgery and relined as necessary). • The laboratory pours the impression and selects and prepares the abutments for the restoration and fabricates a transitional prosthesis. • Then at the suture removal appointment 7 to 12 days later, the dentist delivers the transitional fixed prosthesis. • After healing 4 to 8 months (dependent on the bone density) the transitional restoration may be cut off and the final prosthesis fabricated 01-05-2018 70 40
DIET: • If immediately loaded prosthesis becomes partially un-cemented or fractures, the remaining implants are at increased risk of overload failure. • Diet of the patient should be restricted only to soft foods in order to avoid overloading the provisional prosthesis. 01-05-2018 4170
All on 4 and all on six concept • First described by Paulo Malo, Lisbon, Portugal in his state of art all-on-4tm concept. • The back implants are slanted distally to place the implant head at the second premolar or first molar position. • Longer implants, stabilizing them into the anterior higher density bone, and reduces the distal cantilever of the prosthesis. • 10 to 12 unit screw retained metal to plastic (hybrid) splinted prosthesis is placed over these implants. 01-05-2018 70 42
01-05-2018 70 43 All four implants in position, two distally tilted back implants and two straight anterior implants A 30° multiunit abutment is being screwed on the top of distal implant to correct the prosthetic angulations
01-05-2018 70 44 The long flanges and palatal extension of the denture are removed Healing abutments are replaced with the titanium cylinders Prefabricated denture or patient’s old denture is used to make the immediate fixed provisional prosthesis.
IMMEDIATE LOADING OF IMPLANTS WITH OVERDENTURE PROSTHESIS • In early progressive loading, the dentures are not worn for 1 to 2 weeks, or else worn, but completely relieved from the healing abutment. • relined after 3 to 4 months when the definitive prosthesis and attachments (ball or bar assembly) are connected. • In immediate early functional loading, the retentive attachments are connected within 5 days ( bar/clip). 01-05-2018 4570
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Comparison of patient-reported outcomes between immediately and conventionally loaded mandibular two-implant overdentures: A preliminary study Yuri Omura Journal of prosthetic dentistry 2016 • To compare patient-reported outcomes between immediately and conventionally loaded mandibular two-implant overdentures retained by magnetic attachments • 50 participants. Each participant received 2 implants in the inter-foraminal region by means of flapless surgery. Prostheses in the immediate and conventional groups were loaded using magnetic attachments on the same day as implant placement or 3 months after surgery, respectively. • Immediate loading of mandibular two-implant overdentures with magnetic attachments tends to improve oral health-related quality of life and patient assessment earlier than observed with a conventional loading protocol. 01-05-2018 5170
The Partially Edentulous Patients 01-05-2018 5270 Nonfunctional Immediate Teeth Concept The N-FIT concept presents a similar approach to the immediate- loading technique for the completely edentulous patient, with two major exceptions. 1st : 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. 2nd : The implant-supported transitional prosthesis is placed out of all direct opposing occlusal contacts during the bone-healing period. 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.
01-05-2018 70 53 • Indications • • Partially edentulous patients with centric occlusal contacts and excursions on natural teeth (or healed implants) • • D1, D2, and D3 bone in regions of implants • • Screw-shaped implant bodies, 4 mm or more in diameter, with increased surface area designs to decrease crestal stresses (e.g., BioHorizons Maestro dental implant) • Contraindication • • Patients with parafunctional oral habits (i.e., anterior and lateral tongue thrust or biting on a pipe while smoking)
• Advantages of Nonfunctional Immediate Teeth • Patient has a fixed esthetic tooth replacement soon after stage I surgery. • No stage II surgery is necessary (eliminates discomfort for the patient and decreases overhead for the doctor). • Implants are splinted during initial healing for biomechanical advantage. • The greatest bite force is only during eating and is less than 30 psi. No parafunctional forces from occlusion are possible. • 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 is mature when the final restoration is fabricated because the tissue has been healing for many months. If surgical correction is required, then the dentist still may perform the correction before the final bone maturation. 01-05-2018 70 54
• 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. • 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 01-05-2018 70 55
TWO CLINICAL APPROACHES TO THE N-FIT TECHNIQUE • The first option is to use a surgical-prosthetic protocol similar to immediate loading with a diagnostic waxup to fabricate the provisional restoration. Once the implants are inserted, the dentist recontours and relines the acrylic provisional prosthesis to the abutments 01-05-2018 70 56
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Second alternative 01-05-2018 70 59
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SINGLE-TOOTH NONFUCTIONAL IMMEDIATE-RESTORATION PROCEDURES • Worhle and Misch presented the single-tooth immediate restoration in 1998 • The single-tooth implant is considered for immediate restoration most often when the following occur: • 1. The natural tooth requires extraction and is still present in the mouth. • 2. The natural tooth is in the esthetic zone. • 3. The soft tissue drape in its current form is ideal. • 4. The bony housing around the natural tooth is intact, including the facial plate. 01-05-2018 70 61
Transitional Restoration • Two options exist for the transitional restoration for a single-tooth immediate implant restoration: • 1st: An acrylic crown with no occlusal load for 3 to 4 months. In addition, the transitional crown may be splinted to a natural tooth that has no clinical mobility (i.e., a canine). • 2nd: A premade crown is modified to fit over the abutment and places the gingival margin in close approximation to the tissue. 01-05-2018 70 62
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RISKS OF IMMEDIATE OCCLUSAL LOADING • Early crestal bone loss after implant loading may have a relationship to occlusal overload. • The early loading was speculated to interfere with the ability of necrotic bone (created by the surgical trauma) to be replaced by newly formed bone. • Successful implants with greater than 5-mm soft tissue pockets may be more often a result of immediate loading. • In the immediate-loading technique for the completely edentulous patient, more implants usually are inserted, which increases the fee and makes patient acceptance less likely. • Implant 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. 01-05-2018 70 65
REVIEW OF LITERATURE 01-05-2018 70 66
Immediate Loading of Single Implants in the Anterior Maxilla: A 1-Year Prospective Clinical Study on 34 Patients • Aim : To present the outcomes of immediately loaded single implants placed in the anterior maxilla. • Methods: • 34 patients • 43 tapered implants • Inclusion criteria were single-tooth placement in postextraction sockets or healed sites of the anterior maxilla. • All implants were immediately loaded and followed for a period of 1 year after the placement of definitive crowns. • Results: Positive outcomes were reported, with high survival (100%) and success (95.2%) rates 01-05-2018 70 67
Immediate versus delayed functional loading of implant in the posterior mandible: a 2-year prospective clinical study of 12 consecutive cases • Aim : To evaluate the clinical success of immediately loaded implants versus implants loaded in a delayed fashion in the posterior mandible. Three implants were placed distal to the canines bilaterally in the edentulous distal mandibular ridges of 12 patients. • Results: Twenty-nine of the examined sites showed no bone loss. After 2 years of loading in the posterior mandible, test and control implants had the same prognosis 01-05-2018 70 68 Romanos GE, Nentwig G. Immediate versus delayed functional loading of implant in the posterior mandible: a 2-year prospective clinical study of 12 consecutive cases. Int J Periodontics Restorative Dent. 2006;26:459–469
Changes In Alveolar Bone Density Around Immediate Functionally And Non-functionally Loaded Implants • Aim: T o quantitatively assess radiographic changes in alveolar bone density around immediate functionally and nonfunctionally loaded implants. • Material and methods. A prospective longitudinal study was conducted in which 20 participants with partially edentulous mandibles received implants that were immediately loaded either functionally (IFL) or nonfunctionally (INFL). Standardized intraoral periapical radiographs were made at baseline, 3, and 6 months. • Results: Immediate loading of implants helps to stimulate bone ossification around implants at the lateral apical level and at the crest from 3 months to 6 months. • Furthermore, the immediate functional loading of implants resulted in a significantly greater degree of bone demineralization at the alveolar crest from the time of implant placement up to 3 months compared with immediate nonfunctional loading. 01-05-2018 70 69 Ramachandran A, Singh K, Rao J, Mishra N, Jurel S, Agrawal K The Journal Of Prosthetic Dentistry. 2016;115(6):712-717.
Immediate loading of implants placed in patients with untreated periodontal disease: a 5-year prospective cohort study. 01-05-2018 7070 Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I. Immediate loading of implants placed in patients with untreated periodontal disease: a 5-year prospective cohort study. European journal of oral implantology. 2014 Sep 1;7(3). Purpose: To report the 5-year outcome of immediately loaded dental implants in patients with untreated periodontal disease. Method: 103 consecutive patients were rehabilitated with 380 implants supporting 145 prostheses in both jaws . The implants were inserted in patients with active and untreated periodontitis. The patients did not receive any previous periodontal treatment before implant surgery, except for an oral hygiene session immediately before the implant surgery. In maintenance (every 6 months) patients received periodontal treatment as needed.
01-05-2018 70 71 Conclusion: A cumulative survival rate of 97.9% and 99.4% at 5 years of follow up was noted. Rehabilitation of patients with untreated periodontitis using immediately loaded dental implants is feasible, when periodontal therapy is provided after rehabilitation and the patients are regularly maintained.
• Objective: To assess longitudinal quantitative changes in bone density around different implant loading protocols and implant surfaces measured by digital subtraction radiography (DSR). • Methods: 12 patients received bilateral homologous machined surface standard implant and an oxidized surface implant TiUniteH (Nobel Biocare, Kloten, Switzerland) single-tooth implants under 2 implant—loading protocols: immediate loading and conventional loading.Standardized periapical radiographs were taken immediately after implant placement (baseline image) and at the 3-month, 6-month and 12-month follow ups. Radiographic images were digitized and submitted to digital subtraction using the DSR system. • Results: No effect of implant surface treatment was observed. • IML protocol induced mineral bone gain around single-tooth implants after the first year under function for cases with favourable bone conditions. Carneiro L, da Cunha H, Leles C, Mendonça E Dentomaxillofacial Radiology. 2012;41(3):241-247. Digital subtraction radiography evaluation of longitudinal bone density changes around immediate loading implants: a pilot study 19 72
Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up. • Aim: of this prospective study was to report the outcome of treatment with implants inserted after tooth extraction and immediately loaded. • Fifty-six patients with single tooth loss were treated with 116 IPX Galimplant® implants with internal connections and a sandblasted, acid-etched surface. All implants were placed after tooth extraction using a flapless approach without bone regeneration, and they were then immediately loaded with cemented acrylic prostheses. After a period of three months, definitive cemented ceramic prostheses were placed. • Clinical results indicate an implant survival and success rate of 97.4%. dental implants that are inserted after tooth extraction and immediately loaded may constitute a successful and predictable alternative implant treatment. 01-05-2018 70 73 Velasco-Ortega E, Wojtovicz E, España-Lopez A, Jimenez-Guerra A, Monsalve-Guil L, Ortiz-Garcia I, Serrera-Figallo MA. Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up. Medicina oral, patologia oral y cirugia bucal. 2018 Feb.
Immediate Loading of Short Implants in Posterior Maxillae: Case Series • Aim: To evaluate immediate loading of short dental implants in the posterior regions of the maxillae. • Materials and methods • Patients having short implants ( 7.5 mm or 8.5 mm) in maxillae posterior areas inserted before December, 2010 and immediately loaded were selected • Result: One prosthetic complication occurred. No prostheses failed resulting in a survival rate of 100%. • The immediate loading of short implants in maxillae posterior areas could save time, cost and could be regarded as a successful treatment. 01-05-2018 70 74 Anitua E. Immediate Loading of Short Implants in Posterior Maxillae: Case Series. Acta stomatologica Croatica. 2017 Jun 20;51(2):157-62.
Conclusion 01-05-2018 7570 Patient care requires implants to restore function, esthetics, bone and soft tissue contours, speech and intra oral health. In some patient conditions, the delayed healing process can cause psychological, social, speech and or function problems. Immediate restoration of a patient after implant surgery is one of these alternatives. Careful patient screening and selection are required when an immediate implant placement with immediate loading procedure is a treatment consideration.
References and Cross-References • Contemporary implant dentistry 3rd edition Carl E. Misch • Endosteal Dental Implants: Mc kinskey • Osseointegration and dental implants: Jokstad • Implant dentistry today: A multidisplinary approach 3rd edition Piccin • Principles and Practice of implant dentistry: Weiss • Oral rehabilitation and Implant supported prosthesis: Jimenez- Lopez • Computer-guided versus free-hand placement of immediately loaded dental implants: 1-year post-loading results of a multicentre randomised controlled trial : Pozzi et al Eur J Oral Implantol 2014;7(3):229–242 • Immediate loading of implants placed in patients with untreated periodontal disease: A 5-year prospective cohort study • Factors Affecting the Outcome in the Immediate Loading Rehabilitation of the Maxilla: A 6-year Prospective Study : Paulo Pera et al Int J Periodontics Restorative Dent 2014;34:657–665. doi: 10.11607/prd.1970 01-05-2018 7670
References and Cross-References • Immediate non-functional versus immediate functional loading and dental implant failure rates: A systematic review and meta-analysis: RC BRUNO: journal of dentistry 42 (2014)1052 – 1059. • Immediate Versus Early Loading of Mini-Implants Supporting Mandibular Overdentures: A Preliminary 3-Year Clinical Outcome Report :HM Waleed et al Int J Prosthodont 2014;27:553-560. • Distal Cantilever in Full-Arch Prostheses and Immediate Loading: A Retrospective Clinical Study : ER Giorgious : Int J Oral MaxiIllofac implants 2014;29:427-431 • Evaluation of crestal bone loss and stability of immediate functional loading versus immediate non-functional loading of single-mandibular posterior implants: A pilot randomized controlled clinical trial : Mantena et al. Dental Research Journal September 2014 Vol 11 Issue 5 01-05-2018 7770

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Immediate loading- Kelly

  • 1. Immediate loading Presented by: DR. KELLY NORTON 01-05-2018 170
  • 2. CONTENTS: • Introduction • Definition • Indications and contra-indications • Advantages and disadvantages • Rationale for immediate loading • Diagnosis and treatment planning • Completely edentulous patients • Immediate loading with overdentures • Partially edentulous patients. • Single implant studies • Risk of Immediate loading protocols • Cross-References • Conclusion • References and Cross-References 01-05-2018 270
  • 3. INTRODUCTION • The introduction of osseointegrated implants in dentistry symbolizes a turning point in clinical dental practice. • Immediate loading (IL) of dental implants has recently gained popularity due to several factors including reduction in treatment time and trauma as well as aesthetic and psychological benefits to the patient. 01-05-2018 370
  • 4. • The two-stage surgical protocol established by Brånemark et al. to accomplish osseointegration consisted of the following guidelines:  Countersinking the implant below the crestal bone.  Obtaining and maintaining a soft tissue cover over the implants for 3-6 months.  Maintaining a non-loaded environment for 3-6 months. 01-05-2018 470
  • 5. • The primary reasons cited for this submerged, countersunk surgical approach to implant placement were:  To minimize or reduce the risk of bacterial infection  To prevent apical migration of oral epithelium along the body of the implant  To reduce & minimize the risk of early implant loading during bone remodeling. * Following this procedure, a second stage surgery is necessary to uncover these implants and place a prosthetic abutment. 01-05-2018 570
  • 6. • One stage or non-submerged approach has advocated that, implants osseointegrate , even when they reside above the bone & soft tissue during early healing and has the following advantages: 1. Eliminates second stage surgery. 2. Tissue discomfort and healing associated with 2nd stage surgery are eliminated. 3. Surgical time for suture removal and uncovering are avoided. 4. Soft tissue is already mature before the fabrication of the final prosthesis. Immediate loading of a dental implant not only includes a non-submerged one stage surgery, but also actually loads the implant with a provisional restoration at the same appointment.01-05-2018 670
  • 7. DEFINITION Immediate Restoration or /Occlusal Loading (IOL)— • immediate occlusal-loading protocol is an implant supported temporary or definitive restoration in occlusal contact within 2 weeks of the implant insertion. 01-05-2018 770 Contemporary implant dentistry Carl E. Misch 3rd Edition
  • 8. Non functional early restoration: • A restoration in a partially edentulous patient delivered between 2 weeks and 3 months after the implant insertion. 01-05-2018 870 Contemporary implant dentistry Carl E. Misch 3rd Edition Non functional immediate restoration: • An implant prosthesis with no direct occlusal load within 2 weeks of implant insertion and is primarily considered in partially edentulous patients.
  • 9. Early occlusal Loading: • An implant-supported restoration in occlusion between 2 weeks and 3 months after implant placement and may use the time period in parentheses (i.e., early [5-week] occlusal loading). Delayed loading/ staged occlusal loading: • An implant prosthesis with an occlusal load after more than 3 months after implant insertion. 01-05-2018 970 Contemporary implant dentistry Carl E. Misch 3rd Edition
  • 10. TIMING OF IMPLANT PLACEMENT 19 10Chen S, Buser D. Implants in post-extraction sites: A literature update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment Guide.Vol 3: Implants in extraction sockets. Berlin: Quintessence, 2008.
  • 12. INDICATIONS • Adequate bone quality (Types I, II, or III) • Sufficient bone height ( i.e. approximately 12mm ) for a minimum length of 10 mm implant • Sufficient bone width ( i.e. approximately 6 mm) • Ability to achieve an adequate antero- posterior spread between the implants. • A poor AP spread decreases the mechanical advantage gained by splinting and the ability to cantilever the restoration 01-05-2018 1270
  • 13. CONTRAINDICATIONS 1. Poor systemic health 2. Severe parafunctional habits 3. Bone of poor quality 4. Bone height less than 12 mm 5. Bone width less than 6 mm 6. Inability to achieve an adequate AP spread 01-05-2018 1370
  • 14. ADVANTAGES AND DISADVANTAGES OF IMMEDIATE OCCLUSAL LOADING Advantages: 1. Eliminates the need for and maintenance of a removable provisional prosthesis 2. Provides emotional benefit for a patient scheduled to be rendered edentulous 3. Improves bone healing 4. Facilitates soft tissue shaping 5. Eliminates premature implant exposure often associated with wearing of a removable denture during healing period. 01-05-2018 1470
  • 15. DISADVANTAGES: • Micro-movement of implant that can cause crestal bone loss or implant failure is greater than two stage procedure. • Direct visual evaluation of crestal bone during 2nd stage surgery is lost. • Parafunction from tongue or foreign bodies( Pen biting) may cause trauma and crestal bone loss. • Too soft bone, small implant diameters or implant designs with less surface area, may cause too great crestal stress contours and cause bone loss or implant failure. • If immediate loading leads to failure of the implants, there may be adjuvant bone loss, which may require additional bone grafting procedures. 01-05-2018 1570
  • 16. 01-05-2018 70 16 RATIONALE FOR IMMEDIATE LOADING
  • 17. (A)SURGICAL TRAUMA: • Bone interface is stronger on the day of implant placement compared with the time three months later. • The surgical process of implant osteotomy preparation and implant insertion, causes a regional acceleratory phenomenon of bone repair around the implant interface. • The implant bone interface is the weakest & most at risk of overload at 3 to 6 weeks, due to bone remodeling at the interface. • Causes such as thermal injury & microfracture of bone, can lead to osteonecrosis and fibrous encapsulation of the implant. • Heat generated may depend on the amount of bone prepared, drill design and sharpness, depth of osteotomy, irrigation and rpm of the drill. 01-05-2018 1770
  • 18. (B) BONE LOADING TRAUMA • The woven bone of surgical trauma has been called repair bone • The woven bone formed from a mechanical or loading response may be called reactive woven bone • Remodeling from mechanical strain or bone turnover, permits the repair of the bone after trauma or allows the bone to respond to It’s local mechanical environment. • Lamellar bone is organized, highly mineralized, is the strongest bone type, has the highest modulus of elasticity -> Load Bearing Bone. • Woven bone in comparison is unorganized, less mineralized, weaker, more flexible, though it forms at a faster rate than lamellar bone. • The rationale for immediate loading hence, is not only to minimize woven bone formation or fibrous tissue formation, but also to promote lamellar bone maturation to sustain occlusal load. 01-05-2018 1870
  • 19. HISTOLOGIC EVALUATION 01-05-2018 1970 Histological studies by Randow et al. have suggested that immediate loading may enhance bone remodeling and further enhance bone density. Short term study results show that immediately loading of the implant does not necessarily place the interface at the risk of fibrous tissue formation. Long term study results showed that immediately loaded implants exhibited twice the BIC compared to unloaded implants.
  • 20. IMMEDIATE OCCLUSAL LOADING FACTORS THAT DECREASE RISKS (A) Bone Microstrain : • Goal for an immediately loaded implant/ prosthesis system is to decrease the risk of occlusal overload & resultant increase in remodeling rate of the bone. • One method to decrease microstrain & remodeling rate in bone is to provide conditions that increase functional area to the implant bone interface. • The area of load may be increased by :  Implant number  Implant size  Implant design  Implant body surface conditions 01-05-2018 2070
  • 21. 1. IMPLANT NUMBER: • The functional surface area for an occlusal load at an implant interface can be increased by increasing the number of implants. • The decrease in the number of pontics may also decrease the risk of fracture of transitional prosthesis, which could have again be a source of overload to remaining implants. • maxilla : 8 - 12 implants • mandible 5-9 implants are recommended. • Increased number of implants may be used, in case of reduced bone density in either arches. 01-05-2018 2170
  • 22. 2. IMPLANT SIZE: • Implant length is a more relevant factor in case of immediate loading, especially in case of softer bone. • For every 3mm increase in implant, the overall surface area will increase by 20%. • The additional implant length may also permit the implant to engage the opposing cortical plate (bi-cortical stabilization), which further increases implant initial stability. • Width is more important for the crestal bone where the occlusal stress are greatest. • Major increase in tooth size occurs in the molar region where the surface area is double than the rest of the dentition. Therefore implant diameter is increased in the molar region. • If increasing width is not possible, then bone grafting or additional implants may be considered for replacing teeth. 01-05-2018 2270
  • 23. Do Longer Implants Improve Clinical Outcome In Immediate Loading? • It is generally believed that longer implants (length >13 mm) have higher success rates than standard implants (length = 13mm) • A total of 244 standard and 536 long implants were inserted and immediately loaded. The mean follow-up was 3 years. • Only 4 of 780 implants (99.5%) were lost, and these 4 were all 13 mm long. • Only 4 of the 244 13-mm-long implants were lost (98%), but this was statistically different from the survival rate of longer implants. • Poor quality bone was related to increased marginal bone loss and thus a worse outcome in both groups. • IL standard length implants have a high survival rate, but it is statistically worse than that of IL longer implants. Standard or longer implants are reliable devices for insertion in poor quality bone, although slightly higher bone resorption is to be expected. 01-05-2018 2370 M. Degidi & A. Piattelli International Journal Of Oral And Maxillofacial Surgery 2014
  • 24. 3. IMPLANT BODY DESIGN: • Threaded implants are preferred in comparison to press fit implants. • The increase in the number and depth of threads, corresponds to the increase in the functional surface area of the implants, hence corresponds to better load distribution, which is critical in the success of immediate loading of implants. • The thread depth of the implant body is related to the initial functional surface area for immediate load. • Implant design affects functional surface area more than implant size – Square thread design are better than v shaped thread design. • Parallel walled threaded are better for immediate loading than tapered threaded.01-05-2018 2470
  • 25. IMPLANT SURFACE CONDITIONS • Implant surface conditions affect the rate of bone contact , lamellar bone formation and percentage of bone contact which are beneficial in immediate loading. • HA coatings decrease the remodeling rate , therefore beneficial in D4 bone and may decrease the risk in case of immediate loading. • Calcium phosphate coated and titanium plasma sprayed also have been found to increase BIC. • Coating or surface condition is most beneficial during initial healing and early loading conditions. 01-05-2018 70 25
  • 26.  The greater the occlusal force applied to the prosthesis , the greater the stress at the implant bone interface and the greater the strain to the bone.  Patients with parafunctional habits present with increased duration and magnitude of force along with a more horizontal direction of force on the implant with a greater shear component.  Parafunctional loads increase the risk of abutment screw loosening, un-retained prosthesis or fracture of the transitional prosthesis used for immediate loading.  One should have narrow occlusal tables and eliminate posterior cantilevers for immediately loaded implants.  Axial load to the implant bodies are preferred whenever possible. 01-05-2018 2670 PATIENT FACTORS
  • 27. IMPLANT POSITIONS • Splinted arch position concept is advantageous in immediate loading as it is effective in reducing stresses to the entire implant support system. • In the completely edentulous maxilla: • Anterior implants - bilateral canine position and • Posterior implants -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. • In the mandible: • At least three implants, one in the anterior and one in each posterior region, are necessary. 01-05-2018 70 27
  • 28. 01-05-2018 2870 • The modulus of elasticity of bone is related to the bone quality. The less dense the bone, the lower the modulus. • The strength of the bone is also directly related to the density of the bone. • The amount of bone–implant contact is also decreased for less dense bone. • Cortical bone is more likely to remain lamellar in structure during the immediate loading process, compared with trabecular bone. • More implants, larger implants (length and width), greater surface area, implant designs, implant positions with greater A-P dimensions, and reduced cantilevers should all be considered in lower density bone types. MECHANICAL PROPERTIES OF BONE
  • 29. DIAGNOSIS AND TREATMENT PLANNING • Reason for extraction of tooth. • General systemic and oral health status • Amount of available bone , bone shape, quality, width and height • Sufficient distance from maxillary sinus floor, inferior alveolar canal 01-05-2018 29 A minimum of 4-5mm of bone width at the alveolar crest and 10mm length above inferior alveolar canal 70
  • 30. TOOTH EXTRACTION AND IMPLANT PLACEMENT PROCEDURES • Teeth to be removed and implants placed immediately after extraction can be assessed using either an open flap surgery or a minimally invasive surgical technique. • Avoid damaging the buccal plate during extraction. • Surgical guides should be used for precise osteotomy site preparation. • In anterior region, the implants must correspond to the incisal edges of the adjacent teeth or be slightly palatal to this landmark. • Implant should be placed at least 3mm apical to the imaginary line joining the cementoenamel junction of adjacent teeth- Good emergence profile 01-05-2018 3070
  • 31. IMMEDIATE LOADING PROTOCOLS  Patients should be healthy or a controlled systemic condition  Cigarette smoking to be avoided  Avoiding /reducing bone tapping of the osteotomy site or tapping osteotomies sites in dense bone only.  Engaging both cortices where available to provide bicortical stabilization  Performing under preparation of the osteotomy site using narrower twist drills  Using wider implant when primary stability was not obtained with the initial implant.  Avoid placing immediate loading in areas of active infection. 01-05-2018 3170
  • 32. PRIMARY STABILITY • Primary stability is one of the most critical factors and must be obtained at the time of the implant’s insertion, before any load is applied. 01-05-2018 3270
  • 33. PERIOTEST • An electronic device, the Periotest (Siemens AG, Bensheim,Germany), • able to measure the damping characteristics of the periodontium in a very reproducible way, • permit the objective discrimination between an implant that has a close bone apposition and one that is fibrously encapsulated. • of values ranging from -8 to -50 01-05-2018 70 33
  • 34. Resonance frequency analysis • Developed by Meredith and colleagues, provides a clinical, noninvasive, and nondestructive method to assess the implant stability and osseointegration • Resonance Frequency Analysis (RFA) is the measurement of the frequency with which a device vibrates. • A Smart Peg sensor is mounted on top of the implant and the sensor is then brought to vibration by gently moving it with magnetic pulses. The sensor will vibrate for a short while and then stop. • If the implant stability (stiffness of the bone-implant interface) increases, the vibration frequency of the sensor will increase. 24 34 RESONANCE FREQUENCY ANALYSIS (RFA)
  • 35. The role of primary stability for successful immediate loading of dental implants. A literature review. Journal of dentistry. • Objectives: To assess the role of primary stability for successful immediate loading (IL) of dental implants. • Original articles studying the role of primary stability for successful immediate loading of dental implants were included. • Results: • There is a significant biological response by the hard and soft tissues to IL of dental implants. • Within the limitations of the present literature review, it is evident that the core issue to observe during IL is the establishment of a good implant primary stability. • There is sufficient evidence to suggest that the degree of achieved primary stability during IL protocols is dependent on several factors including bone density and quality, implant shape, design and surface characteristics and surgical technique. 01-05-2018 70 35 Javed F, Romanos GE. The role of primary stability for successful immediate loading of dental implants. A literature review. Journal of dentistry. 2010 Aug 1;38(8):612-20.
  • 36. COMPLETELY EDENTULOUS PATIENTS • Option 1: Loading the implants the same day as the surgery. 01-05-2018 70 36
  • 39. 01-05-2018 70 39 De Bruyn H, Raes S, Östman PO, Cosyn J. Immediate loading in partially and completely edentulous jaws: a review of the literature with clinical guidelines. Periodontology 2000. 2014 Oct 1;66(1):153-87.
  • 40. Option 2 : Split the surgical appointment from the prosthesis delivery appointment • Place the implants and make an impression at surgery. • In addition, the dentist records a vertical occlusal dimension and centric bite registration. • The bite registration may be made with the shell of the transitional restoration on the abutment or with a baseplate and wax rim (made before surgery and relined as necessary). • The laboratory pours the impression and selects and prepares the abutments for the restoration and fabricates a transitional prosthesis. • Then at the suture removal appointment 7 to 12 days later, the dentist delivers the transitional fixed prosthesis. • After healing 4 to 8 months (dependent on the bone density) the transitional restoration may be cut off and the final prosthesis fabricated 01-05-2018 70 40
  • 41. DIET: • If immediately loaded prosthesis becomes partially un-cemented or fractures, the remaining implants are at increased risk of overload failure. • Diet of the patient should be restricted only to soft foods in order to avoid overloading the provisional prosthesis. 01-05-2018 4170
  • 42. All on 4 and all on six concept • First described by Paulo Malo, Lisbon, Portugal in his state of art all-on-4tm concept. • The back implants are slanted distally to place the implant head at the second premolar or first molar position. • Longer implants, stabilizing them into the anterior higher density bone, and reduces the distal cantilever of the prosthesis. • 10 to 12 unit screw retained metal to plastic (hybrid) splinted prosthesis is placed over these implants. 01-05-2018 70 42
  • 43. 01-05-2018 70 43 All four implants in position, two distally tilted back implants and two straight anterior implants A 30° multiunit abutment is being screwed on the top of distal implant to correct the prosthetic angulations
  • 44. 01-05-2018 70 44 The long flanges and palatal extension of the denture are removed Healing abutments are replaced with the titanium cylinders Prefabricated denture or patient’s old denture is used to make the immediate fixed provisional prosthesis.
  • 45. IMMEDIATE LOADING OF IMPLANTS WITH OVERDENTURE PROSTHESIS • In early progressive loading, the dentures are not worn for 1 to 2 weeks, or else worn, but completely relieved from the healing abutment. • relined after 3 to 4 months when the definitive prosthesis and attachments (ball or bar assembly) are connected. • In immediate early functional loading, the retentive attachments are connected within 5 days ( bar/clip). 01-05-2018 4570
  • 50. Comparison of patient-reported outcomes between immediately and conventionally loaded mandibular two-implant overdentures: A preliminary study Yuri Omura Journal of prosthetic dentistry 2016 • To compare patient-reported outcomes between immediately and conventionally loaded mandibular two-implant overdentures retained by magnetic attachments • 50 participants. Each participant received 2 implants in the inter-foraminal region by means of flapless surgery. Prostheses in the immediate and conventional groups were loaded using magnetic attachments on the same day as implant placement or 3 months after surgery, respectively. • Immediate loading of mandibular two-implant overdentures with magnetic attachments tends to improve oral health-related quality of life and patient assessment earlier than observed with a conventional loading protocol. 01-05-2018 5170
  • 51. The Partially Edentulous Patients 01-05-2018 5270 Nonfunctional Immediate Teeth Concept The N-FIT concept presents a similar approach to the immediate- loading technique for the completely edentulous patient, with two major exceptions. 1st : 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. 2nd : The implant-supported transitional prosthesis is placed out of all direct opposing occlusal contacts during the bone-healing period. 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.
  • 52. 01-05-2018 70 53 • Indications • • Partially edentulous patients with centric occlusal contacts and excursions on natural teeth (or healed implants) • • D1, D2, and D3 bone in regions of implants • • Screw-shaped implant bodies, 4 mm or more in diameter, with increased surface area designs to decrease crestal stresses (e.g., BioHorizons Maestro dental implant) • Contraindication • • Patients with parafunctional oral habits (i.e., anterior and lateral tongue thrust or biting on a pipe while smoking)
  • 53. • Advantages of Nonfunctional Immediate Teeth • Patient has a fixed esthetic tooth replacement soon after stage I surgery. • No stage II surgery is necessary (eliminates discomfort for the patient and decreases overhead for the doctor). • Implants are splinted during initial healing for biomechanical advantage. • The greatest bite force is only during eating and is less than 30 psi. No parafunctional forces from occlusion are possible. • 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 is mature when the final restoration is fabricated because the tissue has been healing for many months. If surgical correction is required, then the dentist still may perform the correction before the final bone maturation. 01-05-2018 70 54
  • 54. • 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. • 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 01-05-2018 70 55
  • 55. TWO CLINICAL APPROACHES TO THE N-FIT TECHNIQUE • The first option is to use a surgical-prosthetic protocol similar to immediate loading with a diagnostic waxup to fabricate the provisional restoration. Once the implants are inserted, the dentist recontours and relines the acrylic provisional prosthesis to the abutments 01-05-2018 70 56
  • 60. SINGLE-TOOTH NONFUCTIONAL IMMEDIATE-RESTORATION PROCEDURES • Worhle and Misch presented the single-tooth immediate restoration in 1998 • The single-tooth implant is considered for immediate restoration most often when the following occur: • 1. The natural tooth requires extraction and is still present in the mouth. • 2. The natural tooth is in the esthetic zone. • 3. The soft tissue drape in its current form is ideal. • 4. The bony housing around the natural tooth is intact, including the facial plate. 01-05-2018 70 61
  • 61. Transitional Restoration • Two options exist for the transitional restoration for a single-tooth immediate implant restoration: • 1st: An acrylic crown with no occlusal load for 3 to 4 months. In addition, the transitional crown may be splinted to a natural tooth that has no clinical mobility (i.e., a canine). • 2nd: A premade crown is modified to fit over the abutment and places the gingival margin in close approximation to the tissue. 01-05-2018 70 62
  • 64. RISKS OF IMMEDIATE OCCLUSAL LOADING • Early crestal bone loss after implant loading may have a relationship to occlusal overload. • The early loading was speculated to interfere with the ability of necrotic bone (created by the surgical trauma) to be replaced by newly formed bone. • Successful implants with greater than 5-mm soft tissue pockets may be more often a result of immediate loading. • In the immediate-loading technique for the completely edentulous patient, more implants usually are inserted, which increases the fee and makes patient acceptance less likely. • Implant 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. 01-05-2018 70 65
  • 66. Immediate Loading of Single Implants in the Anterior Maxilla: A 1-Year Prospective Clinical Study on 34 Patients • Aim : To present the outcomes of immediately loaded single implants placed in the anterior maxilla. • Methods: • 34 patients • 43 tapered implants • Inclusion criteria were single-tooth placement in postextraction sockets or healed sites of the anterior maxilla. • All implants were immediately loaded and followed for a period of 1 year after the placement of definitive crowns. • Results: Positive outcomes were reported, with high survival (100%) and success (95.2%) rates 01-05-2018 70 67
  • 67. Immediate versus delayed functional loading of implant in the posterior mandible: a 2-year prospective clinical study of 12 consecutive cases • Aim : To evaluate the clinical success of immediately loaded implants versus implants loaded in a delayed fashion in the posterior mandible. Three implants were placed distal to the canines bilaterally in the edentulous distal mandibular ridges of 12 patients. • Results: Twenty-nine of the examined sites showed no bone loss. After 2 years of loading in the posterior mandible, test and control implants had the same prognosis 01-05-2018 70 68 Romanos GE, Nentwig G. Immediate versus delayed functional loading of implant in the posterior mandible: a 2-year prospective clinical study of 12 consecutive cases. Int J Periodontics Restorative Dent. 2006;26:459–469
  • 68. Changes In Alveolar Bone Density Around Immediate Functionally And Non-functionally Loaded Implants • Aim: T o quantitatively assess radiographic changes in alveolar bone density around immediate functionally and nonfunctionally loaded implants. • Material and methods. A prospective longitudinal study was conducted in which 20 participants with partially edentulous mandibles received implants that were immediately loaded either functionally (IFL) or nonfunctionally (INFL). Standardized intraoral periapical radiographs were made at baseline, 3, and 6 months. • Results: Immediate loading of implants helps to stimulate bone ossification around implants at the lateral apical level and at the crest from 3 months to 6 months. • Furthermore, the immediate functional loading of implants resulted in a significantly greater degree of bone demineralization at the alveolar crest from the time of implant placement up to 3 months compared with immediate nonfunctional loading. 01-05-2018 70 69 Ramachandran A, Singh K, Rao J, Mishra N, Jurel S, Agrawal K The Journal Of Prosthetic Dentistry. 2016;115(6):712-717.
  • 69. Immediate loading of implants placed in patients with untreated periodontal disease: a 5-year prospective cohort study. 01-05-2018 7070 Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I. Immediate loading of implants placed in patients with untreated periodontal disease: a 5-year prospective cohort study. European journal of oral implantology. 2014 Sep 1;7(3). Purpose: To report the 5-year outcome of immediately loaded dental implants in patients with untreated periodontal disease. Method: 103 consecutive patients were rehabilitated with 380 implants supporting 145 prostheses in both jaws . The implants were inserted in patients with active and untreated periodontitis. The patients did not receive any previous periodontal treatment before implant surgery, except for an oral hygiene session immediately before the implant surgery. In maintenance (every 6 months) patients received periodontal treatment as needed.
  • 70. 01-05-2018 70 71 Conclusion: A cumulative survival rate of 97.9% and 99.4% at 5 years of follow up was noted. Rehabilitation of patients with untreated periodontitis using immediately loaded dental implants is feasible, when periodontal therapy is provided after rehabilitation and the patients are regularly maintained.
  • 71. • Objective: To assess longitudinal quantitative changes in bone density around different implant loading protocols and implant surfaces measured by digital subtraction radiography (DSR). • Methods: 12 patients received bilateral homologous machined surface standard implant and an oxidized surface implant TiUniteH (Nobel Biocare, Kloten, Switzerland) single-tooth implants under 2 implant—loading protocols: immediate loading and conventional loading.Standardized periapical radiographs were taken immediately after implant placement (baseline image) and at the 3-month, 6-month and 12-month follow ups. Radiographic images were digitized and submitted to digital subtraction using the DSR system. • Results: No effect of implant surface treatment was observed. • IML protocol induced mineral bone gain around single-tooth implants after the first year under function for cases with favourable bone conditions. Carneiro L, da Cunha H, Leles C, Mendonça E Dentomaxillofacial Radiology. 2012;41(3):241-247. Digital subtraction radiography evaluation of longitudinal bone density changes around immediate loading implants: a pilot study 19 72
  • 72. Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up. • Aim: of this prospective study was to report the outcome of treatment with implants inserted after tooth extraction and immediately loaded. • Fifty-six patients with single tooth loss were treated with 116 IPX Galimplant® implants with internal connections and a sandblasted, acid-etched surface. All implants were placed after tooth extraction using a flapless approach without bone regeneration, and they were then immediately loaded with cemented acrylic prostheses. After a period of three months, definitive cemented ceramic prostheses were placed. • Clinical results indicate an implant survival and success rate of 97.4%. dental implants that are inserted after tooth extraction and immediately loaded may constitute a successful and predictable alternative implant treatment. 01-05-2018 70 73 Velasco-Ortega E, Wojtovicz E, España-Lopez A, Jimenez-Guerra A, Monsalve-Guil L, Ortiz-Garcia I, Serrera-Figallo MA. Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up. Medicina oral, patologia oral y cirugia bucal. 2018 Feb.
  • 73. Immediate Loading of Short Implants in Posterior Maxillae: Case Series • Aim: To evaluate immediate loading of short dental implants in the posterior regions of the maxillae. • Materials and methods • Patients having short implants ( 7.5 mm or 8.5 mm) in maxillae posterior areas inserted before December, 2010 and immediately loaded were selected • Result: One prosthetic complication occurred. No prostheses failed resulting in a survival rate of 100%. • The immediate loading of short implants in maxillae posterior areas could save time, cost and could be regarded as a successful treatment. 01-05-2018 70 74 Anitua E. Immediate Loading of Short Implants in Posterior Maxillae: Case Series. Acta stomatologica Croatica. 2017 Jun 20;51(2):157-62.
  • 74. Conclusion 01-05-2018 7570 Patient care requires implants to restore function, esthetics, bone and soft tissue contours, speech and intra oral health. In some patient conditions, the delayed healing process can cause psychological, social, speech and or function problems. Immediate restoration of a patient after implant surgery is one of these alternatives. Careful patient screening and selection are required when an immediate implant placement with immediate loading procedure is a treatment consideration.
  • 75. References and Cross-References • Contemporary implant dentistry 3rd edition Carl E. Misch • Endosteal Dental Implants: Mc kinskey • Osseointegration and dental implants: Jokstad • Implant dentistry today: A multidisplinary approach 3rd edition Piccin • Principles and Practice of implant dentistry: Weiss • Oral rehabilitation and Implant supported prosthesis: Jimenez- Lopez • Computer-guided versus free-hand placement of immediately loaded dental implants: 1-year post-loading results of a multicentre randomised controlled trial : Pozzi et al Eur J Oral Implantol 2014;7(3):229–242 • Immediate loading of implants placed in patients with untreated periodontal disease: A 5-year prospective cohort study • Factors Affecting the Outcome in the Immediate Loading Rehabilitation of the Maxilla: A 6-year Prospective Study : Paulo Pera et al Int J Periodontics Restorative Dent 2014;34:657–665. doi: 10.11607/prd.1970 01-05-2018 7670
  • 76. References and Cross-References • Immediate non-functional versus immediate functional loading and dental implant failure rates: A systematic review and meta-analysis: RC BRUNO: journal of dentistry 42 (2014)1052 – 1059. • Immediate Versus Early Loading of Mini-Implants Supporting Mandibular Overdentures: A Preliminary 3-Year Clinical Outcome Report :HM Waleed et al Int J Prosthodont 2014;27:553-560. • Distal Cantilever in Full-Arch Prostheses and Immediate Loading: A Retrospective Clinical Study : ER Giorgious : Int J Oral MaxiIllofac implants 2014;29:427-431 • Evaluation of crestal bone loss and stability of immediate functional loading versus immediate non-functional loading of single-mandibular posterior implants: A pilot randomized controlled clinical trial : Mantena et al. Dental Research Journal September 2014 Vol 11 Issue 5 01-05-2018 7770

Editor's Notes

  • #11: Implant placement is considered from the point of tooth extraction whereas implant loading is considered from the point of placement of the implant
  • #18: The surgical process of implant osteotomy preparation and implant insertion, causes a regional acceleratory phenomenon of bone repair around the implant interface. One of the methods to reduce the risk of immediate occlusal overload is to decrease the surgical trauma & amount of initial bone remodeling at the surgical site.
  • #19: Woven bone 60um/day lamellar bone 1-5 um/day The interface remodeling rate is period of time for bone at the implant interface to be replaced with new bone
  • #23: It is essential in case of the Bone implant interface rather than the crestal bone interface where stresses are more during loading.
  • #29: The remodelling rate of cortical bone is slower than trabecular bone.
  • #30: Smile line Gingival phenotype
  • #35: By comparing resonance frequencies, the stability of a dental implant can be determined as the resonance frequency changes with different stabilities.
  • #40: BIOMET3i).
  • #41: After the impression the dentist removes the abutments from the implant bodies and replaces them with permucosal extensions (PMEs)
  • #52: All participants completed questionnaires (the Japanese version of the Oral Health Impact Profile for edentulous [OHIP-EDENT-J], the patient's denture assessment [PDA], and general satisfaction) before implant placement (baseline) and 1, 2, 3, 4, 5, 6, and 12 months after surgery
  • #73: Quantitative analysis of bone density was performed using Image Tool H software (University of Texas Health Science Centre, San Antonio, TX) to assess pixel value changes in five areas around the implants (crestal, subcrestal, medial third, apical–lateral and apical). Changes were depicted as a darkened area for mineral bone loss, a neutral grey for no change and a brightened area for increased mineral bone gain. A linear increase in grey levels was found for immediate loading (IML) implants and a significant decrease in grey levels was observed in the 12-month follow up for conventional loading implants.