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IMMEDIATE LOADING

Alejandro Kleinman DDS. Associate Professor Advanced Education in Implant Dentistry Loma Linda University

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IMMEDIATE LOADING The use of such protocol has obvious advantages for the patient: Treatment time Surgical interventions Discomfort Anxiety

However, the concepts of immediate loading challenge previous theories and understanding of implant integration, in which healing and osseointegration before loading was anticipated as a precondition for a successful outcome. It cannot be ruled out that application of immediate loading may pose an increased risk of implant failure AK


Alberektsson et al. 1981

"A direct, on the light microscopic level, contact between living bone and an implant."

OSEOINTEGRATION

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Branemark et al. 1985

"A structural and functional connection between ordered, living bone and the surface of a lowcarrying implant."

OSEOINTEGRATION

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Roberts 1994 Direct bone apposition onto surface of the an implant; no interposed fibrous connective tissue between the implant and supporting bone; ring on percussion due to direct conduction to bone; absence of physiologic drift; no movement when used for orthodontic anchorage; functional equivalent of dental ankylosis."

OSEOINTEGRATION

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Roberts, E.W. Bone Tissue Interface J Dent Ed 1988

Woven Callus Lamellar Compaction Interface Remodeling Compacta Maturation

6w 18w 18w 54w

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Traditional Protocol

QuickTim e™ and a DV/DVCPRO - NTSC decompress or are needed to see this picture.

Two Stage Sequential Drilling Healing Times

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Surgical Technique Root Form Implants Two Stage

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Surgical Technique Root Form Implants Two Stage

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Surgical Technique Root Form Implants Two Stage

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Surgical Technique Root Form Implants Two Stage

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Branemark et al.

1977

Adell et al.

1981

Branemark et al.

1983

Surgical Approach: Albrektsson et al. Surgical Protocol

1983

Zarb & Jansson

1985

Albrektsson et al.

1986

W

Use a biocompatible material Use a 2-stage procedure Use of a stress-free healing period of 3-6 months before loading Use of an atraumatic surgery involving low speed drilling Use a mucobuccal incision and avoid a crestal one

Why?

They settled the requirement for osseointegration a delayed loading period of at least 3-6 months

Use of sterile conditions Use of titanium ancillary Avoid Xrays before the end of the healing period Use of acrilic occlusal contact surfaces

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98 97 96 95

Surgical Technique Root Form Implants Survival Rates

94 % Survival

93 92 91 90 89 15 years

20 years

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Why change the protocol?

Surgical Approach: Surgical Protocol

Two-Stage One-Stage Immediate-delayed Immediate Placement Immediate Loading Immediate Placement and Loading

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IMMEDIATE LOADING

Confused terminology

TERMINOLOGY FOR THE TIMING OF IMPPANT LOADING

Immediate Loading: The prosthesis is attached to the implants the same day the implants are placed

Early Loading; The prosthesis is attached at a second

procedure, earlier than the conventional period of 3 to 6 months; time of loading should be stated in days/weeks

Delayed Loading: The prosthesis is attached at a

second procedure after a conventional healing period of 3 to 6 months

Sociedad Espanola de Implantes World Congress, Barcelona. 2002 Aparicio,Rangert, Sennerby

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IMMEDIATE LOADING

Confused terminology

TERMINOLOGY FOR IMPLANT LOADING

Occlusal Loading: The crown/bridge is in contact with opposing dentition in centric occlusion

Nonocclusal Loading; The crown/bridge is not in

contact in centric occlusion with opposing dentition in natural jaw positions

Sociedad Espanola de Implantes World Congress, Barcelona. 2002 Aparicio,Rangert, Sennerby

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Year

Mean healing period

Study stage

Protocol status

(days) 1965-1967

Surgical Approach: Surgical Protocol

1968-1971

no loading 84-68-45-77

Initiation period Development period

Implant design modifications + Surgical protocol modifications + Demanding prosthetic biomechanics + Negative selection of patients

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Year

Mean healing period

Study stage

Protocol status

Routine period

Definitive implant design +

(days)

Surgical Approach: Surgical Protocol

1972

116

1973

124

1974

175

1975

89

Relined surgical protocol+ Prosthetic amelioration+ Negative selection of patients

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Why long healing period?

Patients with poor bone quality and quantity Non-optimized implant design

Surgical Approach: Surgical Protocol

Short implants Non-optimized surgical placement Non-optimized surgical protocol Biomechanically non-optimized prosthesis

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It’s possible change it?

Premature loading may lead to fibrous tissue encapsulation (Albrektsson, 1981; 1986) Necrotic bone at the implant bed border is not capable of load-bearing (Branemark, 1977; 1983)

Surgical Approach: Surgical Protocol

Rapid remodeling of the dead bone layer compromises the strength of the osseous tissue supporting the bone-implant interface (Roberts,1984) Integrity of the periostal margin may be threatened by undermining remodeling of adjacent bone during the late healing period (Roberts, 1989)

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Surgical Protocol: Immediate Loading

The effect of movement on the bonding of porous metal to bone

al.

Cameron H. et

J Biomed Mat Res, 1973;7:301-311

They found that micromotion amounting to about 200 microns at the bone-to-implant interface results in occupation by fibrous tissue thus preventing bone-toimplant contact.

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Surgical Protocol: Immediate Loading

Biomechanical of Oral Implants: Future Research Directions John B.

Brunski Journal of Dental Education, Vol. 52 No 12, 775-787;1988

It is known from both orthopedic and dental literature that "relative motion" at bone-implant interface, especially if it occurs during the early postoperative healing phases, and regardless of implant material, correlates with development of a thick (0.1-2.0 mm.) layer of fibrous, no- mineralized connective tissue at the interfacial region

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Surgical Protocol: Immediate Loading

In vivo bone response to biomechanical loading at the bone/dental implant interface Brunski

Adv Dent Res 1999;13:99-119

John B.

He have proposed that micromotion of about 100 microns is the threshold level for machined surfaces.

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Surgical Protocol: Immediate Loading

Pilliar (1995) Brunski (1992, 1999) Szmukler-Moncler et al. (1998)

Today's knowledge indicates that the degree of micro-motion at the bone-implant interface during the initial, critical healing phase is utmost importance to reach proper osseointegration and maybe not premature loading perse.

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Surgical Protocol: Immediate Loading

Ledermann, P.D. (1979)

3-4 TPS screw implants (Straumann Institute), to stabilize mandibular overdenture Bicorticalization Splinted Loaded the same day

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1-81 months follow-up

Ledermann, P.D. Surgical Protocol: Immediate Loading

(1984)

476 implants in 138 patients 91.2% of survival rate Most failures occurred during the first year (34/42, 81%) Failures were accounted for lack of primary stability, lack of splinting, lack of at least 11 mm. of available bone, buccal or lingual perforation, too early insertion in an extraction socket and insufficient hygiene

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53 ITI-type F cylinder implants in 14 patients

Schroeder, A. Surgical Protocol: Immediate Loading

(1983)

5-48 months ths follow-up 98.1% of success rate (1 implant failed due lower cortical perforation) Most failures occurred during the first year (34/42, 81%) Also reported 3 cases with 4 implants inserted in the anterior mandible supporting immediate loading FPD, No failures after 19-22 months of follow up

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Titanium plasma-sprayed screw implants for the reconstruction of the edentulous mandible Babbush CA, Kent JN, Misiek DJ. J Oral Maxillofac Surg 1986;44:274-282.

"The TPS screw implant system is a predictable, cost-effective means by which patients can be restored in an outpatient setting. The TPS screw system has demonstrated a 86 per cent rate of success in 484 patients with 1739 implants from four countries."

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Final Prosthesis 2 Weeks after surgery All Implants Used

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Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement Schnitman-PA; Wohrle-PS; Rubenstein-JE; DaSilva-JD; WangNH Int-J-Oral-Maxillofac-Implants. 1997 JulAug; 12(4): 495503

63 standard 3.75 Branemark implants were  placed in the mandible 10 patients 28 were loaded immediately with provisional FPD 35 adjacent implants were allowed to heal submerged and stress-free

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Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement Schnitman-PA; Wohrle-PS; RubensteinJE; DaSilva-JD; WangNH Int-J-Oral-Maxillofac-Implants. 1997 JulAug; 12(4): 495-

4 immediate loaded implants failed 10-year survival rate of 93.4% 10-year life-table analysis of survival is 84.% for immediately loaded implants and 100% for submerged implants

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Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement JE; NH

Aug;

Schnitman-PA; Wohrle-PS; RubensteinDaSilva-JD; Wang-

Int-J-Oral-Maxillofac-Implants. 1997 Jul12(4): 495-503

These data demonstrate that although mandibular implants can be successfully placed into immediate function in the short term to support fixed provisional prostheses, long-term prognosis is guarded for those implants placed into immediate function distal to the incisor region. Provisional Prosthesis Instantaneous No Delay Some Implants Used

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Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Tarnow-DP; Emtiaz-S; ClassiA J Oral-Maxillofac-Implants. 1997 May-Jun; 12(3): 319-24

The patients selected had to be completely edentulous. A minimum of 10 implants were placed in each patient's arch. A minimum of five implants were submerged initially for medicolegal reasons and allowed to heal without loading. The remaining implants were loaded the day of stage 1 surgery. A total of 107 implants were placed in these 10 patients; 6 had them placed in the mandible, and 4 in the maxilla Six patients were treated with Nobel Biocare implants, one with ITI Bonefit implants, two with Astra Tech TiOblast implants, and one with a 3I implant.

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Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Tarnow-DP; Emtiaz-S; Classi-A J Oral-Maxillofac-Implants. 1997 May-Jun; 12(3): 319-24

Sixty-seven of 69 implants that were loaded integrated, and 37 of 38 submerged implants integrated. All 10 patients have been restored with a definitive prosthesis, and all had a fixed provisional prosthesis from stage 1 surgery. The results of this study indicate that immediate loading of multiple implants rigidly splinted around a completely edentulous arch can be a viable treatment modality. Provisional Prosthesis Provisional Prosthesis

Instantaneous No Delay Some Implants Used

Instantaneous No Delay Some Implants Used

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Implant retained mandibular overdentures with immediate loading. Chiapasco M; Gatti C; Rossi E; HaefliggerW; Markwalder TH. Clin Oral Impl Res 1997: 8: 4857.

194 patients and 776 implants followed between 2 to 13 years Multicenter study (Geneva, Switzerland, Milan) Implants used: TPS and ITI screws; HA-Ti screw implants (Mathys) and NLS implants (Friatec) The patients received 4 implants in the interforaminal area. Ushaped Dolder bar delivered after 24 hours Overall failure rate of implants was3.1%(24/776 implants)  No significant relationship between failure and implant type Final Prosthesis 24 Hrs after surgery All Implants Used

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Hydroxyapatite coating converts fibrous tissue to bone around loaded implants. Soeballe-K; Hansen-ES; Brockstedt-Rasmussen-H; Bunger-C J-Bone-Joint-Surg-Br. 1993 Mar;

75(2): 270-8

Implants were inserted in the medial femoral condyles of 14 dogs and subjected to 150 micron movements during each gait cycle. After four weeks (when a fibrous membrane had developed), half the implants were immobilized to prevent further micro movement. The dogs were sacrificed at 16 weeks and the results were evaluated by push-out tests and histological analysis.

The continuously loaded Titanium implants were surrounded by a fibrous membrane, whereas bridges of new bone anchored the HA-coated implants. The tolerated micromotion for roughened bioinert implant surfaces amount to 50-150 microns.

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Hydroxyapatite coating converts fibrous tissue to bone around loaded implants. Soeballe-K; HansenES; Brockstedt-Rasmussen-H; BungerC J-Bone-Joint-Surg-Br. 1993 Mar; 75(2): 2708

The immobilized implants were surrounded by bone irrespective of the type of coating. Push-out tests of the continuously loaded implants showed better fixation of those with HA coating (p < 0.001). The immobilized Titanium implants had four times stronger fixation than did continuously loaded Titanium implants (p < 0.01) but there was no equivalent difference between the two groups of HA-coated implants.

The amount of bone ingrowth was greater into immobilized HAcoated implants than into immobilized Titanium implants (p < 0.01). Two-thirds of the HA coating had been resorbed after 16 weeks of implantation, but 25% of this resorbed HA had been replaced by bone.(13) AKS


A comparative study of Hydroxylapatite coated vs. uncoated titanium blade implants in delayed and immediately loaded applications, demonstrated a predictable protocol from which coated implants can be loaded immediately and still result with a high percentage of bone-implant contact and maintenance of prosthesis function. The immediately loaded coated blade shows direct bone contact and no fibrous tissue gap.

Lawrence B. Lum, DDS/O. Ross Beirne, DMD, PhD/Donald A. Curtis, DMD Int J Oral Maxillofac Implants 1991;6:456-462

Final Prosthesis 24 Hrs after surgery All Implants Used

Uncoated titanium blade implant Coated titanium blade implant

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Immediately Loaded Implants. Can evidence support change in Protocol? 6 year report.

Lozada JL; Kan J; Raungashensen K. J-Dent Symp June 1997

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EXPERIMENTAL CLINICAL EXAMPLE Lozada JL; Kan J; Raungashensen K. J-Dent Symp June 1997

Preoperative edentulous mandible and surgical placement of experimental implants. One stage experimental implants in position and placement of plastic copings

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PROSTHODONTIC PROCEDURES Lozada JL; Kan J; Raungashensen K. J-Dent Symp June 1997

Intraoperative splinting of plastic copings and removal of pattern for laboratory completion Completion of implant overdenture bar and placement of metal structure and final prosthesis within 24 hrs. po

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Lozada JL; Kan J; Raungashensen K. J-Dent Symp June 1997

12 patients were treated with the experimental implants from May 1991 to July 1992. 3 patients were lost to follow-up. 1 patient died with the implants in place after 5 years in function. The 8 remaining patients have being followed for 6 years. No failures have occurred with the experimental implant with the 8 remaining patients. The bone loss was measured using periapical radiographs made with a custom jig attached to the abutments heads. The mean bone

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Lozada JL; Kan J; Raungashensen K. J-Dent Symp June 1997

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5 patients each received 4HA-coated implants The implants were rigidly splinted within 24 hrs. All implants were stable at the end of

K. Rungcharassaeng, J. Peri-implant tissue response of immediate loaded, threaded, HA- Lozada, J. Kan, J.Kim, coated implants: 1-year results W. Campagni, C. Munoz. J Prosthet Dent 2002;87:17381

the observation period The mean marginal bone changes were 0.42, -0.84, -1.14 and -1.16 mm. At the 1-3-6-and 12 months follow-up There were significant decreases in probing depth and plaque index, but not in the frequency of bleeding upon probing

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