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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
