Immediate loading of dental implant -...

Department of Periodontology

School of dentistry, SNU

R2. Young-ju Park

Immediate loading

of dental implant

Patients for implant treatment want

Pain

Cost

Better quality of life

Number of procedures

Treatment period

Immediate loading of implant

Extraction

Implantation

Prostheses fabrication(loading)

3~4 months

Maxilla – 6 months

Mandible – 3 months

Shortened periods with no teeth or with

removable denture

Provide immediate esthetics and function

Advantages of immediate loading

Definition of immediate/early loading

Evidence for application in dental clinics

Effect on osseointegration

Success rate

Consideration for success of immediate/early

loading

Comment

Pär-Olov Ö stman, 2008 Carl E. Misch, 2004

Immediate loading Within 24 hours Within 2weeks

Early loading Within days/weeksBetween 2 weeks

and 3 months

Coventional/

delayed loading3~6 months More than 3 months

Definition

Osseointegration

1) Countersinking implant below

the crestal bone

2) Soft tissue covering over the

implant

3) Maintaining a minimally loading

environment for 3~6 months

Immediate loading have any impact on osseointegration?

1. Interruption of osseointegration

Immediate/early loading induces fibrous tissue

encapsulation

Brunski et al. 1979, Akagawa et al. 1986, Lum et al. 1991

Immediate/early loading

and osseointegration

2. No effect on osseointegration

Not found fibrous encapsulation

Hashimoto et al. 1988, Deporter et al. 1990

Immediate/early loading

and osseointegration

3. Better bone quality of osseointegrated site

More compact bone and less marrow space

around loaded implant

Piattelli et al. 1993,1997,1998

Bone-implant contact ratio;

unloaded impalnt < immediately loaded implant

Testori et al. 2001, Degidi et al. 2003

Less marginal bone resorption than

conventional loading(clinical result)

Fischer & Stenberg 2006

Immediate/early loading

and osseointegration

Mechanical stimuli

(immediate loading)

More favorable healing

response for implant

1. Interruption of osseointegration

2. No effect on osseointegration

3. Better bone quality of osseointegrated site

Implant surface, design modification

Smooth surface rough surface

Blade, cylinder shape screw, root-form

Immediate/early loading

and osseointegration

Acceptable micromovement for osseointegration

50 ~ 150 µm

Anderson et al.1990, Pilliar et al. 1986, 1995, Brunski et al. 1993

Immediate/early loading

and osseointegration

Physiologic load

Direct bone healing

Overload

Fibrous encapsulation

Totally edentulous mandible

Totally edentulous maxilla

Partially edentulous area

Single-tooth replacement

Success rate

Ledermann et al. 1979

Titanium plasma-sprayed screw implant(Straumann)

Implant supported overdenture

Schnitman et al. 1990

Bränemark implant, 7~9 implants/each patient

3 implants in strategic position were connected

Immediately loaded fixed prostheses

4/28 implants failed

Success rate- totally edentulous Mn.

Authors Implant survival rate

Schnitman et al. 85.7%

Tarnow et al. 97.4%

Bränemark et al. 98.0%

Testori et al. 98.9%

Wolfingeret et al. 97.0%

Engstrand et al. 93.3%

Henry et al. 91.0%

Alam et al. 96.6%

Success rate- totally edentulous Mn.

High number of implants more than six

Splinting implants, fixed prostheses

Success rate- totally edentulous Mx.

Success rate- totally edentulous Mx.

Authors Implant survival rate

Tarnow et al. 100%

Horiuchi et al. 96.5%

Grunder et al. 87.5%

Bergkvist et al. 98.2%

Degidi et al. 98.0%

Balshi et al. 99.0%

Ö stman et al. 99.2%

Fisher et al. 100%

Short term result

(<5 years)

Often placed in a straight line – exposed to lateral

force

In the posterior region – less bone density, strong

bite force

Success rate- partially edentulous area

Non-functional immediate provisionalization

- not loaded in CO, eccentric movement

Mechanical stress

Immediate loaded implant in posterior Mn.

- 97.5% success rate

Cornelini et al. 2006

Success rate- partially edentulous area

Success rate- partially edentulous area

Authors Implant survival rate

Testori et al. 97.7%

Cochran et al. 99.1%

Roccuzzo et al. 97.2%

Vanden Bogaerde et al. 99.1%

Rocci et al. 95.5%

Ö stman et al. 98.4%

Cornelini et al. 97.5%

Machtei et al. 90.0%

All possible type of moment

more challengeable situation to clinician

Non-functional immediate provisionalization

- not loaded in CO, eccentric movement

Success rate- single-tooth replacement

Success rate- single-tooth replacement

Authors Implant survival rate

Andersen et al. 100%

Ericsson et al. 86%

Hui et al. 100%

Calandriello et al. 100%

Rocci et al. 81%

Lorenzoni et al. 100%

Degidi et al. 95.5%

Healed extraction socket vs. fresh extraction socket

Higher risk of failure

De Bruyn et al. 2002, Degidi et al. 2005

Similar success rate

Grunder et al. 2001, Airer et al. 2002, Cooper et al. 2002,

Jaffin et al. 2004, Villa et al. 2005, Nordin et al. 2007,

Pieri et al. 2009

Immediate loading

& immediate placement

Neugebauer et al. 2009

6 mini pigs, crestal or apical defect

Implant splinting, immediate loading

3/107 implant failed

If primary stability was reached, GBR procedure

did not disturb osseointegration for immediate

loaded implants

GBR and immediate loading

Patient selection

No parafunctional habit

Good oral hygiene

Optimizing primary stability

Minimizing forces at the bone-implant interface

For success of immediate/early loading

Optimizing

primary

stability

Good bone

quality

Appropriate implant

morphology

Underpreparation

of implant site

Measurement with insertion torque

Measurement with the Periotest

Measurement with the Osstell

Measurement of primary stability

The simplest method

Sufficient torque: 35 Nm

Support complete mandibular denture

Testori et al. 2003,2004

Partial mandibular FPD

Testori et al. 2003, Nikellis et al. 2004

Single maxillary anterior implant

Nikellis et al. 2004, Norton et al. 2004, Drago et al. 2004

Measurement with insertion torque

Measurement of mobility of natural tooth

Electromechanical device

Scale : from -8 to +50

Lower value = High stability

Periotest (Medizintechnik Gulden)

Value Interpretation

-8 to 0 Good osseointegration

+1 to +9 A clinical examination is required

+10 to +50 Osseointegration is insufficient

Negative value ≠ fully osseointegrated state

Value for immediate/early loading: 0 ~ +2

Tortamano et al. 2006

Periotest (Medizintechnik Gulden)

Electronic device using eletromagnetic wave

ISQ (Implant Stability Quotient) value from 1 to 100

High ISQ value = High stability

Osstell (Osstell)

For immediate loading

Greater ISQ value than 60

Sennerby et al. 2002, Cornelini et al. 2004

ISQ value of 54 to 60

Less than 54, implant under immediate loading was

osseointegrated

Nedir et al. 2004

Osstell (Osstell)

Implant length

Implant diameter

Implant type

Implant surface

Optimizing primary stability

≥ 10mm

Large diameter does not improve

implant stability

Biscof et al. 2004

Tapered type > Straight type

Not a contributing factor to

primary stability

O’Sullivan et al. 2000

Great influence to the bone

healing process – rough, bioactive

surface

Bone density for immediate loading

Type 2,3 > Type 1 > Type 4

Post-extraction site(immediate placement)

3~5 mm drilling beyond the apex

Optimizing primary stability

1. Number of implants

Totally edentulous Mn.: 5~10 implants

Totally edentulous Mx.: 6~12 implants

2. Distribution of implants

Widest possible tripod shape

Anteroposterior distance

Minimizing forces

at the bone-implant interface

3. Management of forces exerted on the prosthesis

Implant splinting

For single crown, tight contact: M-D movement

Metallic reinforcement Fournier et al. 2004

Completely edentulous Maxilla

Minimizing forces

at the bone-implant interface

4. Management of occlusal contacts

- Immediate occlusal loading versus

immediate non-occlusal loading

No statistical differences Lindeboom et al. 2006

Partially edentulous state, single crown missing

Out of occlusion

Completely edentulous Maxilla, Mandible

Occlusal contact

Minimizing forces

at the bone-implant interface

Success rate

immediate/early loading ≈ conventional loading

Consideration

Patient selection

Primary stability

Effort to reduce micromovement

success rate

Comment

Thank you for your attention