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The Effect of Two Different Immediate Loading Protocols in Implant-Supported Screw-Retained Prostheses Heba E. Khorshid, BDS, MS,* Hamdy Aboul Fotouh Hamed, BDS, MS, PhD,† and Essam A. Aziz, BDS, MS, PhD‡

he ultimate goal for modern dentistry is to restore the patient to normal facial contour, function, aesthetics, speech, health, and comfort.1 Clinical studies on humans and animals have shown that immediately loaded implants develop bone at the implant surface and are able to tolerate occlusal forces.1,2 The choice of an occlusal scheme for immediately loaded implant-supported prosthesis is broad and often controversial.3 Because of this controversy, it would be wise to study the effect of different occlusal schemes in immediately loaded implants to assess the possible consequences on the supporting structures of the dental implants. Various immediate loading protocols for dental implants have been advocated4,5:

T

• Immediate Functional Loading Protocol (Direct Occlusal Loading Protocol): where the restoration makes full contact with the opposing dentition. • Immediate Nonfunctional Loading Protocol (Indirect Occlusal Loading Protocol): where the res-

*Assistant Lecturer, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. †Professor, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. ‡Assistant Professor, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.

Reprint requests and correspondence to: Heba Ezzeldin A. Khorshid, BDS, MS, 9 Addey Street, Messaha Square, Dokki, Giza, Egypt 12311, E-mail: hebakhorshid@hotmail.com ISSN 1056-6163/11/02002-157 Implant Dentistry Volume 20 • Number 2 Copyright © 2011 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0b013e31820fbd09

Background: The aim of this work was to evaluate the changes that occur in the supporting structures of implants placed bilaterally in the posterior mandibular region as a result of 2 different immediate loading protocols: the immediate functional loading protocol and the immediate progressive loading protocol. Materials and Methods: Thirty implants were placed in 5 patients with unmodified mandibular Kennedy Class I. For each patient, 3 implants were placed on each side of the patient’s dental arch at the premolar/ molar mandibular region. At one side, the implants were immediately loaded following an immediate functional loading protocol, whereas the other side was loaded following an immediate progressive loading protocol. Radiographic evaluation was carried out using dental computed tomography at intervals of 0, 4, 9, and 24 months after implant surgery.

Results: Statistical analysis showed a more favorable bone reaction with a statistically significant difference in the crestal bone height (P ⫽ 0.011) and in the crestal periimplant bone density (P ⫽ 0.009) in the immediate progressive loading group than the immediate functional loading group. Conclusion: The immediate progressive loading protocol yields a more predictable bone reaction in the periimplant crestal bone and ensures better implant prognosis than the immediate functional loading protocol; supporting the idea that gradual loading or stimulation will allow bone to mature and grow denser in a 2-year implant follow-up period. (Implant Dent 2011;20:157–166) Key Words: immediate loading, progressive loading, functional loading, bone density, computed tomography

toration makes no direct contact with the opposing dentition. • Progressive Loading Protocol: where the restoration is restored with light contact initially and then gradually brought into full contact with the opposing dentition. The concept of progressive loading arose in 1980 based on empirical information supporting the idea that lowgrade bone stimulation of gradual loading will allow bone to mature, grow denser and improve in quality.6 Nonfunctional immediate teeth reported by

Misch and Scortecci7 entail a procedure that allows progressive loading of the implant. Roberts et al8 and Rotter et al9 described the progressive loading protocol as a method to control the load applied onto the dental implant by controlling the size of the occlusal table, the location of the occlusal contacts, the firmness of the diet, and the absence of cantilevers. In a clinical study performed by Appleton et al,10 progressively loaded implants demonstrated less marginal bone height loss


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than conventionally loaded implants. Furthermore, the progressively loaded implants showed a progressive increase in the periimplant bone density.

MATERIALS

AND

METHODS

Five patients were selected from the outpatient Prosthodontics Clinic, Faculty of Oral and Dental Medicine, Cairo University. Patients were with unmodified Class I Kennedy mandibular arch with equal bilateral distal extension length showing normal maxillomandibular relationship (Class I angle classification), with no parafunctional habits and free from any systemic disease. The average patient’s age was 40.3 years. The opposing arch (maxilla) was completely dentulous either by a complete set of natural dentition or restored with satisfactory fixed restorations. ScrewIndirect one-piece implants (ImplantDirect LLC Spectra-System Dental Implants, Calabasas Hills, CA) were the implants used in this study. For each patient, 6 osteotomies were prepared to receive 6 implants, 3 on each side of the patient’s dental arch at the premolar/molar mandibular region over which 3-unit screw-retained fixed/ detachable restorations were constructed. The insertion torque of the implants was checked by an adjustable torque wrench at 30 N cm.11 Patients were strictly instructed to follow a soft diet protocol for the first month. 48 Hours After Surgery

The provisional restorations were delivered to the patients. On one side of the dental arch, the acrylic resin was constructed to be in “infraocclusion”. Infraocclusion was defined as a piece of 0.025-mm thick shim stock passing freely through the occlusal contact region with no resistance. This side was referred to as the “Immediate Progressive Loading side.” On the other side of the dental arch, the acrylic resin was constructed to be in direct (full) occlusal contact with the opposing maxillary teeth. This side was referred to as the “Immediate Functional Loading side” where the following occlusal protocol was followed:

Fig. 1. A, Occlusal view of the restorations 21⁄2 months after surgery. Note the progressive side with slight contact only in the central fossae of the occlusal surface. B, Occlusal view of the restorations 3 months after surgery. Note the progressive side with more contact only in the central fossae of the occlusal surface than 2 weeks before. C, Occlusal view of the restorations 31⁄2 months after surgery. Note the central fossea and buccal inclines of the lingual cusps in full contact with the opposing dentition in the progressive side. D, Four months after surgery, progressive side is placed in full contact with the opposing dentition as in the functional side.

• Evenly distributed occlusal contacts and force (Cusp-fossa/cuspembrasure occlusal contacts). • Wide freedom in centric occlusion (wide groove and flat fossa). • Slight reduction of the cusp inclination especially the buccal inclines of the mandibular buccal cusps was performed to avoid interference in lateral excursive movements of the mandible. • Narrowing the buccolingual and mesiodistal dimensions of the prosthesis. 21⁄2 Months After Surgery

The occlusion of “The Immediate Progressive Loading Side” was adjusted into light (point) contact. A small mix of self-cure tooth-colored acrylic resin was adapted over the central fossae of the occlusal surface of the restoration. The patient was then asked to close lightly over a 0.025-mm shim stock placed on the doughy acrylic resin which was then left to fully polymerize. The 0.025-mm plastic shim stock was pulled out with resistance when the patient was applying maximum biting force. Using this technique, axial forces are transmitted to the implant body (Fig. 1, A).

3 Months After Surgery

Two weeks later, the occlusal contacts of “The Immediate Progressive loading Side” were adjusted into full contact (area contact) over the central fossae only. A normal diet was allowed 3 months after surgery (Fig. 1, B). 31⁄2 Months After Surgery

Two weeks later, the occlusal contacts of “The Immediate Progressive loading Side” were adjusted so as to allow contact over the central fossae and buccal inclines of the lingual mandibular cusps. No contact was allowed over the buccal and lingual inclines of the buccal mandibular cusps (Fig. 1, C). 4 Months After Surgery

The occlusal contacts of “The Immediate Progressive loading Side” were adjusted into full contact as that followed in “The Immediate Functional Loading Side” (Fig. 1, D). 9 Months After Surgery

The dental implants received the final metal ceramic screw-retained restoration with an occlusal surface


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Fig. 2. Online re-slicing of the project was performed to obtain panoramic view and buccolingual views. 3D construction of the implants and mandible is also shown. Fig. 3. Panoramic view obtained where also mesiodistal bone height and crestal bone density was measured. Fig. 4. Two sagittal (buccolingual) cuts shown where bone density and bone height measurements were obtained.

designed to make full occlusal contact with the opposing dentition.

were calculated, tabulated and statistically analyzed.

tion. No pain was as well noted on palpation, percussion, or function.

Radiographic Follow-Up

RESULTS

Statistical Methods

Radiographic assessment was performed using dental computed tomography (General Electric Co., Light Speed Plus 4-Multislice CT machine, USA) at 0, 4, 9, and 24 months after surgery. After obtaining the images, a computer software program (Mimics, Materialise HQ, Leuven, Belgium) was used, whereby coronal and sagittal reformatting and panoramic views were obtained (Fig. 2). The crestal bone density and bone height were measured at each implant site to obtain 4 readings: middistal, mid-mesial, mid-buccal, and midlingual around each implant for both groups (Figs. 3 and 4). The mean values

The results comprised the assessment of the hard tissue reaction (bone density and bone height) surrounding the 3 implants placed bilaterally in each side of the posterior mandibular areas as a result of 2 different immediate loading protocols; the immediate functional loading protocol and the immediate progressive loading protocol at 0, 4, 9, and 24 months after implant installation. At the end of this study, all implants were considered osseointegrated. None of the subjects evidenced peri-implantitis, peri-mucositis, or clinical implant mobility in any direc-

Data management and analysis were performed using Statistical Analysis Systems. To measure the effect of time, surface (buccolingual or mesiodistal) and loading protocol (the immediate functional group versus the immediate progressive group) on the percentage change of the bone height and bone density, a 3-way repeated measures analysis of variance was performed as described by Dawson and Trapp.12 P values âą•0.05 were considered significant. The Bone Height

The mean values (m) and SD measured in millimeters (mm) of the


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Table 1. The Mean Bone Height and Density Values and Standard Deviation Around the Implants in Both Groups

Time

Side

Immediate Functional Bone Height (mm)

0 months

BL MD BL MD BL MD BL MD

11.23 ⫾ 0.62 11.47 ⫾ 0.41 10.09 ⫾ 0.43 10.32 ⫾ 0.32 9.72 ⫾ 0.33 10.03 ⫾ 0.13 8.92 ⫾ 0.43 9.16 ⫾ 0.22

4 months 9 months 24 months

Immediate Progressive Bone Height (mm)

Immediate Functional Bone Density (HU)

Immediate Progressive Bone Density (HU)

11.36 ⫾ 0.32 11.27 ⫾ 0.55 10.28 ⫾ 0.38 10.79 ⫾ 0.44 9.78 ⫾ 0.44 10.53 ⫾ 0.37 9.12 ⫾ 0.39 9.75 ⫾ 0.36

1070 ⫾ 136.5 768.8 ⫾ 66.3 971.9 ⫾ 140.2 663.1 ⫾ 55.2 1104.4 ⫾ 181.2 833.9 ⫾ 117.5 1125.0 ⫾ 191.4 792.9 ⫾ 157.8

1046.2 ⫾ 84.2 766.0 ⫾ 145.0 1126.0 ⫾ 92.7 898.3 ⫾ 152.6 1206.7 ⫾ 181.2 1029.1 ⫾ 173.2 1336.9 ⫾ 108.7 1019.9 ⫾ 204.8

HU indicates Hounsfield unit; BL, buccolingual; MD, mesiodistal.

0.208) between the mesiodistal and the buccolingual surfaces in both groups along the whole study period. There was, however, a statistically significant decrease (P ⬍ 0.001) in the time period of 0 to 4 months than the time period of 4 to 9 months. The Bone Density

Fig. 5. A histogram showing the mean bone height values in both groups at both the buccolingual and mesiodistal surfaces at 0, 4, 9, and 24 months.

buccolingual and mesiodistal bone height in the immediate functional and the immediate progressive loading group at 0, 4, 9, and 24 months are shown in Table 1 and Figure 5. There was a statistically significant decrease (P ⫽ 0.011) in the percentage change

of the crestal bone height of the immediate functional loading group than the immediate progressive loading group in both the buccolingual and mesiodistal surfaces along the whole study period. There was no statistically significant difference (P ⫽

The mean values and SD measured in Hounsfield Unit of the buccolingual and mesiodistal crestal bone density in the immediate functional and the immediate progressive loading groups at 0, 4, 9, and 24 months are shown in Table 1 and Figure 6. There was a statistically significant decrease in the percentage change of bone density (P ⫽ 0.009) of the immediate functional loading group than the immediate progressive loading group in both the buccolingual and mesiodistal surfaces along the whole study period. On the other hand, there was no statistically significant difference (P ⫽ 0.241) between the mesiodistal and the buccolingual surfaces in both groups along the whole study period. There was, however, a statistically significant difference (P ⫽ 0.023) in the bone density percentage change in the time period of 0 to 4 months than the time period of 4 to 9 months and no statistical difference (P ⬎ 0.05) in the time period of 9 to 24 months in both surfaces and groups as shown in Figure 6.

DISCUSSION Analysis of the periimplant bone height revealed a reduction in the bone height around the implants in both the immediate functional loading group


IMPLANT DENTISTRY / VOLUME 20, NUMBER 2 2011

Fig. 6. A histogram showing the mean bone density values around the implants in both groups and at both the buccolingual and mesiodistal surfaces at 0, 4, 9, and 24 months.

and the immediate progressive loading group. This might be attributed to the fact that the interface between the implants and bone begins to remodel due to 2 main causes as reported by Parfitt13; the surgical trauma and the mechanical loading response produced by the immediate delivery of the implant prosthesis leading to the inevitable crestal bone resorption. Statistical analysis showed a more favorable bone reaction in the immediate progressive loading group in both the buccolingual and mesiodistal surfaces along the whole study period. This was in accordance with a study performed by Appleton et al10 who demonstrated that progressively loaded single osseointegrated implants placed in the posterior part of the maxilla showed less marginal bone

height loss than in the conventionally loaded implants. Roberts et al8 also confirmed in another study that the decreased crestal bone loss around the progressively loaded implants together with the increased bone density are due to the response to a stress level that stimulates bone growth and maturation. The results also demonstrated that there was a statistically significant increase in the crestal periimplant bone resorption in the time period from 0 to 4 months than the time period of 4 to 9 months and in the time period of 4 to 9 months than the time period of 9 to 24 months. Roberts et al14 explained that the surgical process of the implant osteotomy preparation, implant insertion and prosthetic loading cause a regional accelerated phenomenon of

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bone around the implant-bone interface resulting in crestal bone loss during the first 3 to 4 months. Bone remodeling from mechanical strain does not only repair damaged bone but also adapts to its new biomechanical situation thus explaining the reason why the amount of bone height reduction decreased in the study period of 9 to 24 months. This was in accordance with Slaets et al15 who also demonstrated that the bone offered good adaptation possibilities in immediately loaded implants rendering adequate osseointegration. Moreover, Vercruyssen and Quirynen16 concluded that the amount of annual bone resorption is reduced after the first year of initial bone remodeling. Regarding the crestal periimplant bone density, the percentage change of the bone density was significantly greater in the immediate progressive loading group than the immediate functional loading group at both sides along the whole study period. In the immediate progressive loading group, data obtained from the radiographic follow-up showed a continuous increase in the crestal bone density in the first 9 months of this study. This was in accordance with the findings of Misch6 who mentioned that progressive loading attempts to control the level of stresses transmitted to the damaged crestal bone. The load applied matches the load-bearing capacity of the maturing bone leading to an increase in the periimplant bone density. Roberts et al8 added that the high stress produced in this region causes remodeling of the immature bone that is still undergoing lamellar compaction and crystal growth thus explaining the reason behind this increase in the bone density. On the contrary, there was a significant decrease in the bone density of the immediate functional loading group from 0 to 4 months. This might be attributed to the fact that the amount of load transmitted to the implant-bone interface in this region might be beyond the physiologic limits of bone; “pathologic overload zone� as reported by Frost.17 This results in additional biomechanical influences that greatly affect the bone


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maturation as explained by Bra¨gger et al.18 This is also in agreement with the findings of Piattelli et al19,20 who reported that the increase in bone density around loaded implants is a biological response to the mechanical stress below a certain threshold, whereas loss of marginal bone and decrease in the periimplant bone density may be the result of a mechanical stress beyond this threshold.

CONCLUSION Immediate progressive loading of implants yielded a more favorable bone reaction at the bone-implant interface than the immediate functional loading throughout a 2-year study period as it controlled the level of stresses transmitted to the damaged crestal bone thus preserved the periimplant bone height and improved the periimplant crestal bone density. There was, however, an improvement in bone height and density over time in both groups due to the bone accommodation. Disclosure

The authors claim to have no financial interest in any company or any of the products mentioned in this article.

ACKNOWLEDGMENTS The authors thank Professor Dr. Gerald A. Niznick for his invaluable help and support and for supplying the dental implants used in this study (ImplantDirect LLC, Calabasas Hills, CA).

REFERENCES 1. Misch CE. Rationale for Dental Implants. 3rd ed. St. Louis, MO: Elsevier Mosby; 2008;1:3-25. 2. Romanos G, Toh CG, Siar CH, et al. Peri-implant bone reactions to immediately loaded implants. An experimental study in monkeys. J Periodontol. 2001;72:506511. 3. Zarb G, Schmitt A. The edentulous predictament. I. A prospective study of the effectiveness of implant supported fixed prostheses. J Am Dent Assoc. 1996;127: 59-65. 4. Morton D, Jaffin R, Weber HP. Immediate restoration and loading of dental implants: Clinical considerations and protocol. Int J Oral Maxillofac Implants. 2004; 19(suppl):103-108. 5. Wang H, Ormianer Z, Palti A, et al. Consensus conference on immediate loading: The single tooth and partial edentulous area. Implant Dent. 2006;15:324333. 6. Misch CE. Progressive bone loading. St Louis, MO: Elsevier Mosby; 2005; 26:511-530. 7. Misch CE, Scortecci GM. Immediate Load and Restoration in Implant Dentistry: Rationale and Treatment. 3rd ed. St Louis, MO: Elsevier Mosby; 2008; 35:799-838. 8. Roberts WE, Smith RK, Zilberman Y, et al. Osseous adaptation to continuous loading of rigid endosseous implants. Am J Orthod. 1984;86:95-111. 9. Rotter BE, Blackwell R, Dalton G. Testing progressive loading of endosteal implants with the Periotest: A pilot study. Implant Dent. 1996;5:28-32. 10. Appleton RS, Nummikoski PV, Pigno MA, et al. A radiographic assessment of progressive loading on bone around single osseointegrated implants in the posterior maxilla. Clin Oral Implants Res. 2005;16:161-167. 11. O’Sullivan D, Sennerby L, Meredith N. Measurements comparing the initial sta-

ET AL

bility of five designs of dental implants: A human cadaver study. Clin Implant Dent Relat Res. 2000;2:85-92. 12. Dawson B, Trapp GT. Basic and Clinical Biostatistics. 3rd ed. Lange Medical Book. Norwalk, CT: Appleton & Lange; 2001. 13. Parfitt AM. The physiological and clinical significance of bone histomorphometric data. In: Reck RR, ed. Bone Histomorphometry, Techniques and Interpretation. Boca Raton, FL: CRC Press; 1983:143-223. 14. Roberts WE, Turley PK, Brezniak N, et al. Implants: Bone physiology and metabolism. J Calif Dent Assoc. 1987;15: 54-61. 15. Slaets E, Naert I, Carmeliet G, et al. Early cortical bone healing around loaded titanium implants: A histological study in the rabbit. Clin Oral Implants Res. 2009; 20:126-134. 16. Vercruyssen M, Quirynen M. Longterm, retrospective evaluation (implant and patient-centered outcome) of the twoimplants-supported overdenture in the mandible. Part 2: Marginal bone loss. Clin Oral Impl Res. 2010;21:466-472. 17. Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthod. 2004;74:3-15. 18. Bra¨gger U, Bu¨rgin W, Lang NP, et al. Digital subtraction radiography for the assessment of changes in the peri-implant bone density. Int J Oral Maxillofac Implants. 1991;6:160-166. 19. Piattelli A, Corigliano M, Scarano A, et al. Immediate loading of titanium plasma-sprayed implants: An histologic analysis in monkeys. J Periodontol. 1998; 69:321-327. 20. Piattelli A, Corigliano M, Scarano A, et al. Bone reactions to early occlusal loading of two-stage titanium plasmasprayed implants: A pilot study in monkeys. Int J Periodontics Restorative Dent. 1997;17:162-169.


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Abstract Translations GERMAN / DEUTSCH AUTOR(EN): Heba E. Khorshid, BDS, MS, Hamdy Aboul Fotouh Hamed, BDS, MS, PhD, Essam A. Aziz, BDS, MS, PhD Auswirkung zweier unterschiedlicher Protokolle mit unmittelbarer Belastung bei Implantatgestu¨tzten und Schraubengehaltenen Prothesen ZUSAMMENFASSUNG: Hintergrund: Die vorliegende Arbeit zielte darauf ab, die Vera¨nderungen zu beurteilen, die bei den stu¨tzenden Strukturen von bilateral in den hinteren Unterkiefer eingepflanzten Implantaten auftreten, und dies als Ergebnis zweier unterschiedlicher Protokolle zur unmittelbaren Belastung: das Protokoll der unmittelbaren funktionellen Belastung und das Protokoll der unmittelbaren progressiven Belastung. Materialien und Methoden: Bei fu¨nf Patienten mit unvera¨nderter Kennedy-Klasse I im Unterkiefer wurden dreißig Implantate eingepflanzt. Bei jedem Patienten wurden drei Implantate auf jeder Seite des Zahnbogens an der pra¨molaren/molaren Unterkieferregion eingepflanzt. Auf der einen Seite wurden die Implantate unmittelbar gema¨ß dem Protokoll zur unmittelbaren funktionellen Belastung belastet, wa¨hrend die Implantate auf der anderen Seite gema¨ß Protokoll zur unmittelbaren progressiven Belastung ¨ ber zahntechnischen CT wurde eine ro¨ntbelastet wurden. U genologische Bewertung nach 0, 4, 9, sowie 24 Monaten nach dem Implantierungseingriff durchgefu¨hrt. Ergebnisse: Die statistische Analyse wies bei Vergleich der Gruppe mit unmittelbarer progressiver Belastung mit der Gruppe mit unmittelbarer funktionaler Belastung eine bessere Knochengewebsreaktion bei einer statistisch bedeutsamen Differenz in der krestalen Knochendicht im das Implantat umlagernden Gewebe (P ⫽ 0.009) fu¨r die Belastungsgruppe mit progressiver Belastung auf. Schlussfolgerung: Das Protokoll mit sofortiger progressiver Belastung erzielt eine besser vorhersagbare Knochengewebsreaktion im das Implantat umgebenden krestalen Knochen und stellt eine bessere Implantatprognose sicher als das Protokoll mit unmittelbarer funktionaler Belastung. Es wird die These unterstu¨tzt, dass eine allma¨hliche Belastung oder Stimulation den Knochen reifen la¨sst und in einer u¨ber zwei Jahre laufenden Nachfolgezeit ein dichteres Knochenwachstum fo¨rdert. ¨ SSELWO ¨ RTER: Unmittelbare Belastung, progresSCHLU sive Belastung, funktionale Belastung, Knochengewebsdichte, Computertomografie

SPANISH / ESPAÑOL AUTOR(ES): Heba E. Khorshid, BDS, MS, Hamdy Aboul Fotouh Hamed, BDS, MS, PhD, Essam A. Aziz, BDS, MS, PhD

El efecto de dos protocolos diferentes de carga inmediata en pro´tesis retenidas con tornillos y apoyadas en implantes ABSTRACTO: Antecedentes: El objetivo de este trabajo fue evaluar los cambios que ocurren en las estructuras de apoyo de implantes colocados bilateralmente en la regio´n mandibular posterior como resultado de dos protocolos distintos de carga inmediata: El protocolo de carga funcional inmediata y el protocolo de carga progresiva inmediata. Materiales y me´todos: Se colocaron treinta implantes en cinco pacientes con una mandíbula sin modificacio´n Kennedy Clase I. En cada paciente, se colocaron tres implantes en cada costado del arco dental del paciente en la regio´n mandibular molar/ premolar. En un costado, los implantes se cargaron inmediatamente usando un protocolo de carga funcional inmediata mientras que en el otro costado se cargaron usando un protocolo de carga progresiva inmediata. La evaluacio´n radiogra´fica se realizo´ usando una tomografía computada dental en intervalos de 0, 4, 9, y 24 meses luego de la colocacio´n quiru´rgica de los implantes. Resultados: El ana´lisis estadístico demostro´ una reaccio´n ma´s favorable del hueso con una diferencia estadísticamente significativa en la altura del hueso crestal (P ⫽ 0.011) así como en la densidad del hueso crestal periimplante (P ⫽ 0.009) en el grupo de carga progresiva inmediata que en el grupo de carga funcional inmediata. Conclusio´n: El protocolo de carga progresiva inmediata produce una reaccio´n ma´s predecible del hueso en el hueso crestal periimplante y asegura una mejor prognosis del implante que el protocolo de carga funcional inmediata; lo que apoya la idea de que una carga o estimulacio´n gradual permitira´ que el hueso madure y adquiera mayor densidad en el período de dos an˜os de seguimiento del implante. PALABRAS CLAVES: Carga inmediata, carga progresiva, carga funciona, densidad del hueso, tomografía computada

PORTUGUESE / PORTUGUÊS AUTOR(ES): Heba E. Khorshid, Bacharel em Cirurgia Denta´ria, Mestre em Cieˆncia, Hamdy Aboul Fotouh Hamed, Bacharel em Cirurgia Denta´ria, Mestre em Cieˆncia, PhD, Essam A. Aziz, Bacharel em Cirurgia Denta´ria, Mestre em Cieˆncia, PhD O Efeito de Dois Diferentes Protocolos de Carregamento Imediato em Pro´teses Retidas por Parafuso e Suportadas por Implante RESUMO: Antecedentes: O objetivo deste trabalho era avaliar as alterac¸o˜es que ocorrem nas estruturas de suporte de implantes colocados bilateralmente na regia˜o mandibular posterior como resultado de dois diferentes Protocolos de Carregamento Imediato: o Protocolo de Carregamento Fun-


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cional Imediato e o Protocolo de Carregamento Progressivo Imediato. Materiais e Me´todos: Trinta implantes foram colocados em cinco pacientes com Kennedy Class I mandibular naËœo modificada. Para cada paciente, treˆs implantes foram colocados em cada lado da arcada denta´ria do paciente na regiaËœo mandibular pre´-molar/molar. De um lado, os implantes foram carregados imediatamente em seguida a um Protocolo de Carregamento Funcional Imediato, enquanto o outro lado foi carregado em seguida a um Protocolo de Carregamento Progressivo Imediato. Foi realizada avaliac¸aËœo radiogra´fica usando tomografia computadorizada denta´ria a intervalos de 0, 4, 9, e 24 meses apo´s a cirurgia de implante. Resultados: A ana´lise estatĂ­stica mostrou uma reac¸aËœo o´ssea mais favora´vel, com uma diferenc¸a estatisticamente significativa na altura da crista o´ssea (P ⍽ 0.011), bem como na densidade do osso de peri-implante da crista (P ⍽ 0.009) no grupo de carregamento progressivo imediato do que no grupo de carregamento funcional imediato. ConclusaËœo: O protocolo de carregamento progressivo imediato produz uma reac¸aËœo o´ssea mais previsĂ­vel no osso da crista de peri-implante e garante melhor progno´stico de implante do que o protocolo de carregamento funcional imediato, apoiando a ideia de que o carregamento ou estĂ­mulo gradual permitira´ que o osso amadurec¸a e cresc¸a mais denso em um perĂ­odo de acompanhamento de implante de dois anos. PALAVRAS-CHAVE: carregamento imediato, carregamento progressivo, carregamento funcional, densidade do osso, tomografia computadorizada

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ĐžŃ Од  ĐžĐž Ń ŃƒĐşŃƒ НО, ŃƒŃ ĐžĐť  Ń ĐžĐą  Ń ĐžĐž  Đ´ ОйНŃ    ĐťŃ ,   ŃƒĐť Ń ОНĐž Đ´Ńƒ Đť  ĐžОкОНО   Đ´Đť ОгО ĐłŃƒ : ĐžОкОН Ń„ŃƒĐşĐžĐťОгО   Đ´Đť ОгО ĐłŃƒ   ĐžОкОН Ог Ń Ń ОгО   Đ´Đť ОгО ĐłŃƒ . $ Đť   Од.    йН ŃƒŃ ĐžĐť  Đ´ НО ( ОдŃ„Đž кНŃ Ń I Đž Đš  Đ´    ĐťŃ ). ĐšĐ´ĐžŃƒ  Ńƒ ĐąНО ŃƒŃ ĐžĐť Đž Đž  Đť Ń ĐşĐ´Đž

ET AL

Ń ĐžĐž ŃƒĐąĐž Đ´ŃƒĐł  ОйНŃ   ОН/ОН   ĐťŃ . ĐĄ ОдĐž Ń ĐžĐž Đť йН   Đ´Đť Đž ĐłŃƒ  Ń ĐžĐłĐťŃ Đž ĐžĐžĐşĐžĐťŃƒ Ń„ŃƒĐşĐžĐťОгО   Đ´Đť ОгО ĐłŃƒ ,  Ń Đ´ŃƒĐłĐž Ń ĐžĐž ĐłŃƒ  ĐžОдĐťĐžŃ  Ń ĐžĐłĐťŃ Đž ĐžĐžĐşĐžĐťŃƒ Ог Ń Ń ОгО   Đ´Đť ОгО ĐłŃƒ . ĐžОдĐťŃ   Đł ОгŃ„ Ń Đş Đž Đş Ń ĐžĐž! ŃƒĐąĐž ĐžОгŃ„ Ń  Đť 0, 4, 9  24  Ń  ĐžŃ Đť Đž  Đž Đť.  ŃƒĐť. ĐĄŃ  Ń Đş Đť ОкĐť йОН

йНгОŃƒ ĐşĐžŃ Ńƒ  Đş Ń Đž Ń Ń  Ń Đş   Đť    Ń Đž

Đť ОНОгО Đł Đą (p ⍽ 0,011),  Đş  НОĐžŃ  Đť ОНĐž  НО ĐşĐžŃ  (p ⍽ 0,009)  ĐłŃƒ Ń Ог Ń Ń    Đ´Đť  ĐłŃƒ   Đž Ń   Ń ĐłŃƒĐž Ń Ń„ŃƒĐşĐžĐť   Đ´Đť  ĐłŃƒ  . Од. ĐžОкОН Ог Ń Ń ОгО   Đ´Đť ОгО ĐłŃƒ  Ой Ń    йОН

ОгĐžŃƒ Ńƒ ĐşĐžŃ Ńƒ  Đş   НО Đť ОНĐž Đł Đą  Đ´  йОН

йНгО ОгĐž ĐžĐžŃ  НО Đť,  ĐžОкОН Ń„ŃƒĐşĐžĐťОгО   Đ´Đť ОгО ĐłŃƒ , Đž Од Đ´   Đ´ОНО  Đž Đž, Đž ĐžŃ   Đž ĐłŃƒ  Đť Ń ŃƒĐť ĐžОН ĐşĐžŃ  Ń Đž   ŃƒНОŃ   Đž  Đ´ŃƒĐť  гО  Од ĐžŃ Đť Đ´Ńƒ! гО йНĐ´   НО. КЛ#(!! ХЛО:   Đ´Đť Đž ĐłŃƒ  , Ог Ń Ń Đž

ĐłŃƒ  , Ń„ŃƒĐşĐžĐťĐž

ĐłŃƒ  , НОĐžŃ  ĐşĐžŃ , кО  ĐžОгŃ„

¨ RKC TURKISH / TU ¸E YAZARLAR: Heba E. Khorshid, BDS, MS, Hamdy Aboul Fotouh Hamed, BDS, MS, PhD, Essam A. Aziz, BDS, MS, PhD IË™mplantla Desteklenen ve Vida ile Bag˘lanan Protezlerde IË™ki FarklÄą Hemen Yu¨kleme Protokolu¨nu¨n Etkisi ¨ ZET: Bilgi: Bu c¸alÄąs¸manÄąn amacÄą, iki farklÄą Hemen Yu¨klO eme Protokolu¨ ile posterior alt c¸enenin iki tarafÄąnda yerles¸tirilen implantlarÄąn destek yapÄąlarÄąnda olus¸an deg˘is¸iklikleri deg˘erlendirmekti. C¸alÄąs¸mada, Hemen Fonksiyonel Yu¨kleme Protokolu¨ ile Hemen Progresif Yu¨kleme Protokolu¨ deg˘erlendirildi. Gerec¸ ve Yo¨ntem: Deg˘is¸tirilmemis¸ mandibu¨ler Kennedy SÄąnÄąf I olan 5 hastada toplam 30 implant yerles¸tirildi. Her bir hastada, hastanÄąn dis¸ arkÄąnÄąn premolar/ molar alt c¸ene bo¨lgesinin her bir tarafÄąna u¨c¸er implant yu¨klendi. Bir tarafta implantlar Hemen Fonksiyonel Yu¨kleme Protokolu¨ ile yerles¸tirilirken dig˘er tarafta Hemen Progresif Yu¨kleme Protokolu¨ kullanÄąldÄą. BilgisayarlÄą dental tomografi ile implant cerrahisinden 0, 4, 9, ve 24 ay sonra radyografik deg˘erlendirmeler gerc¸ekles¸tirildi. Bulgular: IË™statistiksel


IMPLANT DENTISTRY / VOLUME 20, NUMBER 2 2011

analizlere go¨re hemen progresif yu¨kleme grubu, hemen fonksiyonel yu¨kleme grubuna nazaran daha olumlu kemik reaksiyonu vererek, kret kemik yu¨kseklig˘inde (P ⫽ 0.011) ve kret peri-implant kemik yog˘unlug˘unda (P ⫽ 0.009) istatistiksel ac¸ıdan anlamlı bir farklılık go¨sterdi. Sonuc¸: Hemen progresif yu¨kleme protokolu¨, peri-implant kret kemig˘inde daha o¨nceden tahmin edilebilir bir kemik reaksiyonu olus¸turdug˘u gibi, hemen fonksiyonel yu¨kleme protokolu¨ne

JAPANESE /

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nazaran daha olumlu implant prognozu da sag˘lar. Bu da, progresif yu¨kleme veya uyarının iki yıllık implant takip do¨neminde kemig˘in olgunlas¸masına ve yog˘unlas¸masına olanak sag˘ladıg˘ı du¨s¸u¨ncesini desteklemektedir. ANAHTAR KELI˙MELER: hemen yu¨kleme, progresif yu¨kleme, fonksiyonel yu¨kleme, kemik yog˘unlug˘u, bilgisayarlı tomografi


166

EFFECT

OF

CHINESE /

KOREAN /

TWO DIFFERENT IMMEDIATE LOADING PROTOCOLS • KHORSHID

ET AL

The Effect of Two Different Immediate Loading Protocols  

The Effect of Two Different Immediate Loading Protocols in Implant-Supported Screw-Retained Prostheses

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