Review Article

Overview: Immediate And Delayed Loading of Implants

Goswami RomaA, Singh S.PB, Arora GurleenC, Agarwal KanikaD A Professor, Department of Prosthodontics, Subharti Dental College and Hospital B Head & Professor, Department of Prosthodontics, Subharti Dental College and Hospital C Reader, Department of Prosthodontics, Subharti Dental College and Hospital D PG Student, Department of Prosthodontics, Subharti Dental College and Hospital
Manuscript reference number: NJMDR_407_13

National Journal of Medical and Dental Research, April-June 2013: Volume-1, Issue-3, Page 70-78

Abstract: Implant- supported restorations are positioned in relation to esthetics, function and speech, and offer a more predictable treatment course than traditional restorations. Thus the profession and public are becoming increasingly aware of this dental discipline. High implant success rates of the order of 78-100% have been published, with more than 15 years. Predictable formation of a direct bone-implant interface is a consistent treatment goal in implant dentistry. The aim of this article was to accomplish an overview about the principles of the indication and of the success parameters involving immediate and delayed loading dental implants procedures. Studies about the philosophies (immediate and delayed loading dental implants) and their clinical indications will be discussed in order to overview the rules for the clinical success in both techniques More important than the philosophy selection, is how and when to use it according to biomechanical rules and principles. Keywords : Dental implants, immediate loading, delayed loading, osseointegration. Natl J Med Dent Res 2013; 1(3) : 70-78

Date of submission: 15 March 2013 Date of Editorial approval: 22 March 2013 Date of Peer review approval: 02 June 2013 Date of Publication: 30 June 2013 Conflict of Interest: Nil; Source of support: Nil Name and addresses of corresponding author: Dr. Kanika Agarwal, Department of Prosthodontics, Subharti Dental College and Hospital, Swami Vivekanand Subharti University, Delhi-Haridwar bypass road, Meerut-250001, Uttar Pradesh, India. E-Mail: docagarwal87@gmail.com Mob: 09458731424

Introduction:
The therapeutic goal of implant dentistry is not merely tooth replacement, but, total oral rehabilitation. Dental implants can be considered as a treatment option, which can provide patients with positive, longterm results. They provide excellent support for fixed as well as removable prosthesis, which increases function, compared with conventional complete and partial denture prosthesis.

Success with dental implant procedures largely depends on the presence of osseointegration. In 1977, two-stage protocol or delayed loading [1] concept was introduced, which stated the placement of implant prosthesis with an occlusal load after 3 months of implant insertion. The primary reasons cited for this approach was to reduce the risk of bacterial infection and to prevent apical migration of the body of the implant, following this procedure, a second-stage surgery is necessary to

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uncover these implants and place a prosthetic abutment. But in some patients, the delayed healing process can cause psychological, social, speech, and/or functional problems. In 1978, one-stage or nonsubmerged implant [2] procedure was introduced which eliminated the second-stage implant surgery, but the problem of waiting period of 3-6 months before placement of prosthesis remained intact. But later in 1979, non-submerged implant placement was replaced by the concept of immediate loading of implants , which can be defined as an implant supported temporary or definitive restoration in occlusal contact within 2 weeks of the implant insertion. Since then the authors have further developed and refined this protocol Known as Teeth in a day. The factors collectively support the bright scope as well as explain the rationale for dental implants are increased life expectancy, age related tooth loss, fixed prosthesis failure, anatomical consequences of edentulism, poor performance of removable prosthesis, consequences of RPDs, psychological aspects of tooth loss, predictable long term results of implant supported prosthesis advantages of implant supported restorations, increased awareness among masses.

Loading Conditions [4]:

The original recommendation to achieve osseointegration is still valid: a two-stage implant insertion. The implant is first inserted in the bone, and then the soft tissues are sutured back so that the implant will be incorporated in the bone under protected conditions. At a second surgical procedure, i.e. a minimum of 3 to 6 months later, the buried implant is exposed and connected to the oral cavity by means of a transepithelial abutment. This procedure guarantees that the implant is well protected during its incorporation in bone when the osseous interface has not been established properly, as evidenced from experimental and clinical studies.

One Stage Surgical Approach or Immediate Loading of Implants:

Immediate loading of a dental implant actually loads the implant with a provisional restoration at the same appointment, or shortly thereafter. These implants yielded a wide range of clinical survival. 1970s, Ledermann [5] began placing titanium plasma-sprayed implants and the same day splinting and immediately loading them with mandibular overdentures. In 1984, he reported a 91.2% survival rate for 476 implants placed in 138 patients. Schroeder et al (1983) [6] and Babbush et al (1986) [7], following the same protocol, reported success rates of 98% and 96.1% respectively. Indications for Immediate Loading of Implants [8]: A. Failed endodontically treated teeth, B. Teeth with periodontal disease, C. Root fractures,

Conventional Or Delayed Loading:

About 25 years ago, Branemark et al. (1977) [3] published the first long-term follow-up on oral implant, providing the scientific foundation of modern dental implantology. The 3 to 6 month period of healing time required prior to loading of implants has been a mandatory requirement for the conventional or the delayed loading protocol. The rationale for such a long delayed loading period was A. Premature loading may lead to fibrous tissue encapsulation instead of direct bone apposition B. The necrotic bone at the implant bed border is not capable of load bearing and must be first replaced by new bone C. Rapid remodeling of the dead bone layer compromises the strength of the osseous tissue supporting the boneimplant interface

D. Advanced caries beneath the gingival margin.

Contraindications [9]
The suggested contraindications, in general, for consideration of an immediate loading include the following: A. Severe metabolic disease, B. Heavy cigarette smoking ,

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C. Inadequate bone volume for correct implant placement D. Very poor bone density (D4) E. Severe parafunction habit such as bruxism, F. Clenching, G. Tongue thrust , H. Teeth associated with a history of trauma, I. Infection or periodontal inflammatory response. disease with active

hygiene, medications, and systemic diseases such as human immunodeficiency virus (HIV) acquired immunodeficiency syndrome (AIDS), diabetes mellitus, and osteoporosis. The clinical history of the tooth to be replaced at the time of extraction should also be considered. Teeth associated with a history of trauma, infection, or periodontal disease with active inflammatory response may not be candidates for immediate implant placement or immediate loading. Radiographic and physical examination are also necessary for evaluation of bone quality and quantity. The quality of bone often controls the prosthetic choices when immediate loading is considered. Higher failure rates have been reported in type IV bone for immediate loading of implants [14]. With the growing marketplace for dental implants and the advent of new technologies, implant design principles can affect success of immediately loaded implants. The screw design type has been shown to have higher mechanical retention and greater ability to transfer compressive forces. Implant length and diameter critical values for immediate loading have yet to be defined; however, early reports have suggested that lengths greater than 10 mm provide dramatically higher success rates. Another factor of implant design that may contribute to success of immediate loading is surface texture. A variety of surface coatings and treatments are available and a multitude of studies have proven high success rates. A roughened implant surface clearly has shown improved success rates over its machined counterpart. Success rates on average of 91% were found when comparing the studies. The recommended occlusal scheme for immediately loaded implants is one of maximal interocclusal contacts without lateral contacts. Patients with parafunctional habits or compromised occlusion should not receive immediate loading options. Studies by Balshi and Wolfinger demonstrated that approximately 75% of failures with immediate loading occurred in patients with parafunctional habits.

The Selection Criteria of Patient For Immediate Loading Depends Upon Four Factors [10] 1. The surgical factors pertain primarily to implant stability and surgical technique. 2. Host factors include not only bone quality and density but also proper healing environment. 3. Implant factors are based on the structure and design of the implant system utilized. 4. Occlusal factors relate to the importance of proper prosthetic design under occlusal forces. In the factors related to surgical technique, the establishment of primary stability has been described as the single most important variable for success of immediately loaded implants. The transmission of micromotion to an implant body after placement can result in crestal bone loss and failure of osseointegration. It has been shown that micromotion must be limited to less than 100 nm to achieve implant-to-bone contact. Clinically, the torque during implant placement is a good predictor of implant stability. Studies have reported that implants placed with an insertion torque of 35-45 Ncm [11-13] resulted in higher success rates for immediate loading. Additionally, to ensure adequate bone health and stability, proper implant placement technique includes copious irrigation both internally and externally to maintain temperatures less than 47 C for prevention of necrosis of the surrounding bone. Host factors includes patients medical history in evaluating immediate loading, including tobacco use, oral

Protocol for Immediate Load Implant [15, 16]:

There have been two protocols to immediate load the complete edentulous patient. First protocol, involves placing several more implants than the usual treatment plan for conventional healing period.

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Five implants inserted between the mental foramina in a two-stage approach. Three additional implants positioned for immediate occlusal loading of a transitional restoration (Fig - 1). Then, selected implants around the arch are loaded immediately with a transitional prosthesis (Fig - 2). Enough implants are left submerged for a regular healing period to allow delivery of fixed prosthesis, even if all immediately loaded implants fail. After 4 months panoramic radiograph is taken (Fig 3). 1) The other protocol for immediate loading implants in completely edentulous patients loads all the implants at the same time. Since all the implants are splinted together, the risk of overload is decreased due to a greater surface area and improved biomechanical distribution. Often more implants than the usual used in the two-stage surgery approach are inserted. Over the last few years, several authors have reported on immediate loading in the completely edentulous patient with this protocol, with 95 to 100% success rates. Following is the case discussion on this protocol (Fig -4) Fig 4 (a) - Pre-operative panoramic radiograph of eight failing mandibular teeth. Fig 4 (b) - An intraoral view of the eight failing teeth in the mandible. Fig 4 (c) - The eight mandibular teeth are extracted. Fig 4 (d) - A rongeur is used after the tissues are reflected to perform anterior mandibular osteoplasty. Fig 4 (e) - The reflected mandibular arch after osteoplasty. Fig 4 (f) - A surgical template indexed to the upper teeth to evaluate the position of six guide pins in the initial implant osteotomies. Fig 4 (g) - 15 mm long and 4mm diameter implants inserted between the foramina. Longer implants used for immediate occlusal loading. Fig 4 (h) - An implant positioned over each foramen to increase the number of implants, increase the anteroposterior distance, and decrease the cantilever length of the final prosthesis.

FIG 4 (i) - The completed surgery demonstrates seven Bio Horizons implants: five between the mental foramina and two above the foramina. Fig 4 (j) - A torque wrench is used to tighten the abutment screws to 35 N-cm to decrease abutment screw loosening during the initial loading period. Fig 4 (k) - A light cured material is used for the transitional restoration to eliminate acrylic monomer contact on the bone and decrease restorative material shrinkage during setting. Fig 4 (l) - An acellular dermal matrix is used around the implants to act as a barrier membrane for the extraction sites and to develop a zone of immobile tissue around the implants. Fig 4 (m) - A panoramic radiograph obtained to evaluate implant position at the conclusion of the surgery. Fig 4 (n) - After 4 months, the immediate loaded transitional prosthesis is removed and the implants evaluated. Fig 4 (o) - A full arch fixed, porcelain-metal cemented prosthesis is delivered. A clinical report by Buchs et al [17] found immediate loaded implant failure primarily between three to five weeks after implant insertion, and occurred as mobility without infection. On the other hand, the immediate loaded implant has no opportunity for bone to grow into the implant design, or attach itself to the implant. Therefore, implant design is more specific and implant surface condition less important during the first few weeks of immediate load. More important factors such as implant number and position, or patient force factors (as parafunction) should be considered for immediate load situations. Bone remodeling around an implant after surgery replaces a 1 mm or more devital zone of bone because of trauma as reported by Robert et al [18] (Fig. 5).

Bone Loading Trauma:

A rationale for immediate loading is not only to reduce the risk of fibrous tissue formation (which results in clinical

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failure), but also to minimize woven bone formation and promote dense lamellar bone maturation to sustain occlusal load. Guidelines [1] for this prospective report for completely edentulous patients used a biomechanical approach to reduce stress and reduce microstrain at the developing interface. These guidelines may be used for future reports on clinical application and include:

Implant Surface Condition

A. Hydroxyapatite coated implants in poor bone density types e.g. D4. B. Rough versus smooth or machine surface condition implants in good bone density situations. E.g. D2 and D3

Force Factors: Patient Conditions:

A. Parafunction, crown height, muscular dynamics require more implant surface area. B. Severe parafunction may be a contraindication for the completely edentulous patient.

Surface Area Factors:

Implant Number Eight splinted implants or more for the maxillary arch and six splinted implants or more for the mandible. More implants, if very soft bone (D4) is present, or force factors are greater (eg. crown height, parafunction)

Implant Size:
Larger diameter implants in the posterior regions of the mouth. If larger diameter is not possible, bone grafting or greater implant number is suggested (e.g. two implants for each molar) Wider root form implants provide a greater area of bone contact than narrow implants (of similar design). The crest of the ridge is where the occlusal stresses are the greatest. As a result, after interface integration, width is more important than length of implant. However, the immediate loaded implant does not have a histological attachment of bone to the interface. As a result, length is a more important parameter during the initial loading condition. The surface area of implant support may also be increased by the length of the implant

Implant Position:
A. In the completely edentulous maxilla, anterior implants should be at least in the bilateral canine position and posterior implants in the first to second molar position for the largest anterior - posterior dimension. B. In the mandible the largest anterior posterior dimension possible should be used. At least three implants, one in the anterior and one in each posterior region, are necessary.

Occlusal Load Direction:

C. Narrow occlusal tables and no posterior offset loads on the transitional prosthesis. D. Long axis loads to the implant bodies whenever possible. E. No posterior cantilevers should exist on the transitional restorations in either arch.

Implant Design
A. Parallel walled threaded implants (tapered implants contraindicated) B. High surface area implants (more threads, deeper threads) C. Compressive vs. shear loads (square shape threads) compressive forces decreases the microstrain to bone compared with shear forces. Squares shape threads have more compressive forces than shear forces.

Conclusion:
The dentist must first determine what type of prosthesis is to be fabricated. Only then, the specific implant requirements including number, length, diameter, and thread pattern can be determined..Treatment planning software can also be used to demonstrate try-ins to the patient on a computer screen. When options have been fully discussed

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between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as SimPlant (simulated implant) or Nobel Guide use the digital data to build a treatment plan. A data set is then produced and sent to a lab for production of a precision in-mouth drilling guide. During the last decade, several studies have shown that dental implants with a two-stage design demonstrated similar success rates when placed in a one-stage surgical procedure as when inserted according to the original twostage protocol. For immediate or early loading approaches splinting of the implants for reduction of micro motion at the bone-implant interface appears important for achieving osseointegration. Treatments with immediate or early implant loading can be advantageous for many edentulous patients in several respects.

Fig -3: The panoramic radiograph after 4 months of immediate occlusal loading.

Fig - 4(A) Pre-Operative View

Fig - 1: Eight Implant Inserted

Fig 4(B) Intra Oral View

Fig -2: The Transitional Restoration Is Connected To The Three Additional Implants For Immediate Loading.

Fig 4 (C) Intra Oral View After Extraction

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Fig. 4 (D) : Usage Of Rongeur

Fig 4 (H) Position Of Implants Over Each Foramen

Fig. 4 (E) Intra Oral View After Osteoplasty

Fig 4 (I) : Seven Bio Horizons Implants

Fig. 4 (F) Position Of Six Guide Pins

Fig 4 (J) Torque Wrech Used To Tighten The Abutment

Fig. 4 (G) Implant Inserted Between The Foramina

Fig 4 (K) Transitional Restoration

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Fig 4 (L) Acellular Dermatl Matrix

Fig 5: Arrows Indicate The Devital Zone Of Bone Replacement. Fig 4 (M) Panoramic Radiograph

References:
1. Carl E. Misch, Contemporary Implant Dentistry, 3rd edition, Mosby; 2008: 543-556, 3-25,799-836. 2. Albrektsson, T., Zarb G., Worthington P. & Eriksson A.R. The long-term efficacy of dental implants: a review and proposed criteria for success. Int J Oral Maxillofac Implants 1978; 1125. 3. Brnemark P, Hansson B, Adel R, Breine U, Linstrm J, Halln O. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10 years period. Scand J Plast Reconstr Surg 1977; 16: 1-132. 4. Brnemark PI. Introduction to osseointegration. In Branemark PI , Zarb GA , Albrektsson T , editors: Tissue-integrated prostheses, Osseointegration in clinical dentistry , Chicago , 1985 , Quintessence Publishing Co,Inc , pp 11 76 5. Ledermann P, Complete denture support in edentulous problem mandibles with help from 4 titanium plasmacoated PDL screw implants, 1979; 89(11): 1137-8. 6. Schroeder A, Maeglin B, Sutter F. Das ITIHohlzylinderimplantat Typ F zur Prothesenretention beim zahnlosen Keifer. Schweiz Mschr Zahnheilk 1983; 93: 720-33.

Fig 4 (N) Removal of Transitional Prosthesis

Fig 4 (O) Porcelain Metal Prosthesis.

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7. Babbush CA, Kent J, Misiek D. Titanium plasmasprayed (TPS) screw implants for the reconstruction of the edentulous mandible. J Oral Maxillofac Surg 1986; 44: 274-82. 8. Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KW. Rationale for the application of immediate load in implantdentistry: Part I. Implant Dent. 2004; 13: 207-17. 9. Misch CE, Wang HL, Misch CM, Sharawy M, Lemons J, Judy KW. Rationale for the application of immediate load in implant dentistry: part II. Implant Dent. 2004; 13: 310-21 10. Gapski R, Wang HL, Mascarenhas P, et al: Critical review of immediate implant loading , Clin Oral Implants Res 14 : 515 527. 11. Dragoo CJ, Lazzara RJ: Immediate occlusal loading of Osseotite implants in mandibular edentulous patients: A prospective observational report with 18-month data. J Prosthodont 15 : 187 - 194 , 2006. 12. Ottoni JM, Oliveira ZF, Mansini R : Correlation between placement torque and survival of single tooth implants. Int J Oral Maxillofac Implants 20 : 769 - 776, 2005 . 13. Neugebauer J, Traini T, Thamus Ul: Peri-implant bone organization under immediate loading state. Circularly polarized light analyses: a minipig study, J Periodontol 77 : 152 - 160, 2006. 14. Jaffi N RA, Berman CL: The excessive loss of

Branemark fi xtures in type IV bone: a 5-year analysis, J Periodontol 62 : 2 - 4 , 1991 . 15. Schnitman DA,WohrlePS. Branemark implants immediately loaded with fixed prosthesis at implant placement:ten year results. J Oral Implantology 1990;16: 96-105. 16. Attard NJ, Zarb GA. Immediate and early implant loading protocols: a literature review of clinical studies. J Prosthet Dent. 2005; 94: 242-58 17. Buchs AU, Levine L, Moy P. Preliminary report of immediately loaded Altiva natural tooth replacement dental implants. Clinical Implant Dent Relat Res 2001; 3: 97-105. 18.  Roberts WE, Smith RK, Zelirman Y. Osseous adaptation to continuous loading of rigid endosseous implant.Am J Orthodon 1984; 86: 95-111.

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