Editorial

OUR HOPES FOR THE BARCELONA CONSENSUS

Immediate loading of a recently placed implant is not, by any means, a new concept. The implantology prac- ticed three or four decades ago preceded the present day osseointegrated implant with subperiosteal or endosseous implants. At the time immediate or early Ioading of an implant following its placement was con- sidered a “natural process.” However, immediate load- ing of these implants often resulted in a high level of failures and difficulties, which included periimplant bone loss and implant mobility.

Current implantology protocol, based on the reha- bilitation of edentulous patients with dental substitutes fixed to osseointegrated implants, is accepted worldwide owing to its high initial success and long-term pre- dictability. The surgical protocol employed by most existing implant systems involves two surgical interven- tions or procedures. This protocol is based on the philos- ophy that, after implant insertion, we must allow a bone- healing period, undisturbed by masticatory forces and with minimal risk of contamination from the oral cavity. To accomplish bone healing, following implant installa- tion, the implants were covered by mucosa. The duration of the bone-healing period was determined empirically, and it was recommended that it be extended in low- quality bone situations. Implants were then connected to the oral cavity with transmucosal abutments. The tech- nique is known as two-stage implant placement.

Recently some authors have written about the suc- cessful modification of the original protocol; many clini- cians have tried to omit second-stage surgery or combine both steps in one surgical appointment. The abbrevia- tion of the waiting period for implant loading, from many months to a few hours or days, does infer obvious advantages for both the patient and the clinician. Presently we have data that show comparable results, in some specific situations, between the original two-stage and the one-stage “immediate-loading’’ technique.

Because this one-stage philosophy has become so enticing, it has become necessary for us to reach agree- ment to ensure that it is as predictable as the two-stage protocol. Some of the questions that we must assess before we modify the original protocol are as follows:

What do we currently know about immediate loading that permits us to practice implantology with predictable results using treatment philosophies that used to present high failure rates? Is there a greater respect for bone tis- sue? Is the improvement owing to the use of screw-type implants over blade-type implants? Do clinical guide- lines exist that make it a predictable method? Can we apply the immediate-loading concept in every situation? Can we even employ immediate loading in any zone we desire? Do implant design and conformation influence the outcome? What role do occlusal forces play? How should treatment planning be done? Is there any con- traindication for immediate loading of an implant?

Recently an altruistic effort was made by a group of renowned professionals, versed in evidence-based implantology, who met in Barcelona with the intent to clarify and reach a consensus on the current position of the scientific community in relation to immediate load- ing. Preparations were made a year in advance; differ- ent aspects and opinions were discussed via e-mail, including the terminology to be applied. Finally, after sharing their personal views on the subject, a consensus document was drafted in the presence of an audience composed mainly of members of the Spanish Implant Society (SEI).

One of the most important conclusions reached in this consensus was the need to reconsider the objectives of current implantology; immediate loading is the first alternative to implant treatment. The attainment of osseointegration is no longer our prime objective. On the contrary, the resulting clinical conduct will be cen- tered on the maintenance of primary stability obtained earlier in placement surgery. Being that primary stabil- ity is determined by the bone properties, the implant design, and the surgical technique, it is possible that the success rate may be more susceptible to factors such as clinician ability and training than two-stage surgery.

Since the writing of the Barcelona consensus, there are still many unanswered questions. For example, What is the stability or micromovement necessary to load an implant? How can we measure this primary sta- bility? Are sophisticated diagnostic devices needed or can we trust simple methods such as torque control on

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2 Clinical Implant Dentistry and Related Research, Volume 5, Number 1, 2003

implant insertion? Should we measure implant stability after the prosthesis connection or is it better not to manipulate the implants with percussion or screwing diagnostic elements during the early part of the healing period when the implant stability may be compromised by bone resorption?

We are much obliged to the editors of Clinical Implant Dentistry and Related Research for their vision and interest in the progress of science. We speak for all who were present in Barcelona when we state our wish

that this monographic document will serve the purpose for which it was created: to better serve our patients. This would constitute the best reward for our efforts. We also acknowledge the trust and support afforded us by the SEI. We truly hope that this document, with all its ques- tions and doubts, serves as a template, so that in the not- so-distant future we can reunite and respond, compare, complete, or modify the fields that still remain obscure.

Carlos Aparicio, MD, ODs, MS