PROGRESSIVE BONE LOADING

MODERATED BY: PRESENTED BY:

DR MANJIT KUMAR SHAVETA KAUSHAL
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CONTENTS

 Introduction

 Definitions

 Dental implant loading

 Evolution of concept of loading

 Bone physiology

 Loading protocols

 Progressive loading

 Conclusion

 References

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INTRODUCTION

 Prosthetic rehabilitation of missing structures in the oral

and maxillofacial region in accordance with DeVan's
principle of preservation has been the ultimate challenge
to the prosthodontist.

 Over the years, traditional methods of tooth replacement

are slowly and steadily being replaced by newer
modalities like implants.

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 High success rates of implants and the advantages that
go with them have earned them the name of the "third
dentition".

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 Various factors like bone strength, volume, density,
biocompatability of implant materials, design of implant,
and forces or LOADS acting on the implant play an
important role in establishing a good bone to implant
interface.

 To load the implant immediately or not is indeed the

question today.

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 If the treatment plan provides adequate support, the three most
common causes of early prosthetic implant failure are :

 non passive superstructures,

 partially unretained restorations

 loading of the implant support system beyond the strength of

the bone – to – implant interface.

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WHAT IS LOAD ?

 It is a measurement of the forces exerted onto the implant

or teeth.

WHAT ARE LOADS APPLIED TO DENTAL IMPLANTS?

 Occlusal loads during function.

 passive loads like those applied to implants during

healing stage

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 Horizontal loads like perioral forces of tongue and
circumoral musculature.

 Forces due to application of non- passive prostheses to

implant bodies.

 Forces due to para functional oral habits or tongue

thrust.

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 Progressive Loading (1998): the gradual increase in the

application of force on a dental implant whether intentionally

done with a dental prosthesis or unintentionally via forces

placed by adjacent anatomic structures or parafunctional

loading.

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 The concept of progressive or gradual loading during prosthetic
reconstruction is to decrease crestal bone loss and early implant
failure.

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EVOLUTION OF CONCEPTS OF
IMPLANT LOADING

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 About 25 years ago, Branemark et al (1977) published the
first long-term follow-up (15 years) on oral implant,
providing the scientific foundation of modern dental
implantology.

 The predictability of implant integration according to

Branemark and collaborators was obtained by adherence
to a strict surgical and prosthodontic protocol.

 One of the most emphasized requirements was a stress-

free healing period of 3-6 months, making implant
treatment lengthy.
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 Increasing functional and aesthetic challenges have
prompted implantologists to reduce the treatment period
by loading the implant immediately at the time of
placement.

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 BRANEMARK’S ORIGINAL PROTOCOL :

3 - 6 months Stage I Surgery

Tooth Extraction or Implant Placement
Osseointegration
4-6 Months
Period

Stage II Surgery or
Prosthesis Placement

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PROTOCOLS OF IMPLANT LOADING

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1.BRANEMARK’S LOADING PROTOCOL

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 The surgical and prosthetic protocols for the development
of a predictable direct bone-to-implant interface with root-
form implants were developed and reported by Branemark
et al.

 He proposed the concept of osseointegration through

delayed loading protocol which showed that direct bone
apposition at the implant surface was possible.

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 Consequent to their 10-year clinical experience, they
asserted that osseointegration required a long healing
period of atleast 3months in the mandible and atleast 5-6
months in maxilla.

 THE RATIONALE FOR SUCH A LONG DELAYED

LOADING PERIOD WAS THAT:

– Premature loading may lead to fibrous tissue

encapsulation instead of direct bone apposition

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– The necrotic bone at the implant bed border is not
capable of load-bearing and must be first replaced by
new bone

– Rapid remodeling of the dead bone layer compromises

the strength of the osseous tissue supporting the
bone-implant interface

– Integrity of the periosteal margin may be threatened by

undermining remodeling of adjacent bone during the
late healing period

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 ADVANTAGES OF BRANEMARK’S PROTOCOL:

 minimal risk of infection

 prevention of apical downward growth of mucosal

epithelium

 reduced risk of undue early loading.

 DISADVANTAGES:

 Longer treatment duration

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BONE PHYSIOLOGY IN LOADING

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 Wolff’s law states that “Every change in the form and
function of bone or their function alone is followed by
certain definite changes in their internal architecture and
equally definite alteration in their external conformation
in accordance with mathematical laws.”

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 A decrease of 40% in CORTICAL BONE and 12% in
trabecular bone is reported by disuse.

 The density decrease in jaws is related to length of time

the region has been edentulous, original density of bone,
muscle attachments, bone flexure and torsion,
parafunction, hormonal and systemic changes.

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 Bone quality is one of the key determinants to ensure
Primary Implant Stability, which is the key to a successful
osseointegration.

 Dense Bone is contributory to increased Implant-bone

contact and thus Primary stability.

 D1 and D2 bones are ideal for immediate and progressive

loading. In D3 and D4 delayed loading should be
followed.

 D1 bone is 10 times stronger than D4 bone to stresses

that cause microfacture.

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 Ideal bone for implant prosthetic support is lamellar bone

 It is highly mineralised ,takes longer time for formation

 Woven bone is fastest and first type of bone to form

around implant interface.

 It is partly mineralized and unorganised.

 For a good impalnt success, its interface with lamellar

bone is very much essential. More the contact with
lamellar bone, more stronger is the implant in bone.

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 periotest

 This instrument evaluates the dampening effect of

implants prostheses, and/or teeth ,which is directly
related to mobility.

 Its values range from -8 to 99.

 The poorer the bone density(D3 andD4),more the decrease

in PTVs,which relates to increased mobility.

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 By reducing the risk of fibrous tissue formation, by
minimizing woven bone formation and promoting lamellar
bone maturation we can achieve success through implant
loading.

 Progressive bone loading aims at increasing the bone

density, decreasing the risk of bone implant failure, and
decreasing crestal bone loss.

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2. PROGRESSIVE LOADING
PROTOCOL

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Concept of progressive loading/
gradual bone loading

 By CARL. E. MISCH in 1980

 the concept of gradual bone loading- to decrease crestal

bone loss and early implant failure

 In a more recent report (KLINE et al 2002), 99.5% success

rate at 5 years for 495 implants

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 submerged implant-loading after 3-6 months of initial
healing.

 the 2 surgical appointments used: Stage I surgery and

Stage II uncovery ,are separated by a period of 4-8
months depending upon the density of bone at the initial
surgery.

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 5 prosthodontic steps are suggested for the
reconstruction of the partial or completely edentulous
patient, with endosteal implants supporting a cemented
prosthesis.

 for screw retained-6 appointments are required.

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 The loading forces applied to the newly integrated
implants are gradually increased through the use of
provisional restorations and dietary modifications.

 The rate of increase is based on the bone density noted at

the surgical site during implant placement.

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 At each appointment, the provisional restoration is
modified or replaced in an attempt to progressively
increase the occlusal contact and to develop the desired
occlusal scheme.

 The definitive prosthesis is then delivered.

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ELEMENTS OF IMPLANT LOADING

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ELEMENTS OF IMPLANT LOADING

 Time interval
 Diet
 Occlusal material
 Occlusal contacts
 Prosthesis design

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1. TIME INTERVAL

 The two surgical appointments used for initial implant

placement and Stage II uncovery are separated by 3 to 8
months depending on the bone density at the initial
surgery.

 The macroscopic coarse trabecular bone heals about 50%

faster than dense cortical bone.

 Although it heals more slowly, D1 bone has the greatest

strength and greater lamellar bone contact. 36
 The healing time between the initial and second-stage
surgeries is kept similar for D1 and D2 bone and is 3 to 4
months.

 A longer time is suggested for the initial healing phase of

D3 and D4 bone (5 and 6 months, respectively) because of
the lesser bone contact and decreased amount of cortical
bone to allow for the maturation of the interface and the
development of some lamellar bone.

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2.DIET

 During the initial healing phase, the dentist instructs the

patient to avoid chewing in the area .

 The patient is limited to a soft diet, from the initial

transitional prosthesis delivery until the initial delivery of
the final prosthesis.

 The masticatory force for this type of food is about 10 psi.

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 This diet not only minimizes the masticatory force on the
implants but also decreases the risk of temporary
restoration fracture or partially decemented restoration.

 After the initial delivery of the final prosthesis, the patient

may include normal diet, which requires, about 21 psi in
bite force.

 The final restoration can bear the greater force without

risk or fracture or decementation of average 27 psi.

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3.OCCLUSAL MATERIAL
 Initial healing period- no occlusal material over implant

 subsequent appointments for transitional prosthesis -

acrylic ( lower force )

 metal / porcelain - the final occlusal material

 In Para function or cantilever length - the softer diet and

acrylic restoration for several months

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4.OCCLUSAL CONTACTS
 No occlusal contacts are permitted during initial healing .

 The first transitional prosthesis is left out of occlusion in

partially edentulous patients.

 no occlusal contact are made on cantilevers.

 The occlusal contacts of the final restoration follow the

implant-protective occlusion concepts.

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5.PROSTHESIS DESIGN

 The first transitional acrylic restoration in partially

edentulous patients has no occlusal contact and no
cantilevers.

 Its purpose is to splint the implants together, to reduce

stress by the mechanical advantage, and to have implants
sustain masticatory forces solely from chewing.

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 In the second acrylic transitional restoration, occlusal
contacts are placed on the implants with occlusal tables
similar to the final restoration but with no cantilevers in
nonesthetic regions.

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PROGRESSIVE LOADING
PHASES

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 The progressive bone loading appointment sequence (for
cement retained prosthesis) is as follows.

 1st appointment :-

– inital abutment selection and preliminary impressions

– Laboratory phase 1

 2nd appointment :-

– Final impressions and transitional prosthesis

– Laboratory phase 2

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 3rd appointment
– Metal try in

– Laboratory phase 3

 4th appointment

– Initial prosthesis delivery

 5th appointment

– Final delivery and evaluation

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PROGRESSIVE LOADING PROTOCOLS
IN
PARTIALLY EDENTULOUS SITUATIONS

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APPOINTMENT - 1

 1. INITIALLY, check for bone healing and soft tissue

healing after 1st stage surgery

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2. 2nd stage surgery done to expose implants

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3. Radiographic assessment done

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4. Abutments or transfer copings fixed after
permucosal extensions are removed

 One piece straight

abutments are used for
multiple parallelly placed
implants.

 If abutments are not

parallel or angled more
than 300, a two piece
angled abutments along
with fixation screw are
used for easy impression
making.

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5. Making preliminary impression

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7.Mounting the casts with bite registration record
after preliminary impressions

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8. Preperation of 1st and 2nd transitional
prosthesis with acrylic

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APPOINTMENT 2

 9. Prepared abuments placed after removing the

permucosal extensions and assessed
radiographically.

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 For a straight implant, a one piece abutment is inserted
by hand into position with about a 10-N/cm force.

 For an angled implant, the dentist inserts a two-piece

abutment using a countertorque system and torque
wrench to preload the abutment screw at a force of 20 to
35 N/cm, depending on screw material and design.

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 The dentist also may reline the transitional prosthesis to
foster soft tissue healing and create an improved
emergence profile.

 The dentist obtains a final impression; records the centric

occlusal registration with a closed-mouth centric position
when centric relation is harmonious with centric
occlusion; and makes a face-bow record along with
protrusive and check bites when required.

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 10. Make the final impression after fixing the prepared
abutments into implants intraorally to obtain definitive
casts having separate dies.

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10.Fixation of transitional prosthesis-1 (with out
occlusal contacts)

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 11.Fabricatin of wax patterns and metal
substructure

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APPOINTMENT -3

 12. Try in of metal super stucture in the mouth

and verification of centric relation

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 13. fixation of transitional prosthesis -2
( with occlusal contacts)

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APPOINTMENT - 4

14. initial fixation of final prosthesis with same

cement used for transitional prosthesis fixation.

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 15. Radiographic Examination Of Final
Prosthesis And Bone For Crestal Bone Loss.

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APPOINTMENT-5
 The dentist evaluates retention first. If retention is
adequate, the dentist does not remove the restoration and
uses the soft access cement for the definitive restoration.

 If the dentist can remove the prosthesis with finger

pressure, the dentist cements the restoration with
stronger cement.

 The diet of the patient may now include raw vegetables

and harder foods.

 The patient is scheduled for a maintenance appointment

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in 3 to 4 months.
PROGRESSIVE LOADING PROTOCOLS
IN COMPLETELY EDENTULOUS
PATIENTS

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 Some modifications – are included with fabrication of full

arch restorations.

 Because no teeth are present, the implants necessarily are

loaded when the initial transitional prosthesis is delivered.

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Phases:
 1st appointment - abutment selection & preliminary
impression

 2nd – final impression & transitional prosthesis I

 3rd – metal try in & transitional prosthesis II

 4th – initial delivery

 5th - final delivery

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 APPOINTMENT – 1- initial abutment selection and
preliminary impression
- Fabrication of treatment prosthesis– to restore OVD,
correct tooth position.

- Fabricate a clear prosthesis over this removable

prosthesis & trims it to the soft tissue border.

- Act as a custom tray for impression making

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 Place denture and clear template in mouth and record a bite

registration.

 Remove the indexed template – denture

 Place abutments into the implant bodies- & place template with

bite registration over them to evaluate proper seating of

template.

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 Using this template as custom tray for closed tray impression –
make preliminary impression using putty material.

 Remove the abutments – attaches them to the implant body

analogs & seats them into the impression.

 Reinsert the permucosal extension into the implant body

 Instruct the patient to limit mastication to soft food & remove

denture at night.

 Recall after 1-2 weeks for next appointment.

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Lab phase I
- Pour impression with dental stone

- Mount the cast on an articulator using prosthetic template &

occlusal registration before it is separated from the cast.

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- Adjust the abutment in length, angulation & proper clearance for
crown contours.

- Wax up is done & clear template is fabricated over this.

- Fabricate a transitional acrylic prosthesis on the cast using

template.

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Care should be taken:

1. No posterior cantilever should be present in first transitional

restorations.

2. Pontics should be left out of occlusion

3. Only implants that can be loaded with axial forces within 20

degree should exhibit occlusal contact.

4. No posterior contacts on lateral excursions

5. Posterior occlusal table should be narrow.

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2nd appointment – final impression and transitional
prosthesis I
 Remove the permucosal extension and inserts the final

abutments for cement.

 Place the clear template into mouth and evaluate abutment for

their position.

 Then, Insert the first transitional prosthesis.

 Evaluate incisal edge position for esthetics and phonetics.

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 Make an impression and occlusal registration when the
transitional prosthesis has the correct incisal edge, vertical
dimension and necessary prosthetic guidelines.

 Make a face- bow transfer of the maxillary arch to permit correct

mounting of the cast on an articulator.

 Cement the transitional prosthesis with temporary cement.

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 Carefully evaluates the occlusal contacts .

 Only axial loads should be there on implants

 No offset loads or cantilever should be present

 Diet should remain soft

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 Lab phase II
 Make wax-up of the final restoration & then cut backs
2mm for porcelain thickness in the appropriate regions.
Then fabricate the metal framework.

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3rd appointment- metal try-in & transitional
prosthesis II

- Evaluate the transitional prosthesis retention and remove

the prosthesis.

- Tries- in the metal framework.

- Using the posterior occlusal acrylic indexes check the

centric occlusion & OVD.

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fixation of transitional prosthesis- 2

 no nonworking and
working occlusal contacts
 pontic areas and angled
abutments- light contact.
 Heavier contacts are
developed on the implants
in ideal position.
 No cantilevers unless
need for esthetics
 occlusal scheme similar
to the final

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4th appointment- initial delivery
- 2to 4 weeks later
- Marks initial delivery of final restoration
- Adjust final occlusion as indicated
- Use soft access cement in the restoration.
- Stress on oral hygiene maintainence

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APPOINTMENT -5- final delivery

FINAL CEMENTATION AND EVALUATION OF FINAL

PROSTHESIS

4 weeks later.

 No posterior contacts are present during excursions when

opposing natural dentition or a fixed prosthesis.

 Zinc oxide eugenol with 2-ethoxybenozoic acid - if no

cantilevers are present.

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 The dentist may use harder cement (e.g., zinc phosphate)
on the most distal and anterior abutments when
cantilevers are present because tensile forces are more
likely on these positions.

 Parafunction dictates the use of an acrylic night guard for

bruxism or a soft occlusal appliance for clenching

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Conclusion
 Maintenance of rigid fixation during the first year of prosthesis
construction and function with minimum bone loss is related to
the bone remodelling process.

 The progressive bone loading approach provides the

environment favourable for the development of load bearing
bone at the implant interface in two ways:

- Extended time period before introduction of full magnitude

functional forces.

- Limiting these forces to functional forces.

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 Gradual increase in loads permits :

-the adaptation of the bone

- Increases bone density

- Increased implant survival rate

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